• “If it’s OK with you, we could go over this handout I have of foods that raise your blood sugars.”
Provide
• Provide brief information snippets.
• Gauge interest level and understanding by looking at changes in nonverbal cues while you talk.
• Avoid jargon and use common terms instead.
� Salt instead of sodium.
� High blood sugar instead of hyperglycemia.
• If you feel it necessary to explain metabolic processes, do so with simple analogies.
Elicit
• Check in for understanding, engagement, and interest level.
• “What do you make of this?”
• “What’s your reaction to this?”
• “What do you think?”
FIgure 12.2. E-P-E to clarify misinformation.
from external sources, but also from internal sources. These internal or
“core” beliefs have the same effect on behavior as simple misinformation but require a little more work to evoke and discuss.
exPlorIng unheAlthy BelIeFs ABout Food,
Body IMAge, And exercIse
Internal misinformation refers to that which your clients tell themselves about food, exercise, and their bodies. This type of information may or may not have come from another resource. It may even be a compilation of many sources. Detecting unhealthy
beliefs, or those based on incorrect Unhealthy beliefs about nutrition information, is an important focus and exercise can negatively
within MI. Within the nutrition and influence emotional and social fitness professions, a primary goal is health, thereby hurting one’s to help clients improve their relation-overall health and well-being.
ship with food and discover enjoyable
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BEYOND THE BASICS
ways to move their bodies. Dietary and activity patterns are important, but physical health is only one dimension of health. Unhealthy beliefs about nutrition and exercise can negatively influence emotional and social health, thereby hurting one’s overall health and well-being.
The spirit of MI is ideal for exploring unhealthy beliefs. You will
notice a client’s belief system seems to slowly permeate the room as you start to engage, evoke, and reflect what you hear. Resist the righting reflex and focus on evoking those beliefs while expressing compassion, empathy, and self-worth whether or not you agree with them.
By asking open-ended questions about the client’s previous experiences
with health counselors, diets, and exercise programs, the client provides small morsels of information that give you an idea about her attitude on certain topics. A simple statement such as “I don’t bring ice cream into the house” highlights an important theme within the client’s belief system about food and her locus of control. Listen for statements that expose the client’s attitudes as you go along. Consider the following dialogue and the beliefs the client alludes to. The practitioner uses complex reflections and open-ended questions to engage and evoke more from the client. Once the client and practitioner unpack the origins of the thought or feeling, they can begin exploring whether there is truth in the belief and how the internal misinformation may have kept the client from making a positive health change in the past.
client: I don’t bring ice cream into the house. That way I’m not
tempted.
pRactitioneR: You believe you cannot be trusted with a whole con-
tainer of ice cream. You think you’ll lose control. [continuing the
paragraph reflection]
client: I don’t think I will. I know I will.
pRactitioneR: At what age do you remember first thinking that you
couldn’t be trusted with food? [closed-ended question]
client: Oh, gosh . . . probably 9 or 10.
pRactitioneR: What happened to make you think that you couldn’t
control yourself around food? [open-ended question—evoking]
client: I remember it exactly, actually. I was spending the summer
with my grandparents. It was after dinner one night. I think I may
even have gone to bed already, but I still wanted something to eat.
I crept out to the kitchen to get a snack and my grandma found
me poking through the refrigerator. She said to me, “Why can’t
you just stop eating?” I can feel my stomach tense now the way it
did then. I didn’t have an answer for her. I still don’t know why I
can’t stop eating.
Health Misinformation and Unhealthy Beliefs 185
pRactitioneR: When your grandmother said, “Why can’t you just
stop eating?” what you really heard was, “There is something
wrong with you.” You’ve held that belief for some time now.
[reflection]
This example comes from a chronic dieter who has lived her whole
life under the assumption that there was something wrong with her and
she could not be trusted with food. Other beliefs common among chronic
dieters are:
“I won’t get enough to eat.”
“I don’t deserve to eat what my body wants.”
“I won’t be able to handle my negative emotions without food.”
“Food is the enemy.”
Changing these core beliefs starts with identifying them and reflect-
ing them back to the client in a clear and concise way. Allow the client to consider the statement objectively. Is it true? It may have made sense at one point in time, but is it true in the present moment? In discussing unhealthy beliefs about food, fitness, and body image, practitioners often draw upon principles from cognitive-behavioral therapy (CBT), a treatment strategy that focuses on changing thought patterns as a gateway to changing feelings and, ultimately, client actions (Beck, 2005). More on CBT is discussed in Chapter 14. In the dialogue below, the practitioner marries MI and
CBT to address internal misinformation and evoke change talk for taking steps to improve body image. The practitioner in the script below senses an unhealthy belief may be at the core of the client’s distaste for clothes shopping. She engages and evokes with reflections and open-ended questions.
The practitioner asks permission before offering solutions.
client: Ugh, I hate shopping. I only go if I absolutely have to, and then it’s in and out. I don’t even try things on anymore. If it doesn’t
work out, I’ll just take it back later.
pRactitioneR: Shopping is a rather arduous experience for you.
[reflection] What is it about shopping that turns you off so much?
[open-ended question]
client: It’s just hard to shop when you’re at this size. Nothing fits
right. I always have to dig through all the normal sizes, and even
then I might not find my size. I am just so tired of this. Going into
the dressing room and coming out with nothing is too much.
pRactitioneR: You feel defeated when nothing fits. [reflection]
client: That’s a good word for it. I do feel defeated. I just don’t have the energy for it anymore.
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BEYOND THE BASICS
pRactitioneR: It’s exhausting to constantly be let down and disap-
pointed when you go shopping. [reflection] I wonder if talking
about ways to improve your body image might be a good focus
for us today. [asking permission] It’s just one thing we could talk
about; what else might you want to talk about today? [focusing]
client: I have hated my body for a long time. I see other overweight
women embracing their bodies, but I just don’t know how they
can do it. They seem happier, though.
pRactitioneR: You’d like to be happier in your own skin too. [reflec-
tion]
client: I would
like to be happier in my own skin. [change talk]
pRactitioneR: It would make you feel better about yourself if you
were able to accept your body as it is today. [reflecting change
talk]
These are pretty disturbing thought patterns that are common among
clients hoping to lose weight. Although common, they are destructive to self-esteem, often fuel overeating, and sabotage efforts at reconstructing a healthy relationship with food. Drawing attention to this negative inner dialogue is the first step in helping clients change it.
pRactitioneR: How would quieting your inner self-critic improve
your life? [open-ended question]
client: I’d probably go out more often and I’d definitely enjoy shop-
ping more. [change talk]
pRactitioneR: You’re noticing some real benefits to improving your
body image. Your inner dialogue is making it miserable for you.
[brief summary] What do you think about trying an experiment
to help neutralize that voice and make it a little easier to shop?
[asking permission]
client: What are you thinking?
pRactitioneR: I’m thinking that the shopping itself is not painful,
but your thought patterns are. If you work on changing those,
dressing yourself in clothes that flatter and fit you can be a way
of treating yourself with respect instead of making you miserable.
People don’t usually change when they feel bullied and put down,
even by themselves. They change because they feel inspired and
supported. Right now, you seem to be your own bully. [provide]
What do you think? [elicit]
client: But how can I change that? It only seems to get worse as I get
older.
Health Misinformation and Unhealthy Beliefs 187
pRactitioneR: That’s where the experiment comes in. During the
next week, when you find yourself feeling low or defeated, you
could pay attention to the inner voice and what it’s saying to you.
Some clients even find it’s useful to grab a scrap of paper and write
down everything it says in exactly the words it uses. By shining a
light on all the hateful things you say to yourself, you bring it out
of the shadows and take away its power. [provide] How do you
feel about that idea? [elicit]
client: Yeah, I see what you’re saying.
pRactitioneR: If you’d like, you can bring your paper back here next
week and we can go over it together. [provide]
client: It sounds hard. There’s a lot in there that I’m not sure I want to fess up to, but I need to do something if I want to get better.
[change talk]
pRactitioneR: It sounds scary, but you’re up for the challenge and
see how conquering this fear could radically improve your life.
[reflection of change talk plus affirmation]
This entire dialogue came about by the practitioner picking up on the
underlying belief that the client felt she was abnormal and would never reach her goals. CBT exercises that highlight negative self-talk are powerful tools within topics on body image. In nutrition and fitness counseling it all tends to be connected. One’s relationship with food, exercise, and body
image can be a microcosm of how Evoking these core beliefs about
one functions in the world. Chronic self-worth and the basic rights to dieters, for example, operate under feel nourished and whole must
the assumption that they do not sometimes be addressed before
deserve to eat when they are hungry; meaningful change can occur.
they think they are insatiable crea-
tures that require external forces to
restrict their eating behaviors and protect them from themselves. Evoking these core beliefs about self-worth and the basic rights to feel nourished and whole must sometimes be addressed before meaningful change can occur.
Whether destructive health beliefs arise from a pervasive culture that
tells people that eating chocolate is indulgent and sinful or from caregivers who imply that children can’t trust their own hunger and fullness cues, misinformation clouds and confounds clients’ attempts to engage in changes that positively affect health and well-being. Knowing how to evoke and
address external and internal misinformation can deepen engagement and
foster an environment where clients feel free to discuss the issues that actually have an effect on change.
PArt v
A Closer Look at
Motivational Interviewing in
Nutrition and Fitness Industries
chAPter 13
Put ing Motivational Interviewing
to Work in Nutrition Counseling
There are no good or bad foods. Just foods I love and
those I don’t.
—michelle may
You may be a font of nutrition knowledge, but the key to nutrition counseling isn’t just what you know about food and the human body; it’s also what you know about your client. Dietary changes can be challenging, as many clients have emotional and cultural ties to food. Solutions to everyday eating dilemmas are often individualized. No one meal plan can promise
optimal health for everyone, just as no single routine can help one to quit smoking or improve sleep habits.
Nutrition recommendations are better received when offered within
the context of a client’s experiences. In the spirit of MI, the client is the expert, knowing exactly which nutritional changes are feasible. Your client doesn’t need you to be the food police. What she needs is a practitioner who is interested in coming alongside and supporting her in managing her disease or condition as she discovers which foods make her feel alive, energetic, satisfied, and give a sense of well-being.
The purpose of this chapter is to connect the dots between MI and
topics commonly encountered in nutrition and dietetics. Many topics arise in nutrition counseling, such as adding more fruits and vegetables, reducing sugar-sweetened beverages, or emotional eating. While it’s impossible to address all topics that may arise in nutrition counseling, in this chapter we highlight a few key topics that commonly surface during nutrition appointments, including dietary changes to manage disease, meal planning, increasing dietary variety, and coping with food cravings that result in overeating.
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MI IN NUTRITION AND FITNESS INDUSTRIES
dIetAry chAnges necessAry For dIseAse MAnAgeMent
A new diagnosis that requires dietary management can overwhelm some
clients. They often arrive at the office of a nutrition practitioner looking for lists of foods they can eat and foods they will need to avoid. They are hungry for meal ideas and often overwhelmed with concern for managing
their disease and required medications. Some are frightened and ready for action and others are angry and hesitant to consider change.
The engaging process of a motivational interviewing session provides
the perfect opportunity to ask the client about the new diagnosis. Questions might include:
“What was it like to receive that diagnosis?”
“What concerns you most about the diagnosis?”
“How might this diagnosis change the way you do things?”
The client may not be ready for information. At first, he may just need a sounding board, someone to listen and to empathize. The overwhelming
nature of new diagnoses provides opportunities to demonstrate compas-
sion.
New diagnoses will not only affect dietary needs, but may also influ-
ence medication regimens and a need for other lifestyle changes such as smoking cessation or stress management. Therefore, dietary changes may
take a back seat t
o more pressing life-
style changes. In using MI, the prac-
It’s important not to overwhelm
titioner can encourage the client to
the client with facts, figures, and
focus on the changes that are most
food rules.
important to the client, accepting that
at times this may not be nutrition.
For the client who is ready to make dietary changes, consider the speed of change. In some cases, the client may need to make dramatic changes
right away. For example, a client diagnosed with lactose intolerance may choose to make an immediate reduction in lactose that will alleviate symptoms. In other cases, the client may choose to make small, gradual changes.
Making small changes over time will likely increase the client’s self-efficacy and result in lasting change. For example, a client diagnosed with heart disease may begin by replacing high-fat meats for leaner choices, changing from whole milk to 2%, or from cooking with butter to cooking with olive oil. Each small change that is successfully made builds the client’s confidence for attempting the next change.
It’s important not to overwhelm the client with facts, figures, and food rules. Take the time to set the course and collaborate on what topics to discuss. By focusing with the client, you give him or her the autonomy
to decide what you’ll talk about. Miller and Rollnick’s agenda-mapping
MI in Nutrition Counseling 193
technique from Chapter 3 can help to focus the conversation faster. Use menu options to describe changes your clients typically make with these conditions and allow the client to find a starting place that feels manageable. A dietitian might say the following:
“I have a list here of changes that clients with diabetes often make. May I show it to you? [“Yes.”] Here you will see some ideas like adding
physical activity, spacing meals or snacks more frequently throughout
the day, adding fiber and protein to meals and snacks, and reducing
sugar sweetened beverages. Which, if any, from this list sound like a
good place to start?”
For clients who are ready to make changes to food choices and eat-
ing patterns, recommended dietary modifications can provide opportuni-
Motivational Interviewing in Nutrition and Fitness Page 25
