Short Narrative for Session One

To start off session one with my client, Stella, I began by introducing myself and

a little bit about what my major was, how these counseling sessions would work, and

what my expectations are (mainly just expressing honesty because I expressed there

would be no judgment). Next, I had her fill out the necessary paperwork for the first

session, such as the questionnaire, food frequency form, 24 recall diet form, and a

couple of others. As I explained, the main goal for session one would be outlining any

concerns she has/had in the past and/or what goals she wants to work on throughout

the course of the 4 week sessions. Some of the main goals she outlined were weight

management, healthy food preparation, portion size, eating less fat, and meal planning.

These were selected on the lifestyle management form 5.1 in the last section. We

discussed any potential barriers that could have prevented her from being more

confident such as not planning ahead in terms of a long class day or packing snacks to

hold her over until the next main meal. Some of the main counseling strategies I used

were motivational interviewing and using the scale of her readiness to change.

By going over her 24 hour recall chart in combination with what kinds of foods

she likes most and eats most often, I was able to motivate her to focus on her

expressed concerns since she followed the mediterranean diet, which I explained to be

a good basis for getting all of the required nutrients for the body. The major thing that I

suggested she try before the next session was being more mindful of when she would

most likely get hungry throughout the day to plan how many meals or snacks she would

have to pack for that day.

SOAP Note for Session One

S - Subjective - Nutrition counseling client is a 19 year old college student who reports

that she wants to eat healthier foods overall and not be so bloated after eating certain

foods. Some of the factors she reports that may impact this desire are her mother

usually does the food shopping, she rarely eats out, and she typically eats foods in the

Greek cuisine.

O - Objective - The client is approximately 5’4,” weighs about 125 pounds, has a BMI of

21.5, takes women’s vitamins daily, and a B12 supplement. She also recently had blood

work done and her LDL levels were higher than the recommended range given on the

results.

A - Assessment - Excessive fat intake related to consumption of animal products

numerous times a day as evidenced by high LDL levels on blood work results.

P - Plan - The client plans to use sectioned tupperwares while going to school for the

day to plan out how much of each food group she will be having.

ADIME Note for Session One

A - Assessment - 19 year old female college student has higher than recommended

LDL levels, bloating symptoms when consuming milkshakes and certain milks, and

claims to not have enough time to eat throughout the day nor engage in exercise.

D - Diagnosis - Excessive fat intake related to consumption of animal products

numerous times a day as evidenced by high LDL levels on blood work results.

I - Intervention - Reduce fat intake through animal products to two-three times a day,

rather than five times a day.

M - Monitoring - Monitor how many times a day and how much client consumes of

animal products.

E - Evaluation - Evaluate how much fat is consumed and how client feels after reducing

amounts and portion sizes.

Client Calculations for

Session One
BMI:

Client: 21.5 BMI

Calorie needs:

Basal Metabolic Rate: Females

BMR = (10 x weight (kg)) + (6.25 x height (cm)) - (5 x age) - 161

BMR = (568.18) + (1016) - (95) - 161

BMR = (1584.18) - (95) - 161

BMR = 1328.18 cal x 1.2 (sedentary/little exercise factor)

Calorie needs: 1593.816 kcalories

IBW - Ideal body weight:

100 lb for first 5 feet + 5 lb for each additional inch

IBW = 120 pounds

Target Heart Rate:

220 - 19 years of age = maximum heart rate of 201 bpm

201 bpm max - 67 bpm resting = 134 HRR bpm (heart rate reserve)
(50 -70%)

134 bpm HRR x 0.5 = 67 bpm + resting hr 67 bpm = 134 bpm

134 bpm x 0.7 = 93.8 bpm + resting 67 bpm = 160.8 bpm

Between 134 bpm and 160.8 bpm = heart rate range for moderate exercise

intensity

Short Narrative for Session Two

Session two focused on food monitoring and Stella’s physical activity. At the

beginning of the session, we filled out the physical activity forms required for the second

session. After she finished filling out the paperwork for this session, I outlined verbally
how the session would be going; starting off with food monitoring, then talking about

how often she does physical activity, and then discussing whatever she wants regarding

those two topics and identifying any potential barriers she might be facing.

When discussing food monitoring, Stella expressed that she’s always wanted to

do it but never really knew how much to put in for each type of food, since she doesn’t

have much experience with weights and measurements. Because of this, we went into

the myfitnesspal app and explored a little bit of what kinds of features they offer. Stella

was very interested in the app and said she would use it more often since it had

different forms of measuring foods, such as a certain amount of oz for each package of

a certain food, which was much easier for her to understand compared to grams. From

here, we discussed a little bit about MyPlate and I gave her a handout on the D.A.S.H.

diet, which we went over.

After we spoke more about her dietary choices and food monitoring, we

discussed her physical activity. One of her main concerns was her family history of

weak ankles and knees. Due to this issue, she expressed concern about high intensity

workouts and high impact, such as the stairclimber. I gave my personal opinion

regarding this because I, personally, do not like high impact exercises either so I told

her that I usually do either the elliptical or stationary bike since it’s not constantly

pounding on your shins, ankles, and knees. She expressed an interest in these things

and we proceeded to speak about other workouts that are beneficial such as weight

lifting/strength training, that didn’t put a lot of pressure on the joints around the knees

and ankles. We ended the session with discussing any other concerns she might have
had regarding physical activity or food monitoring and went over goals for what she

wanted to begin implementing, as explained in the SMART format below.

SMART Format - Session Two

S: Specific - Meal prep for the week through sectioned tupperware.

M: Measurable - Being more aware of portion sizes and exactly how many grams
in total each food group consumed was.

A: Attainable - Increasing walking/steps for the day to begin with a little exercise.

R: Rewarding - Feeling healthier, in terms of body image and actual feelings after
eating.

T: Timely Manner - Working out for 150 minutes a week, for at least 4-5 days out of
the

week.

ADIME NOTE for Session Two

A - Assessment - Client wants to engage in some different types of physical activity

throughout the week, rather than only doing one thing for a short amount of time.
D - Diagnosis - Client is concerned about weak knees and ankles, therefore, she is

scared to engage in exercises because she thinks they will be too high of impact or

intensity.

I - Intervention - Counselor expressed that she has similar concerns with her own

workouts and made suggestions for how to prevent those concerns but still engage in

meaningful workouts.

M/E - Monitoring and Evaluation - Client will track what workouts she completes, for

how long, and how much weight (if applicable). Client is confident that she will be able

to engage in the exercises discussed with smaller weights and more repetitions to tone

her muscles.

Myfitnesspal

Aspects covered:

- Daily calorie calculation:

 We discussed how the app calculates your daily allowance of calories based on

weight and desired outcome: maintenance, weight loss, weight gain.

- Exercise factor:

While I explained that I don’t usually take this into account, we went over what it

uses to come up with a number.

- Calories and info for each food:

We discussed how each food product has specific details and then went over

which ones she should really be looking at and that have the most impact.

MyPlate
Aspects covered:

- We discussed the MyPlate model in terms of

the D.A.S.H. diet and focused on the handout

below from the counseling room.

- We also used the physical plate in the room

and used some of the food models that were

in the closet to place some food she would eat

into each category.

Short Narrative for Session Three

Session three started out with the counselor outlining what would be covered,

starting with Lifestyle Management Form 7.2, which was the stress awareness journal,

and then we went over the three day diet recall analysis and proceeded to go over any

other concerns that the client wanted.

 Some of the main symptoms of stress that Stella outlined in LMF 7.2 consisted of

anxiety, physical symptoms, mental symptoms, and nagging. We then went over the

activities that are involved in her stress and then internal self-talk that she experiences

with the stresses. Since we could both relate on a lot of the symptoms and stresses, we

were able to discuss a lot about our own thoughts and what might trigger our stress.

From here, we went over her three day diet recall and spoke about how she thinks she

did. Overall, her diet analysis was well-balanced for the most part. The main things we

worked on during this session regarding her diet recall were making healthier

substitutions for certain foods as well as working on paying closer attention to portion

sizes.

ADIME Note for Session Three

A - Assessment - Client enjoys consuming most healthy foods but engages in late night

snacking with foods she deems as unhealthy.

D - Diagnosis - Client has negative feelings surrounding guilt of eating food late at night

as well as eating any unhealthy foods.

I - Intervention - Counselor expresses that she has similar feelings surrounding

unhealthy food and late night snacking, but shared with the client some tips and

techniques that she engages in to help with any anxiety surrounding these issues.

M/E - Monitoring and Evaluation - Client will use myfitnesspal like the past sessions to

see if she has enough calories left at the end of the day to allow herself to have the

snacks. Client is confident that this will help her to be more aware of what she is eating

late at night, as well as see any nutritional value in the snacks or “unhealthy” food she is

consuming.

Short Narrative for Session Four

For session four, I had asked Stella (the session prior - three) if she wanted to

have the counseling session in the gym or somewhere on campus or even at a

supermarket, since it is defined as the creative session. She expressed that she would

be most comfortable in the same counseling room as always, so that is the reason we

decided to meet in the Center for Clinical Services. For this session we focused on

keeping things comfortable and evaluating how she really felt about the enhancements

she’s made and plans to continue with, to see if there was anything we might need to
change before our last meeting. We began the session by talking about some things

she felt she was doing better with, such as the sectioned tupperwares and packing

snacks/food for her long days in class.

She expressed her excitement about the sectioned tupperware and how she was

actually excited to meal prep for the week or even just the next couple of days. She

expressed that the only problem is her mom might take some of the food she prepares

for dinner that night so she doesn’t have to cook but we worked on a way for her to

prevent that from happening. If she labeled the tupperwares when they went into the

refrigerator and made a little extra for her mom to have for dinner, her mom was more

inclined and energized to make something different for that night since she had already

tasted some of it.

The initial idea of the sectioned tupperware came from her classmates in her

nutrition class (that she’s taking as her general education requirement for science) and

she explained how useful it has actually been for her to have the ability to eat at the

same time as everyone else and not be starving by the time she got home.

The session ended with us discussing how when she goes to Greece, the food is

much less processed and you typically know the actual origin of everything, all the way

down to the water which runs from a nearby stream. She showed me some pictures of

the food she ate in Greece and things she did, which then prompted conversation about

how she might implement these types of feelings into her eating in America. She then

expressed that a lot of things are much safer here and while we don’t have fields of food

year-round, she was still able to pick out fresh produce, meat, and other foods in the

supermarket that would satisfy both her physical and emotional satisfaction/hunger.
Overall, while she did start with a fair amount of knowledge in nutrition (since she is

taking NUFD 192), she felt that the sessions had made her much more confident in

herself and her abilities to pick healthy options while still being able to enjoy food.

ADIME Note for Session Four

A - Assessment - Client knows what kinds of food fit her palate as well as which are

considered healthy. She has a very good balance of healthy and unhealthy foods on a

daily basis.

D - Diagnosis - Client is not confident in her nutrition knowledge and ability to implement

healthy food related techniques into dietary choices.

I - Intervention - Counselor suggested using myfitnesspal to track food on a daily basis

to help client to be more confident in themselves and what they consider to be healthy

and unhealthy.
M/E - Monitoring and Evaluation - Client has successfully logged meals into

myfitnesspal app and understood more about the portion sizes that are serving sizes,

rather than eating an excess amount of calories. Counselor helped client to understand

more about the knowledge they already have as well as resources to reinforce them.

Case Study : 1-2 page report

1. The client for the nutrition counseling sessions was Stella Spyropoulos. Her age

is 19 years old, her race is caucasian, her marital status is single, she has no

children, and her height and weight are 5’4” and 125 pounds.

2. She is currently an undergraduate student in her sophomore year at Montclair

State University, majoring in Business Administration.

3. She does not have any clinical diagnosis except a past condition of Familial

Mediterranean Fever and Beta Thalassemia Trait.

4. Her family history does not include any major concerns, as listed in Lifestyle

Management Form 5.1.

5. As stated above, her medical history includes familial mediterranean fever (not

anymore) and the Beta Thalassemia Trait (which does not have a major impact

on her day-to-day life.

6. Lab values mentioned in terms of LDLs but no numbers mentioned.

7. Stella takes a women’s daily vitamin supplement and B12 supplement everyday.

The multivitamin may help with any nutrient deficiencies she may have for that

specific day and the B12 supplement helps with energy, metabolism, and

potential deficiencies in the nutrient.

8. The nutrition and eating behavior as Stella explained includes not typically eating

enough calories on a daily basis. She expressed that she eats a lot when she

goes to her grandma’s house, however, on a typical day that she has classes,

she usually forgets to pack snacks and/or lunch. She will typically eat before she

goes to class, however, if she has more than one class, she will be at the school

for at least five hours and will therefore, get hungry throughout the day and not

eat until she gets home. She also has the mindset that she should have three

meals a day and not much else, which is better than other mindsets that could

limit food intake even more than that, however, it suggests that those are the only

times they are “allowed” to eat.

9. Stella’s social factors do not really pose any kind of harm to her dietary changes

or enhancements. She expressed that she is financially comfortable and just

doesn’t like to spend an excessive amount of money on food that she knows

won’t bring her any nutritional value. As for her psychological mindset, she is

confident in herself and just wants to be her healthiest possible version of herself
 while also feeling satisfied in terms of the amount of food she is eating (she does

not want to constantly feel hungry). As for social factors, the only major things

that could pose as barriers would be her grandmother’s philosophy of eating and

friends wanting to go out to eat. Both of these factors, however, were not major

issues she would have to deal with, as she expressed.

10. Our goals for Stella throughout the course of the 4 week counseling sessions

changed slightly to incorporate new things she wanted to try. For example, she

originally wanted to focus on her favorite foods and incorporating them into her

everyday meals, however, by the end, we discussed getting tupperwares that

were sectioned off as well as trying new foods that she saw other people in her

nutrition classes were eating, as long as they were healthy (example: quinoa).

Audio-Tape Evaluation
1. The materials that I prepared and reviewed before meeting with my client again

consisted of the client questionnaire, the three day food recall, and some of the

worksheets that were in the binder in the counseling room, consisting of heart

disease prevention and vegetarian diets. Another thing that I intended to work on

with her was the usage of the food models, in the pantry/closet.

2. The verbal techniques that appeared to be most effective with my client were

confrontation (in a positive context, as will be explained later), paraphrasing, and

questioning. Some of the ways I used these techniques was in terms of analyzing

her stress/triggers of stress as well as her food choices, in regard to what times

she would consume food. By confronting Stella with regard to saying something

such as, “you say you are not eating healthy enough foods, however, the “diet”
 you follow for almost every meal/snack helps to prevent a lot of major health

conditions (she follows the mediterranean diet).” This was also a major topic that

I paraphrased when speaking with her to show her that there are major health

benefits to what she is consuming already. After we had analyzed her dietary

choices, I asked her some questions about how she felt about these and what

she would want to do to improve them even more so that she feels her most

comfortable and confident. This was one of the most effective strategies because

she was able to work a lot out for herself and organize her own thoughts.

Allowing her to complete this task for herself also created an even more

comfortable environment since it showed that I was ready to listen to how she felt

about things and give my own experiences, so she didn’t feel alone in her guilt or

other feelings. From there, we were also able to work on these feelings of guilt so

she could analyze why she might feel that way and what techniques she could

use to combat them.

3. As stated in the previous bullet point, we were able to work on her feelings of

guilt when either not consuming food that her family had made her or eating

somewhat unhealthy snacks late at night, since she had most likely gone the

whole day without eating (prior to starting nutrition counseling). One of the most

effective strategies to combating these feelings was motivational interviewing.

After she expressed her negative feelings surrounding guilt, I asked her

questions about the rest of her dietary choices throughout the day to try and

remind her of the healthy dietary choices she has been making since the

beginning of the 4 week counseling sessions. By asking these questions, she

 was able to come to the conclusion that she did not have to feel guilty about

eating some of the desserts her grandmother had made her or being hungry at

night after a long day of classes. She was able to realize on her own that not

everything she consumes has to be the most healthy version. My philosophy of

moderation, I believe, helps some of my peers because they are able to ensure

they get the necessary nutrients for their body, as well as “feed” their emotional

cravings.

4. There really weren’t any messages that I did not understand or interpret

differently on the tape. I feel we had a good basis of understanding the entire

time and remembered the majority of the topics covered.

5. Since there weren’t many major lifestyle issues to begin with with Stella, I felt we

were able to focus on what she wanted to discuss. Her main issues, as outlined

earlier were not eating the majority of the day/not being prepared for when she

became hungry, and any eating habits she felt were not “the best choices.”

6. While we did go off on tangents occasionally, I felt we were able to focus on her

main issues well enough because any time we did get off topic, I would transition

something she had been talking about back to either her dietary choices or

emotions surrounding eating. Since I incorporated the worksheets and diet recall

into the session, we were able to transition fairly easily since there was a fair

amount of new information I wanted to cover with her, therefore, keeping her

interest and attention rather than talking about the same topic for 40 minutes.

7. The emotions expressed on the audiotape were not different from those that I

witnessed or heard in person, however, it did allow me to evaluate more

 specifically certain words or feelings she discussed. While the emotions she

expressed during the audiotape were nothing of major concern, I was able to

more fully evaluate where they might have been coming from and what impact

they may have had on her life.

8. My emotional state throughout the session was very welcoming and comfortable.

Since the start of the sessions, I expressed to her every time that I wanted these

counseling sessions to be comfortable and feel like a judgment free zone. It can

be difficult for her to not see me as a judge of her dietary choices, however, I

believe that since I rarely commented on anything in a negative connotation

during the entire duration of the sessions, she saw me as more of a resource for

asking questions than a judge who would criticize things she did in the past.

9. I believe that my client, Stella, responded extremely well to anything I said,

including recommendations I told her. She really implemented everything we

discussed and I think that one of the major reasons she was so successful with

feeling even better than when she started was because we came up with

recommendations together. She would start with something she wanted to work

on and I would work through more specifics with her such as deadlines, portion

sizes, and just planning for when she would feel most comfortable implementing

the enhancements.

10. I do not believe that the session would work out any better if we were to redo it.

We were able to cover all of her concerns as well as change her mindset, even

just a little bit, and come up with solutions she could use to help her achieve her

main goals.
11. I learned a great deal from this audiotape session, whether in regards to how to

create a comfortable atmosphere, how to most effectively outline goals and

plans, or enhance/change one’s mindset that may have been set in stone for a

long period of time. Since a comfortable environment was set up in the first

session, I think that the resulting sessions were most effective since Stella felt

like she was able to share anything she might have been feeling, struggling with,

or just wanted advice on.

Reflection of the total 4-session experience
1. I believe my best counseling experience was the third session, that was

audiotaped. While the whole session was not discussion about the nutritional

value of food, I felt like both myself and Stella learned the most we had the entire

time. Since we talked about her behaviors surrounding her dietary choices and

actions, we were able to talk about things that not only do I have knowledge in

but also herself. Since Stella was able to express her feelings surrounding her

guilt with not eating every piece of food offered to her by her family and eating

late at night, she was able to contribute to the conversation even more than if we

were talking about the nutritional value of certain foods she was consuming. Just

by asking about her experiences and thoughts surrounding her choices, I was

able to make the session extremely enjoyable for her.

2. The major counseling strategies I used were self-disclosing, self-involving, why

questions, and attending. The first two techniques, self-disclosing and self-

involving, were much easier for me to use since everyone has gone through

some type of guilty feelings when it comes to food. After that, I continued to ask

why questions to her so that she could evaluate her own feelings and thoughts

and potentially be able to think back to this situation when she feels this way

again and is not doing the nutrition counseling sessions. Finally, the attending
 technique of showing that the counselor is listening was extremely effective

because she showed appreciation for this and was able to feel as though the

session was not just to talk about my life or something unrelated to her, but

rather so that she could feel special.

3. I do not believe I really faced many difficulties during any of the sessions. The

only things that may have been of slight concern was trying to stay on topic, and

allowing the client to say whatever she wanted but recognizing when something

is either incorrect or a mindset switch is needed. These difficulties were easily

fixed, however. The first issue could be solved by transitioning back into

mindsets surrounding food and the second issue could be enhanced by using

nutrition education to come up with better phrases to use that have a more

positive connotation rather than self-deprecating in any way. I don’t think

anything could or should have been done differently because these were

difficulties she brought with her to the counseling sessions. By the end of the

sessions, I believe we were able to alleviate any problems these difficulties

presented.

4. I learned the importance of a nutrition counselor in a lot of different types of

people’s lives. Even if there are no major health conditions or concerns, it can be

extremely helpful to any person because everyone struggles at some point in

their life with dietary choices and roadblocks/barriers. These 4 sessions with

Stella were examples of that. While she already had a fair amount of knowledge

regarding nutrition, she was able to use me as a resource to organize her

thoughts and become even more confident in herself.

 References

Can you sing while you work out? (2019, August 6). Retrieved from

https://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/exercise-intensity/art-2006887.

https://study.com/academy/lesson/verbal-nonverbal-communication-in-counseling.html
PES Statement

Low confidence in nutrition knowledge related to not allowing themselves to

eat unhealthy food as evidenced by food restriction in dietary choices.