1. Nutritional Counseling Professor Salma Halai Badruddin Honorary Life President Pakistan Nutrition and Dietetic Society June 2009

2. Salma H Badruddin. PNDS2 What is Counseling?  Communication aimed at fostering an individuals Desire to Change  Principle: to empower the individuals to take responsibility for their own decisions and actions by increasing their self esteem and self efficacy

3. Nutritional Counseling The theoretical basis for the nutrition education process consists of Cognitive-Behavioral Therapy (CBT) This includes  Motivational Interviewing  The Health Belief Model  Trans-theoretical Model or Stages of Change Model  Social Learning Theory Salma H Badruddin. PNDS 3

4. Cognitive Behavioral Therapy  Cognitive behavioral therapy (CBT) is an umbrella term for therapies that share a theoretical basis in behavioristic learning theory and cognitive psychology, and that use methods of change derived from these theoriesumbrella termbehavioristiccognitive psychology Salma H Badruddin. PNDS4

5. 5 Motivational Interviewing  Skillful interviewing techniques can increase the nutritionist’s/dietitian’s understanding of what influences a person’s behavior  Enables the nutritionist’s to include explicit strategies for behavioral intervention.  That it results in better patient compliance, or acceptance of advice.

6. Salma H Badruddin. PNDS6 Motivational Interviewing* The process of motivational interviewing consists of three district phases.  Eliciting phase -open questions, reflection, summarizing, restructuring provoking  Information phase - help the patient gather and assimilate relevant information and look at its implications for change  Negotiating phase -what if any thing does the patient want to change? Define goal, means for achieving it and where to begin Accept patients decision for ‘no change’ but leave door open

7. Salma H Badruddin. PNDS7 The original Health Belief Model was based on four constructs of the core beliefs of individuals based on their perceptions: 1.Perceived susceptibility: an individual's assessment of their risk of getting the condition 2.Perceived severity: an individual's assessment of the seriousness of the condition, and its potential consequences The Health Belief Model*

8. Salma H Badruddin. PNDS8 The Health Belief Model* 3. Perceived barriers: an individual's assessment of the influences that facilitate or discourage adoption of the promoted behavior) 4. Perceived benefits: an individual's assessment of the positive consequences of adopting the behavior.

9. Salma H Badruddin. PNDS9 Demographic variables (age, gender, ethnicity, occupation) Socio-psychological variables ( social economic status, personality, coping strategies) Perceived efficacy (self-assessment of ability to successfully adopt the desired behavior) Cues to action (information, reminders by powerful others, persuasive communications, and personal experiences, environmental cues) The Health Belief Model* Mediating Factors

10. Salma H Badruddin. PNDS10 The Health Belief Model* Mediating Factors Health motivation (is individual driven to stick to a given health goal) Perceived control (a measure of level of self- efficacy) Perceived threat (whether the danger imposed by not undertaking a certain health action recommended is great)

11. Salma H Badruddin. PNDS11 The Intervention Process Using the Health Belief Model* Stepped change

12. The Trans theoretical Model  The objective is to empower individuals to take responsibility for their own decisions and actions by increasing their self- esteem and self-efficacy. The locus of control lies with the individual.  The practitioner respects the patient’s views and concerns. Targets are negotiated and jointly agreed Salma H Badruddin. PNDS12

13. Salma H Badruddin. PNDS13 The Trans theoretical Model  An approach to behavioral counseling especially aimed at fostering the individual’s desire to change.  The central organizing construct of the model is the Stages of Change.  When people deliberately make changes in their behavior, they go through a natural series of stages of change  Each stage has a different frame of mind about the behavior concerned and each prompts a different kind of motivation.

14. Stages of Change Model* 14 Salma H Badruddin. PNDS

15. Social Learning Theory  Social learning theory suggests that people learn new behavior through reinforcement or punishment or via observational learning. observational learning  People learn through observing others' behavior. If people observe desired outcomes in the observed behavior, they are more likely to model, imitate, and adopt the behavior themselves.  It also suggests that the environment can have an effect on the way people behave. Salma H Badruddin. PNDS15

16. 16 Principles of Behavior Modification The goal is to  Help patients move towards a positive decision to change  Provide them the means to make changes  Support them to sustain that change  Ensure that change is consolidated in their everyday life style

17. 17 Principles of Behavior Change* Set a positive, specific and achievable goal. Frame goal in terms of exact behavior. It is easier to replace a behavior with a new one than to stop doing it. Break major goals into smaller less daunting parts. Try only a few changes at a time Establish a system for monitoring the behavior to be changed Helps to assess success in changing behavior Assists in determining what contributes to and detracts from mastery

18. 18 Principles of Behavior Change* Modify the environment so that it supports the change Eliminate negative cues Provide positive cues Set up a plan for rewarding successes Rewards should be those that will be appreciated Appropriate to the magnitude of the achievement Reward should be as immediate as possible Award points towards long-range rewards to make more immediate

19. 19 Principles of Behavior Modification* Recruit support from family and friends. People may want to be helpful but may not know how Tell them of your objectives and how they can help Allow enough time for new behavior to become a habit Be prepared for back sliding and plan for dealing with it.

20. Salma H Badruddin. PNDS20 Self –Efficacy*  The belief in one’s abilities or self-efficacy is influential in determining whether individuals will change their health behavior.  Successes increase a person’s sense of mastery of a particular behavior which raises their feelings of self-efficacy, and gives confidence to continue.  Setting achievable goals for change and ensuring each is mastered before moving to the next goal increases insures success  Personal and social change relies extensively on methods of empowering individuals with the requisite knowledge, skills and belief in their self-efficacy so as to enable people to alter aspects of their lives over which they have some control

21. Conclusion Successful nutrition counseling requires that the counselors are not only well versed with nutrition concepts but also that they are skillful in applying the basic techniques of Cognitive Behavior Therapy and Behavior Modification during the counseling process Salma H Badruddin. PNDS21