Diet Counseling – Is it an under-rated skill?

Padmashri ShanmugarajManaging Partner

www.PrimeHealthConsultants.co.in

A good counselor should

Excel at ‘social marketing’

Successfully ‘sell’ healthy behavior

Stages of change-Transtheoretical model

Precontemplation- Not considering change

Contemplation- Thinking if change is necessary

Preparation- Thinking of ideas to implement the change

Action- Implements the change

Maintenance – Change becomes a part of the routine

Relapse – Considering difficulties involved bcos of change

Stages of change

Can also be listed as:

Not ready-to-change

Considering meeting goals

Ready-to-change

To facilitate behavior change:

Express empathy- Accept patient’s concerns

Understand cultural factors Be familiar with cultural norms Be aware of accepted body language

Develop discrepancy – Identify advantages & disadvantages of behavior modification

Contd….

Avoid arguments- May lead o defensiveness in patient about his ideas

Roll with resistance Invite new perspectives about the same idea Don’t impose – Instead of saying “Eat this!”, say

“Its good for you if you eat this” Support self-efficacy

Words of hope, affirmation, confidence Make patient feel responsible for his change Help him choose & implement his personal

change

Stages of Intervention Interviewing

Purpose: To obtain necessary information Question in non-threatening manner Begin session with introduction of yourself Begin with open-ended questions. [For eg:

Questions starting with What, How, Why & Could]

End with close-ended, follow-up questions Establish rapport- show interest in important

aspects of patient’s life Assess current eating behavior Emphasize self-monitoring tools

Diet diary Adherence ruler, so that patient can rate his

level of adherence to diet

First session is the deciding factor!!

During the first session

Ensure privacy

Reduce interruptions- No telephone calls, no staff or patients knocking on the door etc

Body language [Discussed in detail later]

Begin with introducing goal / subject of the session – “We are here to discuss your CHO intake with regards to your insulin dosage”

Assess ‘stage of change’ & document it – Helps in facilitating the change

Body language / Non-verbal communication

Your manner of sitting should reflect interest Lean forward slightly facilitating better hearing Sit across each other with no barriers in between Maintain respectful but close distance

Introduction should accompany firm handshake

Establish direct yet varied eye-contact

Nod often to show agreement

Brief periods of silence - enables patient to think & accept changes suggested

Verbal Communication

Positive, confidence-building statements “Its great that…….. “I am really impressed that……

Show the patient example of his/her progress “ Its wonderful that you have lost 1 kg in the last fortnight” “I am happy that you are very disciplined about your diet”

Paraphrasing Concise & to-the-point repetition of patient’s history Helps patient in re-thinking about his & dietitian’s views

Summarizing Similar to paraphrasing but is more detailed Enables better communication during follow-up

‘Not-ready-to-change’ patients

Ask key open ended questions

Reflective listening - Involves guessing how the patient is feeling & phrasing it as a statement and not as a question. Helps patient realize that the dietitian understands his feelings

Affirm – Enables alignment & normalization of patient’s barriers to change. {“Its very normal that you are finding it difficult to resist sweets”}

Summarize – Periodically summarize key points

Elicit self-motivational statements – Enables patient to realize problems exist & that solutions can also be worked out

Overcoming resistant behavior Reflective listening [Discussed earlier]

Double-sided reflection: Point out discrepancies, if any, in patient’s views [“On one hand you say its possible but on the other hand you say you don’t have enough time”]

Shift focus: Enable optimistic outlook

Agree with a twist: Agree with him but redirect conversation casually to a key topic

Emphasize personal choice – Advice given can be taken or avoided: It’s a patient’s choice!!

Reframe: Enable looking at things with a fresh, positive perspective

‘Unsure-about-change’ patients

First step Build readiness to change Summarize patient’s perceptions Help him explore his ‘ambivalence’ by asking him to list pros &

cons of the change suggested Talk about how life would be after implementing the change- Tip

the balance away from ambivalence

Second step Help him choose healthier options

Third step Arrive at a plan, TOGETHER!!

‘Ready-to-change’ patients

Collaborate with the patient to set goals

Provide tools to use in meeting nutritional goals

Help him justify the decision to make a change

Map out the specifics of plan of action

Help him recognize his success at achieving a goal

Ending a session

Need not end with ‘agreeing’ to change

Acceptance that change is necessary is good enough!!

Express hope & confidence in patient’s ability to make change

Arrange for next visit : Shows that dietitian is interested!!

Thank You