Faculty(s): ​Food and Agriculture

Academic Year: ​2017/2018.

Semester: ​2.
Course Title:​ Principles of Dietetics
Course Code: ​HUEC 2013

Student Names:​ Tevene Cyrus Tyson.

Phondernelle Boddie
Ellie Jon Honore
Ganesh Seepersad
Savitri Kawall
Student Identification Numbers: ​ 816000637
816003485
816003999
809002730
816002566
Lecturer’s Name: ​Dr. Sa’eed Bawa.
Coursework Assignment: ​Diet Plan for 45 year old male; carrier of APOE e4/e4.
Date of Submission:​ Friday 20th April, 2018.
TABLE OF CONTENT
 TITLE
3-day diet plan for a 45-year old omnivorous male, who is a carrier of APOE e4/e4.

INTRODUCTION

Food is a vital part of life, it sustains and prolongs existing life when taking in the recommended
amounts, in moderation. Food consumption preferences are developed early in life, Yee et al
(2017). The type and range of foods that you regularly eat is defined as one’s diet, Diet planning
is a structured and organized flow, requiring the consumption of various foods taken over a
period of time (24 hours). Diet plans can be made specific for individuals based on varying
factors such as age, gender, health status, environment, energy requirements, genotype, etcetera.

The ApoE also known as Apolipoprotein E is as protein, a subcomponent of lipoproteins which

is used to transport fats such as cholesterol and triglycerides around the body. The e4/e4 (epsilon
4) component is an allele of the ApoE gene on chromosome 19 which poses great health risks
with regards to high cholesterol.

The report highlights intervention strategies in dealing with an omnivorous male who is a carrier
of the gene Apolipoprotein E e4/e4 and other health conditions such as being hypertensive,
smoker, obese, etc. The treatment plan consist of individualize diet plans; using a mixture of the
Dietary Approaches to Stop Hypertension ​(DASH) diet, Mediterranean diet and
Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, also increase
physical activity level, behavioral changes (habits) and an increase nutrition knowledge through
nutrition counselling.The end results would be to change the overall health status of the patient,
in more positive direction.
 BACKGROUND

The beginning of life commence with conception and the inheritance of two copies of genes; one
from each parent. The genotype of an organism is the set of genes that it carries, humans have
approximately 20,000 to 25,000 genes, ninety-nine point nine percent (99.9%) which are exactly
the same in all people. The point one percent (.1%) making each person unique. The phenotype
however, is all of its observable characteristics, the measurable outcomes of deoxyribonucleic
acid (DNA), changes in DNA can be of genetic variant which have a minor impact on function
and is triggered by the environment whereas mutation have a severe impact on function and
results in disease. Genetic disorders is define as abnormality in an individual’s DNA, they can be
single-base mutation; one gene or entire chromosomes, some examples of gene disorders are
phenylketonuria (PKU), lactose intolerance, Prader Willi, etcetera.

The gene can affect how the body metabolize foods, absorb nutrients and utilize it to support
health. The ApoE gene, a subcomponent of lipoproteins which is used mainly to transport fats
around the body however, it has recently been found to be involved in regulation of the immune
system, and cognitive processes within the brain. Three common versions of the gene exist,
which ApoE2, E3 and E4 resulting in very small differences in the ApoE protein which change
the activity of the protein and the lipoproteins it is associated with. The gene E2 provides
protection (low risk of cholesterol) whilst the E4 make you susceptible to diseases (high risk of
cholesterol), abnormal and E3 put one in the category of normal. The combination a child
receives from each parents can be one of six genotypes; E2/E2, E2/E3, E2/E4, E3/E3, E3/E4,
E4/E4. ​Having one copy of E4 (E3/E4) can increase your risk by two to three times while two
copies (E4/E4) can increase the risk by twelve times, Penny Dacks (2016).
This report brings more insight on the E4/E4 genotype which is a condition of the patient health
status. The e4/e4 (epsilon 4) component is an allele of the ApoE gene on chromosome 19 which
poses great health risks with regards to high cholesterol. This genotype ​increases the risk for
Alzheimer's and lowers the age of onset due to an increased susceptibility to the effects of fat
namely, saturated fat and cholesterol in the diet and high glucose intake.
The current report shows that a diet plan can be prepared specific to one’s genotype for
improvements in health status and other health complications since individuals respond
differently to lifestyle interventions, especially those modulating diet, . The information depicts
the significance of knowing which foods and lifestyle habits can have a negative and positive
effect on the patients with ApoE e4/e4/, using a combination of the DASH diet is lifelong
approach to healthy eating that's designed to help treat or prevent high blood pressure
(hypertension). It is a diet that encourage the reduction in sodium intake and consumption of a
variety of foods rich in nutrients that help lower blood pressure, such as potassium, calcium and
magnesium also emphasizes on consumption of vegetables, fruits and low-fat dairy foods and
moderate amounts of whole grains, fish, poultry and nuts. The DASH diet dietary
recommendations to would help prevent osteoporosis, cancer, heart disease, stroke and diabetes.
The Mediterranean diets includes the basics of healthy eating plus a splash of olive oil and at
times a glass of red wine. This diet emphasizes on things such as eating primarily plant-based
foods, such as fruits and vegetables, whole grains, legumes and nuts, replacing butter with
healthy fats such as olive oil, using herbs and spices instead of salt, to flavor foods, limiting red
meat to no more than a few times a month, consuming fish and poultry at least twice a week. The
Mediterranean diet has been associated with a lower level of oxidized low-density lipoprotein
(LDL) cholesterol — the "bad" cholesterol that's more likely to build up deposits in your arteries,
it is also associated with a reduction of cancer, Parkinson's and Alzheimer's diseases. ​The MIND
diet is a combine mixture of the DASH and Mediterranean diet. This diet encourages the intake
of foods that improves brain function, focus entirely on brain health. ​The MIND diet aim is to
prevent dementia and loss of brain function as you age.

The patient is a 45 year old omnivorous male, who is diagnosed to be a carrier of APOE e4/e4.
He is obese, base on BMI ranges, a heavy smoker as evidenced by data given that the patient
smokes one pack (20 cigarettes) a day, which is said to be an evident negative impact for e4/e4
and performs minimal exercise. Th​e ​patient’s blood pressure- 139/89 mmHg (BP), total serum
cholesterol- 260 mg/dl (TSC), low density lipoprotein cholesterol- 110 mg/dl (LDL chol.) and
triglycerides- 220 mg/dl (Trigs.) are high, placing him in the category of having metabolic
syndrome.
 LITERATURE REVIEW

According to Hixson and Vernier (1990)​1​, “Apolipoprotein E plays a central role in cholesterol
transport as reflected by the apoE” When looking at apoE, it is important to note that it plays a
role in developing Alzheimer’s disease (AD). AD is also affected the neuropsychiatric factors. In
order to deal with AD, knowing about apoE is crucial.
In the article written by Hixson et al, the research conducted was based on collecting and
analysing apoE based on gene amplification where the gene was isolated and tested. From results
obtained, it as seen that the gene e4/e4 was found on arginine 158 and were mixed with
fragments of other genes (e2/e2 and e3/e3). Each isoform of the apoE gene behaved differently
and affected the HhaI which was the restriction enzyme in the DNA used. Once genotypes were
extracted from the tests carried out the effect of each showed that e4/e4 had a link to AD due to
its interaction on lipoprotein receptors.
Another research article published by Corder et al (1994)​2 showed that Alzheimer’s disease is the
leading cause of dementia in the elderly and apoE e4 allele is important in substantial risk in a
“dose related fashion”. The dose related fashion means that in certain quantities the e4 allele will
affect the onset on AD in elderly people especially those above (60) sixty years of age. E2 allele
is the protector of AD in the late onset but e4 induces “substantial risk”. Also important to note,
if the e4 allele is in disequilibrium then that can contribute to high risk of getting AD.
In a 1997 study conducted by Lykestsos et al, it was observed that apoE was found on
chromosome 19. The study also indicated that if persons were found with this locus present then
their risk would’ve increased in getting AD. Unlike the other two articles, it was ssen that
persons who had or was at risk for AD were also patients with psychiatric symptoms. The link
between the two showed that although patients had AD, they were affected by their
neuropsychiatric symptoms more than the apoE genotype. Persons who suffered from depression
and were affected by apoE e4/e4 had a higher risk than any of the other alleles (e2/e3, e3/e3).
The findings came negative for apoE gene as the psychiatric disorders were affecting the
patients.
In conclusion, persons prevalent for AD can be noted by testing for the e4/e4 allele. Once noted
they also should be tested for any neuropsychiatric disorders and any other factors that were not
mentioned that may have an impact.
 DIET PLAN

DAY 1
Breakfast:
Whole wheat toast- 2 slices
Avocado, pureed - 1 cup
Cayenne pepper - 1 tbsp
Orange Juice - 1 cup
Bananas, Raw - 2 large

Lunch:
Quinoa, cooked - ½ cup
Black beans ,cooked- ½ cup
Pink Salmon,cooked,dry heat- 3oz
Garlic, cooked,minced - ¼ cup
Feta Cheese - 1 oz
Romaine Lettuce- 3 leaves
Water- 20 fl oz

Dinner:
Sweet potato wedges, baked- 1 cup
Chicken Breast, baked- 2 oz
Cinnamon - 1 tbsp
Roasted split peas- ½ cup
Crushed red pepper flakes- 1 tbsp

Snacks:
Greek yogurt - ¾ cup
Peanuts, unsalted- ¼ cup
DAY 2
Breakfast:
Whole wheat pita- 1 large
Onions, white, raw- 6 thin slices
Black pepper- 1 tsp
Canned Sardines- 3.75oz
Mature red pepper sauce- 1 tbsp
Sapodilla- 1 whole,small
Lemon Juice- 1 fl oz
Water- 20 fl oz

Lunch:
CousCous, cooked- ½ cup
Sweet corn kernels- ½ cup
Green peas, cooked- ½ cup
Mature red pepper sauce- 1 tbsp
Dried Parsley flakes- 1 tbsp
Pink Salmon, cooked, dry heat - ½ fillet
Broccoli, steamed, chopped- ½ cup
Pineapple Juice, unsweetened- 1 cup

Dinner:
Breadfruit slices, baked- 3 slices small
Olive oil- 1 tbsp

Snack:
Granola - 4oz
Red apple slices- 1 whole apple, medium
DAY 3
Breakfast:
Oatmeal​- ​2oz
Strawberries, chopped - 1 cup
Honey- 1 ½ tbsp
Chia Seeds- 1 oz

Lunch:
Brown rice, long grain, cooked - 1 cup
Romaine lettuce, raw, chopped - 2 leaves
Kidney Beans - 1 cup
Olive Oil- 1 oz
Tofu, cooked - 1 cup
Red tomatoes, ripe, cooked- 1 oz
Curry powder- 2 tbsp
Spinach, raw- 1 cup

Dinner:
Beets, boiled, diced- ½ cup
Baby Carrots- 7 whole 70g
Hummus - 4oz
Kale, chopped, cooked- 1 cup
Red Wine, Dry- 5 fl oz

Snacks:
Red West Indian cherries, sour, no pits- 1 cup
Banana - 1 large
Almond butter - 2 tbsp
Roasted pumpkin seeds, unsalted - 1 oz
 TABLES

Table values referenced from the Institute of Medicine’s Dietary Reference Intakes (DRIs).
Table 1: Showing Micronutrient and minerals values.
Micronutrient Upper Level/day Recommended Daily Target values
Intake (per day) (per day)

Vitamin C 2000mg 90mg 100mg

+35mg for smoker

Vitamin E 1000mg 30IU or 20mg 15mg

alpha-tocopherol

Selenium 400ug 200 mcg 60ug

Zinc 45mg 15mg 15mg

Folate 1000ug 400mcg 400ug

B6 100mg 3mg 3mg

B12 2.4mcg 2.4mg 3ug

Niacin 35mg 16mg 18mg

Calcium 2500mg 1000mg 1000mg

Magnesium 400-420mg or 100-420mg 450mg

350mg for only
synthetic forms

Sodium 2300mg 1500mg 1500mg

Iron 45mg 19.3-20.5mg 10mg

Potassium 7000mg 4700mg 4700mg

Copper 10mg 1.0-1.6mg 3mg

Manganese 11mg 2.1-2.3mg 3mg

Table 2: Depicts the target values, normal value ranges and results for the patient
Target Assessment Target values Normal ranges Result
Data

Blood Pressure 139/89 mmHg 120/80 mmHg High

Systolic blood pressure/
Diastolic blood pressure

Total Serum 260 mg/dl 100-129 mg/dl High

Cholesterol

HDL cholesterol 36 mg/dl 60 mg/dl Low (at risk for

cancer)

LDL cholesterol 110 mg/dl <100 mg/dl High

Triglycerides 220 mg/dl <150 mg/dl High

Fasting Blood sugar 75 mg/dl 100 mg/dl Low

Alcohol intake 2 servings daily CDC recommends Within normal

Men -2 drink/day range
1 standard drink=
14.0g or 0.6oz pure
alcohol

Additional alcohol information

● 12 ounces of beer (5% alcohol content).
● 8 ounces of malt liquor (7% alcohol content).
● 5 ounces of wine (12% alcohol content).
● 1.5 ounces or a “shot” of 80-proof (40% alcohol content) distilled spirits or liquor (e.g.,
gin, rum, vodka, whiskey).
Table 3: Showing the exercise routine for increased Physical Activity.
Duration of Exercise Day 1 Day 2 Day 3

10 minutes Cardio (walking Cardio- Burpees (4 Cardio (Jump rope).

around sets of 20 reps).
neighbourhood).

10 minutes Squats (4 sets of 20 Crunches ( 4 sets of Step climbing .

reps). 20 reps).

10 minutes Seated arm Curls ( Flutter Kicks (4 sets Jumping Jacks.

using household of 20 reps).
items)- 4 sets of 20
reps.

10 minutes Lounges ( 4 sets of 20 Bent over rolls (4 sets Kettlebells (using a

reps) of 20 reps). household item).

10 minutes Wall push ups (4 sets Russian Twist (4 sets Cool down ( slow
of 20 reps ) of 20 reps). walking with deep
breaths).
Table 4: showing daily nutrient and mineral value intake over the course of 3 days, in
comparison to recommended values.

NUTRIENT INTAKE Recom Dail Percentage

mende y
d Up
Daily per
Intake Lim
it

DAY DAY DAY D D D

1 2 3 A A A
Y Y Y
1 2 3

Energy 2193 2046 2026 2688.9 -

(kcal)

Carbohydra 292. 272g 279g - 57 55 56

tes 9g % % %

Fats 55.1 51.7g 64.3g - 23 26 29

g % % %

Protein 158. 90.5g 86.4g - 20 19 15

41g % % %

Fibre 65.2 44.3g 63.2g

g

Alcohol - - 15.6g - - 5
%
NUTRIENT INTAKE Recommende Daily Intake
d Daily Intake Upper Given
DAY 1 DAY 2 DAY 3 limit

Vitamin A 43210IU 3421IU 47184IU -

Vitamin C 206mg 251mg 400mg 100mg 2000mg 100mg

Vitamin D - 32.6IU - - - -

Vitamin E 10.3mg 19.5mg 30.9mg 15mg 1000mg 15mg

Vitamin K 70.1mcg 283mcg 396mcg - - -

Selenium 111mcg 191mcg 63.9mcg 60mcg 400mg 60mcg

Zinc 13.mg 9.8mg 16.2mg 15mg 45mg 15mg

NUTRIENT INTAKE Recommended Daily Intake

Daily Intake Upper given
DAY 1 DAY 2 DAY 3 Limit

Folate 852mcg 484mcg 1235mcg 400mcg 1000mcg 400mcg

B6 3.2mcg 1.7mcg 4.4mg 1.3mg 100mg 3mg

B12 3.4mcg 5.4mcg 6mcg 2.4mg 2.4mcg 3mg

Niacin 27.4mg 25.4mg 11.1mg 35mg 35mg 18mg

Calcium 782mg 386mg 2121mg 1000mg 2500mg 1000mg

Magnesium 569mg 476mg 635mg 100-420mg 400-420m 450mg

g

Sodium 1472mg 1327mg 651mg 1500mg 2300mg 1500mg

Iron 18.7mg 17mg 19.3-20.5mg 45mg 10mg

Potassium 5517mg 3734mg 4211mg 4700mg 7000mg 4700mg

Manganese 7.7mg 7mg 9.9mg 2.1-2.3mg 11mg 3mg

Copper 3.1mg 1.8mg 3mg 1-1.6mg 10mg 3mg

Omega 3 1818mg 3089mg 7343mg - - -

Omega 6 9395mg 15178m 18834mg - - -

g

Cholesterol 110mg 115mg - - 200mg <200mg

PUFA 16.2g 17.6g 27.3g

MUFA 24.6g 27.6g 23.4g

Saturated 7.7g 7.8g 8.9g

fat
 DISCUSSION

In reference to Table 2 above the patients BP- 139/89 mmHg, TSC- 260 mg/dl, LDL chol. - 110
mg/dl and Trigs.- 220 mg/dl are high. These values show that the patient is at possible risk for
cardiovascular diseases (CVDs), cerebrovascular accidents (CVAs), and peripheral artery
disease. (PADs). There is little research on the relationship between hypercholesterolemia (high
cholesterol) and hypertension (high BP). Although according to Masaru Sakurai et al, 2011,
linear regression analyses ​proved that dietary cholesterol was found to be directly related to
systolic blood pressure… , but not to diastolic blood pressure. Therefore, of the three choices:
DASH diet​, MIND diet and the Mediterranean diet; the MIND diet was chosen to be the best diet
plan approach for this patient with the ApoE e4/e4 gene and other health complications.
According to the patient’s High density lipoprotein cholesterol - 36 mg/dl (HDL chol.) value he
is at risk for Cancer. The HDL chol. Value is usually low in persons with metabolic syndrome,
which this patient has. This HDL chol. value also adds to the patients already observed risk of
CVD. Recognised is that the patient’s smoking habit, excess weight and sedentary lifestyle, are
contributing factors to this value. Furthermore, the low fasting blood glucose level- 75 mg/dl
(hypoglycemia or FBS), puts the patient at risk or possibly means that this patient has Diabetes
Mellitus (DM).
Accounting for the fact that the patient is a smoker the recommended daily intake of Vitamin C
was superseded and patient was given a higher intake daily of 125 mg. Smoking causes damage
to cells which can result in hypercholesterolemia, coronary, respiratory, and circulation problems
and there is also the possibility of osteoporosis. Smoking drains the human bod of essential
vitamins and minerals which further affects absorption of such, which can lead to poor nutrition
status. In particular, smoking poses a major issue for the vitamin C absorption (main antioxidant
in the body) which lead to low levels of vitamin C and further a lack of iron in the body. Hene
the increased intake of vitamin C to counteract the damage that can occur from this patient
smoking habits.
The recommended daily calorie intake after calculation was 2688.9 kcals, however the patient is
required to lose weight so his daily caloric intake was reduced by roughly 500 kcals daily. The
reduction will aid in his weight loss in accordance with the daily exercise plan, meaning
furthermore that he will not store any unused energy which appears to be a contributing factor to
the unwanted weight gain.
 COUNSELLING

As a counselor , it is not advised to impose several major lifestyle changes to a patient, without
firstly, asking the patient a series of questions to determine the modifications he is comfortable
and willing to make in his life to improve his health and wellbeing. Some of the questions that
will be asked can be found in Appendix 1. The goal is however, to help the patient make and
maintain dietary and beneficially lifestyle changes to reduce and reverse the health effects of his
conditions and increase quality of life positively.
The physical activity level depicted from the patients target value is sedentary. The
recommendation for this patient is to increase the physical activity level from sedentary to low
physical activity level at approximately thirty to sixty minutes for three days per week for three
months. The patient’s physical activity level (PAL) will be carried from 1.0 to 1.5 by use of
Resistance training. Some forms of resistance training that is recommended is listed in Table 3.
A subsequent recommendation is for a modification of lifestyle habits. One way this can be done
is by modification of PAL as mentioned above. Another way, is through the reduction in the
patient’s smoking habits. This recommendation can be achieved by introducing the patient to
nicorette gums as a way to cut done on the one pack a day habit. The goal is to have the patient
cease smoking, as it is contributing factor to the risk of APOE e4/e4. A third way to modify
lifestyle habits would be to change or reduce the amount of alcohol intaked. This can be done by
either, having two glasses of red wine as compared to rum, as red wine is loaded with
antioxidants like polyphenols- reservatoland quercetin and is proven to improve cholesterol and
fight free radical damage. When compared to rum which cause dehydration and potential liver
damage. Another way to to reduce alcohol intake to one and half glass per day for two weeks
and then one glass per day for two weeks until alcohol intake is reduced to at least one glass per
week.
Furthermore the patient’s diet needs to be modified so that all nutrient needs can be met, as
depicts in table 4.The diet plans, would be specific to his genotype which would greatly reduce
his risk of developing diseases, using a combination of all three diet plans mention previously.
Figure 1-3 above incorporate a variety of herb and spices for their antioxidant (which are low in
E4 carrier) and inflammatory properties, high fibre, low sodium, olive oil foods to help with his
hypertension and cholesterol, also reducing his intake of fats and sugar would improve reduce
his susceptibility to heart disease and other conditions due to the fact that he is an E4/E4 carrier
and more so a smokers, by following the diet plan provided the patient would be on his was to a
healthier life. At the end of the session, the counselor would book another appointment for the
patient, keeping track of his progress.
 CALCULATIONS

Resting Energy Need:

Basal Metabolic Rate for men (metric) using the Harris- Benedict Equation:
BMR= 66.47 + (13.75x weight/kg) + (5.003x height/cm) - (6.755xage/years).
= 66.47 + (13.75x 95 kg) + (5.003 x 175 cm) -(6.755 x 45yrs).
= 66.47 + 1306.25 + 875.53 - 303.98.
= 2248.25 - 303.98.
=1944.27kcal/day.
Using globalrph.com the average estimate based on current activity level (sedentary) given is
2333 kcal/day.
A range of ±15%: 1983-2683 kcal day.

Total Energy Requirements:

Activity level: sedentary (1.0-1.39)
Estimated Energy Requirement using Institute Of Medicine equation:
EER= 662 - (9.53 x age/ years) + PA (15.91 x weight/kg) + (539.6 x height/m).
662- (9.53 x 45 yrs) + 1 (15.91 x 95 kg) + (539.6 x 1.75m).
(662 - 428.85) + 1511.45 + 944.3.
233.15 + 1511.45 + 944.3.
=2688.9kcal/day.

Body Mass Index: weight (kg)/height (m)​2

BMI= 95 kg/1.75​2
= 31 kg/m​2
The patient is Obese, class I.

Basal Energy Expenditure for men based on the Mifflin St. Jeor equation:
BEE= 293- 3.8 x age (years) + 456.4 x height (m) + 10.12 x weight (kg).
 = 293 - 3.8 x 45 yrs + 456.4 x 1.75m + 10.12 x 95kg.
= (293 - 171) + 798.7 + 961.4.
= 122+ 798.7 + 961.4.
= 1882.1kcal/day

Based on the EER of 2688.9kcal/day, the following macronutrients were estimated in kcals and
grams:
55% CHO= 1478.895 kcal = 369.72g
20% PRO = 537.78kcal = 134.44g
25% FAT = 672.225 kcal = 74.69g
The following was calculated based on the 25%FAT (672.225 kcal):
15% Energy monounsaturated fat= 403.335 kcal =44.815g
6% Energy saturated fat= 161.334kcal =17.926g
4% energy Polyunsaturated Fatty Acid= 107.556kcal =11.951g

Ratio: Omega 6: Omega 3

4:1

Dietary fiber 30-47g (emphasis on soluble fiber)

 CONCLUSION

Dietary advice that is specific to individuals with a particular genotype should be more effective
at preventing chronic diseases than general recommendations about ​diets therefore, result
expected is that of, should the patient follow the diet plan and PA recommended within three
months time progress should be seen. The patient’s weight is expected to be reduced to at least
5.44kg at the end of the three months. The patient should is also expected, at the end of this
period to set personal and achievable goals such as smoking at least half pack or less of his usual
cigarettes per day. Furthermore, the patient’s cholesterol, hypertension and hypoglycemia should
be under control. Finally, nutrition status should begin to look more balance and his health status
should be nearing optimum.The patient will continued to be monitored monthly as to ensure no
further complications and to evaluate the effectiveness of the the nutrition care plan formulated
to help him achieve optimum health status.
 REFERENCES

● https://www.alzdiscovery.org/cognitive-vitality/blog/what-apoe-means-for-your-heal
th#ref-2
● http://learn.genetics.utah.edu/content/disorders/singlegene/
● https://www.easycalculation.com/health/mifflin-st-jeor-calculator.php
● http://www.globalrph.com/harris-benedict-equation.cgi
● http://www.globalrph.com/estimated_energy_requirement.cgi
● https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/
mediterranean-diet/art-20047801
● https://www.mensjournal.com/health-fitness/the-30-best-abs-exercises-of-all-time/11
-medicine-ball-russian-twist/
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075799/
● https://www.webmd.com/cholesterol-management/guide/diseases-linked-high-choles
terol
 APPENDIX

Appendix 1

The following are a series of questions that the patient would be asked:
1. Tell me about your eating habits.
2. What do you think about your eating habits?
3. What benefits are you getting by not eating smart?
4. What are your fears, concerns about taking the actions needed to eat smarter?
5. What is the worst outcome you can imagine if you don’t start to eat smarter?
6. Compare his reasons for not changing with his reasons for changing
7.Measure his Confidence and Ability to eat smarter, using ruler of change.
8. What encourages you to believe that you can achieve your goals for change?
9.what physical activity do you enjoy doing.
10. What would happen if you reduced the size of your goal?
11. What would you be willing to try?
12.what is important to the client and use this to motivate him/her to change