Nutrition Counseling

1. Nutrition Counseling Counseling for Change

2. Nutrition Counseling Goals “The necessary function of the dietitian or nutritionist is not only to know nutrition but also to facilitate behavior change” Curry& Jaffe in Nutrition Counseling and Communication Skills, 1998, p 4. Facilitate lifestyle awareness Healthy lifestyle decision making Take appropriate action

3. Behaviour Change • Behaviour change • Behaviour does not occur in a vacuum • Adapting new behaviours entails “costs” and “benefits” • Focus on individual internal change processes • Cannot ignore socio-cultural and physical environmental influences

4. Theoretical Approaches • Person Centred Therapy • AKA Client centred • Basic assumptions: • humans are basically rational, socialized and realistic • Inherent tendency to strive towards growth, self-actualization & self direction • Totally accept clients without passing judgments on thoughts, behaviour, or physical self • Acceptance is cornerstone of TRUST

5. Theoretical Approaches • Behavioural Therapy • Behaviours are learned so it is possible to learn new ones • Change environment so it will be conducive to learning new behaviours • Classical conditioning • Operant conditioning • Modeling

6. Theoretical Approaches • Gestalt Therapy • Emphasizes confronting problems • I.e. have clients take dietary responsibility rather than blame spouse for not buying appropriate foods • Setting realistic goals important to gaining ownership over problems

7. Theoretical Approaches • Cognitive Therapies • Negative self-talk and irrational ideas are self defeating learned behaviours • Identify harmful self-monologues, eliminate & replace with productive self-talk • Change thinking and feelings and actions will be modified

8. Theoretical Approaches • Solution Focused Therapy • Work with client to concentrate on solutions that have worked in past • Identify strengths to be expanded upon & used as resources • Language (solution-talk) provides a guide • What can I do that would be helpful to you? • Was there a time when you ate whole grain food? • When was the last time you ate fruit? • Has a family member or friend ever encouraged you to eat low sodium foods?

9. Behaviour Change Models Self-Efficacy • Stands alone & incorporated into numerous models • “our personal belief of how capable we are of exercising control over events in our life” • Attainment of health behaviour changes correlate solidly with strong self-efficacy

10. Behaviour Change Models Health Belief Model • Cognitive factors influence individual’s decision to make & maintain a specific health behaviour • Central tenants: • Belief to which individual is susceptible to a health problem • Belief that specific disease can severely impact quality of life • Changing behaviour will reduce risk of disease • Barriers to change are overcome with reasonable effort • Individual is capable of making change

11. Behaviour Change Models Stages of Change • Is a process in which individuals progress through a series of 6 motivational stages : 6. Termination/ Relapse 5. Maintenance 4. Action 3. Preparation 2. Contemplation 1. Pre-contemplation • Prochaska, 1992

12. Behaviour Change Models Stages of Change • Precontemplation – information & awareness; emotional acceptance • Contempation –  confidence in ability to adopt recommended behaviours • Preparation – initiate change by resolving ambivalence, eliciting a firm commitment, & develop specific action plan • Action – behavioural skill training & social support • Maintenance – develop problem solving & encourage social and environmental support

13. Behaviour Change Models Motivational Interviewing • Complements stages of change model • Focus on strategies to motivate clients to build commitment • Motivation considered a state of readiness • Can fluctuate & be influenced by others • Patient-centred counseling, resolve ambivalence, reduce resistance & encourage action

14. Behaviour Change Models Motivational Interviewing • Basic principles • Express empathy (acceptance & understanding of a clients perspective) • Develop discrepancy between present behaviour & goals • Avoid escalating resistance (defensiveness; denial, arguing, showing reluctance) • Roll with resistance • Support self-efficacy

15. Behaviour Change Models Motivational Interviewing • Specific Strategies • Listen respectively (mirror) • Elicit self-motivational statements (opportunities for client to make arguments for change) • Request clarification, formulate reflective listening statements of previous statements, reinforce self motivational statements, change roles • Ask open ended questions (curiosity, concern, & respect)

16. Behaviour Change Models Health Behaviour Change Method • Two main foundations • Importance • Confidence • Use in assessing readiness to change and designing intervention

17. Counseling • An internal process for the client: • client centered • A sequence of events: • involvement in a problem solving process • The elements of the interpersonal relationship between the counselor and the client: • focuses on the dynamics of communication

18. Models of Decision Making • Paternalistic model • the patient acquiesces to professional authority • Informed model • the provider gives information to enable the patient to make an informed choice • Shared model • the provider and patient share all stages of decision-making equally

19. Problem Solving Nutrition Counseling Model: Goals 1. To help clients become aware of solutions to problems they face 2. To help control nutrition behavior based on nutrition principles and their own lifestyles 3. To help them become more assertive in making nutrition decisions

20. Key Assumptions in Problem Solving Model • Every client situation is different • Individuals are constantly changing • Clients are experts on their own problems • Many different approaches and strategies are needed to deal with each individual problem • Effective counseling is a process that is done with the client, not to or for them

21. Six Stages of Counseling 1. Build the foundation 2. Define problems 3. Select alternative solutions 4. Plan for change 5. Reach a commitment 6. Evaluate progress

22. 1. Building the foundation • Establishing rapport • if rapport is not established it is unlikely that the problem solving process will proceed • Gathering data • for purposes of both screening and assessment • data is needed in order to determine the nature and scope of the problem

23. 2. Define problems multidimensionally • Look at the problem from several dimensions • physiological, psychosocial, the patient, the counselor • may have to address problems that are not direct nutrition issues (smoking and weight control in teen girl) • As problems are defined they evolve into goals

24. 3. Select Alternative Solutions • Explore as many options as possible for addressing the problems • Consider changes in food choices, feelings, attitudes, beliefs, or even interpersonal relationships

25. 4. Plan for Change • Select one or two alternatives • Affirm client’s ability to make desirable changes • Identify coping mechanisms for difficult situations related to the problem

26. 5. Reach a commitment • Bring about genuine commitment to action • Agree on : • What are you going to do ? (goals) • How are you going to go about doing it? (plan) • What will be the consequences of the change? (outcome) • What are the barriers to change? (barriers)

27. 5. Reach a commitment • Offer verbal affirmation and support for client’s commitment • Have clients summarize plan and commitment for actions

28. 6. Evaluate progress • What was accomplished during the session and how does your client feel about the session? • How can achievements be incorporated into new nutrition behaviors • Bring about closure: • Signal end of session

29. Nutrition Counseling Strategies

30. Active Listening • A strategy of communication that involves all of the senses and is the cornerstone for a problem-solving counselling relationship • Most important counseling strategy • Guides effective problem solving • Includes empathy and concrete responses

31. Active Listening • Undivided attention to client • Listen for verbal messages • Observe non-verbal behaviour • Eye Contact • Attentive Body Language • Vocal style • Verbal Following

32. Active Listening • Not simply hearing words • Hard work requiring focused attention & concentration • Essential Components of Effective Listening: • Openness • Concentration • Comprehension

33. Paraphrasing and Summarizing • Paraphrasing/ Summarizing • Briefly restate the essence of what the person has said concisely using different words • Summarize what has been said over a period of time

34. Reflective Listening • Listen to not only the words but also the feelings associated with the message • It is a way of communicating your understanding • Phrased as a statement rather than a question

35. Reflective Listening • Steps: • Correctly identify the feeling being expressed • Reflect the feeling you have identified to the client • Match the intensity of your response to the level of feeling expressed by the client • Respond to the feelings of your client not the feelings of others

36. Questioning OPEN and NEUTRAL QUESTIONS • “Tell me about yourself” • “Tell me about your eating habits” • “What have you been doing to lower your blood cholesterol?” • Tell me what time do you rise in the morning, and what do you have to eat?” • Take me through your day…

37. Questioning CLOSED QUESTIONS • “Do you smoke?” • “Do you salt your food at the table?” • “Do you eat chicken with the skin on?” LEADING QUESTIONS • “Do you eat ice cream every evening?” • “You don’t use whole milk, do you?”

38. Clarifying • Probing & Prompting • Communicate tell me more through body language • Use trailing words • Ask clarifying questions

39. Confrontation/Challenging • To “bring to the front” or to discuss problems, concerns, and issues that may be barriers to a healthy nutrition lifestyle • Note discrepancies

40. Affirming • Alignment: • the counselor tells the client that s/he understands and is there to support at this difficult time • Normalization • the counselor tells the patient that it is perfectly normally to have these feelings/ reactions

41. Advice • Provide possible solutions for problems • Should be: • Given in nonjudgmental manner • Identify the problem • Explain the need to change • Advocate an explicit plan of action • End with an open ended question to elicit a response from the client

42. Directing • Telling a client exactly what needs to be done • Often part of educational component of session • When giving directives: • Be clear and concise • Determine if instructions were completely understood • Have them repeat back instructions

43. Allowing Silence • Silence is a valuable tool! • Clients need space for internal reflection & analysis • After given response to an evaluation • During instructions of complex dietary regimen • After emotional outburst due to demands of coping with newly diagnose illness • Divert eyes for moment • 30-60 seconds • Break silence by repeating last sentence or phrase spoken to client

44. Self-Referent • Self disclosing & self involvement • Increase openness, build trust, provide model to increase client level of disclosure, create more personal atmosphere • Be careful of amount and stage of introduction

45. Assessing Readiness to Change • Readiness to change questions • Provide simple readiness to change statements • i.e. in the past 6 months have you tried to eat less fat? • Are you seriously thinking about eating less fat over the next 6 months? • Do you plan to continue trying to eat less fat over the next 6 months • How confident are you that you can change your diet to eat less fat?

46. Assessing Readiness to Change • Ruler – if 1 corresponds to not thinking about a change and 12 corresponds to highly motivated • 0-4= not ready (precontemplation) • 4-8= unsure (contemplation) • 9-12= ready (preparation)

47. Counseling for ChangeNot ready • Goals: • Raise Doubts • Facilitate patients ability to consider change • Identify and reduce patient’s resistance and barriers to change • Identify behavioural steps toward change that are tailored to each patient’s needs

48. Counseling for ChangeNot ready • Strategies for Success • Raise Awareness • Personalize benefits • Promote change talk • Respect decision • Summarize • Offer professional advice • Respectful acknowledgement of decision that not ready to change – not necessarily going to set out behaviour change goals

49. Counseling for ChangeUnsure • Goals • Build confidence • Strategies • Explore ambivalence • Explore barriers • Imagine the future • Explore successes • Encourage support • Summarize • Ask about next steps

50. Counseling for ChangeReady • Goals • Collaborate with client to set goals for change including a plan of action • Strategies • Praise positive behaviours • Explore options • Negotiate realistic short-term goal/s • Develop action plan