Nutrition Counseling

Objectives

1. Explain the steps in the nutrition care process

2. Identify the information needed in a nutrition assessment
3. Consider appropriate nutrition diagnoses
4. Explain and practice the steps in goal setting with a client
5. List ways to evaluate the outcomes of nutrition intervention, including how to follow up
6. Describe several studies evaluation counseling techniques
7. Explain some of the expanding role for professional

There is no single gold standard method or unifying theory of counseling patients and clients that
ensures success in changing food choices and eating behaviors. Instead, dietetics professionals need to
be proficient in using several different approaches and strategies while adapting them to the people
they are counseling.

The previous chapter examined general counseling approaches and theories. That chapter explore a
basic nutrition counseling process using a model as an outline. It emphasizes the patient centered
counseling model and process, matching the counseling intervention strategies to the stages of change,
and using the goal setting process. Later chapters emphasize other counseling approaches, including
counseling with behavior modification, counseling for cognitive change (because thoughts may influence
eating practice), the role of self efficacy in making lifestyle changes and preventing or dealing with
lapses and relapses.

NUTRITION COUNSELING

Dietetics professionals, whether working in hospitals, academic health science centers, long term care,
corporate wellness programs, sports nutrition, public health agencies, private practice, or other settings,
are responsible for assessing the nutritional status of patients and clients, selecting diagnoses and
intervening through counseling about what they are doing successfully and what they may need to
change. The goal is to change peoples eating behaviors and attitudes for the improvement of their
health and reduction in the risk of chronic disease, such as cardiovascular disease, diabetes mellitus,
hypertension, and renal disease. Nutrition counseling is a supportive process, characterized by a
collaborative counselor patient (or client) relationship, in which to set priorities, establish goals and
create individualized action plans that acknowledge and foster responsibility for self care to treat an
existing condition and promote health.

Patient-Centered Counseling

The patient centered counseling model provides and effective process for dietary change and
long term adherence in clients. The objectives of patient centered counseling for dietary change are to
(1) increase awareness of diet related risk, (2) provide nutrition knowledge, (3) increase confidence to
make dietary changes, and (4) enhance skills to promote long term changes in intake.
 These objectives under lie the four steps of the patient centered counseling model asses, advise,
assist, and follow up.

Asses

Assessment is an important component in the total approach to a patient centered counseling

approach. This involves obtaining information about the clients current and past eating patterns, history
of health problems, readiness to change, interest in waiting to make dietary changes or reasons for
wanting to keep current eating patterns. Discuss concerns about changing dietary change or attempts to
make change. Inquire about strategies that helped in past experiences and those that did not.

The dietetics practitioner should use open ended questions that will assist in tailoring the intervention.
Open ended assessment questions include but are not limited to How do you feel about your current
diet? What problems have you had because of your diet? What would you like to change about your diet
now? What would motivate you to maintain your current diet? Have you ever made changes in your
diet? What helped? What situations make it hard for you to achieve your goal?

Advice

When helping clients change their eating behaviors, the advice should be personalized to health
concerns or clinical conditions and include reasons for change, personal preferences, and other benefits
that modify dietary intake. Advice should be personalized and should validate what the patient is
stating.

“Mr. Atkinson, as your dietitian, I am concerned that your diet is affecting your health. Are you
aware that a major risk factor for heart disease is diet and genetics and your diet suggest risk? I would
like to help you make some nutritional changes in your diet, such as decreasing the amount of saturated
fat”

“Mrs. Jones, as your counselor, I need to advise you of the importance of following your diet for
diabetes management. You expressed concern of complications from uncontrolled diabetes. That is
important and I would be happy to assist you in reducing these risks with diet education on
carbohydrate counting. What do you know about carbohydrate counting?”

Assist

The type of assistance provided to help with dietary and behavior change is dependent on the
patients stage of change, as discussed in chapter 4, and the intervention should be appropriate to the
stage. The dietetics practitioner provides nutrition information and corrects misunderstandings,
addressed and validates feelings about dietary changes, provides support, and expresses realistic
optimism and motivational statements in regard to change. For example “ I know its hard to adhere to
your dietary goals during vacation.” “its difficult to make dietary changes when your job involves taking
clients out to lunch and dinner.”

Follow Up
 Dietary and behavioral changes can be difficult. Therefore, follow up visits are important.
Evaluating and monitoring of progress is imperative as goals may need to be revised or new strategies
implemented for success.

NUTRITION CARE PROCESS

The Nutrition Care Process (NCP) consists of four steps : assessment, diagnoses, intervention,
and monitoring and evaluation.

Nutrition Assessment

Nutrition assessment is the first step in the nutrition care process. Nutrition assessment is used
throughout the NCP for obtaining, verifying, and interpreting data needed to make decisions about the
nutrition related problem.

FIGURE 5-1

The assessment process includes collecting biochemical data and results of medical tests and
procedures anthropometric measurements physical examination findings food and nutrition history and
client or patient history. The assessment assists in identifying a nutrition diagnosis, nutritional goals for
change the type of nutrition intervention designed to achieves the goals and the evaluation of the
outcomes.

The first step in nutrition assessment is to gather in advance data or information about the
patient or client that may have an impact on treatment. In a hospital or clinical setting, the medical
record is the source of data about the patient. Anthropometric measurements, biochemical data, and
patient medical history should be noted. Many factors can have an impact on food and nutrient intake,
such as role in family, occupation, socioeconomic status, educational level, cultural and religious beliefs,
physical activity, functional status, cognitive abilities, and housing situation.

Information that is unavailable from the medical record may be obtained during the interview
by using a self-administered questionnaire or by collecting anthropometric data and food and nutrition
history. Dietetics practitioners are expected to understand their clients physiological, psychological,
social, cultural and economical issues, that is they should know what factors influence their clients
eating and lifestyle behaviors. Counselors must view their client as individuals living and interacting in an
environment that influences their motivation for and ability to change.

A second source of data is the providers own professional records kept from previous counseling
sessions or previous contact with the client. Since the purpose of nutrition counseling is to promote
change, the dietitian should review all data before a follow up session. Therefore, if changes need to be
made or personal and lifestyle factors adjusted, they can be discussed with the client. Establishing good
rapport with the client is an important step both in nutrition counseling and in depeloving a trusting
relationship. For interview skills see chapter 3.
 The counselor may collect data on current eating patterns or habits on physical, social and
cognitive environments and on previous attempts to make dietary changes. (Behavioral assessment and
cognitive assessment are discussed in Chapter 6 and 7). The physical environment includes where meals
eaten ( at home or in restaurants, and in which rooms of the home) and events that occur while eating
(socializing, watching television or reading). The social environment, which may or may not be
supportive, includes family members, friends, social norms, and trends involved with eating behaviors
(e.g meeting friend for dinner, popular food items and beverages when tailgating). See appendix A for a
summary of questions to ask and not ask.

The cognitive or mental environment involves the clients thoughts and feelings about food and
his or her self image and self confidence. It concerns what clients say to themselves about their food
habits and life, since personal thoughts may or may not promote successful change. Positive thoughts,
such as “ I love a steak and baked potato”, or “My favorite snacks are potato chips and beer” may
support continued eating. There may be negative and self defeating thoughts or thoughts of failure,
boredom, stress and hunger. Example included; “it’s too difficult”, “it’s not worth it” , “I can do it”, “I’ve
been on diets before, always failed, and regained all of the weight lost”, or I’m happy the way I am and
don’t want to change”. These may also support continued eating. Since behavior is influenced by beliefs
and attitudes, you need to explore these in relation to the medical condition, nutrition, food choices,
and health. The clients educational level and any language barriers should also be noted.

The assessment may have several important functions, such as making both parties aware of the
current food patterns, problems, knowledge and misinformation, as well as obtaining the health history.
The assessment also provides baseline information from which to determine the nutrition diagnosis and
determine interventions that are realistic. Once all of the data for the assessment have been collected,
the counselor must integrate and assimilate what she or he has read, heard, and observed to distinguish
relevant from irrelevant data, identify discrepancies and gaps in the data and finally organize the data in
a meaningful way and document the assessment.