UNIT VIII. NUTRITION EDUCATION AND COUNSELLING:
BEHAVIORAL CHANGE
Key factors in changing nutrition behavior are the person’s awareness that a change is needed
and the motivation to change. Nutrition education and nutrition counseling provide information
and motivation, but they do differ.
Nutrition education can be individualized or delivered in a group setting; it is usually more
preventive than therapeutic, and there is a trans-mission of knowledge.
Counseling is used most often during medical nutrition therapy, one-on-one. In the one-on-one
setting, the nutritionist sets up a transient support system to prepare the client to handle social
and personal demands more effectively while identifying favorable conditions for change. The
goal of nutrition education and nutrition counseling is to help individuals make meaningful
changes in their dietary behaviors.
Behavior change requires a focus on the broad range of activities and approaches that affect
the individual choosing food and beverages in his or her community and home environment.
Behavior modification implies the use of techniques to alter a person’s behavior or reactions to
environmental cues through positive and negative reinforcement, and extinction of maladaptive
behaviors. In the context of nutrition, education and counseling can assist the individual in
achieving short-term or long-term health goals.
Factors Affecting the Ability to Change
Multiple factors affect a person’s ability or desire to change, the educator’s ability to teach new
information, and the counselor’s ability to stimulate and support small changes.
1.Socio-economic factors
Financial constraints, unstable living environments, inadequate family or social support,
insufficient transportation, and low literacy are some of the socioeconomic factors that may be
barriers for obtaining and maintaining a healthy diet. With a population that is culturally diverse,
it is imperative to appreciate the differences in beliefs or understanding that may lead to the
inability to change.
2. Physical and emotional factors
Physical and emotional factors also make it hard to change, especially for seniors. Older adults
need education and counseling programs that address low vision, poor hearing, limited mobility,
decreased dexterity, and memory problems or cognitive impairments (Kamp et al, 2010).
Expectations of the food preparer, time restraints, routines, preferences, and roles within the
family also may hinder changes in food intake (Brown and Wenrich, 2012). For children, barriers
include taste, ease of eating, and competing foods that may be available that are less healthy
(Nicklas et al, 2013). Across all ages are issues of how culture affects what foods are eaten and
how and perceptions about education, counseling, health, and health care.
Changing behavior is the ultimate goal for nutrition counseling and education. Providing a
pamphlet or a list of foods can reinforce information, but it usually does nothing to change eating
behavior. Because so many different factors influence what someone eats, nutritionists have
been learning from behavioral scientists to identify and intervene based on mediators of
people’s eating behavior. Health professionals can support individuals in deciding what and
when to change by using a variety of health behavior.
A. Behavior Theories Used in Nutrition Education and Counseling
1. Health Belief Model (HBM)
The health belief model (HBM) focuses on a disease or condition, and factors that may
influence behavior related to that disease (Rosenstock, 1974). The HBM has been used most
with behaviors related to diabetes and osteoporosis, focusing on barriers to and benefits of
changing behaviors (James et al, 2012; Plawecki and Chapman-Novakofski, 2013)
Perceived susceptibility: An individual’s belief regarding the chance that he or she may get a
condition or disease
Perceived severity: An individual’s belief of how serious a condition and its consequences are
Perceived benefits: An individual’s belief in the positive effects of the advised action in
reducing the
risk or the seriousness of a condition
Perceived barriers: An individual’s belief about the tangible and psychologic costs of the
advised action
Self-efficacy: An individual’s belief that he or she is capable of performing the desired action
Cues to action: Strategies to activate one’s readiness to change a behavior
2. Social Cognitive Theory (SCT)
Social cognitive theory (SCT) represents the reciprocal interaction among personal,
behavioral, and environmental factors (Bandura, 1977, 1986). This theory is extensive and
includes many variables; some of the most important to counseling include self-efficacy, goal
setting, and relapse prevention (Poddar et al, 2012)
Personal factors: Outcome expectations, self-efficacy, reinforcements, impediments, goals
and intentions, relapse prevention
Behavioral factors: Knowledge and skills, self-regulation and control, and goal setting
Environmental factors: Include imposed, selected, and created environments
3. Theory of Planned Behavior (TPB)
The theory of planned behavior (TPB) and the reasoned actions approach are based on the
concept that intentions predict behavior (Ajzen, 1991; Fishbein and Ajzen, 2010). Intentions are
predicted by attitudes, subjective norms (important others), and perceived control. This theory is
most successful when a discrete behavior is targeted (e.g., vegetable intake) but has also been
used for healthy diet consumption (Sheats et al, 2013).
Subjective norms: The people who may influence the patient
Attitudes: What the patient thinks about the behavior
Perceived control: How much control the patient has to change things that affect the
behavior
Behavioral intention: Whether the patient plans to perform the behavior
4. Transtheoretical Model (TM), or Stages of Change Model
The transtheoretical model (TTM), or stages of change model, has been used for many
years to alter addictive behaviors and often is described as “tailored education.” TTM describes
behavior change as a process in which individuals progress through a series of six distinct
stages of change, as shown in Figure 14-1 (Prochaska and Norcross, 2001). The value of the
TTM is in determining the individual’s current stage, then using change processes matched to
that stage (Mochari-Greenberger et al, 2010).
FIGURE 14-1 A model of the stages of change. In changing, a person progresses up these
steps to maintenance. If relapse occurs, he or she gets back on the steps at some point and
works up them again.
Precontemplation: The individual has not thought about making a change.
Contemplation: The individual has thought about making a change but has done no more
than think about it.
Preparation: The individual has taken some steps to begin to make the desired change.
Action: The individual has made the change and continues it for less than 6 months.
Maintenance: The individual has continued the behavior for longer than 6 months.
Termination: The individual no longer thinks about the change; it has become a habit.
MODELS FOR COUNSELING STRATEGIES
Cognitive behavior therapy (CBT) focuses on identifying and changing erroneous perceptions
of the self, environment, and behavioral consequences. CBT often identifies behavior and
thoughts that have a negative impact on desired behavioral goals and apply strategies to
change those. CBT counselors can help clients explore troubling themes, strengthen their
coping skills, and focus on their well-being (Beck, 2011).
CBT often is used for obesity interventions and eating disorders as well as a range of
psychologic and psychiatric disorders (Cooper et al, 2010; Murphy et al, 2010).
Motivational interviewing (MI) has been used in a variety of conditions to encourage clients to
identify discrepancies between how they would like to behave and how they are behaving and
then motivate them to change. The following are principles used in MI to enhance behavior
change (Johnston and Stevens, 2013).
1. Expressing Empathy.
The nutrition counselor should demonstrate empathy for what a client feels, rather than
giving advice. As clients review situations in their lives and the lack of time for dietary changes,
the nutrition counselor will hear ambivalence. On the one hand, clients want to make changes;
on the other hand, they want to pretend that change is not important.
2. Developing Discrepancy.
An awareness of consequences is important. Identifying the advantages and
disadvantages of modifying a behavior, or developing discrepancy, is a crucial process in
making changes.
Client: I want to follow the new eating pattern, but I just can’t afford it.
Nutrition counselor: Let’s look at your diet record and discuss some healthy, low-cost
changes.
3. Rolling with Resistance (Legitimation, Affirmation)
Rolling with resistance involves inviting new perspectives without imposing them. The client is a
valuable resource in finding solutions to problems. Perceptions can be shifted, and the nutrition
counselor’s role is to help with this process. For example, a client who is wary of describing why
she is not ready to change may become much more open to change if she sees openness to
her resistive behaviors. When it becomes okay to discuss resistance, the rationale for its original
existence may seem less important.
Client: I just feel that my level of enthusiasm for following the diet is low. It all seems like
too much effort.
Nutrition counselor: I appreciate your concerns. At this point in following a new diet,
many people feel the same way. Tell me more about your concerns and feelings.
4. Supporting Self-Efficacy.
Belief in one’s own capability to change is an important motivator. The client is responsible for
choosing and carrying out personal change. However, the nutrition counselor can support selfefficacy by having the client try behaviors or activities while the counselor is there.
Client: I just don’t know what to buy once I get to the grocery store. I end up with
hamburger and potato chips.
Nutrition counselor: Let’s think of one day’s meals right now. Then we can make a grocery
list from that.
Assessing Readiness to Change
One purpose of assessment is to identify the client’s stage of change and to provide appropriate
help in facilitating change. The assessment should be completed in the first visit if possible.
COUNSELING APPROACHES AFTER THE ASSESSMENT
Not-Ready-to-Change Counseling Sessions
In approaching the “not-ready-to-change” stage of intervention, there are three goals:
(1) facilitate the client’s ability to consider change,
(2) identify and reduce the client’s resistance and barriers to change, and
(3) identify behavioral steps toward change that are tailored to each client’s needs.
At this stage identifying barriers from, the influence of subjective norms and attitudes (TPB), or
personal and environmental factors (SCT) that may have negative influences on the intention to
change can be helpful. To achieve these goals, several communication skills are important to
master: asking open-ended questions, listening reflectively, affirming the patient’s statements,
summarizing the patient’s statements, and eliciting self-motivational statements.
To show real understanding about what the client is saying, it is beneficial to summarize the
statements about his or her progress, difficulties, possible reasons for change, and what has to
be different to move forward. This paraphrasing allows the client to rethink his or her reasoning
about readiness to change. The mental processing provides new ideas that can promote actual
change.
UNSURE-ABOUT-CHANGE COUNSELING SESSIONS
The only goal in the “unsure-about-change” session is to build readiness to change. This is the
point at which changes in eating behavior can escalate. This “unsure” stage is a transition from
not being ready to deal with a problem eating behavior to preparing to continue the change. It
involves summarizing the client’s perceptions of the barriers to a healthy eating style and how
they can be eliminated or circumvented to achieve change. Heightened self-efficacy may
provide confidence that goals can be achieved. A restatement of the client’s self-motivational
statements assists in setting the stage for success.
One crucial aspect of this stage is the process of discussing thoughts and feelings about current
status. Use of open-ended questions encourages the client to discuss dietary change progress
and difficulties. Change is promoted through discussions focused on possible reasons for
change.
RESISTANCE BEHAVIORS AND STRATEGIES TO MODIFY THEM
Resistance to change is the most consistent emotion or state when dealing with clients who
have difficulty with dietary change. Examples of resistance behaviors on the part of the client
include contesting the accuracy, expertise, or integrity of the nutrition counselor; or directly
challenging the accuracy of the information provided (e.g., the accuracy of the nutrition content).
The nutrition counselor may even be confronted with a hostile client. Resistance also may
surface as interrupting, when the client breaks in during a conversation in a defensive manner.
In this case the client may speak while the nutrition counselor is still talking without waiting for
an appropriate pause or silence. In another, more obvious manner, the client may break in with
words intended to cut off the nutrition counselor’s discussion.
When clients express an unwillingness to recognize problems, cooperate, accept responsibility,
or take advice, they may be denying a problem. Some clients blame other people for their
problems (e.g., a wife may blame her husband for her in-ability to follow a diet). Other clients
may disagree with the nutrition counselor when a suggestion is offered, but they frequently
provide no constructive alternative. The familiar “Yes, but …” explains what is wrong with the
suggestion but offers no alternative solution.
READY-TO-CHANGE COUNSELING SESSIONS
The major goal in the “ready-to-change” session is to collabo-rate with the client to set goals
that include a plan of action. The nutrition counselor provides the client with the tools to use in
meeting nutrition goals. This is the stage of change that most often is assumed when a
counseling session begins. To erroneously assume this stage means that inappropriate
counseling strategies set the stage for failure. Misaligned assumptions often result in lack of
adherence on the part of the client and discouragement on the part of the nutritionist. Therefore,
it is important to discuss the client’s thoughts and feelings about where he or she stands relative
to the current change status. Use of open-ended questions helps the client confirm and justify
the decision to make a change and in which area.
B. PROGRAMS AND SERVICES AVAILABLE IN GO’s and NGO’s
➢ Araw ng Sangkap Pinoy (ASAP) and Garantisadong Pambata (GP)
The provision of vitamin A capsules, iron tablets, and iodized oil capsules to nutritionally
at risk groups with nutrition education and campaign for home- and community-food
production and the practice of healthy lifestyles and practices.
➢ Barangay Program of Action for Nutrition (BPAN)
Project implemented by the Nutrition Center of the Philippines (NCP) and local
government units to improve the nutritional status of women and children through the
delivery of minimum nutrition services, i.e. Nutrition Information and Education, Home
and Food Security, Micronutrient Supplementation, and Growth Monitoring at the
grassroots level.
➢ Early Child Growth and Development
Project of Department of Health and Helen Keller International to improve specific infant
feeding behaviors of mothers for 0-12 months old children through nutrition classes and
counseling at the home or health center.
➢ Health and Nutrition Kiddie Class
A Health and Nutrition Program of the Nutrition Foundation of the Philippines (NFP)
conceptualized for preschool children to enable them to learn the importance of food in
relation to health, know the various nutrients needed by the body and its sources;
practice personal hygiene; be an advocate of environmental sanitation; help improve
their nutritional status through regular weighing; and be a healthy child (physically and
mentally alert). A unique feature of Health and Nutrition Kiddie Class is the volunteer
teachers who handle all the classes; they are mothers called “mother coordinators or
youth from the community/barangay called nutrition youth coordinators trained to teach
by NFP.
➢ Healthy Diets
Campaign of the Department of Health for a diet low in fat and sodium to prevent
lifestyle-related degenerative diseases by giving Information, Education, and
Communications (IEC) materials under the Iwas Sakit Slogan.
➢ National Nutrition Education Program (NNEP)
The NNEP translates and operationalizes the Nutrition Education impact program of the
Philippine Plan of Action for Nutrition (PPAN) into doable and concrete actions and
projects to achieve nutritional goals by integrating, rationalizing and harmonizing all
nutrition education efforts of government and private sectors towards improving nutrition
and health- related practices of pregnant and lactating women, children 0-5 years old
and school- aged children, including key influencers or those who can affect or influence
the behaviors of the primary targets.
➢ Nutrition Education Reinforcement Project
Project of the Council of American Relief Everywhere (CARE), Department of Health,
and National Nutrition Council using FLANE (Fun Learning Activities for Nutrition
Education) kit in nutrition classes that focused on vitamin A, iron, and iodine in 10
provinces.
➢ Pabasa sa Nutrisyon
An innovative approach to strengthen the implementation of the 5 Impact Programs of
the Philippine Plan of Action for Nutrition namely, Home, School and Community Food
Production, Micronutrient Supplementation, Food Fortification, Nutrition Education, and
Food Assistance. Pabasa sa Nutrisyon is designed by the Nutrition Center of the
Philippines to empower women in reducing their family’s vulnerability to malnutrition
through the adoption of proper nutrition practices and healthy lifestyles.