Rebecca Ray

Case Study
Diagnoses:
My clients first medical condition is anorexia nervosa. Anorexia is a very serious eating
disorder and can be life threatening when the cases become extreme. It is characteristic of
extreme weight loss from self-starvation and a distorted self-body image. Anorexia is a
psychiatric disease which causes serious physical consequences. Women much more often
develop anorexia than men. About 90-95% of people suffering from anorexia nervosa are
females. The most obvious sign that someone has this condition is inadequate caloric intake
causing an unhealthy weight loss. Some other signs that someone has anorexia, although they are
sometimes not as obvious, can be an intense fear of food and weight gain, self-esteem issues, and
not realizing that they have a problem. The last of these signs is one of the hardest to overcome
in patients with anorexia. The patients usually have a much distorted image of themselves in
their mind so they always feel as though they still need to lose weight. This is what causes them
to literally starve themselves to death in some serious cases. People with anorexia often deny that
they are hungry and created food rituals that they follow strictly. In some cases they may eat and
then feel as though they have to burn off every calorie that they consumed through exercise. This
is still considered to be anorexia even though they are consuming food. Obsession over food
often takes over their lives and becomes their main focus. This can affect personal relationships
and alter normal daily activities. There are many other effects that this has on the body too.
Anorexia can lead to an abnormally slowed heart rate and low blood pressure which can cause
heart failure. The severe dehydration from the condition can lead to kidney failure. Muscle loss,
amenorrhea from a drop in estrogen, increase in stress hormones, weakness and fatigue are also
symptoms. The body even grows a thin layer of hair everywhere, called lanugo, in efforts to stay
warm. The lack of nutrients even effects bone density causing osteopenia and osteoporosis,
which is my clients second condition (1).
Osteopenia, as I just introduced, is a decrease in bone density. It is the precursor to
osteoporosis. So, if it is untreated or ignored then the individual will develop osteoporosis which
is harder to reverse. The decrease in bone density causes the bones to become fragile, making
fractures more likely. Osteopenia is usually more of an issue with adults as they age, specifically
women over the age of 65 or who are postmenopausal. This is due to the decrease in the levels of
estrogen produced by the body, which helps maintain bone density. Other factors that can cause
someone to get osteopenia are excessive alcohol intake, genetics, certain medications and
smoking. It can also occur in the case of anorexia because of an inadequate nutrient intake and
the drop in estrogen and growth hormones. When an individual is not taking in enough calories
they are also most likely not getting close to enough calcium or vitamin D which are important to
maintain bone density. Also, exercise can help prevent osteopenia because it can help strengthen
the bones. Osteopenia is a painless condition unless a bone gets fractured. For this reason people
with osteopenia often dont find out right away unless they get tested. The test used to diagnose
someone with osteopenia is called a DXA scan which measures bone mineral density. The scan is
done of the hips, spine and the wrist because these are spots on the body that are easily fractured.
The DXA scan is very accurate at diagnosing osteopenia (2).

Patient Information:
Mary Smith currently a 20 year old girl who attends the University of Connecticut. She
grew up in a rural town in Northeast Connecticut. Growing up as the youngest child in her family
was not easy for her. Her three older brothers constantly picked on her since she could remember.
Since she was her mothers only daughter, she wanted her to be perfect. As a young girl her
mother put her in ballet, pageants, and many other various activities to try and make Mary the
perfect daughter. Her mother always put so much pressure on her to always look perfect
everywhere she went. Going to elementary school, and even through middle school she would
lay out outfits on Marys bed to wear to school. Mary was a very pretty girl, not overweight but
not super thin either. She has always been a healthy weight, but her mother was never happy with
anything. Marys father on the other hand loved everything about her. She is much closer to him
for this reason. When her mom was being too hard on her, he would stick up for her and tell her
mom to lay off. Her father still treats her as his little girl. Whenever Mary needs anything at
college he will make sure she gets it as soon as possible. He was Marys main support system
growing up. Even though her mother was so hard on Mary, Mary still loves her and wants to
make her happy.
Due to her mother always pushing Mary to be perfect she has never gotten to be a
confident, independent women. The only thing that held her together up to this point was her
fathers support. When Mary first got to college she was excited to be out from under her
mothers constant scrutiny. As every other incoming freshman she was nervous to learn her way
around school and to make friends and fit in with a group. Since she did not have much
confidence she thought people wouldnt like her. The first morning after she moved into her
dorm, she was walking around the dining hall trying to find a table to sit at when she made eye
contact with a girl who said she could share her table. The girls name was Julie. Julie was a
sophomore who had joined a sorority her freshman year. When she found out that Mary was
nervous about making friends she suggested that she should join a sorority. Mary loved this idea.
So, halfway into her freshman year she rushed a sorority and got accepted into it. The sorority
would often hang out with the other fraternities on campus, and Mary felt as though none of the
guys wanted to talk to her. She decided that the reason she wasnt getting any attention was
because she was overweight.
Mary started to count her calories at every meal to try and lose a little weight. After a
couple weeks she still didnt feel as though her body had changed as much as she had wanted so
she cut back even more on the amount of food she ate. This cycle continued, and no matter how
much weight she was losing, she was never satisfied with how she looked. Eventually Mary
became so obsessed that she stopped going to the dining hall with her friends because she didnt
want to be around all of the food. She would stay in her dorm room instead and eat only bags of
fat free popcorn, saltines, and Gatorade. She was trying to avoid any food with fat in it. Because
she stopped going to the dining hall with her friends from the sorority, which was the normal
time that they would hang out together, she became more distant from them. One weekend her
father decided to drive to UConn and visit. When he saw Mary he couldnt believe how skinny
she was. He knew that there she had a problem and tried to talk to her about it. As soon as he
mentioned to her that she didnt seem healthy she denied it. Mary did not think that she had a
problem. Her father knew that he needed to get her help, so he brought her to their family

physician. The physician diagnosed Mary with anorexia nervosa and osteopenia. They then
contacted myself, a certified registered dietitian, to help Mary.

Problem Based Questions:

1. Question by Mary: I dont feel like I have a problem and dont understand why everyone is
trying to make a big deal out of nothing. I lost a little weight, what is wrong with that?
My Answer: Mary, freshman year of college can be very stressful and I understand that. I dont
want you to feel like anyone is judging you. We are just trying to make sure you are staying
healthy. The reason your physician referred you to me is because you have had a significant
amount of weight loss in a short period of time when you were at a normal weight to start with.
Your Dad and physician are concerned that you may not be eating enough to stay healthy. Do
you mind if we talk a little bit about your diet?
2. Question by Mary: Isnt it a good thing that Ive lost weight? I thought people are healthier
when they weigh less. It means I dont have as much fat.
My Answer: I understand why you would think that. Losing weight is not always a good thing
however. For people who are very overweight losing weight will improve their health because it
decreases their risk for many diseases such as diabetes and cardiovascular disease. For people
who are at a healthy weight, losing a lot of weight can actually be bad for your health. You were
at a healthy weight going into college, so as health professionals we would not have advised you
to lose weight. Your body needs a certain amount of nutrients from your diet to perform and keep
you healthy. If you do not take in the amount of calories and nutrients that your body needs then
there can be many adverse health effects such as osteopenia. Your physician did some tests that
showed you have developed osteopenia which she said she talked to you about.
3. Question by Mary: The doctor mentioned that I have osteopenia but I dont really know what
that means. I feel fine.
My Answer: That is very good that you feel well. Most patients who have osteopenia do not
have any pain because of it, but if it develops into osteoporosis it can become painful so we want
to try and reverse it before it becomes that severe. Osteopenia means that your bones are not as
strong as they should be for your age. This can be caused by not taking in enough calories over a
long period of time which causes your estrogen and growth hormone levels to go down. Also, it
can be caused by not eating enough calcium and vitamin D which both help maintain bone
density and strength.
4. Question by Mary: So why would my physician send me to you since I lost weight and have
a bone problem? I would think that my physician would treat me for this.
My Answer: I am a registered dietitian which means that I know what a healthy diet for a
women your age is. I want to help you learn to eat a healthy diet that will provide all the
nutrients and calories that your body needs. Hopefully we can work together with your physician
to help reverse the osteopenia you have developed. Its not as hard as you think to eat well! You

just need to give it a chance. Many of my clients say they feel much more energized and healthy
once they start to eat healthy too.

Critical Issues:
Positive:

Mary is young and can easily learn new habits, so she will be able to take in what I teach
her and apply it to her own life.
Mary seems positive and interested to hear what I have to say which will help her
actually implement the changes.
Mary has the support of her family who care about her greatly and see through that she
becomes healthier and pay for her doctor and RD visits.
Mary has access to healthy food at the college dining halls so she will be able to follow
the meal plans that we create for her.
Mary is well educated and can understand when I tell her what the problem is and why
we need to fix it.

Negative:

Mary has self-confidence issues, so she is apprehensive to eat more calories because she
believes if she eats more she will become fat.
Mary does not yet see that she has a real problem which causes her to be reluctant to fully
commit to changing anything.
Mary has isolated herself from her friends at school so she doesnt have their support.
Support from friends can be very influential in situations like Marys where she is
worried about what other people think of her.
Mary is not exercising. Exercising both increases bone strength and would help her with
her body image.
Mary has no knowledge base of what a healthy diet consists. Therefore, it will take a lot
of time to teach her what she should be eating and how to incorporate a healthy diet into
her lifestyle.

Theoretical Issues:
1. Health Belief Model
The Health Belief Model applies very well to this case because it states reasons why
someone thinks that they do not need medical help. In Marys case she believes that there is
nothing wrong with her and she is not too skinny. She believes that there is no threat to her
health. In fact, she believes that she is even healthier now than she was previously. This specific
model says that people will get help based on whether they believe they are in danger of
becoming ill, the severity of the illness, if there are any benefits to taking action against the
illness, and if there is anything preventing them from taking action. It also takes into account

whether the person is exposed to something that will change their mind about the severity of the
illness and if they believe they can successfully prevent the illness (3). In Marys case all may
apply. According to the health belief model Mary is very unlikely to have taken action to receive
help for her anorexia had her father not stepped in. Mary was completely unaware of the severity
of her condition so there would have been no reason, in her mind, to receive help. Another reason
she would not have reached out for help is because she believes that there would be no benefits
to taking action. For her, taking action would actually be a negative thing because that would
mean she would have to gain weight. In her current mindset this is the last thing that she wants to
happen. Lastly, she is not exposed to something, such as media, that would cause her to take
action. In fact, she is exposed to quite the opposite. The media in todays world praises models
and actresses who are extremely skinny. This theory can be useful to help Mary overcome her
illness by showing her the severity of anorexia and the fact that she can overcome it.
2. Social Learning Theories
The social learning theory could help Mary overcome her anorexia. The social learning
theory says that human behavior is determined by three factors. These factors are cognitive,
behavioral, and environmental. The cognitive factors include someones knowledge, expectations
and attitude. Between myself, a registered dietician, and her family physician we can help her
gain knowledge about anorexia to learn that it is actually very common and all of the negative
consequences of it. This may change her attitude about her condition so she can see that she does
in fact have a problem. This may also motivate her to want to get help and overcome her
anorexia. The behavioral factors include someones skills, practice, and self-efficacy. For this
section myself and her counselor can work together to teach her the skills that she needs to
become healthier and give her confidence that she can do it. The last part of this theory is the
effect of environmental factors on a persons behavior. This includes social norms, the
community they are within, and the support from the environment they are living in to help them
make the changes they need to (4). This would apply to Marys recovery because the reason she
became anorexic was partly due to the friends that she had made when she was a freshman. By
joining a sorority she was forced to compete with other girls for the frat guys attention. This
brought down her self-esteem and caused her to think there was something wrong with her. By
encouraging Mary to join other clubs and activities she may make new friends that will provide a
more supportive environment for her.
3. Transtheoretical Model of Health Behavior Change
The transtheoretical model of health behavior change suggests that changing a behavior
involves six stages. These stages are precontemplation, contemplation, preparation, action,
maintenance, and termination. This model can help determine how ready a person is to make a
change. It states that a person will not change if they are not ready. Also, the stages are fluid and
a person can skip stages, revert back to previous stages or jump around depending on different
like events and experiences (5). This model can help myself and the other health care workers
figure out what stage Mary is currently in. We can use this to aim her treatments at the stage she
is in to hopefully get her to eventually progress to the maintenance stage. I would say that right
now Mary is in the precontemplation phase. This means that she does not yet realize that she has
a problem and feels as though there is nothing she needs to change. At this stage her physician
and I should educate her on both anorexia and how it has caused her to develop osteopenia. We

should tell her what will happen if her behavior does not change and hopefully get her to realize
that she does have a problem.

Counseling Goals and Objectives:

Goal 1: Mary will gain knowledge about anorexia and the effects that it has on her body. She will
understand that she needs to change her current habits.
Objective 1: Mary will be able to describe the effects of anorexia and acknowledge that
she has a problem.
Objective 2: Mary will be able to identify current situations in her life that may contribute
to her anorexia.
Objective 3: Mary will attend all medical and mental help sessions that her family and
her care team feel necessary.

Goal 2: Mary will adopt a healthy diet plan to try and reverse the effects of her malnutrition.
Objective 1: Mary will record her food choices in a food log. She will increase the
number of calories, vitamins, and varieties of foods that she consumes every day.
Objective 2: Marys body weight will increase and her bone scans will show that her
osteopenia has slowed or started to reverse.
Objective 3: Mary will be able to describe what a healthy, complete meal consists of.
Plan of Action:
1. Build Foundation
Building a strong foundation is very important when interacting with any patient. When it
comes to Mary, however, it is even more important. This is because anorexia is not only an
eating disorder but also a mental disorder. For this reason it is important to build her trust before
talking to her about her disorder. When she comes into the office I will introduce myself as
Rebecca Ray. I will explain to her that I am a registered dietitian and that my role in her care
team is to talk about nutrition specifically. Before collecting any data I will first have a casual
conversation with her to try and make her feel as though she can talk to me. Getting Mary to
open up is a very important aspect of her care because since she feels as though she has no
problem she may become defensive thinking that everyone is against her. It is also common for
people with anorexia to lie about their daily eating habits because they may be ashamed. People
suffering from anorexia often eat alone when no one is around because of the shame they feel
when they eat. For small talk I will ask her about college, what major she is in, and other
questions such as those to get her to become more comfortable. I will also tell her a little about
my background and relate to what she is saying so that it doesnt seem like a one way interview.

2. Gather Data
After building a foundation with Mary I will begin to collect some data. Her physician would
have already conducted a bone scan that shows she has osteopenia, so I already know that she is
not consuming all of the nutrients she needs. To begin I will ask her what her favorite and least
favorite foods are. This will make the discussion of her diet seem less accusatory since we are
easing into it. From there I will ask her to write down a food recall of her normal day at college.
As I mentioned during the building a foundation section, people with eating disorders are often
ashamed to talk about what they eat. For this reason I have to look at her food recall and take
into account that it is possible that she did not write down her actual daily diet. She may add
some foods in that she would not normally eat to avoid any scrutiny. I will then ask her how
often she eats and whether she exercises or not. It is also important to ask where she gets her
food from. If she eats in the dining hall then she has access to a different variety of foods than if
she goes to the grocery store and buys her own food. After interviewing her about her diet I will
ask her if she minds me getting her weight. In some cases, people with eating disorders do not
like to be weighed because they do not think that their weight matches what they see in the
mirror. Sometimes they will even wear extra layers of clothing to try and deceive the physician
or RD. It would be helpful however to obtain a weight so that I could compare it to her usual
weight, that I would obtain from her physician, and to be able to see in upcoming visits if she has
gained any weight.
3. Discuss Goals/Educate
To start this part of the session I will ask Mary what she would like to get out of our
meetings. Taking her goals into account is very important since it will get her involved in her
own treatment. When a patient feels as though they are part of their own care it could cause them
to be more compliant with the changes that need to be made. After hearing what Marys goals are
I will tell her some of my own goals. The most important one that I will tell her is that I hope for
her to learn how to eat a healthy, balanced diet that is tailored to her. I will explain to her that we
will work together to make a meal plan that will increase the amount of calories she is
consuming each day. At this point I will begin educating her on the importance of getting in the
amount of calories that her body needs. I will explain to her what macronutrients and
micronutrients are to show the significance of consuming a balanced diet that includes all of the
food groups. Her physician most likely will have already talked to her about what exactly
osteopenia is, but I will explain the nutrition side of it and how not consuming enough calcium
and vitamin D contributes to it. At the end of the session Mary and I will come up with some
achievable short term goals that she can accomplish by our next visit.
4. Alternative Solutions/Intervention
It is always important to discuss alternatives with the client if they do not like or disagree
with anything I tell them. When I told Mary that I wanted her to consume at least three servings
of dairy per day along with a calcium supplement she said that she believes she is lactose
intolerant. I told her that this is very possible. When you dont consume dairy for an extended
period of time your stomach can become sensitive to the lactose in the dairy products. Lactose
intolerance can cause a great deal of discomfort as well. I told Mary that she could start out with
taking her supplement, one dairy product a day, and also consuming other sources of calcium
like fortified almond milk or leafy greens.

Another part of the plan we made for her that she did not like was how a goal was that she
has to gain weight. At this time in her treatment she still has a lot of work to do with the
phycologist to work on her body image issues. All I could tell her was that my only goal was to
make her as healthy as possible. I also pointed out the fact that often when someone is
underweight and they gain some weight back they feel more energized and happy. To this point
she admitted that she is often fatigued so gaining some energy could be good for her.
5. Commitment (progress and follow-up)
One of my objectives on my first goal was that Mary would attend all of her scheduled
sessions. This is very important to her health in the long term. There is so much information
given in the first session that probably only one or two things say will really stick in her mind
and follow through into her life. Every session I will talk to Mary about how her diet plan has
been working and if she is having any difficulties following it. Mary will keep a daily food log
for me to look at each session so I can analyze the changes she is making to her diet and if she is
implementing the changes that she needs to make. I will also use physical findings to see is Mary
is looking less fatigued. I will weigh Mary every visit to see if she is gaining weight. If she is
gaining weight then it is a good sign that she has been following the diet plan. If she doesnt gain
any weight then it means she is not following the diet plan correctly or that there is another
underlying problem. Also, every session I will ask her questions to assess her knowledge about a
healthy lifestyle and a healthy diet. If she seems to need more education in certain areas that I
feel she has not yet grasped I will provide that as needed. Hopefully with enough sessions Mary
will be able to consume a healthy diet and reverse the effects of her anorexia and osteopenia.

References:
(1) Anorexia Nervosa. http://www.nationaleatingdisorders.org/anorexia-nervosa. NEDA.
2001. Retrieved September 21, 2016.
(2) Osteopenia. http://www.medicinenet.com/osteopenia/article.htm. MedicineNet Inc.
3/4/2016. Retrieved September 21, 2016.
(3) "Health Belief Model." Health Belief Model. AIPPG, 31 Jan. 2012. Web. 14 Nov. 2016.
<http://www.currentnursing.com/nursing_theory/health_belief_model.html>.
(4) Jorge. ReCAPP: Theories & Approaches: Social Learning Theory. ETR, 2007. Web. 14
Nov. 2016. <http://recapp.etr.org/recapp/index.cfm?
fuseaction=pages.TheoriesDetail&PageID=380>.
(5) Prochaska, J. "The Transtheoretical Model of Health Behavior Change." National Center
for Biotechnology Information. U.S. National Library of Medicine, Sept.-Oct. 1997.
Web. 14 Nov. 2016. <https://www.ncbi.nlm.nih.gov/pubmed/10170434>.