1. Diet Counseling – Is it an
under-rated skill?
Padmashri Shanmugaraj
Managing Partner
www.PrimeHealthConsultants.co.in

2. A good counselor should
 Excel at ‘social marketing’
 Successfully ‘sell’ healthy behavior

3. Stages of change-Transtheoretical model
 Precontemplation- Not considering change
 Contemplation- Thinking if change is necessary
 Preparation- Thinking of ideas to implement the
change
 Action- Implements the change
 Maintenance – Change becomes a part of the routine
 Relapse – Considering difficulties
involved bcos of change

4. Stages of change
 Can also be listed as:
 Not ready-to-change
 Considering meeting goals
 Ready-to-change

5. To facilitate behavior change:
 Express empathy- Accept patient’s concerns
 Understand cultural factors
 Be familiar with cultural norms
 Be aware of accepted body language
 Develop discrepancy – Identify advantages &
disadvantages of behavior modification

6. Contd….
 Avoid arguments- May lead o defensiveness in
patient about his ideas
 Roll with resistance
 Invite new perspectives about the same idea
 Don’t impose – Instead of saying “Eat this!”, say
“Its good for you if you eat this”
 Support self-efficacy
 Words of hope, affirmation, confidence
 Make patient feel responsible for his change
 Help him choose & implement his personal
change

7. Stages of Intervention
 Interviewing
 Purpose: To obtain necessary information
 Question in non-threatening manner
 Begin session with introduction of yourself
 Begin with open-ended questions. [For eg:
Questions starting with What, How, Why &
Could]
 End with close-ended, follow-up questions
 Establish rapport- show interest in important
aspects of patient’s life
 Assess current eating behavior
 Emphasize self-monitoring tools
 Diet diary
 Adherence ruler, so that patient can rate his
level of adherence to diet

8. First session is the deciding factor!!
During the first session
 Ensure privacy
 Reduce interruptions- No telephone calls, no staff or patients knocking
on the door etc
 Body language [Discussed in detail later]
 Begin with introducing goal / subject of the session – “We are
here to discuss your CHO intake with regards to your insulin dosage”
 Assess ‘stage of change’ & document it – Helps in
facilitating the change

9. Body language / Non-verbal communication
 Your manner of sitting should reflect interest
 Lean forward slightly facilitating better hearing
 Sit across each other with no barriers in between
 Maintain respectful but close distance
 Introduction should accompany firm handshake
 Establish direct yet varied eye-contact
 Nod often to show agreement
 Brief periods of silence - enables patient to think & accept
changes suggested

10. Verbal Communication
 Positive, confidence-building statements
 “Its great that……..
 “I am really impressed that……
 Show the patient example of his/her progress
 “ Its wonderful that you have lost 1 kg in the last fortnight”
 “I am happy that you are very disciplined about your diet”
 Paraphrasing
 Concise & to-the-point repetition of patient’s history
 Helps patient in re-thinking about his & dietitian’s views
 Summarizing
 Similar to paraphrasing but is more detailed
 Enables better communication during follow-up

11. ‘Not-ready-to-change’
patients
 Ask key open ended questions
 Reflective listening - Involves guessing how the patient is
feeling & phrasing it as a statement and not as a question. Helps patient
realize that the dietitian understands his feelings
 Affirm – Enables alignment & normalization of patient’s barriers to
change. {“Its very normal that you are finding it difficult to resist sweets”}
 Summarize – Periodically summarize key points
 Elicit self-motivational statements – Enables patient to
realize problems exist & that solutions can also be worked out

12. Overcoming resistant behavior
 Reflective listening [Discussed earlier]
 Double-sided reflection: Point out discrepancies, if any, in
patient’s views [“On one hand you say its possible but on the other
hand you say you don’t have enough time”]
 Shift focus: Enable optimistic outlook
 Agree with a twist: Agree with him but redirect conversation
casually to a key topic
 Emphasize personal choice – Advice given can be taken or
avoided: It’s a patient’s choice!!
 Reframe: Enable looking at things with a fresh, positive
perspective

13. ‘Unsure-about-change’ patients
 First step
 Build readiness to change
 Summarize patient’s perceptions
 Help him explore his ‘ambivalence’ by asking him to list pros &
cons of the change suggested
 Talk about how life would be after implementing the change- Tip
the balance away from ambivalence
 Second step
 Help him choose healthier options
 Third step
 Arrive at a plan, TOGETHER!!

14. ‘Ready-to-change’ patients
 Collaborate with the patient to set goals
 Provide tools to use in meeting nutritional goals
 Help him justify the decision to make a change
 Map out the specifics of plan of action
 Help him recognize his success at achieving
a goal

15. Ending a session
 Need not end with ‘agreeing’ to change
 Acceptance that change is necessary is good
enough!!
 Express hope & confidence in patient’s ability to
make change
 Arrange for next visit : Shows that dietitian is
interested!!

16. Thank You