MODULE ID-F14TN38- TECHNIQUES IN DIET COUNSELLING AND GUIDELINES 
                       PAPER NO.F14- THERAPEUTIC NUTRITION 
                       F14TN38- TECHNIQUES IN DIET COUNSELLING AND GUIDELINES 
                       1.  INTRODUCTION 
                           Diet counselling is a combination of nutrition expertise and psychological skills delivered by 
                       a trained dietitian. Diet counsellor’s role is no longer seen as mere information on dispenser but 
                       rather as an agent for changing food and eating behaviour for better health. 
                           Dietitians must focus on disease prevention in addition to traditional responsibilities. The 
                       change in the role of dietitians will be driven by the shift in disease pattern from communicable to 
                       non communicable diseases in the population. 
                           Epidemiological studies have implicated life style factors such as diet, lack of exercise and 
                       cigarette smoking in the growth of chronic diseases. He solution lies in educating people to 
                       change their behaviour e.g., eating healthy diets, exercising more, quitting smoking.  
                           Dietitians have access to patients and their relatives and they must exploit the opportunity to 
                       give them health and nutritional advice. They can dispel myths and misconceptions about foods 
                       especially fads by media reports and advertisements. 
                       2.  OBJECTIVES 
                                   To understand the techniques involved in diet counselling. 
                                   To learn about stages and process of intervention and models that can be used. 
                                     
                       3.  DIET COUNSELLING 
                           Hospital dietitians could address large groups of patients attending clinics, such as the 
                       paediatrics and gynaecology, OPDs on the importance of nutrition. Dietitians could prepare easy 
                       to understand leaflets on nutrition for distribution to patients. 
                          The major objective of dietary counselling should be to educate the patients regarding the 
                           nature of the disease, its hazards and how it can be recognized and prevented. 
                          Advice on personal hygiene, individual instructions on diet and any specific therapy. 
                          For effective dietary counselling, a team approach (physician- dietitian – nurse- patient) 
                           should be encouraged for success in diet therapy. 
                          A good rapport should be established with the patient. 
                          They should be made aware of the fact that diet plays an important role in the prognosis of the 
                           disease and that they should strictly follow the guidelines of diet therapy. 
                          Also they should be encouraged for a regular follow up programme in order to remain in 
                           sound health. 
                          Apart from food service, the diet clinic an out patient service helps in wider use of dietary 
                           counselling and serves to extend and clarify diet instruction and have follow ups. 
                          Whenever possible, home visits may also help in ensuring the adjustment of the patient to the 
                           home environment. 
                          Programmed instruction through booklets, food models, charts and other audiovisual aids 
                           merit attention due to their great impact and flexibility of use for many kinds of people. 
                   
                  MODULE ID-F14TN38- TECHNIQUES IN DIET COUNSELLING AND GUIDELINES 
                          In food clinic or health centre, group therapy may also be used with advantage for such 
                           groups as pregnant and lactating women, women with preschool children, diabetic patients, 
                           weight control groups and so on. 
                            
                            
                            
                            
                       3.1 NON-COMPLIANCE TO DIET ADVICE 
                       Large proportion of patients fail to adhere to advice on diet, exercise and blood glucose 
                  monitoring leading to risk of complications. Some of the possible reasons for non compliance are: 
                             Primary care providers do not consistently provide counselling to their patients. 
                             Patients are not referred for nutritional counselling. 
                             Resistance to changing a diet. 
                             Competing time and energy demands. 
                             Genetic characteristics may have greater effects. 
                             Lack of relevant educational materials. 
                             Diet therapy is infrequently prescribed. 
                             The changes required are life ling, so lifestyle need to be changed. 
                             Family cooperation is required. 
                             The impact of nutrition counselling is not dramatic and those who do not have patience 
                                may stop compiling. 
                             Festivals and party occasions may disturb the schedule. 
                             Special effort has to be taken when patient eats outside the home in the restaurant or 
                                relative’s place.  
                             Patients who work long hours in the working place may not comply with dietary advice. 
                           When educating patients about the disease, dietitians must first treat any existing depression 
                  and take into account the patient’s education level and cognitive ability. Usually older the patient and 
                  the longer the duration of disease and treatment the better is the compliance with dietary guidelines.  
                           Primary health care personnel need to give due importance to diet and exercise. Dietitians 
                  should focus on providing dietary alternatives for the married and working patients. They can suggest 
                  ways of modifying the family diet according to patient’s needs. 
                                     
                       3.2 COUNSELLING TECHNIQUES 
                       The main objective of counselling is to bring about the changes that need to be made. People are 
                  motivated to change through their ability to self manage behaviours. The nutritional counsellor sets up 
                  an environment that is a transient support system to prepare the patient to handle social and personal 
                  demands more effectively while providing favourable conditions for change. 
                       Different strategies may be used to offer guidance. One style is cognitive behavioural therapy, 
                  which assumes that thinking affects behaviour; that relevant beliefs may be identified and altered; and 
                  that desired behaviour change may be achieved through changes in thinking (cognition). 
                   
       MODULE ID-F14TN38- TECHNIQUES IN DIET COUNSELLING AND GUIDELINES 
         Motivational interviewing, initially developed for addiction counselling, has increasingly been 
       applied in public health, medical and health promotion settings. By using this technique, the 
       counsellor can help the patient move through various stages of change. 
         This helps the client recognize and do something about concerns and problems. The client is 
       responsible for making the change. The goal is to increase the client’s intrinsic motivation so that he 
       or she can express the rationale for the changes. Persuasion and support are key elements of this style 
       of counselling. 
         3.3 Concepts to consider in facilitating dietary changes 
           
            People make behavioural changes only when they are ready to change. 
            The nutrition intervention, including both the content and nutritionist’s style is a powerful 
            determinant of resistance and denial, as well as motivation in persons who want to make 
            changes in their diet. 
            People cycle through different phases of changing and maintaining their dietary 
            modifications. 
            Different interventions are needed for persons who are in different phases of motivation. 
            Ambivalence is a key block that can be resolved through intervention. 
            Resistance and denial get in the way of meeting behavioural goals. 
             
         3.4 STAGES OF CHANGE 
          The transtheoretical model, also referred to as the stages of change model, describes 
         behaviour change as a process in which individuals progress through a series of six distinct stages 
         of change. 
           Precontemplation  
          This is the point at which the patient has not even contemplated having a problem or needing 
          to make a change. A person in the precontemplative stage needs information and feedback to 
          raise his or her awareness of the problem and possibility of change. Nutrition advice for 
          eating changes is counterproductive at this point. 
           
           Contemplation 
          Once some awareness of the problem arises, the person enters a period of ambivalence; the 
          contemplation stage. The contemplator seesaws between reasons to change and reasons to 
          stay the same. At this stage, the counsellor works with the patient on advantages and 
          disadvantages of making dietary changes. 
           
           Preparation  
          The preparation stage is a window of opportunity that allows the patient either to move 
          forward or fall back into contemplation. At this point, the patient needs help in finding a 
          change strategy or goal that is acceptable, achievable and appropriate. 
           
           Action 
          The patient engages in actions that bring about change. At this point, the goal is to produce a 
          change in the problem area. 
           
           Maintenance  
        
                  MODULE ID-F14TN38- TECHNIQUES IN DIET COUNSELLING AND GUIDELINES 
                          During this stage, the challenge is to sustain the change accomplished by previous action and 
                          to prevent relapse. 
                           
                        Relapse  
                          If relapse occurs, the individual’s task is to start the change process again rather than become 
                          stuck in this stage. Slips and relapses are normal, expected occurrences as a person seeks to 
                          change any long standing pattern of behaviour. The goal is to resume action efforts. 
                           
                          Traditional nutrition counselling focuses on the change process matched to the action and 
                  maintenance stages. This works well for persons who are actively trying to make behaviour change; 
                  however, most persons who have problem dietary behaviour are in preaction stage that includes one 
                  of the following: precontemplation, contemplation or preparation.  
                          These persons are not yet ready to change. The traditional approach, which assumes that the 
                  patient is already in the action or maintenance stage, does not meet the needs of many and may be one 
                  of the reasons to lack of success in long term maintenance of many intervention programs. 
                      3.5 ACTIVITIES THAT FACILITATE CHANGE 
                      A variety of principles are important when determining what facilitates change. The following are 
                  important when working with persons struggling with change. 
                      3.5.1    Expressing empathy 
                      Counsellor acceptance of what a patient feels in times of turmoil can often result in change. 
                  Acceptance facilitates change. It is also a skilful form of reflective listening, which would allow 
                  people to describe their thoughts and feelings while the nutritionist reflects back their understanding. 
                      Many people have no one to talk to about problems in their lives. This opportunity to have 
                  someone listen  and really try to understand the emotions behind the words is crucial to eventual 
                  dietary change. 
                      As most people talk about their lives and a lack of time for dietary changes, the counsellor will 
                  hear ambivalence. On one hand, patients want to make changes; on the other hand, they want to 
                  pretend that change is not important. Ambivalence is normal. 
                       
                      3.5.2    Understanding cultural factors 
                      Effective culturally specific nutrition counselling is dependent on sensitive communication 
                  strategies. Changes in eating habits can be affected by what is valued. The nutrition counsellor should 
                  be familiar with the cultural norms regarding indirect or direct questioning, formality or informality, 
                  eye contact and individual space. 
                       
                      3.5.3    Developing discrepancy 
                      An awareness of consequences is important. Identifying the advantages and disadvantages of 
                  modifying behaviour or developing discrepancy is a crucial process in making changes.