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Module 4: Practical Nutrition Support (4.5 - Theoretical & Practical…
Module 4: Practical Nutrition Support
4.1 - Appropriate Use of Food Diaries in Practice
Type of Food Diary
Rationale
Practitioner awareness
Validation technique
Protection tool
Benefits
Client self-awareness/realisation
Monitoring tool
Unsuitable for
Determining supplementation
Giving client specific and strict recommendations
Food Frequency Questionnaries
Appropriate for research, not practice
Cons
Limited detail on foods, only frequency
Details missed
Cooking method
Types of food
Bias for selecting foods from list
Cannot easily quantify foods
Granularity of data can miss the bigger picture
Pros
Can be used to monitor changes in frequency over time
Low time demand
Definition - A finite list of foods and beverages with response categories to indicate usual frequency of consumption over the time period queried
24 hour recall
Definition - A verbal account of all the food and drink consumed during the previous day
Appropriate for
Part of consultation process
Measuring clients compliance
Validate previous food diaries
Gain an insight and starting point
Research if trained interviewer
Pros
Can be completed during consultation and platform for discussion, chance to educate, demonstrate practitioner skills
Tool to understand clients dietary habits, values, beliefs, needs and wants
Low time demand
Cons
Relies on memory and may be influenced by interview situation
Does require some training and practice
Open to under-reporting - 33% under- reporting energy intake compared to 4 day food record – Liberato, Bressan & Hills (2009
Without practice, specific prompts were found to hinder recall compared to free recall - Baxter et al, (2000)
Weighed
One Day Weighed
Pros
Snapshot into dietary habits
Reliable, although as number of food records increase, reliability decreased (Fersovits, Madden & Smickilas-Wright (1978)
Definition - A pre-emptive food record on an entire days food and drink
Cons
May cause a change in dietary habits
May not be accurate if instructions are not provided or client does not provide detail
May be recorded at the end of the day, rather than continuously (memory dependent)
May not be representative - i.e. unable to compare different days training vs rest day, weekday vs weekends
Appropriate
As monitoring or awareness tool in follow ups
During consultation to allow for discussion
Provides background to dietary choices
Opportunity to educate client on how to complete an accurate multiple day food diary
Accurate snapshot
Multiple day weighed
Defintion - A pre-emptive food record for an entire days food and drink (typically between 3-7 days)
Appropriate for
Food dietary analysis
Compare differences between days
Pros
Better picture of dietary habits and allows for a variety of days
Training and rest days
Weekend and weekdays
Allows for a average and to look at fluctuations between days
Method for validating the efficacy of habit-based advice - MacDonald (2016)
Cons
As a prospective and demanding task, may change dietary behaviours
Validity of food record decreases as number of days increases
7 day - underreporting in men = 500kcal and in women 900kcal (Hallfrisch et al, 1982)
Photo diaries
Good for clients unable or unwilling to weight food
Requires skill and tinme as a practitioner
Types of feedback
Qualitative
Trends
Habits
Minimal input - quick and easy
Less suitable for clients with good habits
Needs more skill as practitioner
Less fancy = less buy in?
Quantitative
Specific calories
Macronutrient understanding
Nutrient timing
Time consuming
Requires weighed diary
Irrelevant for some clients
Delivery
Graphs/tables = specific point
Written = good for goals and recommendations
Consider pictorial booklets to help fill out diaries or with feedback
Implementing food diaries
Measurement methods
Portion control
Often very inaccurate
Household measures
Large inaccuracies
Discrepencies between international measurements
Weighed
Useful in combination with others
Demanding on time
Most accurate
Under-reporting
More prevalent in obese Kretsch, Fong, Green (1999); Cook, Pryer & Shetty (2000); Pietilainen et al (2010); Lichtman et al. (1992)
Women are more likely to underreport than men – Seunghee et al (2014); Garriguet (2008)
Financial situation and education (Bedard et al (2004)
Everyone does it - even dieticians
Don't always assume lying - get to know client. Knowing or unknowing, over or under reporting?
When to use food diaries
What will the food diary tell me with this client?
Before initial consultation?
Validation (first point of dietary recall)
Qualitative advice can be provided if service dictates
Can be used to educate client on how to accurately complete a multiple day food diary
After initial consultation?
If it is going to provide further information
Monitoring tool
Implement recommendations for a pre-determined time period and then quantify progress/tweak recommendations
Key tips
Prevent food diary fatigue
Don’t use them too often
Use a hybrid method for food diaries
Portions of fruit, information about packaged food
Get a better understanding of the client
Some clients will happily record their food for a long period
If a client refuses to complete a food diary, why?!
Get them to recored, not track
Maintain authority
Maintain control over type of feedback
Specify influence
Tips for improving accuracy
Don’t lead them
Don't include fixed spaces for meals
Get them to create portions before weighing
Provide a food diary instructions guide for your clients with:
Clear expectations
Ask them to be specific as possible and include detail
This also applies to 24h recalls
4.2 - Consultation Process - Beyond Theory & Science
Pre-consultation preparation
Sets the scene (starts to build rapport)
Insight into personality
Timewasters?
Expectations
Pricing
Platinum
Value for money
Budget
Clients will often pay slightly more than what they suggest
Realistic results?
Timeframe?
Selection process
Do you want to?
Are you able to?
Referral process
Clinical
Area of interest
Understand and compromise for solution
What they want
What they need
Pre-consultation form
What is necessary
What is relevant
Balance
Food relationship!
Key components for consultation success
Consultation room - fill with tools to increase buy-in, build rapport, and start conversations
Professional outlook (branding)
Certificates
Testimonials
Supplements
Magazines
Callipers
Tissues
Environment
Open relaxed environment
Body language
Attention to detail
1st consultation
Hints
Take into account write up
Use opportunities to educate
Identirfy their level of knowledge
Take the pressure off
Identify low hanging fruit
Allow enough time - approx. 90 mins
Process
Obvious start and end
Set expectations
Explain consultation process
Explain service
Discuss note taking
Allow them to take notes
Summarise and reiterate
Key information
Lots of questions and encouraging story-telling
Ask for reasoning
Use templates to prompt free conversations
Repetition isn't a bad thing
Questions
Open questions
Closed questions
Avoid Leading questions
Building client rapport an trust
Can boost adherence
Don't give them the same dynamic
Listen - understand them, and their situation
Maximising buy-in
Self-promote
Use testimonials
Give real-life examples
Boost motivation by using pre-consultation form to understand what they really want
Truly individualised approach
Reflective practice
Recap immediately after session
Reflect
Do anything better?
Techniques improved?
Miss anything?
Build rapport?
Acknowledge positives AND negatives
4.3 - Approaches to Client Nutrition Strategies & Programming
Choosing the correct strategy for your client
Strategies
Strategy type
Non-tracking (guidelines or habits)
Pros and Cons
Pros
Less education needed
Less time consuming
Less obsessive
Always possible
Intuitive
Seamless (when it works)
Cons
More restrictive
Need to be aware of satiety factors
Food variety
Social situations
Sleep
Food palatability
Stimulates hedonic hunger
Harder to manipulate
Hunger major issue for some
When appropriate
Most of the time
When goals are not time-dependent
When client has poor nutritional habits
When client has a low level of nutritional knowledge
When you don't believe someone will effortlessly maintain bodyweight
When client doesn't want to track
Multiple forms
Ad libitum
Intermittent fasting
Windowed eating (16:8)
Alternate day fasting
Eat, stop, eat (one fasting day a week)
CHO bunching (e.g. remove carbs from a section of the day)
CHO and Fat separation
Low carb (Johnstone et al 2008)
Low fat (Mueller-Cunningham et al 2003)
Meal
Skipping
Replacement (protein shakes)
Spontaneous calorie reduction
Regular protein feedings
Adding satiating foods (protein) (Baer et al 2011)
Increasing food volume (vegetables) (Tanumihardjo et al 2009)
Reduce food palatability
Food swaps
Crisps for popcorn
Fizzy drinks for diet versions
5% greek yoghurt for 0% greek yoghurt
Reduce food variety (Raynor et al 2012)
Reducing sugar intake
Table sauce
Ready meals
Sweetener replacement
Changing food environment
Reducing portion sizes
Don't have snacks in the house
Eat mindfully (at lable without distraction)
Smaller plate size
For performance
Post-training recovery shake
Peri-training CHO
Fasted training
Train low
Recover low
Monitoring urine colour + drinking to maintain hydration
Add salt to post training meal
Pre-bed cherry active post competition
When to use?
Increaded vegetables + fish oil only 'universal rule'
Very client dependent
Useful interventions
Checklists
Example protein sources
Traffic light decision making guide (CHO periodisation)
Low hanging fruit
Liquid calories
Reduce alcohol
Cook from scratch
Trigger times of day/week/month
Non-efficacious advice
Eat more fruit (Houchins et al 2012)
Eat less exercise more
Certain food swaps
Butter to margarine
Whole milk to skimmed milk Rautianen et al. (2016), Yakoob et al (2006), Mullie et al (2012)
Tracking
Pros and cons
Pros
The numbers don't lie
Easy to manipulate
Over-rides hunger cues
More speific
Immediate feedback
Cons
Requires more education
Time consuming
Can encourage obsessive behaciours
Not always possible
Can 'unlearn' intuitive eating
When appropriate
With specific outcomes
When client wants to
When goals are time-dependent
With high client buy-in
When client has a good relationship with food
When the client has good habits already to support non-tracking periods
Number oriented
Multiple forms (increasing commitment top to bottom)
Continuous food records
Portion control
Protein tracking
Macro ranges
Calorie tracking
Everyday
Specific days
Macro tracking
Use different types depending on client and their goal speciificity/difficulty
Sample meal plans
Bespoke
High level service
Needs support and education
Normally wouldn't be supplied until habits ahave formed
Cookie-cutter
Have a place in certain short term situations
Group settings
Give an example of 'perfect'
Low cost services
Pros + Cons
Cons
Don't use for too long
Not especially helpful without support/education
Must not be prescriptive (insurance)
Be careful not to promote nutrient deficiency
Pros
Teaches about portion size
Can build habits
Takes the thinking out of the process (reduces decision fatigue)
Can highlight non-adherences/misreporting in 'trackers'
They are the 'tracking' version of the 'non-tracking' strategies
Strategy selection
Extremity of goal?
Duration of service?
Client
Personality
Preferences
Habits
Nutritional knowledte
Skills?
Lifestyle/resources
Interventions
Time-limited (guidelines)
Life-long (habit)
Methods to support principles
Tips and tricks for specific outcomes
Weight loss
Performance
Muscle gain
Healthyh
Advanced practitioner techniqued
4.4 - Effective Client Monitoring
Qualifying monitoring
Quantitative monitoring
Physical monitoring of changes
Verbal Monitoring
Hunger
Menstrual cycle awareness
Sleep
Athletes require more (<8 hours = 1.7x injury)
Can impact insulin sensitivity + nutrient partitioning
Libido
Very low energy availability
Nutritional monitoring
Habits checklist
Daily supplements
Vegetable intake
Protein servings
Hydration
Urine colour
Bodyweight
Monitoring physical activity and exercise
Steps
Heart rate
Overtraining
Very lean individuals
Body-temperature
Recovery/DOMS
Qualitative monitoring
Check-ins
How are they feeling
Brain dumps
Method
Phonecall
Electronic
Automated
Rationale
If you can't manage it you can't measure it
Changes are more than just bodyweight (not always physiological)
Takes away focus from final 'outcome' (process based success)
Quantitative monitoring considerations + types
Factors effecting body weight
Intestinal weight
Glycogen storage (up to 15g/kg BW)
average = 500-900g glycogen
maximal = approx 1.2kg glycogen
Blood volume
Untrained - 4.7L
Runner - 6L
Weighing
Wing et al 2007
:arrow_down: disinhibition
:arrow_down: depressive symptoms
:arrow_up: dietary restraint
Maybe increased negative risk of psychological risk factors in females and younger individuals (pacanowski et al 2015
Must set expectations and educate
2kg of 'fat' = 15,400kcals!
Empower them to really understand how body weight changes
Weighing frequency (in morning) is client dependent
Can the separate self-worth from number on scales?
Skinfolds
Every 4-12 weeks
Who for?
for off-season athletes
for weight loss and not losing weight
Body fat measure
Girths
Crude measure of fat + muscle
Who for?
Health - Waist:hip ratios
Weight loss
Every 4-12 weeks
DEXA
Measures fat free mass, soft tissue mass, bone mineral density
Every 3-6 months
Who for?
Weight loss
Muscle gain
Health
Photos
Standardise lighting
Give client guidance
Watermark before and afters
Blood testing
Let doctors do their jobs (but empower clients with questions)
Avoid non-HCPC registered
Beware iatrogenesis
4.5 - Theoretical & Practical Behaviour Change (part 1)
Behaviour change
Useful for
Weight loss
Performance
Health
Weight maintenance
Research
Relative dearth in nutritional and dietary realms
Prevalent within
Smoking
Exercise
Sexual health
Alcohol
The product of individual or collective human actions, seen within and influenced by their structural, social and economic context - NICE
Theory of planned behaviour (TPB)
Theory
Intention = main determinant of action and predicted by
Attitude
Subjective norms
Perceived behavioural control
Actions easy to perform?
Sense of self-efficacy?
Self-Determination theory
Competence
Achieving control and mastery of nutritional knowledge
Difference between tracking and 'lifestyle competence'
Autonomy
Urge to be a causal agent in one's own life and act in harmony with one's integrated self
Opposite - being pressured to think or behave in certain way
Empowering people with choice about their behaviours
Relatedness
Relationships
Connectivity
Social support
Social support contributes to nutrition behaviour
Motivational interviewing theory
The focus of MI is to help people talk about and solve their ambivalence about change, and using their own motivation, energy and commitment to do it
-Rollnick et al 2008
Person-centered approach to counselling
Elicit, don't impose motivation to change
Build a good rapport to help client resolve ambivalence to change
Emotional intelligence
Refrain from being judgemental
Refrain from the 'righting reflex'
Demonstrate empathy
Cognitive behavioural therapy
Problem focued
Action oriented
Qualities
Pragmatic
structured
Focused on current problems
Positive
Chunks problems
Thoughts, feelings, behaviours
Transtheoretical Model of Behaviour Change
Assesses readiness to change
Consider exercise domain vs nutrition
Model
Contemplation
Preparation
Precontemplation
Action
Maintenance
Termination
Is it a paying client or have they been put there?
Goal theory
Approach goals
Can improve intrinsic motivation
Avoidance goals
Associated with less satisfaction with progress
Decreased self-esteem, personal control and vitality
Feeling less competent in relation to goal pursuits
Outcome goals
Process goals
4.6 - Delivering Corporate Nutrition Programmes & Other Group Education Settings
4.7 Online Coaching - Delivering Nutritional Support & Counselling Online
4.5 - Theoretical & Practical Behaviour Change (part 2)
Identity-based behaviour change
Layers of behaviour change
Your identity - the person you believe you are
The actions you take
The way the world perceives you
Goals designed to change habits
To believe in a new identity, we need to prove it to ourselves
Reminder
Tie it to a habit you already do
Routine
Reward
Create a chain of habits - 'meaningful enough to make a difference, but simple enough to get it done'
Current behaviours are a reflection of current identity
Appropriate goal setting
Outcome
Bodyweight ranges
Manage expectiations
Appropriate and agreed time frames
Process
Peformance tracking form
Habit checklist
Daily step count
Encourage clients to plan goals/behaviours that are based on process improves feelings of control, autonomy and self-efficacy
Implementation intentions
Helps prevention of relaps
Doesn't always = success
Can seem patronising!
SDT and MI in practice
SDT
Encourage autonomy
Offer clear rationale
Acknowledge internal conflict
Pros/cons
Explore clients' why
Offer alternatives
Promote confidence, focus on client strengths
Give positive feedback
It works (Silva et al 2001)
Empower client to not need you
Minimise persuasion, give them time to come to answer
MI
Principle of MI
Express empathy
Non-judgemental
Active listening
Avoid argument
Support self-efficacy
Roll with resistance - challenge thought processes
Relfection
Question
Ask for clarification
Exaggeration
Develop discrepancy
SDT & MI Checklist
8 steps for implementation
Identify ambivalence to change
Elicit self-motivating statements (I would like to...)
Sharpen focus (break down behaviour into small components)
Handle resistance effectively
Assess readiness to change (probe about barriers to change)
Shift the focus
Set an agenda (goals)
Build rapport, be professional
Encouraging change talk
Out of 10, how likely to achieve X
anything other than 9 or 10 - reply with 'never mind'
Efficacious messages (low hanging fruit)
Liquid calories
Reduce alcohol
Reduce junk food - more clean eating, more cooking from scratch
Consider
Effective
Don't eat until noon
Don't drink orange juice
Overkill
Eat 5-6 x per day
Don't eat carbs post 6pm
Practical considerations
Write it down
Behavioural contracts
Checklists
Martin's advice
Who do they want to be?
What are the habits of this person?
Gauge motivation and likelihood of being like this (1-10)
They must prove to themselves they have the ability to be that person
Leave them with automaticity (engrained behaviour)
