DIE 3211 - Nutrition Therapy I

Dr. Alireza Jahan-Mihan

Case Study III

Weight Management for Metabolic Syndrome
10 / 27 / 2015
Ezgi Ertemin-Pearson
N00922002

Weight Management for Metabolic Syndrome

1- Describe the stages of readiness for change, and identify where you think she
falls on this continuum.
Stages of change models, also known as transtheoretical models (TTM),
describe behavior change as a process in which individuals progress through a series of
six distinct stages. 1 These stagesprecontemplation, contemplation, preparation,
action, maintenance and terminationreflect a sequence of cognitive and behavioral
stages through which people progress over time to change a behavior. 2 The patient
tried different kinds of diets, yet, she couldnt maintain her dietary change. The patient
experienced a relapse and currently she falls into the contemplation category as
evidenced by her statement : I want to set a good example for my children, but I am too
busy to exercise. 3 She has thought about making a change but has done no more than
think about it. Coming to see a dietitian can be interpreted to mean that the patient is
ready to take a step. However, the patient was referred to dietitian by her physician and
it was not her choice to come see a dietitian at the first place. Assessing patients
readiness to tailor an intervention is an effective approach to attain desired behavior
change. Patient can move to preparation stage with a successful counseling strategy.
2- Calculate her BMI. How would you interpret it? How does her waist
circumference measurement add to your assessment?
Height: 56
1 in= 2.54 cm.
67 in x ( 2.54 cm /in) = 170.1799 cm = 170.18 cm
1 m = 100 cm , 170.18 cm = 1.70 m
Weight: 178 lbs
2.2 lbs = 1 kg
178 lbs x ( 1 kg / 2.2 lbs) = 80.9 kg
Metric BMI = Weight (kg) / Height (m2)
BMI = 80.9 kg / 1.70 m2 = 27.99 = 28 kg / m2
According to her 28 kg / m2 BMI measurement patient is overweight. Even
though BMI is commonly used for monitoring the occurrence of obesity in the
2

population, it has numerous limitations. It does not provide any information on the
distribution of the adipose tissue in the organism. 4 Due to the limitations of BMI
methodology, current reports by the World Health Organization and other organizations
suggest combining the measurements of BMI and abdominal obesity. 5 The patients 38
inches waist circumference (WC) indicates that abdominal obesity is prevalent.
Abdominal obesity is the most frequently observed component of metabolic syndrome. 4
Her WC measurement suggests that her risk of having coronary artery disease,
dyslipidemia, hypertension, stroke and Type 2 diabetes is increased.
3- What does her history of giving birth to heavier than average babies suggest?
The patients postpartum weight and BMI were in the healthy range140 lbs and
22 kg / m2 consecutively. The normal recommendation for Pregnancy weight gain in
women is 25-35 lbs. (11.4 - 15.9 kg), which is lower than patients 40-50 lbs. weight gain
with each pregnancy. 6 Her excessive weight gain during pregnancy is concerning as it
increases the risk of gestational diabetes mellitus (GDM) in mother and obesity in
children. 6 Her children were both close to 90th percentile and heavier than average
babies; the first baby was born at 8 pounds, 11 ounces, and the second weighed 9
pounds at birth. Excessive maternal weight gain during the first trimester (>2 kg) has
been found to be a significant predictor of GDM, independent of BMI prior to conception.
7 It can be suggested that the patients metabolic syndrome may be triggered by GDM.
In order to conclude definitely, her fasting, 1 h and 2 h plasma glucose levels during
pregnancy should be evaluated.
4- Does she meet the criteria for this syndrome according to the National
Cholesterol Education Panels Adult Treatment Panel III? How is metabolic
syndrome treated with diet and physical activity?
Yes, the patient exhibited all the risk factors to be diagnosed with the metabolic
syndrome according to the National Cholesterol Education Panels Adult Treatment
Panel III. Her waist circumference was 38 inches ( > 35 inches); serum triglyceride was
189 mg / dL ( > 150 mg / dL); HDL cholesterol was 38 mg / dL ( < 50 mg / dL); blood
pressure was 140 / 90 mm Hg ( > 110 / 85 mm Hg) and fasting glucose was 126 mg / dL
( > 110 mg / dL). 3
A combination of diet, physical activity, and behavioral therapy is generally
recommended for the metabolic syndrome patients. Overweight occurs as a result of an
imbalance between food consumed an physical activity.1 Beyond weight control and
reduction of total calories, the diet should be low in saturated fats, trans fats,
cholesterol, sodium, and simple sugars. In addition, there should be ample intake of
fruits, vegetables, and whole grains; fish intake should be encouraged. 8 Increases in
energy expenditure through exercise and physical activity are crucial for weight loss and
and its maintenance.1 Increasing physical activity not only assist in weight reduction but
also has beneficial effects on metabolic risk factors and reduces overall atherosclerotic
cardiovascular disease risk. 8

5- What can you do to help her become motivated from within herself to change
her diet and exercise behaviors?
I would incorporate motivational interviewing (MI) as a counseling strategy in my
treatment plan. MI, has been used to encourage clients to identify discrepancies
between how they would like to behave and how they are behaving, and then motivate
them to change. 1 The patient states that she would like to set a good example for her
children yet she doesnt have time to exercise. Through MI, patient can discuss her
problems such as this one. Expressing empathy and reflective listening and accepting
patients challenges can result in change. In cases of resistance to an intervention,
motivational interviewer can utilize other techniques such as legitimation, affirmation,
supporting self efficacy. Effective weight loss requires a combination of caloric
restriction, physical activity, and motivation. 8 Considering that patients have varying
levels of motivation over time, and the probability of relapses in stages of change,
combining MI with the TTM can be a helpful strategy to help patients change their
behavior.
6- Assuming she becomes ready to take action, identify some initial steps that
she might take to improve her diet.
According to the nutrient and food and calories reports created in USDA
Supertracker based on her usual, one day diet log, patient consumed 2209 calories. 9
Her daily calorie requirement calculated by using Mifflin-St. Jeor Equation is 1506.63
kcal / day. The patient consumes approximately 700 calories more than her need.
Considering that patient doesnt engage in daily physical activity, her caloric intake and
calorie consumption is not well balanced. Effective lifelong maintenance of weight loss
essentially requires a balance between caloric intake and physical activity. 8 One of the
first actions to take is to create individualized menu plan for the patient which is lower in
calories and help her set goals for increasing her exercise time. Adhering to healthy
diets such as the Mediterranean diet and/or national dietary guidelines can reduce
inflammation and the Metabolic syndrome.10 Also DASH (Dietary Approaches to Stop
Hypertension) diet has been shown to reduce systolic and diastolic blood pressure. The
DASH diet emphasizes fruit, vegetables, whole grains, poultry, fish, nuts, and low-fat
dairy products. 11
Patients calorie requirement:
Mifflin-St. Jeor Equations 1
Females = kcal/day= 10 (wt)+ 6.25 (ht) - 5 (age)- 161
= 10 (80.9 kg) + 6.25 (170.18 cm) - 5 (41) - 161 = 1506.63 kcal / day
Patients snacks are high in refined grains and her empty calorie consumption for
the given one day diet log is 515 calories, which is 257 calorie more than her daily
allowance. 9 As discussed, previously metabolic syndrome patients diet should be low
in simple sugars as well as saturated fats, trans fats, cholesterol and sodium. 8
However, the patients diet is high in total and saturated fat (36 % of calories) and
4

sodium ( 3557 mg). Another action to take is to educate patient about consequences of
over consumption of sodium, fat and simple carbohydrates, and empty calorie sources.
The patients carbohydrate, protein and fiber consumption is in the normal range.
However, her choice of nutrient sources is poor. She also doesnt take caution to
regulate her blood sugar levels. She needs to increase the consumption of nutrient
dense foods, fruit and vegetables especially dark green, red-orange vegetables, and
beans. 9 Mild elevations of blood pressure often can be managed with weight control,
increased physical activity, moderation of alcohol consumption, sodium reduction, and
increased consumption of fresh fruits and vegetables and low-fat dairy products. 8 High
fiber foods also enhance glucose control. 11
There is a trend to a poorer nutritional and biochemical profile in patients with
metabolic syndrome, who also tend to have a greater degree of oxidative stress. 11
Consuming Antioxidant foods from fruit and vegetable sources would be beneficial for
the patient to reduce oxidative stress. Fruit and vegetable consumption also increases
phytosterol intake levels. Phytosterols inhibit the intestinal absorption of cholesterol and
numerous clinical trials have demonstrated that daily consumption of foods enriched
with at least 0.8 g of plant sterols or stanols lowers serum LDL cholesterol. 12
Micronutrients that were below the daily target amounts were potassium, iron,
Vitamin A, Vitamin D, Vitamin E and choline. 9 Consumption of eggs, nuts and redorange color vegetables, dark leafy greens would bring her micronutrient status to a
desirable level. Patient uses multivitamin daily. It is important to encourage her to follow
a healthy well balanced diet and help her get micronutrients from real food sources.
Also patient needs to be cautious on taking certain vitamins. The AAFPrecommends
against the use of beta-carotene or vitamin E supplements for the prevention of
cardiovascular disease or cancer. 13
The patients one day diet log reported that her caloric intake of alpha-linolenic
acid (ALA) was low. Several controlled clinical trials have found that increasing ALA
intake decreased serum concentrations of C-reactive protein (CRP), a marker of
inflammation that is strongly associated with the risk of cardiovascular events, such as
MI and stroke. 14 The patient can increase ALA levels by consuming nuts and nut oils.
She can also increase omega-3 fatty acids Eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA) consumption by consuming two to three 3-oz servings of
fish weekly. 14
Vitamin D deficiency might affect glucose homeostasis and cause impaired
glucose tolerance and insulin resistance. 15 A recent study found that the prevalence of
type 2 diabetes was associated with suboptimal levels of serum 25-hydroxyvitamin D
(<30 ng/mL) in 1,801 patients with metabolic syndrome. 15 The patient may benefit from
Vitamin D supplementation and getting adequate sun exposure.

7- What is the role of physical activity in weight loss and weight maintenance?
How do aerobic activity, strength training, and stretching all contribute to optimal
weight management?
Physical activity increases energy expenditure, lean body mass (LBM) in
proportion to fat and HDL cholesterol (HDL-C). 1 Increase in HDL-C levels protect
against cardiovascular heart diseases. The exercise-induced changes in HDL-C are the
result of the interaction amongst exercise intensity, frequency, duration of each exercise
session, and length of the exercise training period. 8 In addition to weight reduction,
physical exercise also strengthens cardiovascular integrity, increases insulin sensitivity
and expands additional energy and, therefore, calories. 1 Current recommendations call
for at least 30 minutes of moderate-intensity exercise on most, and preferably all, days
of the week. However, more exercise will be particularly beneficial for persons with the
metabolic syndrome. At least 60 minutes of continuous or intermittent aerobic activity,
preferably done every day, will promote weight loss or weight-loss maintenance. 8
Both aerobic and resistance training should be recommended to patients.
Resistance training increases LBM, adding to the RMR and ability to use more of the
energy intake, and increases bone mineral density, especially for women. 1 Aerobic
exercise is important for cardiovascular health through elevated RMR, calorie
expenditure, energy deficit and loss of fat. 1 Stretching is also crucial to prepare the
body for strength training. In addition, stretching is beneficial in stress reduction. In a 1year multi-center randomized controlled trial conducted by Corey S, et al., low impact
stretching intervention for individuals with the metabolic syndrome was effective in
decreasing salivary cortisol, chronic stress severity, and stress perception. 16
8- What methods would you suggest she could use for self-monitoring?
Self monitoring with daily records of place and time of food intake, as well as
accompanying thoughts and feelings, helps identify the physical and emotional settings
in which eating occurs.1 She can use food and activity log, use a daily planner and
perform regular weigh-in.1 Using an app to self regulate and compare intake and
physical activity levels by days and weeks is possible. She can also use products such
as Fit Bit to monitor herself and stay motivated.
9- Make suggestions for handling family meals, special occasions, and holidays.
The patient stated her wish to be a better example for her children who are
eating junk food frequently. She can turn meal preparation time into a family time and
prepare meals with her children. In a study conducted by Berge et al. concluded that
family meals during adolescence were protective against the development of overweight
and obesity in young adulthood. 17 She can help herself and her children by simply
increasing the frequency of family meals. She can plan the menu ahead and shop when
she is not hungry. 1 Also, making eating a singular activity may be beneficial. 1 For
example, watching television (TV) while eating tends to increase food intake. 18

Holidays are usually the times family gather around food and enjoy special
recipes. Many people avoid saying no to food offerings to be polite; however, it is also
important to be able to say no when certain food items offered in special occasions.
The patient can prefer smaller portions of food and keep herself busy with fun family
activities instead spending her whole time around the dinner table. Taking walks after
meals can also beneficial to reduce blood sugar. Even slow post-meal walking can
reduce the blood glucose response to a carbohydrate-rich meal. 19
10- Write a PES statement based on her initial presentation. How would you
monitor and evaluate the effect of your interventions?
PES Statement :
Overweight/obesity (NC-3.3) related to excessive energy intake and lack of physical
activity as evidenced by 28 kg / m2 BMI, 38 inches WC, elevated levels of fasting
glucose (126 mg / dL), blood pressure (140 / 90 mm Hg), dyslipidemia ( 38 mg / dL
HDL-C ,119 mg / dL LDL-C) and patient report. 20
Monitoring and Evaluation
I would specify when is the next appointment and the goal to be met. For
example, I would recommend appointment in 4 to 6 weeks to evaluate dietary intake
according to behavioral goals.1
I would assess the patients anthropometrics, biochemical data and nutrition related
physical signs and symptoms to see if the patient was reaching her target goals. Also, I
would evaluate the patients level of motivation and continue with MI to help her reach
her goals and not relapse. I would also set up future plans for nutrition care.

1 Day meal plan for a 41 years old female patient with metabolic syndrome 9
Breakfast
Oatmeal topped with blueberries and sunflower seeds.
1 cup oatmeal, regular , cooked ( wit salt no fat added)
1 cup milk, low fat ( 1%)
1 cup blueberries, raw
&
1 large egg, boiled
Snack
Yogurt topped with almond flakes
1 cup yogurt, plain, fat free
1 tbs almond
Lunch
Kidney bean and brown rice stuffed winter squash topped with green onions
1/2 cup kidney beans, with salt no fat added
1/2 cup brown rice, no salt and fat added
1/2 a winter squash
1 small onion, green, raw
Dinner
Herring fish with steam spinach and cinnamon tossed sweet potato
1 small herring, baked
1 cup spinach, cooked, no salt added
1 medium sweet potato, baked ( peel not eaten)
1 tsp cinnamon
Snack
1 medium banana
A cup of green tea
* Plenty of water
Nutrients Report 9
Total calories: 1556 calories
Carbohydrate: 50 % of calories
Protein 27% of calories
Total fat 27% of calories
8

Dietary fiber: 36 g.
Water Soluble vitamins: Meal plan meets the targeted amount
Fat Soluble vitamins: Meal plan meets the targeted amount, except Vitamin D (3 mcg
more Vitamin D needed)
Minerals: Meal plan meets the targeted amount.
Sodium 1858 g.

References
1- Mahan, LK, Escott-Stump, S, Raymond JL. Krause's food and the nutrition care process /St.
Louis, Mo. : Elsevier/Saunders. 2012
2- Boyle AM, Holben DH. Community Nutrition in Action An Entrepreneurial Approach. 6th ed.
Cengage Learning
3- Emery EZ. Clinical Case Studies for the Nutrition Care Process. 2012. Jones&Bartlett
Learning. Burlington, MA
4- Gierach M,Gierach J,Ewertowska M,Arndt A, Junik R. Correlation between Body Mass
Index and Waist Circumference in Patients with Metabolic Syndrome. ISRN Endocrinology
Volume2014(2014), Article ID514589. http://dx.doi.org 10.1155/2014/514589 Retrieved from
http://www.hindawi.com/journals/isrn/2014/514589/
5- M. Shields, M. S. Tremblay, S. Connor Gorber, and I. Janssen, Abdominal obesity and
cardiovascular disease risk factors within body mass index categories, Health Reports, vol. 23,
no. 2, pp. 715, 2012.
6- Brown J. Nutrition Through The Life Cycle [e-book]. Belmont, CA : Thomson/Wadsworth,
c2008.; 2008. Available from: UNF Catalog, Ipswich, MA. Accessed October 26, 2015.
7- Mays L. Gestational Diabetes and Postpartum Metabolic Syndrome. International Journal Of
Childbirth Education[serial online]. October 2014;29(4):101-105 5p. Available from: CINAHL
Plus with Full Text, Ipswich, MA. Accessed October 25, 2015.
8- Armstrong C. Practice Guidelines: AHA and NHLBI Review Diagnosis and Management of
the Metabolic Syndrome. Am Fam Physician.2006Sep15;74(6):1039-1047. Retrieved from
http://www.aafp.org/afp/2006/0915/p1039.html
9- United States Department of Agriculture. Supertracker. Retrieved from
https://www.supertracker.usda.gov/foodapedia.aspx
10- Ahluwalia N, Andreeva V, Kesse-Guyot E, Hercberg S. Review: Dietary patterns,
inflammation and the metabolic syndrome. Diabetes And Metabolism [serial online]. April 1,
2011;39:99-110. Available from: ScienceDirect, Ipswich, MA. Accessed October 26, 2015.
10- Kokkinos PF, Fernhall B. Physical activity and high density lipoprotein cholesterol levels:
what is the relationship? Sports Med. 1999 Nov;28(5):307-14. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/10593643
11- Bernab Garca J, Zafrilla Rentero P, Mulero Cnovas J, Gmez Jara P, Leal Hernndez M,
Abelln Alemn J. Original article: Biochemical and nutritional markers and antioxidant activity in
metabolic syndrome. Endocrinologa Y Nutricin (English Edition) [serial online]. June 1,
2014;61:302-308. Available from: ScienceDirect, Ipswich, MA. Accessed October 26, 2015.

10

12- Oregon State University Linus Pauling Institute. Micronutrient Information Center.
Phytosterols. 2015. Retrieved from http://lpi.oregonstate.edu/mic/dietary-factors/
phytochemicals/phytosterols
13-AAFP. Vitamin, Mineral, and Multivitamin Supplements for the Primary Prevention of
Cardiovascular Disease and Cancer. Retrieved from http://www.aafp.org/patient-care/
clinical-recommendations/all/vitamin.html
14- Oregon State University Linus Pauling Institute. Micronutrient Information Center. Essential
fatty acids. Retrieved from http://lpi.oregonstate.edu/mic/other-nutrients/essential-fattyacids
15- Oregon State University Linus Pauling Institute. Micronutrient Information Center.Vitamin D.
Retrieved from http://lpi.oregonstate.edu/mic/vitamins/vitamin-D
16- Corey S, Epel E, Kanaya A, et al. Effect of restorative yoga vs. stretching on diurnal cortisol
dynamics and psychosocial outcomes in individuals with the metabolic syndrome: The PRYSMS
randomized controlled trial.Psychoneuroendocrinology [serial online]. November 1,
2014;49:260-271. Available from: ScienceDirect, Ipswich, MA. Accessed October 26, 2015.
17- Berge J, Wall M, Hsueh T, Fulkerson J, Larson N, Neumark-Sztainer D. Original Article: The
Protective Role of Family Meals for Youth Obesity: 10-Year Longitudinal Associations. The
Journal Of Pediatrics [serial online]. February 1, 2015;166:296-301. Available from:
ScienceDirect, Ipswich, MA. Accessed October 27, 2015.
18- Braude L, Stevenson R. Research report: Watching television while eating increases
energy intake. Examining the mechanisms in female participants. Appetite [serial online]. May 1,
2014;76(Abstracts of the 23rd European Childhood Obesity Group (ECOG) Congress):9-16.
Available from: ScienceDirect, Ipswich, MA. Accessed October 27, 2015.
19- Nygaard H, Tomten S, Hstmark A. Slow postmeal walking reduces postprandial glycemia
in middle-aged women. Applied Physiology, Nutrition & Metabolism [serial online]. December
2009;34(6):1087-1092. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed
October 27, 2015.
20- International Dietetics And Nutrition Terminology (IDNT) Reference Manual : Standardized
Language For The Nutrition Care Process [e-book]. Chicago, Ill. : American Dietetic Association,
c2011.; 2011. Available from: UNF Catalog, Ipswich, MA. Accessed October 26, 2015

11