CASE STUDY 1

Mr. G is a White man, 54 years of age, with a past medical history of hypertension. At his yearly physical, he reports that he is doing well overall, with no complaints other than some dyspnea on exertion, which has been long-standing. Current medications include a thiazide diuretic and aspirin. He works as an accountant and does not get much physical activity during the day.

On exam, Mr. G is 5'11" and 210 lbs. His BMI is 29. This classifies him as overweight.

(BMI may be used to help define overweight and obesity, which is weight-adjusted for height. It is calculated by [weight in kg] divided by [height in meters]² OR [weight in pounds] divided by [height in inches]² x 703. A BMI of 25.0 or greater is defined as overweight, and a BMI of 30.0 or more is considered obese.)

His waist circumference is 40.5 inches, and his blood pressure is 135/80 mm Hg (sitting) and 130/80 mm Hg (standing). His heart rate is 86 beats per minute, his temperature is 98.6° Fahrenheit, and his respiration is 18 breaths per minute. His physical exam is unremarkable. Laboratory data as follows:

Based on his waist circumference, IFG, decreased HDL, and increased triglycerides, Mr. G. meets the definition of metabolic syndrome. Aggressive treatment of the risk factors is warranted.

Currently, Mr. G snacks on sugary treats throughout the day, as he does not take time to eat breakfast and frequently goes without lunch. By the time he eats dinner, relatively late in the evening, he is famished and tends to overeat. Mr. G has very little nutritional information about the food he eats. Either the physician can provide some basic dietary information, or the patient can be referred to a dietitian. The goals of dietary counseling for Mr. G would be:

Currently, Mr. G is not physically active. He does not engage in any type of exercise. After a discussion of activities he either enjoys or might enjoy, it is agreed that he should begin a walking routine. He will begin walking with a goal of 30 minutes per day, with an initial goal of three days per week. Because he has been mostly sedentary, he can try to break the 30 minutes down into three 10-minute segments or two 15-minute segments, gradually building up to 30 minutes, and eventually 60 minutes, five days of the week. A program of interest to some patients is the 10,000 steps per day program. This is based on studies showing that a daily regimen of 10,000 steps can improve cardiovascular fitness and improve glycemic control. Depending upon stride, walking 10,000 steps is roughly equivalent to 5 miles. As a reference, most people average less than 5,000 steps per day, so 10,000 steps will represent a significant increase in activity. Mr. G's physician suggests that he start wearing a pedometer without changing activity level so a baseline can be obtained. For about three to four days, Mr. G writes down the amount at the end of each day and calculates the average daily step count. As a weekly goal, he adds an additional 500 steps per day. His physician advises him to increase the number of steps until he reaches 10,000 steps per day. After a few weeks, Mr. G can add some resistance type exercises, such as pushups or workouts with light dumbbells.

As noted, Mr. G is on a thiazide for blood pressure control. Because his blood pressure is well controlled, this medication was not changed. Instead, the focus was to concentrate on lifestyle intervention (nutrition/physical activity) and re-evaluate in six to eight weeks.