4_Case study form - Rogeria

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©IINH 2018
 Nutrition & Health Coaching Case Study Consultation Form
 Section 1: Health and Diet Interview
	Student Name: Regiane Miglioli
	Date of 1st Meeting: 26/01/2019
	Client Details
	Name [Anon]:
	Rogeria
	Gender (M/F): F
	Telephone:
	
	Age: 52
	Children:
	2
	Smoker? (Y/N) (include former): No
	Type of Occupation (Sedentary/Active): Active
	Pregnant or planning to be? (Y/N):
No
	Stress Levels at work/home (1-10 Max): 6
	Likes Cooking? (Y/N): No, but it´s learning how to enjoy.
	Current medication: (including frequent non-prescription)
none
	Supplement use: none
	Background:
[anything you consider important from what you know about them, or observe]
We are related. Always looking sad and depressive. Never looks stressed but tired.
	Concerns, issues and goals: 1) health, 2) anything else
[food knowledge, eating habits, kids’ meals, etc. In their own words and the order given]
Rogeria told me that she want to lose weight (about 21kgs) and learn to eat a healthy diet. She want to learn more.
	Medical and Health background: [childhood health and environment, traumas, chronic stress, illnesses etc. Any diagnoses received and when? Do they think diet is key in their health/condition? Anything else?]
She always had a good Health.
	Family members’ health: [health problems (or cause of death) among parents, siblings, kids’]
Breast Cancer - Aunt (mother´s sister)
	Digestion/Lower Bowel: [ask: appetite, heartburn, pain, bloating, wind, constipation/diarrhoea, etc. Also, how soon do problems occur after eating, where is the problem located - e.g. ‘bloating/pain happens right after meals and just below diaphragm, what foods make it worse/better, does stress make it worse, what else makes it better/worse, etc. etc]
All fine. Any concerns about Digestion.
	Energy: [changed in recent months/years? When worse and better during the day? Better on holiday? Do foods/stress make it worse?]
Low energy. Feels tired when wake up.
	Hot/Cold type? [or which do they avoid more?] 
Hot
	Sleep: [trouble falling asleep, do they wake at night, and why, restless?]
Sleeps bad – Restless.
	Mental/Moods/Stress: [moody/often feel down/easily stressed?]
Said depressive because her body. (She feels overweight and this is the reason that makes her down).
	Seasonal Influences: [hay fever, low mood in winter, etc]
Rogeria is Brazilian, but she lives in Ireland 12 years. She said that got use about the weather. But feels low mood on winter time because she can't go for walk.
	Menstruation: [Problems? On the pill? PMS etc]
She is menopause. No hormons replacement
	Immunity: [Catches colds/flu easily? How long to recover? Any allergies/intolerances?]
Don't catches cold or flu easily. No allergies or intolerances.
	Joints/Lower back pain: [pain, stiffness, swelling etc. Similar both sides of body? What triggers or worsens it?]
She said has back pain every day. But this can be because she is Cleaner. It's a hard work cleaning sometimes 2 houses per day.
	Skin: [dry/greasy. Rashes/acne, etc – where on body, itchy? What worsens it?]
Her skin is greasy. Has no acne.
	Thirst/urination: [how much water drunk? Dark coloured urine?]She said 
She said that drinks water all day. Use to have a bottle of water 600ml with her. Urination is light yellow collor usually but simetimes dark.
	Thrush/bladder infections: [recent or formerly]
None.
	Hair/Nails: [hair dry/dull/greasy? White spots on nails, horizontal ridging?]
Nails is ok. Hair is greasy (she considered as normal).
	Headaches: [Location, how often, how intense, what triggers?]
Headaches when she stay more than 4 hours not eating anything.
	Other Pains or complaints: [anything else?]
Feels pain all body because overweight.
	Exercise: [what and how often? Do they like it? What exercise did they do formerly?]
She use to walk everyday, this is the only exercise, and she loves!
	RED FLAG? [If you have serious, acute concern about their health - if so, insist they see their doctor without delay and tell me!]
None.
TYPICAL WEEKLY DIET
INSTRUCTIONS: Record meal times; also weekend items, if different. If not, put ‘same’. Include enough detail to show quality and variety of foods and portions eaten.
	
	Weekdays
	Weekends
	Breakfast
	Bread with margarin, scramble eggs, spaghetti, cream cheese.
	same
	Time
	
	
	Snack
	Cookie and smoothie
	
	Lunch
	Pasta, chocolate cake, chicken with tomato
	same
	Time
	
	
	Snack
	
	
	Dinner
	Pasta with cream cheese, rice with strognoff
	Same with vodka with SPRIT or glass beer
	Time
	
	
	Before Bed
	Chocolate bar every day and coca-cola
	same
	Takeaways/restaurant
Meals
[what kind, how often]
	Not usually
CHECKLIST: How much eaten/drunk of the following? [specify per day (pd) or per week (pw)]
	Product
	Quantity
	Product
	Quantity
	Product
	Quantity
	Bread/Pasta/
Cakes/
Biscuits etc.
[e.g. bread 4 slices/day, wraps x2/week, biscuits 2-3 /day]
	
7 slices of bread
Per w
	Cheese
	
	Milk/Yogurt
	 Yes, almost every day
	Eggs
	fried
	Meat/Chicken
	
	Fish (oily)?
	 Yes, fried
	Beans
	No
	Soy foods/Drinks
	
	Potatoes
	Yes, 3 times per w
	Vegetables (type), Salads
	
	Fruits
	
	Nuts/Seeds
	
	Fizzy Drinks (Diet?)/Juices
	
	Tea/Coffee
	
	Sugar/Chocolate/
Sweets
	
	Crisps/
Peanuts/
Popcorn, etc
	
	Alcohol
	
	Other Frequent Foods
	
Section 2: Assessment of Client
(Seen by the supervisor and assessor but not by the client)
INSTRUCTIONS: Summarise, using numbered bullet points: Client’s Goals, Health, Lifestyle, Diet, Attitude, Beliefs, Motivation, Knowledge, Skills, etc.
	Looking into Rogerias's, the problem areas are: 
a) She is overweight since a year ago. Said that lost 10kgs last year by herself but had a personal problem that made her to go back to eat with no control. 
b) After a week with food diary on my hands, we talked about the portion of Carbohidrates that she has been eating. I asked her to reduce, and introduce more salads and veggies (good carbs) on her diet.
c) She asked me to help her with a menu to understand how to replace some foods. So I gave an e-book that I prepared for my clients with 10 nices Brazilians Food receipt – natural, nutritive and taste. 
d) We prepared together a list for grocery shop. 
e) I recommended trying Yoga and Meditation to help her with emotional issues. She said that it would try. 
Our next meeting it will be in 2 weeks.
Section 3: Recommendations and Explanations for the Client
INSTRUCTIONS: Using numbered bullet points, outline the recommendations you made to the client, along with the explanation you gave for each one (1 page max)
Note 1:  For one of your case study clients, you will also need to recommend and explain an exercise programme appropriate to the client. Please indicate below which of your case studies this applies to.
Note 2: For one of your case study clients (it may be the same client as in Note 1) you will also need to explain to the client how stress can impact physical and mental health, and the benefits of stress management. Explain several suitable options to them on how to manage stress. Please indicate below which of your case studies this applies to.
Note 3: For one of your case study clients (it may be the same client as in Note 1) you will need to explain the importance of a healthy balanced diet, regular exercise and hydration for helping to manage their weight. Please indicate below which of your case studies this applies to.
	1. As Rogeria feels very depressive, I couldn't look only for her Nutritional Diet, I had to think on her as a Woman who needs (claiming) help! I recommended to her a GP visit to ask a Psycologist; Couseling. All about her weight is from emotional feelings. During this conversation,
she expressed a bad mood, negative and down dialogs.
2. Asked her to go for walk everyday for 30 minutes of exercise as usually. This action it will help her to have more energy and to start to improve her health. After 2-3 Weeks I will recommend a gradual increase in activity levels over the following weeks, but for now it’s just a matter of taking the time out.go for walk and taking time for herself to Yoga and Meditation (I sent to her some videos from Youtube in Portuguese language) it will help her significantly in losing the weight she wants and also it will give her some time to herself and to think about her own health as priority.
I explained to my client the benefits of exercising are so big, including ; to help to keep her mind healthy, enhances immune system, strengthens heart, increases energy levels, improves muscle mass, helps prevent osteoporosis, improves to sleepy very well, and can be a great way to relieve stress.
3. I recommend to her organize herself to cook and prepare her own food. I said that I know how hard is her work and how tired she feels in the end of the day to prepare dinner. So I suggested to take a day of, part time to cook for all week. 
4. She loves deep fried food (like fish and chips), so I suggested to replace to rosted or boiled and to add oily fish in her diet, like salmon, herring, sardines, tuna or mackerel at least once a week to start. This would be a good way to increase her omega 3 intake, which will help her keep a healthy heart; brain and nerve function, and improve her digestive system.
5. I recommended her to introduce dark green veggies – and to think in a very coloured plate as much as she can. Explained eating a variety of foods helps ensure that you’re covering your bases, nutritionally.
6. As she needs to eat every 4 hours, fruits as snack and I Each food having their own set of nutritional value. But a varied diet, can also be fun, so we discussed this a little how her plate can be colourful and enjoyable.
I explained her, showing image how a plate must be, and how it’s very important to give attention on the portions. Specially and we feels anxious we use to eat more than we really need. 
Section 3: (contd.) Summary Guide for Foods, Meals and Lifestyle
	Eat More Of
	Omega 3 rich foods, flax seeds, pumpkin seed, walnuts, oily fish like salmon, tuna, sardines. Good quality protein - fish, beans & legumes, eggs (organic if possible) and green leaf.
	Eat Less Of
	White bread or Croassants or biscuits, Pasta
	Avoid totally
	Short term; eliminate Potatoes, White Wheat Flour control high portions and times per day of carbohidrates foods.
	Breakfast
	Try more scrambled or boiled Eggs / porridge with berries and mixed seeds, with almond milk or water / smoothie / fresh fruit salad with and seeds.
	Lunch
	Prepare a salad at home the night before for her lunch as she it will be working. Try to have a colourfull homemade food.
	Evening Meal
	Fresh oily fish 3 times per week, good quality red meat 1 per week, chicken /turkey 2 per week (stir-fry). Lots of varied veggies dark colour green, Avocado, Quinoa, Sweet potato.
	Snacks
	Fruit with nuts / seeds /natural yogurt or Apple slices with cinnamon, oatcakes with hummus
	Drinks
	As she drinks around 2 litters of water per day, I just reminded to control on weekends, the alcohol consume.
	Special Foods (e.g. spirulina, sea vegetables)
	Add seaweed to smoothies or soup to help to improve nutrients.
	Type of meals to eat/cook/order
	Grill, Cooked foods, roosted or steamed.
	Foods to buy (anything new, or to be bought from health store)
	Sweet potatoes, Pumpkin or Quinoa are good choice. Don't be afraid to try new foods.
	Exercise, Lifestyle, Stress Management etc.
	Yoga and meditation. 30 minutes walking will help with both Depressive Mood and weight loss.
Section 4: Progress Report
	Outline client’s response and the agreed final plan: [e.g. they may not accept everything] Use bullet points.
Rogeria has brought to our meet a lot concerns how hard has being to her to change. 
She doesn’t looks excited and not putting much energy to move on. All her conversation was about her family problems related with her daughters. She looks sad and say that feels tired and cold to go for walk. 
So I tried to listen as much as I could, my big idea was to find a new motivation for her. In the end I suggested to her:
- Remember you are unique and special. If you don’t give any effort to change, no one will be able to do it for you or just help you. I am here with you, I understand all your problems, but if you stay seated on your sofa just waiting that all it will solve you gonna lose your time and your dreams. 
- Go for walk, even when you are tired and look to the nature and how beautiful and perfect is. Remember that you are part of this entire Universe and you must be grateful. Have a deep brief and start again. Tomorrow it will be a new day, new chances, new opportunities.
Our next meeting was decided to be in 2 weeks I am concerning her emotional issues.
	
	First Follow-up Report: [How long since 1st meeting? What progress with changes? Any improvements? Any problems? Other feedback from client....]
Unfortunatly, any progress. Rogeria feels depressive and not motivated. 
Follow-up suggestions:
Looking forward to see if she will be able to change all this negative mood using Meditation videos that I have sent to her again, but now special ones that can helps to motivate and raise a positive way to see her life.
We are going to meet again in 2 weeks.
	Second Follow-up Report: [as above]
2 weeks after our last meeting and Rogeria looks much better. She spend the last 2 weeks going for walk. Her energy levels are great and is loving to cooks for her and her family. She said that had a very honest conversation with her 2 daughter and since that, her mood is better.
She said: “I have started eveything again!” - So she was excited to tell she went to shopping, bought organic and healthy food by the list that we made togheter. She is planning and organizing her agenda to cook and prepare her meals, in special because the work time.
Follow-up suggestions:
I suggested that she continued efforcing all energy and good vibes to move on for her goals. Recommended to stay preparing her food, in special colloured plate as much as possible to ensure a nutriotional diet. Yoga could be a good way to exercise and meditation.
	Any Further Follow-up Report? [as above]
She is currently down just 2.5kgs, which made her excited and very happy! 
She noticed a small difference in her body shape and this encouraged her to still giving her best to see more changes. My client has embraced the changes that I have suggested in all aspects of her diet and lifestyle. I am overwhelmed by how good she is doing. She does ask details about my recommendations and seems happy with the explanations. Especially the info reference activity levels, taking 'time out', and explaining the purpose of the differnent foods groups for the body. She said theat having this understanding of the different purpose for each food group has made her have a different view on what to eat. She now looks at food, more from a nutritional value to her body, than just food to satisfy her taste. We agree to meet in 4 weeks’ time.
Section 5: Overall Conclusions and Reflective Practice
OVERALL CONCLUSION:
INSTRUCTIONS: Sum up progress made by the client, and any remaining problems/issues.
	On the begining it was very hard but in the end, after a small results she felt confident and brave to go on. She doesn't reach her targets but even with the results, she is happy. 
Rogéria took everything I suggested onboard after a emotional crise. She went to a counseling and doctor is helping her. 
I am deligted with her progress. Her emotional levels have been greatly reduced, which can only have a positive effect on her long term health. Her activity levels
have also increased significantly as she followed my recommendations to Yoga. 
Now she said that enjoy to cook and love all food plates that prepares. Take time to herself to relax, meditate and have fun. Her words was: “I would never to understand by myself how nutrition diet could change my life!”
STUDENT REFLECTIVE PRACTICE:
How was it for you? Reflect on your own thoughts, feelings and performance – what did you do well, what would you do differently in the future?
	This case study was a big chanlenge to me. As all other cases was very successfull but with Rogeria, I felt that maybe I wouldn't be able to help to lost weight and make her confidence to go on about her emotional issues. 
In the end, even with 2,5kgs down only, we celebrated a lot as she improved her self and made a great job.