Name: Joanie Appleseed

Age: 17

Occupation: High School Senior

Case file: Admitted to Yellow Creek Treatment Center two weeks prior to being referred to the nutritionist.

Joanie is a 17-year-old pregnant Native American who was referred to the outpatient nutrition clinic to visit with Nutritionist Goodie TwoShoes about her and her baby’s health concerns. Joanie is 5’7’’ and 145 pounds with a medium frame. She has long, dark hair cut to frame her sculptured cheekbones and accentuate her almond-shaped eyes. The bronze highlights and meticulous makeup allow her to appear ten years older than what she is. This is Joanie’s first pregnancy, and she is a chronic smoker and binge drinker. Joanie has been receiving treatment at the Center for two weeks but is not cooperative with the staff. This is her first visit with the nutritionist. As Joanie meanders into the office, Nutritionist Goodie TwoShoes notices her expressionless face and disinterested attitude. Goodie knows this was going to be a tough patient, however, unrelentingly tries to appear enthusiastic to the discouraging patient. Goodie is sitting at her desk sifting through some papers when Joanie walks through the door.

Nutritionist TwoShoes: (standing up to shake her hand) Good morning. My name is Goodie TwoShoes. How are you doing today? She thinks to herself, This is going to be a challenge, but it is worth the fight.

Joanie: (pokerfaced) Okay, I guess.

Goodie motions to a seat as Joanie comfortably sits down. Gazing around the room, Joanie slouches into her chair, crosses her legs, and folds her arms across her chest. Goodie recognizes her defensive posture and decides to ease her apprehension by telling a little about herself.

Nutritionist TwoShoes: I am the Center’s Nutritionist and will be answering any questions you may have regarding your pregnancy. I would also like to help in any way to make your pregnancy healthier for both you and your baby. Today, we’re going to spend the next 50 minutes together to work on whatever questions you may have. What you tell me will be held in confidence with a couple exceptions, and these are if you threaten to do harm to yourself or to others. Are you clear to this procedure and what we will do today?

Joanie: Yes. She thinks, I wish I didn’t have to be here.

Nutritionist TwoShoes: Okay, now, do you have any questions to get us started?

Joanie: (in a stern voice) No. 

Looking directly at Goodie, Joanie makes no sign of interest or cooperation.

Nutritionist TwoShoes: (enthusiastically) Okay then, I’ll begin by asking you a few questions. Okay? Please open up, she thinks, I'm drowning here.

Joanie: Why? What is it with this woman? Can't she see I don't want to be here.

Nutritionist TwoShoes: Well, the questions I ask will allow me to see where you are in your understanding of nutrition and experience with your pregnancy. With the nutritional counseling I will give you, you will be able to expand your understanding to help you make better decisions down the road of motherhood. I understand this is going to be your first baby, right?

Joanie: (With anger apparent in her voice) Yeah, but why do you care? All of you! Everyone here acts like they care and none of you even know who I am!

Joanie’s eyes become fixated on Goodie while questioning her sincerity. Joanie’s eyes are strained, brows furrowed and mouth tightened into a small point. Goodie recognizes her anger and tries to calm the situation.

Nutritionist TwoShoes: Is it okay that I call you by your first name? Okay, at least I got her to open up. . . although it's not the response I would have liked to hear, it's workable.

Joanie: (Disinterested) As long as I can call you by yours.

Nutritionist TwoShoes: (Smiling) I would actually prefer that, Joanie. (Digging in her purse) I have something to show you that will help you understand why I want to help you and your baby’s health. 

Goodie comes out from behind her desk, sits next to Joanie, and places a sonogram on the desk in front of her.

Nutritionist TwoShoes: This here is my baby girl Theresa when she was 12-weeks-old. . . (Placing a picture next to the other) and this here is her when she passed away three weeks after she was born. She was premature and had to stay in intensive care until her lungs were more developed before I could have her.  My little Theresa. . .

Joanie: (Expressionless) What happened?

Nutritionist TwoShoes: Well, just let me tell you. . . (Pausing) if I would have known there was help available, I would have sought it for both myself and Theresa. You see, I use to smoke and occasionally drink. And although I knew it was not healthy for myself, I had no idea how damaging it was for my baby girl. Even though she was not born yet, what I put into my body had a huge impact on her development. I know I can make a difference in Joanie’s life, even if by example as a wounded healer.

Joanie: (Looking down at the ground) I’m sorry.

Nutritionist TwoShoes: (Leaning forward) Joanie, our children are our future (Handing her a piece of paper) Here, take a look at these figures. Can you tell me what they mean to you?

Joanie begins to become interested in what Goodie had to say and sits up in her chair.

Nutritionist TwoShoes: (Displaying a graph) Maybe this will help. Those numbers and this picture are telling us that the Native American population is younger than the Nation’s total population. In fact, the average age for American Indians is 26 years old while the U.S. average age is 33 years. As you can see, we are a considerably younger race than the rest of the Nation. (Displaying another graph) If you look at the infant mortality rate, you can see that we are also dying at an earlier age than the rest of the Nation. Our children are dying at rates that are 3.5 times higher than the national average!

Joanie: (Becoming frustrated) So what does all this mean?

Nutritionist TwoShoes: Well, to me it means that as a Native American, I am going to make wiser decisions in my life to prolong my life expectancy. And for you, I hope it means that you will make better decisions to promote the life of your child as well as yours. There is abundant research that demonstrates the benefits of improved nutrition regarding mortality and morbidity of infants as well as mothers. Prenatal nutrition has also had an impact on the vulnerability of the pregnant woman and fetus to effects of malnutrition. (Smiling) Joanie, we can outlive those numbers in that table and live a long, healthy, and productive life by eating healthy and abstaining from alcohol and drug use.

There is a pause of silence as Joanie studies the graph and soaks in what Goodie just said.

Joanie: (With concern in her voice) Why aren’t we living as long as everybody else in the U.S.?

Nutritionist TwoShoes: (Excited) I’m glad you noticed that Joanie. According to the graph, only a small percentage of us are living to be over 70 years, around 4% compared to the total population of about 9%, right. Why do you think that is?

Joanie: (Grinning) I asked you first.

Nutritionist TwoShoes: (Giving in) Okay. Well, there are lots of reasons. The major reason is for making bad decisions in life; specifically concerning the choices we have for alcohol and drug use. (Displaying another table) Take a look at this. These are the top ten causes of death among Native Americans. Do you see any similarities among them?

Joanie: (Leaning forward and grabbing the graph) Hmmm, are they all related to alcohol use?

Nutritionist TwoShoes: You’re on the right track. The three leading causes of death are due to alcohol abuse. And the others are associated to prenatal nutrition and the maternal use of alcohol and smoking. Joanie, did you know that your nutrition before you were pregnant and your nutrition while you are pregnant has a direct impact on the health of your baby not only at birth, but also throughout his or her lifetime? Here, take a look at these diseases that can be prevented through making healthy choices as a to-be-mother.

Joanie: (Astonished) Goodie, I had no idea my baby could develop diabetes or heart disease when he is older because of what I ate when I was pregnant with him.

Nutritionist TwoShoes: So you think he’s a boy, huh (smiling).

Joanie: (Holding her tummy) I’m hoping.

Nutritionist TwoShoes: Well, his decisions will also affect his health when he is older, but right now the best thing you could do to prevent disease for the both of you is to make healthy and responsible decisions.

Joanie: (Uncomfortably) I will be honest with you Goodie. . .(Pausing) I know I have a problem with drinking otherwise I wouldn’t be here.

Joanie looks down at the ground and takes a couple of deep breaths.

Nutritionist TwoShoes: Take your time Joanie, I’m listening.

Joanie: I want to quit, but I don’t think I can.

Nutritionist Twoshoes: You don’t think you can.

Joanie: I’ve tried in the past.

Nutritionist Twoshoes: And. . .

Joanie: I’ve been drinking since I was fourteen.

Nutritionist Twoshoes: Uh-huh.

Joanie: (Turning away) Well, I didn’t even want this baby.

Goodie recognizes Joanie’s pain as she tries to talk her through the discussion. Joanie’s eyes begin to fill up with tears.

Joanie: (Frustrated with the conversation) I can’t even take care of myself. How am I supposed to take care of a baby?

Nutritionist TwoShoes: That is why we are here Joanie, so we can help you.

There is a moment of silence, and then Joanie slowly raises her head toward Goodie.

Joanie: How dangerous really is it for my baby. . . if I do decide to have a few drinks. . .I mean, will there be immediate effects on my baby.

Nutritionist TwoShoes: Joanie, the most serious and immediate consequence you are placing your baby at risk of developing is irreversible mental and physical retardation with visible abnormalities known as fetal alcohol syndrome (FAS). The syndrome is totally preventable, and pregnant women should drink absolutely no alcohol. The most critical time for your baby to get the nutrient it needs is early in development. Any dangerous influence felt early can have a much more serious impact than one felt later on. Drinking during pregnancy also places you at risk of a miscarriage.

Goodie stands up and walks to the other side of the room motioning Joanie to follow.

Nutritionist TwoShoes: (Pointing to a picture on the wall) Look at the critical organs of your baby developing right now as we speak.

Joanie: (Looking at week 8) Wow! So my baby’s heart is the major organ developing right now?

Nutritionist Twoshoes: Yes, and right now it is the most defenseless to harmful substances that you put into your body.

Joanie: (Sounding it out) What is a trrrat-oh-jin, Goodie? It sounds scary.

Nutritionist Twoshoes: A teratogen is scary, Joanie. It is any dangerous substance that causes birth defects in a developing fetus.

Joanie: (Thinking) Hmm, and that includes alcohol, doesn’t it?

Nutritionist Twoshoes: Yes, it does, one of the most dangerous teratogens there is.

Joanie: Well, what does alcohol do to MY body that is so dangerous?

Nutritionist Twoshoes: How old are you Joanie?

Joanie: Seventeen, going to be eighteen in three months.

Nutritionist Twoshoes: Your body is still growing Joanie, and has a high demand for a nutritionally balanced diet. And when you’re pregnant, your nutritional needs increase even more, which makes your pregnancy unique and also risky. You need to eat almost twice as much as what you were used to before, just to meet the needs of both yourself and your baby’s. Alcohol provides calories, but no nutrients, and is therefore robbing your body of nutrients that it needs to grow.

Joanie: So, in other words I won’t be getting enough nutritional foods into my diet because alcohol will be replacing them?

Nutritionist Twoshoes: Exactly. You will be starving your body as well as your baby’s. There is evidence that malnutrition during pregnancy not only has long-term adverse effects on development of the growing fetus, but it has harmful effects on the mother herself. Here are nutrients that need to be increased in your diet in order to meet all of yours as well as your baby’s nutritional needs. Can you tell me which ones they are?

Joanie: Looks like I need more protein, vitamin E, K, C, and a lot more folate (Looking over at Goodie with confusion on her face).

Nutritionist Twoshoes: Keep going.

Joanie: Niacin, (Sounding it out) Rr-ibo-flavin, thiamin, vitamin B_b , vitamin B₁₂, magnesium, iodine, iron, zinc, and selenium. Okay, I’ve never even heard of any of these before. . .

Nutritionist Twoshoes: I can see the confusion on your face, but don’t worry . . . (smiling) I am giving you a list of specific foods that contain these vitamins and minerals to make sure you get them in your diet. Okay.

Joanie: So, is that why you get so full after you drink a beer?

Nutritionist Twoshoes: Yes, a gram of alcohol provides 7 calories of energy while a gram of carbohydrates provide 4 calories, a gram of protein provides 4 calories, and a gram of fat provides 9 calories of energy.

Joanie: (Reflecting on the information) Oh. She thinks to herself, No wonder why I could go for weeks on end without eating and just partying all summer long on the pow wow trail!

Nutritionist Twoshoes: We have about ten minutes left. Is there anything else you want to talk about?

Joanie: Well, there is something I want to talk to you about . . . (Pausing)

Nutritionist Twoshoes: Go on.

Joanie: This is my senior year and this weekend is our graduation (Reading Goodie’s face for any disruption so she doesn’t have to continue). Crap, now I have to tell her.

Goodie remains attentive, with her eyes eager to listen to Joanie’s plea for advice.

Nutritionist Twoshoes: Um-hum.

Joanie: (Hesitating) And. . . well I don’t want to miss out on my senior keg. There, I said it.

Nutritionist Twoshoes: So you’re telling me you want to go to the senior keg?

Joanie: I mean, I really want to go, but I don’t know how to say no if I was offered a drink. Oh God, what did I just say.

Nutritionist Twoshoes: (Understanding) You feel torn, because you want to go but you don’t know how to avoid drinking at the party.

Joanie: I guess so.

Nutritionist Twoshoes: Personally Joanie, as a counselor and as a friend, I wouldn’t advise you to place yourself in such a risky situation, but if you INSIST on going, I do have some advice for you. Do you have any friends who don’t drink?

Joanie: Yeah, I guess I can go with Jewel, and Jen, and Kris (Losing enthusiasm). Oh great, now my reputation is going to be ruined.

Nutritionist Twoshoes: Or can you think of any other options you could do?

Joanie: (Sarcastically) Besides hanging out with the “dud club”?

Nutritionist Twoshoes: (Laughing) Well, Joanie, have you ever considered taking along something else to drink?

Joanie: Like a soda?

Goodie releases a small grin from the corner of her mouth and nods her head, encouraging Joanie to continue.

Joanie: Or. . . a bottle of juice. Great, now I’m growing faster than my fetus!

Goodie smiles at Joanie as she realizes the strength Joanie has within herself to make the appropriate changes for herself and her baby. Joanie smiles and wonders how the idea is going to fly at the keg without anyone harassing her. Then, an idea pops into her mind.

Joanie: (Eagerly) Or even better, I could take a carton of milk and be the highlight of my senior keg.

Nutritionist Twoshoes: (Pleased) That’s a great idea Joanie. And you’ll be nourishing both your baby’s and your body, not to mention how well you’ll be remembered at your class reunion.

Nutritionist Twoshoes: Since the session is almost over, I’m wondering if you could tell me what you learned or experienced as a result of our work together today.

Joanie: Well, the biggest thing I have learned is how dangerous alcohol is for both of us (She looks down at her baby). And I also found out how alcohol steals the space for nutrients that my body needs, right?

Nutritionist Twoshoes: (Smiling with pleasure) That’s right Joanie. I’ll meet with you next week, same time and same place. I’ll be looking forward to your stories you have to share.

So will we, Joanie says to herself as she rubs her belly and begins to walk down the hall toward the entrance of the center, wondering what the weekend may hold.

RESOURCES

Pagliaro, Ann M. and Louis A. Substance Use Among Women. Taylor & Francis, 2000.

Rolfes, Sharon R. et al. Life Span Nutrition. Wadsworth Publishing Co., 1998.