Promoting Change to Facilitate Self-Management

1. Promoting Change to Facilitate Self-Management Chapter 6

2. Key Terms • ABC’s of Behavior • Barriers • Behavior Chains • Cognitions • Cognitive Restructuring • Contract • Countering • Cue Management (Stimulus Control) • DASH Food Plan • Exchange Lists • Journaling • Modeling • MyPlate • Problem Solving • Reinforcement or Rewards • Thought Stopping

3. Food Management Tools • A variety of tools are available to aid in the management of eating behavior • Nutrition professionals need to become familiar with a variety of strategies • Tools differ in their degree of structure and amount of work needed on the part of clients to use the approaches • See Table 6.1 for “Advantages and Disadvantages of Food Management Tools”

4. Food Management Tools • Meal Replacements • Detailed Menus and Meal Plans • Exchange List for Weight Management • MyPlate • DASH Food Plan • Goal Setting

5. Meal Replacements • Long-term weight and health benefits have been observed in studies using meal replacements • Can take the form of shakes, bars, or portion-controlled frozen meals • Advantages: Simplify food choices, reduces exposure to temptation, portion sizes clear • Disadvantages: Maybe some concerns with taste acceptability or may interfere with social plans

6. Detailed Menus and Meal Plans • Very structured plan that may include grocery lists, menus, recipes. • Reduces stress of making choices • Software programs and websites are available • Should be planned to include client preferences • Advantages: Clearly defined, provide structure, useful with complex dietary requirements • Disadvantages: Does not allow for spontaneous events, food items needed may not be available, difficult to design to complement client’s lifestyle

7. Exchange List for Weight Management • Provides some structure but also freedom to make some choices (Appendix C) • 2 versions: • 1) diabetes meal planning • 2) weight management and more general needs • Exchange lists are organized into 4 main groups: • Carbohydrates, Meat and Meat Substitutes, Fats, Alcohol • Advantages: Offers choices, provides structure, allows for variety, meal pattern is individualized • Disadvantages: May be too complex for some individuals

8. MyPlate or DASH Food Plan • Provides guidance with some structure, but also allows freedom to select foods • MyPlate.gov provides individualized downloadable food group plans • DASH has additional food group consisting of legumes, seeds and nuts; developed for individuals with high blood pressure • Advantages: Easy to understand, flexible • Disadvantages: Requires computer technology (MyPlate), some foods may not be part of client’s usual intake (nuts, seeds, beans – DASH plan)

9. Goal Setting • For clients that do not want any type of structured eating plan, lifestyle changes can be made solely through goal setting • Complements non-dieting programs for weight management • See Chapter 5 for goal setting guidelines

10. Tracking Progress • Clients should be encouraged to track progress, regardless of method selected • Difficult to evaluate goals without self-monitoring method • Method selected should depend on the client’s ability to work with structure and details • There are several options available

11. Tracking Methods • Journaling • Checking off • Messaging • Using art • Empty bowl • Electronic note pads

12. Journaling • Shown to be effective in altering behavior and food habits • Effective tool by increasing awareness and providing a “time out” for making a decision • Intake should be recorded immediately before or after eating…. Don’t wait! • Requirements can be simple: list of foods consumed with portion sizes, physical activity • Requirements can be complicated: time, place, mood, thoughts, concerns, degree of hunger, other behavior management details

13. Journaling • Analysis of records helps counselors and clients develop new goals • The following procedures are successful in guiding clients to help manage their food intake: • Provide training on how to keep journal • Use estimates or approximations • Set meaningful and achievable goals • Provide a variety of record keeping options • Provide nonjudgmental feedback

14. Checking Off • For clients following food group plans or the exchange system, checking off boxes throughout the day can be used • Names of exchanges or food groups could be listed on form for client to “check off” • Information collected for evaluation is limited with this procedure • May appeal to those who resist writing

15. Messaging • Hand held, voice-activated recorders or leaving messages on a confidential voice mail system has been reported to work successfully

16. Using Art • Drawing pictures, scribbling or choosing colors has been used to assist clients in getting in touch with feelings or moods while consuming food

17. Empty Bowl • Put desired food objectives in a visible spot such as a bowl • Can be in the kitchen or other frequented area • Objectives are put in bowl at beginning of the day or week • Goals are assessed according to the amount in the bowl at the end of the day or week

18. Electronic Note Pads • ipad, cell phones, tablets, laptops, etc. • Good for clients that are comfortable with the technology • Can take pictures and review with counselor • Various applications available for cell phones

19. ABC’s of Eating Behavior A: Antecedent (stimulus, cue, trigger) • Focus on cues that trigger unconscious eating or eating large quantities • Behavior change strategies concentrate on physical availability of food, social, emotion or psychological • Ex/ cookie jar, parties, stress, destructive thought patterns • Behavior change can focus on avoiding or altering the cue • Ex/ remove cookies from the house or cover a piece of cake with pepper

20. ABC’s of Eating Behavior B: Behavior (response, eating) • May address the actual act of eating (speed), physical (eat in one place), emotional (do not clean your plate), awareness (pay attention to eating - no TV) or attractiveness (sparkling water in a wine glass with a lemon slice) • Behavior change may focus on providing a substitute for eating C: Consequence (punishment, reward) • Can be positive reinforcement (reward) or punishment (losing privileges)

21. Behavior Chain • Behavior Chain: Sequence of events from antecedent to consequence • See examples in Exhibit 6.1 • Behavioral strategies can address all aspects of a behavior chain or can zero in on one aspect • Eating behavior journal or diary can give clues as to what behaviors are in the greatest need of change • See Form 6.1 in Appendix D

23. Behavioral Strategies • Cue Management (Stimulus Control) • Countering • Reinforcement and Rewards • Contracting • Encouragement • Goal Setting • Modeling • Problem Solving

24. Cue Management (Stimulus Control) • Deals with the “A” (antecedent) component of a behavior chain • Identifying and modifiying social or environmental cues that trigger undesirable eating • Prearranges those cues to increase a desired response or to suppress a detrimental one • New scheme should include reminders to perform the new activity • Ex/ post-it note, note on calendar, entry on daily to-do-list, cartoon posted on refrigerator • Best if focuses on producing beneficial behaviors

25. Countering • A technique of exchanging healthy responses for problem behaviors • Deals with the “B” (behavior) component of behavior chain • Substituting one behavior for another behavior, or a food for a food • Ex/ riding an exercise bike instead of eating 2 cups of ice cream each night in front of TV • Ex/ baked chicken in lieu of fried chicken

26. Reinforcement: Rewards • Provides incentives by addressing the end of the behavior chain • Some clients need added incentive to regulate and strengthen behavior • Deals with the “C” (consequence) component of behavior • Rewards provide positive consequences • Can be tangible, especially in the initial stages of making lifestyle changes • Should be individualized, well defined • Should be timed to come after the behavior • as soon as possible after, and not before!

27. Contracting • An agreement between a counselor and a client to implement a particular goal • Can be short or long-term goals • Used for clients who want structure and accountability; should be recorded in writing

28. Contracting • Factors to consider: • Clients should define their intended behavior change • Behavioral goals should be clearly defined • Time limits should be delineated - What will happen, how often and when? • Reinforcers should be stated • Rewards have greater impact than punishment • Signing and dating the contract to reinforce client’s commitment

29. Encouragement • Usually well received, however, impact can be influenced by a client’s past experiences • The effect will vary with the credibility, trustworthiness and prestige of the person giving the words of encouragement • Can be done using email, cards, notes, voice mail, personalized signs, notes, or recorded tapes

30. Goal Setting • Provides a pathway to actually performing the new behavior • Break down desirable behavior patterns into small achievable steps • Allows for success and improvement in self-efficacy • “Nothing breeds success like success”

31. Modeling • Observing others accomplishing a similar goal can increase a client’s belief in their own ability • Can be videotapes, written testimonials, success stories, counseling buddies, role playing • Models with prestige, status or expertise are more likely to influence behavior • Clients are more likely to imitate an individual who is similar in age, gender, and culture • Modeling has greatest impact if client can practice the behavior under supervision and receive immediate feedback

32. Problem Solving • A process that involves a counselor and client working together to: • Identify a behavior chain • Detect barriers to change • Brainstorm possible options • Weigh the pros and cons of the alternatives • Objective is to design an action plan by selecting as many breaks in the behavior chain as possible • Should include a reward • Once the plan is implemented, the counselor and client should evaluate the outcomes and make any adjustments needed

33. Problem Solving: Barriers • Barriers are obstacles or roadblocks to achieving a desired lifestyle change • 4 major obstacles to reducing barriers have been identified by Danish and Laquatra: • Lack of knowledge -Lack of risk taking • Lack of skill -Lack of adequate social support

34. Problem Solving • Glasgow et al. describe a specific technique called STOP for systematically analyzing a problem and developing a solution • This problem solving method involves the following: • S-Specify the problem • T-Think of options • O-Opt for the best solution • P-Put the solution into action

35. Cognitive Restructuring • Focuses on identifying irrational thoughts and modifying them • Challenges destructive thoughts, beliefs, and internal self-talk and substituting self-enhancing cognitions • Based on the idea that cognitions are learned thinking behaviors, so they can be relearned • Thinking patterns are categorized as: • Opportunity thinking • Obstacle thinking

36. Cognitive Restructuring • Opportunity thinking allows finding constructive ways to deal with difficult situations • Obstacle thinking leads to self destructive behavior-making a difficult situation worse or giving up/retreating from problems

37. Dysfunctional Thinking • 3 components of changing dysfunctional thinking: • Internal dialogue: Ever-constant dialogue that influences our feelings, self-esteem, behavior, and stress level; clients can cope better by influencing this dialogue to provide self-enhancing messages • Mental images: Helps produce desired performance and helps clients to visualize accomplishments of intended tasks • Beliefs and assumptions: Core beliefs are deeply ingrained, leading to assumptions that trigger automatic thoughts • Exercise 6.8 “Core Belief Activity”

39. Changing Cognitions & Interventions • Steps of changing patterns of thinking: 1. Education 2. Identify dysfunctional thinking 3. Explore validity of self-destructive statements 4. Stop destructive thoughts 5. Prepare constructive responses to substitute automatic dysfunctional cognitions 6. Substitute constructive thought for destructive ones

40. 1. Education • First step is to educate your clients that their thoughts are “controllable” • Do not want self-destructive thoughts and irrational messages to remain as they will influence our actions • Written by a leading psychologist: “One of the most significant findings in psychology in the last twenty years is that individuals can choose the way they think”

41. 2. Identify dysfunctional thinking • Analyze existing beliefs and assumptions, self-talk messages, and mental imagery patterns

42. 3. Explore validity of self-destructive statements • Ask self-evaluating questions; can provide a template for clients to challenge their irrational beliefs on their own • Use humor; popular technique used by (REBT) rational emotive behavior therapy practitioners to illustrate absurdity of certain self-destructive behaviors

43. 4. Stop destructive thoughts • Thought stopping technique was developed to put an end to recurrent, self-destructive thoughts and self-dialogue • Involves mentally saying the word “STOP”, pushing away destructive automatic thoughts, andthensubstituting constructive thoughts • Imagine a big red stop sign

44. 5. Prepare constructive responses to substitute automatic dysfunctional cognitions • Intervention techniques: • Identify and develop constructive thoughts to substitute for dysfunctional ones • Use challenging self-evaluation questions • Use imagery • An intense mental rehearsal is used to set new patterns of thinking • Can imagine worst-case scenario and allow negative thoughts to emerge, then make a plan for a better response

45. 6. Substitute constructive thoughts for destructive ones • Replace destructive thoughts with previously prepared constructive thoughts • Ex/ “I learned that I shouldn’t buy potato chips”

46. Cognitive Distortions • Cognitive distortions are negative thinking patterns that have little in common with reality and hamper behavior change • They are exaggerated or irrational thought patterns • “should”, “must”, “have to” • “always”, “never”, “every” • May involve “all-or-nothing attitude”

47. Education During Counseling • Education is the primary step to changing dietary behavior and maintaining dietary objectives • Education helps clients to understand why the dietary change is important and be informed to make their own decisions • In the Nutrition Care Process (NCP), nutrition education is divided into 2 categories: • Content • Application

48. Education During Counseling • Per AND Nutrition Care Process: • Content is defined as “instruction or training intended to lead to nutrition-related knowledge” • Application addresses assistance in skill development and interpreting medical results related to a nutrition prescription • Education component of nutrition counseling must include intervention that facilitates behavior change

49. Effective Ways to Enhance Education • Effective Education Strategies • Effective Education Language • Positive or Negative Approaches

50. Education During Counseling:Effective Education Strategies • Educational targets have been linked to specific educational interventions (see below):