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Mary Fraser
Nutrition Counseling Theory & Practice, Professor Lynn Schultz
Steinhardt, NYU
March 20, 2018

Biopsychosocial Assessment #1 /Stage of Change/Goals. 2-4 pages

Client is a 59 yr old. single female, who lives alone, has no children and is estranged
from her family, and does not appear to be in any close relationship, which appears to really
affect her. The client’s chief complaints are that she is “depressed, ‘fat’, lonely, old and has type
2 diabetes (T2DM)”. She complains of feeling disconnected, isolated, lonely and is very unhappy
at work, and her appearance that day seemed a bit down trodden. Client also states she does not
sleep well. She is aware that she eats for comfort and does not exercise portion control. Although
approachable, the client appeared to be tired, depressed, protective and expressed a negative spin
on most subjects.
Client is 5’2” (1.57 m) and weighs apx. 225 lb (102 Kg), and has a BMI of 41.3, severely
obese. Besides T2DM, she is not aware of any food allergies or intolerances or other digestive
issues other than constant bloating. She believes her blood pressure is somewhere around
normal. Her medical family history is not well known, but her grandmother had T2DM and her
father had Leukemia. She had a hernia operation apx. 5 years ago, claims nothing else major
medically is going on.
Client was wearing several layers of clothing and no skin was visible below her neck
other than her wrists and hands. (It was a cold day however). She explained that she volunteered
for the sessions because she is overweight and says she would like to lose some weight and get
off of her T2DM medication, which she started approximately 1 ½ years ago. She currently
takes the following medication for diabetes, depression, ADHD: Prozac, Adderall, Metformin,
Levemir, Victoza. She explained that the main reason why she wants to get off the medication is
simply because she may lose her health insurance. This is not a very strong impetuous for change
for her.
She did not seem to be able to express anything that she really enjoyed doing other than
her volunteer work at the shelter. She does some physical labor at the shelter but otherwise does
not exercise. She said that she sometimes rides her bike when it is good weather. It is unclear if
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there is any social circle she is part of other than her volunteer work at the shelter. She has also
been an Elder at a Presbyterian Church.
This client be tricky to approach, as her depression, stress, unhappiness with work and
insomnia affect solving her portion control problems and evening binge eating. These conditions
may delay change and the client feels confident enough that she can make her life better. She
brought up that food is a sensual and caring experience for her and that eating food may be one
of the only times she feels this way. She usually eats alone and at night and states that she has no
one to eat with, in other words, food has somewhat become her friend. This is important, and she
needs to find some other source of comfort, and social interaction. We talked about looking into
other ideas for social interaction.
Although she knows how to cook, and cooks at a shelter near where she lives, she does
not cook meals for herself, and relies mostly on Trader Joes frozen dinners. She also does not
look at the nutritional labels. Additionally, she states that her stove is broken and has no ability
to fix it because of her landlord and a super low rent situation. Money is a concern for her. (note
for future: A portable induction burner may be useful for her at some point)
The client is very sensitive about her body and what she eats. Reflection on a typical day
combined with a 24 Hour recall was spotty at best as she would not disclose her day or what she
fully ate, other than that she started the day with a Red Bull, and that she ate next to nothing until
on her way home from work. This was a big tip off that this exercise would not be terribly
effective.
When I asked her what she would like to do she stated that she wanted to get off of her
T2DM medication and lose weight, and not discuss current habits. I asked her what she thought
might be beneficial to her and she wasn’t sure other than to ask for a nutritionist for a few
recipes. I asked her if she would agree to food journal or take photographs of the food she eats
and drinks for 1 weekday and 1 weekend day. I also asked her to note her stress levels
throughout the day. She agreed as I told her we would build off of that to create a meal plan and
some ideas to make her life easier.
Surprisingly although the client stated that her readiness for change is an 8, she was
unsure about what direction she would like to proceed, and where she would like to start, and
seemed to not to want to discuss it. I think the 8 was more a reflection of her depression, and
desire to change things, but not the energy to actually do it. I felt that while the client states she is
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an 8, she is still in the pre-contemplation stage with making nutritional changes and is not fully
committed at this point. (problem- how do I deal with this? Can I get her more committed?) It is
however clear that she is very unhappy with where she currently is.
The client did state that her long-term goal was 3 fold: 1-Be less depressed, 2-Get off her
T2DM medication and 3-Lose some weight. Her shorter-term goal is to develop some sort of
plan to get off her diabetes medication and lose some weight. She did not want to give a number
for pounds to lose or time frame. This also made me question her readiness for change. Although
she says she wants change, she does not know yet what she is willing to do to change anything.
She made the first step by seeing me, and I congratulated her on that. (How do I pull her
forward?)
Not knowing exactly where to start, we agreed to a short-term goal of 2 days with a food
and stress journal. She agreed to 2 days of journaling or photographing and making some sort of
stress notes. I explained that this way, we could get an idea of her food preferences, stress, and
time, and better create a plan of action for her together that fit with her lifestyle. I didn’t want to
push it further than that. She agreed and thought that was doable. We also set up a time to meet
the following week.
Getting the client to start in the right direction so that she can maintain motivation will be
tricky. One of the first things is to get her starting to feel better about herself, and see what she
really feels comfortable with changing.
Two areas I need to research is stress management, and easy to cook meals that are
diabetic friendly. She would like a recipe menu. I need to further discuss with her exactly how
she would like to proceed. The client really needs to open up about what she is ready to change
at this point and start putting herself as a priority. She may just be coming to the meetings
because she wants someone to talk to. A psychiatrist might be a good idea for her. My concern is
that the clients eating disorder and subsequent T2DM is a result of poor eating habits which is a
result of emotional problems. I do not know if the emotional problems are because of the weight,
but she has isolated herself in many fashions and is depressed because of it. (problem: which side
to approach first?)
We agreed to meet the following week and that I would send her a fish recipe.
General overview of Nutrition Diagnosis & Observations:
Client appears to have multiple problems:
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• Obesity
• T2DM
• Depression
• Stress
• Lack of exercise
• Lack of sleep
• Inability to control diet
• Binge Eating Disorder
• Financial Stress

PES:
1- Overweight & disordered eating pattern due to excessive energy intake as evidenced by her
BMI.
2- Excessive Medication related to the disease of T2DM, as evidenced by lack of insulin control.

Problems:
1- (problem: she asked me about my family and diabetes and kept asking about my
personal history, education and experience)
2-(problem – how to deal with mental/emotional problems and intense depression.)
3-I felt that while the client states she is an 8 in readiness to change, she is still in the pre-
contemplation stage with making nutritional changes and is not fully committed at this point.
4- She made the first step by seeing me, and I congratulated her on that. (How do I pull
her forward?)
5- I do not know if the emotional problems are because of the weight, but she has isolated
herself in many fashions and is depressed because of it. (problem: which side to approach first?)