Nutritional Counseling

Definition of Nutrition Counseling

 Nutrition is both a science and an art.

 The nutrition counselor converts theory into

practice and science into art.

 This ability requires both knowledge and skill.

 Nutrition counseling is a combination of nutrition
expertise and psychological skill delivered by a trained
nutrition counselor who understands how to work
within the current medical setting.
 It focuses on both foods and the nutrients contained
within them, emphasizing our feelings as we experience
eating.
Theories of Nutrition Counseling

 Theories form the basis for developing counseling skills

to change eating habits.

 Both clients and nutrition counselors use theories and

beliefs in determining what will take place during an

interview.
Clients come to counseling with:
• attitudes and beliefs about people

• ideas and feelings about counselors and counseling

• self-images
• basic incongruities in desired outcomes:
1. a desire to continue along a familiar course
2. a desire to make changes to improve health and
wellbeing
 Theories Influence Counselors
Many theories influence the way a nutrition counselor
conducts a session. This text will focus on the
following specific theories:
1. behavior modification
2. cognitive-behavioral theory and rational-emotive
therapy (RET)
3. social learning theory
4. standard behavioral therapy
5. transtheoretical model
6. person-centered therapy

7. theory of planned behavior and theory of reasoned action

8. Gestalt therapy
9. family therapy

10. self-management approach

11. the health belief model
12. developmental skills training.
Behavior Modification
 Behavioral counseling, as described by Pavlov, Skinner,
Wolpe, Krumboltz, and Thoreson, states that people are
born in a neutral state.
 Environment, consisting of significant others and
experience, shapes their behavior.
 Three modes of learning are basic to behavioral counseling:
1. Operant conditioning holds that if spontaneous behavior satisfies a
need, it will occur with greater frequency. For example, a person
who switches to a high-fiber eating pattern and finds that
constipation problems decrease will probably increase fiber in all
meals.
2. Imitation does not involve teaching a new behavior; instead, the
emphasis is on mimicking. For example, a client with elevated lipids
selects a snack low in saturated fat after a spouse or friend has just
ordered one in a restaurant.
3. Modeling extends the concept of imitation, which tends to be

haphazard, by providing a planned demonstration. Modeling implies

direct teaching of a certain behavior. For example, an overweight

client watches a videotape of someone who has lost a large amount of

weight. The model’s description or demonstration of successful weight

loss behaviors helps the client begin a weight-loss program

 Behavior modification is often described by using the ABCs

of behavior: A is the antecedent of a behavior or the

environmental cue that triggers an act. B is the behavior

itself. C is the consequence of that behavior.

 Cognitive Behavioral Therapy, Rational-Emotive
Therapy, and Disinhibition
 Cognitive behavioral therapy (CBT) focuses on the way we think about
actions we take.
 Dobson describes this form of therapy as focusing on thinking and its
effect on behavior.
 When changing behavior, relevant beliefs may be identified and altered.
 Desired dietary behavioral change may be the result of changing thought
processes or cognitions.
 Rational-emotive therapy (RET) was founded by Albert Ellis. As
one of many models of CBT, it has definite similarities to Dobson’s
approach. Ellis determined that irrationality is the most frequent
source of individuals’ problems. Self-talk—the monologues
individuals have with themselves—is the major source of emotion-
related difficulties. The major purposes of RET are to demonstrate to
clients that negative self-talk, the cause of many of their problems,
should be reevaluated and eliminated along with illogical ideas.
 Disinhibition is defined as overeating triggered by emotional and
external factors. One study supported the use of only moderate
caloric restriction in clients with a high risk of disinhibition. Data
from this study showed that rigid caloric regimens fostered
feelings of hunger and disturbance of healthy eating behaviors.
 These researchers found that disinhibition can be diminished by
enhancing self-control without a focus on restrained eating, and
by negotiation of more appropriate ways of dealing with feelings
than overeating.
Social Learning Theory
 Social learning theory builds on the idea of modeling.
 The concept is that people learn through seeing someone model a
positive behavior.
 In group counseling, one participant who is doing well might
describe or model her experiences.
 By seeing how someone else handles a difficult situation, it
becomes more feasible for a client to take on that experience and
succeed.
 Bandura has written about this theory and focuses on the

importance of self-efficacy.

 The client who is able to say, “I can do this,” is more likely to

achieve success in changing dietary behaviors.

 Those clients who see the task as too monumental will have

difficulty realizing success.

 Standard Behavioral Therapy
 A review of most lifestyle change programs reveals that both cognitive
and behavioral strategies are used simultaneously to promote diet and
exercise change.
 During the process of tailoring the programs to each client’s needs,
different components of the program may be emphasized.
 This process often involves a mixture of both cognitive and behavioral
strategies—and with the melding comes the new label, standard
behavioral therapy.
 Fabricatore and Foster discuss the collapsing of cognitive and behavioral
strategies into this one overall category
 Transtheoretical Model
 The transtheoretical model focuses on the concept of behavioral
change and occurs in stages of motivation as clients move to a more
healthful lifestyle.
 Clients may begin in initial precontemplation stage with thoughts
like: “I really don’t need to change my diet. Things are fine as they
are.” They may then move to contemplation, in which the client
looks at the pros and cons of making a behavioral change.
 A third stage is preparation, in which planning and

motivation to commit to a behavioral change occur.

 A fourth stage is action, in which actual behavior in a positive

direction is observed.

 The fifth and final stage is maintenance, in which the

behavioral change has become a habit and is sustained as a

longterm part of daily life.

 Person-Centered Therapy
 Three major concepts form the basis of this theory.
1. All individuals are a composite of their physical being, their
thoughts, and their behaviors.
2. Individuals function as an organized system, so alterations in one
part may produce changes in another part.
3. Individuals react to everything they perceive; this is their reality.
 When counselors try to change dietary behaviors, they also must be
concerned with clients’ thoughts.
 Behavioral alterations may produce changes in the clients’ physical
being as well as the cognitive (thoughtful) being.
 Counselors must also assess client perceptions thoroughly because
what clients perceive as reality influences their ability to follow an
eating pattern.
 The skill of listening is very important to this therapy.
 The goals of client-centered therapy include the following:
• promoting a more confident and self-directed person

• promoting a more realistic self-perception

• promoting a positive attitude about self16
 Rogerian, person-centered therapy focuses on each person’s worth
and dignity.
 The emphasis is on the ability to direct one’s own life and move
toward self-actualization, growth, and health.
 Gestalt Therapy
 Gestalt counseling, a form of therapy made popular in
the 1970s, emphasizes confronting problems.
 Steps toward solving them involve experiencing these
problems in the present rather than the past or the
future.
 The major goal in Gestalt therapy is to make clients
aware of all the experiences they have disowned and
to recognize that individuals are self-regulating.
 Being aware of the hidden factors related to a
problem is the key to finding an eventual solution.
 Using Gestalt therapy to help clients with dietary change involves
asking them to recognize how many “disowned” factors can
contribute to their dietary problems.
 Showing clients how to be responsible for regulating their
behavior is a practical application of the Gestalt approach to
counseling.
 The goal is for clients to take responsibility for making dietary
changes.
 For example, adolescent clients with diabetes who continuously
blame poor glucose control on parents who don’t help them
control foods or teachers who cause them to be under stress are
disowning behaviors that they could control. Helping clients set
reasonable behavioral goals when they are ready to change can aid
in solving the problem of disowning.
 Family Therapy
 In family therapy, the family is considered a system of relationships
that influence a client’s behavior, which is examined as a component
of the system.
 The individual client is always seen in the context of relationships,
with emphasis on understanding the total system in which the
inappropriate behavior exists.
 The goal is to help individuals and families to change themselves and
the systems within which they live
 One of the major techniques used in family therapy is to
involve the client’s entire family in solving problems
through open and closed questioning.
 Role-playing may be used to illustrate both the negative
aspects of “blaming” and the positive aspects, in which
praising behavioral change is emphasized.
 Health Belief Model
 The health belief model focuses on the individual’s ability to
envision success while moving toward better health by changing
behavior.
 This model includes several assumptions:

1. A person will adopt a behavior if failing to do so has consequences

that are a critical threat to lifestyle as it exists. Tied to this is the idea of
being in a situation where, without change, the client feels defenseless.

2. Changing a behavior depends on a balance between barriers versus

benefits to change.
 For example, a client decides to follow a diet low in saturated
fat after a heart attack. He feels very vulnerable, and the
consequences of not changing to healthier eating behaviors
are very real. When he looks at the scale of pros and cons to
changing dietary habits, the positive aspects of living a longer
life outweigh the barriers of socializing with friends and
eating food high in saturated fat.
Theory of Reasoned Action and Theory of
Planned Behavior
 The theory of reasoned action proposes that behavior is shaped by
the beliefs and attitudes of a person.
 A later version of this theory, the theory of planned behavior, adds
the concept of personal control as a predictor of eventual behavioral
change.
 For example, the person who believes that he/she can make a dietary
behavioral change (self-efficacy) will be more likely to achieve that
change.
Self-Management Approach
 Researchers have found that behavioral approaches support shortterm change but
usually fail to maintain change in the long run.
 Leventhal proposed several reasons for this failure: behavioral techniques fail when
contact with a health care professional is less frequent or absent, when initial symptoms
of illness lessen, and when relapse into a previous behavior pattern does not provoke any
symptoms.
 Leventhal’s theory of self-regulation is based on concepts from the behavioral approach
and the health belief model, self-efficacy, and self-management.
 The basic premise in self-regulation allows individuals to choose their own goals based
on their perceptions of their illness and related challenges.
 Individuals seek, discover, and select coping behaviors and evaluate the outcome in
emotional and cognitive terms.
 The nutrition counselor is a guiding expert who reinforces, supports, and
encourages individuals as they select, evaluate, and adjust goals and
strategies for behavioral change.
 In the contemporary self-management approach, nutrition counselors and
clients are partners. Clients problem solve and use resources beyond those of
the nutrition counselor.
 Clients develop skills and confidence (belief in personal efficacy) through
guided mastery experiences, social modeling, social persuasion, and the
reduction of adverse physiological reactions.
 Health care professionals and a social network encourage self-management
practices.
 Developmental Skills Training
 Mellin has devised a combination of theories while focusing on what she
calls the brain-based intervention program designed to promote two skills:
self-nurturing (recognizing feelings and needs and providing support) and
effective limit-setting (setting reasonable expectations, accepting difficult
situations, and experiencing the reward and benefit of such acceptance).
 Mellin’s writings focus on promoting resilience to daily life stressors and
decreasing vulnerability to stress.
 She emphasizes the tie between daily stressors and their negative effects on
mind and body which leads to the onset and progression of chronic disease.
 The theories described above are only a few of over 200 orientations
to helping clients change their behavior.
 The communication and counseling skills presented in the next two
chapters provide a
 format through which counselors can consider and use ideas based
 on these theories.
 All theories are concerned with change—the generation of ways of
thinking, being, deciding, and behaving.
 When a client changes a dietary behavior in a small way, the nutrition
counselor has a foundation upon which to support further change.
 Integrating tenets of many theories into the treatment of a client’s
dietary problems is the goal.
 One theory may work best in promoting change at one stage in a
client’s treatment; another may work well at a different point.