1. Unit 7 Nutritional Counseling Sue Roberts, MPH MS RD/CN

2. Counseling Counseling

3.  Developed in 1991 for alcohol abuse issues  Aims to improve self control for behavior change  Uses interactive, empathic listening style  Personal goals and current behavior  Articulation by clients provides power  Reflective listening and summarizing  “Roll with resistance”

4.  “Why should I change?”  “How will I do it, and can I?”

5. “What if you woke up tomorrow and the change that you desire had already happened. What would your life be like?

6.  Key for behavior change  Four categories: 1. problem recognition 2. concern about the problem 3. intention to change 4. optimism about change

7.  Use open-ended questions to initially explore the client’s concern  Follow up with additional open ended questions to clarify and summarize  Examples

8.  Ask about prior experience with trying to solve or manage the issue  Ratings for current motivation  Envision what success looks like  Personal review of progress can be motivating

9.  Why?  Detailed summaries increase the probability that deeper reasons for change will be expressed by the client.

10. http://www.youtube.com/watch?v=nwctPF fyG8M&feature=related http://www.youtube.com/watch?v=ziH33Jq CGAU&feature=related http://www.youtube.com/watch?v=cj1BDP BE6Wk&feature=related http://www.youtube.com/watch?v=5ePJw0 NjEec&feature=related

11. J.R., a 16 year old female is present with her mother to discuss elevated blood sugars. The mother tells you her daughter has had diabetes since the age of 8 and has always done really well with it- monitoring, taking the correct amount of insulin and eating about 45-60 gm of total carbohydrates at breakfast, lunch and dinner and about 30 gm of carbohydrates for an afternoon and possibly an evening snack. Her mother is concerned because for the past 6 months, since she has started her junior year of high school and started to date a boy, her blood sugars have been erratic and more or less in the 300-500s.

12. She reports she does not believe her daughter is checking her blood sugars like she needs to be or eating correctly or even taking the right amount of insulin. She also indicates her daughter has lost about 30 lbs within these past 6 months and she does not know what to do. The daughter is very quiet during this time, so you ask both her and the mother if it would be alright for the mom to wait outside. The daughter, who is the client, eagerly agrees.

13. When you have the client alone she tells you all her friends are super skinny and because of all this insulin she has to take she got fat (however when you look at her, she looks emaciated.) She heard that if you keep your blood sugars really high you can lose weight very quickly. She also tells you she eats 2 meals a day and does not even count carbohydrates any longer. She informs you she takes half of the insulin amount she needs to and does not do the correction factor.  Height: 5’4” Weight: 110 lbs Weight history: 140 lbs (4 months ago per MD)  Labs: Blood sugar monitor for past 3 days only 4 numbers on there: 350-high

14.  Is this a form of an eating disorder and if so which type?  How would you counsel this client?  Would you tell the mom your conversation?

15. Case Study #2  A 42 year old woman, R.S., is present and very distraught that she will have to be on dialysis in another year if she does not start taking care of herself. When asked, the client told you the doctor told her this would happen. She informed you she does have a past medical history of diabetes, hypertension, renal failure and high cholesterol. She reports she is eating very little protein, not that much salt and just does not know what else to do.

16. She brought in her most current labs: BUN 24 Creatinine 2.3 Sodium 135 Potassium 4.1 Phosphorus 5.0 Glucose 105 Height: 5’5” Weight: 130 pounds Medications: Multivitamins, Omega 3s, Lipitor, Lasix, Atenolol

17. What stage of change do you believe the patient is in? What is her BMI and what do her labs indicate to you? What nutrition information would you provide to her? What goals would you establish with her? Would you follow up with her? Case Study #2

18. Case Study #3 Case Study #3  A 20 year old female, E.D., is present with type 1 diabetes and is coming to you because her blood sugars have been high for the past month. She currently is in her 3 rd year of undergraduate studying engineering. She reports she has had diabetes since the age of 5 and knows how to carbohydrate count and administer the correct amount of insulin to the amount of carbohydrates consumed, she also checks her blood sugars at least 4 times per day and when she feels bad or is sick. She admits she has been staying up later at night and eating more because of her difficult classes.

19. She also goes out on Friday nights and will drink 2-3 bottles of beer. She has not been exercising as much and has gained at least 10 pounds within the past 6 months. She would like to know how many calories and carbohydrates she needs to consume per day and how to stop the late night eating. Height: 5’9” Weight: 170 pounds Weight history: 160 pounds (6 months ago) Labs for the past 24 hours: fasting 150, before lunch 200, before dinner 180, before bed 300 Medications: Rapid acting insulin (Novolog), Long acting insulin (Lantus)

20. What is her BMI? What do her labs mean to you and what about the medications? What stage of change is the client in? How many calories and carbohydrates would you provide to her? Would you provide her with anymore nutrition information? What goals would you establish with her? Would you follow up with her? What do you think?

21. QUESTIONS?