Nutrition Intake Note

Family medical history: Maternal Hx of T2DM and hypothyroidism; paternal Hx of HTN and hyperlipidemia. Sister has a Hx of anorexia nervosa.

Client's medical history: GAD, IBS-C, osteopenia (diagnosed 14/11/2023), and iron-deficiency anemia.

Social information: Client is a 26-year-old female (she/her) who works full-time as a graphic designer and lives alone in a studio apartment, currently single.

Nutritionally significant medications/supplements: sertraline (Zoloft®) 50 mg PO daily, ferrous sulfate 325 mg PO every other day, cholecalciferol (Vitamin D3) 2,000 IU PO daily.

History with food: The client grew up in a household where weight and dieting were frequently discussed by her mother. Sweets and processed snacks were strictly forbidden, leading the client to hide food in her bedroom during childhood. She began her first formal diet at age 14 using a calorie-tracking app. Throughout high school and college, she cycled between rigid clean eating and episodes of loss-of-control eating. She reports feeling significant guilt after consuming carbohydrates or dietary fats. Currently, she views food primarily as a source of anxiety and numbers rather than nourishment or enjoyment. Social gatherings involving restaurant meals cause high distress, prompting her to review menus days in advance. She expresses a strong desire to stop obsessing over food rules, though she fears weight gain if she relinquishes control.

Weight history: Highest adult wt: 68 kg at age 20. Lowest adult wt: 49 kg at age 23. Current wt: 52.5 kg (Ht: 165 cm, BMI: 19.3 kg/m²). Wt has fluctuated by 4.5 kg over the past year.

Current food restrictions: Avoids gluten, dairy, fried foods, and added sugars (self-imposed due to fear of GI distress and wt gain; negative celiac panel).

Connection to hunger/fullness cues: Poor interoceptive awareness. Relies on external clocks rather than internal hunger cues to initiate meals, and typically stops eating based on predetermined portion sizes rather than physical satiety.

Symptoms of malnutrition: Chronic fatigue, orthostatic dizziness, constipation, bloating, early satiety, cold intolerance, diffuse hair thinning, and secondary amenorrhea (last menstrual period 8 months ago). Recent labs from 02/05/2024 show low ferritin (11 ng/mL) and mild leukopenia.

Eating disorder behaviors: Daily caloric restriction (< 1,200 kcal/day), rigid food rituals (cutting food into tiny pieces, eating only from specific bowls), body checking 5–6x/day. Denies bingeing, self-induced vomiting, or laxative/diuretic misuse.

Relationship with exercise/movement and current physical activity level: Compulsive relationship with movement; experiences severe guilt and restlessness if a workout is missed. Currently runs 5 km 5x/week and attends heated yoga 2x/week despite fatigue.

Typical day of eating/24-hour recall: 07:30 – Black coffee (350 mL). 12:30 – Salad with mixed greens, 85 g grilled chicken breast, cucumber, and balsamic vinegar; 1 rice cake. 16:00 – 1 medium apple and 10 almonds. 19:30 – 115 g baked salmon, 1 cup steamed broccoli, and 0.5 cup quinoa. 21:00 – Herbal tea. Total fluid intake: ~1.5 L water/day.

Current food environment: Client performs all grocery shopping and meal preparation alone. Eats all meals alone at her work desk or in front of the television. Keeps minimal food in the apartment to "avoid temptation," shopping every 1–2 days for specific items.

Other notes: Vitals obtained at 10:15 (America/Denver): BP 96/62 mmHg, HR 54 bpm, Temp 36.2 °C. Blind weight obtained today: 52.5 kg. Client requested not to know her weight. Occupational therapy and nutrition co-assessment indicates high sensory sensitivity to food textures and abdominal distension, impacting meal completion and IADL participation (grocery shopping/meal prep fatigue).

Client's goals for nutrition counseling: "I want to have enough energy to get through my workday without feeling like I am going to pass out." "I want to be able to go out to dinner with my friends and order off the menu without panicking for three days beforehand."

Recommendations: 1. Establish regular eating pattern: 3 meals and 2–3 snacks daily, eating every 3–4 hours. 2. Add a morning meal within 1 hour of waking (e.g., oatmeal with nut butter or toast with eggs) prior to consuming coffee. 3. Reduce running to 2x/week max and replace with gentle stretching until energy availability improves and menses resume. 4. Utilize sensory coping strategies (wearing loose clothing, distraction during meals) to manage bloating discomfort.

Will follow up in: 1 week.