Nutrition Interview

NUTR 348

Virginia A. Bennett, PhD, RD


Class Syllabus Class Schedule
Forms Assignment
Mid-term  Project  Final Project
JADA research paper SMOG
Interview Schedule : Welcome to International Food Information Council Foundation

Text: Bauer, Kathleen and Carol Sokolik: Basic Nutrition Counseling Skill Development
VHS video required.

General Description: This course will focus on identifying techniques, procedures and skills related to nutrition interviewing and counseling. This course is a pre-requisite for participating in the Peer Nutrition Counseling Program at the Health Center (along with the completion of NUTR 448, Nutrition, Weight Control and Exercise).

Student Outcomes:
At the end of this course the student will be able to:
1. Develop a foundation knowledge about nutrition counseling goals and theories.
2. Understand the basics of an effective counseling relationship.
3. Develop interpersonal skills needed for productive counseling intervention.
4. Utilize effective counseling responses.
5. Follow a stet-by-step protocol to implement a counseling intervention.
6. Develop a nutrition care plan.
7. Select appropriate food management tools according to a client's desire for structure.
8. Chart a counseling intervention using two methodologies.

Exams and Exam Schedules: Exams will be derived from lectures and assigned readings and will consist of short answer discussion questions. No exams will be given outside of the agreed upon test time unless the student has had a family tragedy, and extended illness, or some other acceptable excuse. Notification of instructor must be made prior to the test. No notification will result in a zero grade.

Assignments: Assignments must be turned in at the beginning of class. Assignments turned in later in the day will be considered late. Late assignments will be docked 10% of the point total fore each day they are late.

Assignment 50 points
Mid Term Project 50 points
Final Project 100 points
Total Points 200 points

90 - 100 % = A Grade
80 - 89 % = B Grade
70 - 79 % = C Grade
60 - 69 % = D Grade
< 60% = F Grade

Typical Class Schedule

Date Class Content Assignments
9/25 Course Overview-Preparing to Meet the Client Chapter 1
10/2 Video Critique  See Assignment
10/9 Basic Counseling Responses Chapter 2
10/16 The Counseling Interview Chapter 3 Assignment Due
10/23 The Counseling Interview  
10/30 Class discussion  
11/6 Developing a Nutrition Care Plan Mid-term Project Due Chapter 4
11/13 Promoting Change Chapter 5
11/20 Promoting Change  
11/27 Final Student Project  
    Final Project Due


Nutrition Interview
Student Outcomes:
Develop foundation knowledge about nutrition counseling
Understand the basics of an effective counseling relationship
Identify the methods for obtaining diet history information
Evaluate the nutritional status of an individual

Nutrition Interview
Student Outcomes:
Identify the techniques for effective nutrition counseling
Develop a nutrition care plan
Select appropriate food management tools according to the client’s needs

Medical Nutrition Therapy
Delivering nutrition services to treat illness, injury and chronic medical conditions.
Guiding a client toward a desirable nutrition lifestyle to:
treat and or prevent certain disease states and,
solve problems that are barriers to change.

Medical Nutrition Therapy
Two Phases:
Assessment of the nutrition status of the patient or client and
Treatment, which includes diet therapy, counseling and use of specialized nutrition supplements.

Evidence of Cost Effectiveness of MNT
For Cancer - $10,535 savings because MNT enhances effectiveness of chemotherapy and radiation therapy
For Heart Disease - $9,134 savings because MNT reduces the need for drugs and other artery-clearing procedures and or surgery

Evidence of Cost Effectiveness of MNT
For Type I Diabetes - $9,949 savings because diabetic complications that cause hospitalization are reduced.
For Type II Diabetes - $1,994 savings because MNT reduces or eliminates the need for insulin or oral agents.
For Kidney Disease- $18,467 savings by postponing the need for dialysis.

Evidence of Cost Effectiveness of MNT
For High Cholesterol - $2,709 savings by reducing the need for drugs
For Hypertension - $4,075 savings by reducing the need for drugs and preventing complications such as stroke.

Goals for Nutrition Counseling
Facilitate lifestyle awareness
Facilitate lifestyle decision making
Take appropriate action to obtain a healthier lifestyle and become self sufficient

Factors Affecting Food Choices
Biological Factors
Special physiological conditions - i.e. pregnancy
Special diseases or abnormal conditions
Taste preferences (genetically determined)
Individual cravings or idiosyncrasies

Factors Affecting Food Choices
Environmental Factors
Time constraints
Food availability
Housing features
Societal and family pressures

Factors Affecting Food Choices
Cultural Factors
Understanding of nutrition/ Health concepts
Social class, status
Traditions, beliefs, values

Factors Affecting Food Choices
Awareness, motivation and attitudes about the role of food in health and disease

Nutrition Counseling- Trans -theoretical Model
Stages of Change:
person is unaware that a problem exists, denies there is a problem or is not interested in change.
is aware the problem exists, but has no serious thought or commitment to change.
May remain in this stage for months or years.

Nutrition Counseling
Preparation Stage
more determined to change or intending to take action soon (~30 days).
Action Stage
Over-come the problem by actively modifying their habits.

Nutrition Counseling
Maintenance Stage
consolidate and stabilize gains made for several months to maintain the new, healthier habits and prevent relapse.

Stages of Change

Nutrition Counseling - Precontemplation
Raise self-awareness of their behavior
Raise awareness of health concern and implications.
Show how their behavior may effect others around them
Encourage them to express their feelings

Nutrition Counseling - Contemplation
Identify and discuss their concerns, beliefs and perceived barrier toward their behavior
Show how benefits of change outweigh the risks to not changing
Clarify any ambivalence felt toward changing
Provide or suggest resources for learning more about the solution

Nutrition Counseling - Preparation
Help them develop a plan of action
Teach specific “how to” skills
Help build their self-confidence they can form a new behavior
Help them access education programs and obtain resources needed for change

Nutrition Counseling - Action
Reinforce their decision to change
Provide emotional support to continue behavior change they’ve started
Explain the difference between lapse vs. relapse
Help them evaluate their progress and teach additional skills as needed.

Nutrition Counseling -Maintenance
Offer ideas or ways to maintain change
Help them build a supportive environment around them to maintain the change
Continue teaching relapse prevention techniques
Help validate rationale for change

Components of Nutrition Counseling Process
Opening – Involving Phase
Establish rapport
Discuss purpose

Components of Nutrition Counseling Process
Exploration – Education Phase
Assesses food behavior and activity patterns
Explores problems, skills and resources
Provides nonjudgmental feedback
Provides education
Elicit client response
Assesses readiness to change

Components of Nutrition Counseling Process
Resolving Phase
Tailors education experience to clients needs
Level 1 – Not motivated, not ready
Goal – Raise doubt about present dietary behavior
Raise awareness
Personalize benefits
Promote change talk
Respect decision

Resolving Phase
Level 2 – Unsure, low confidence
Goal – Build Confidence
Raise awareness of benefits of change
Explore ambivalence
Explore behaviors
Imagine the future
Encourage support
Explore successes

Resolving Phase
Level 3 – Motivated, confident, ready
Goal – Develop an action plan
Phrase positive behaviors
Explore options
Negotiate realistic short-term goals
Develop action plan

Parts Of The Interview
Closing Phase
Support self-efficacy
Summarize issues and strengths
Arrange for follow-up

Basic Counseling Responses
Attending –
Attending behavior including listening
Reflection or Empathizing –
Identifying feelings being expressed by client

Counseling Responses
Ligitimation –
Acknowledging that it is normal to have such feelings and reactions
Respect –
Words of appreciation on the ability of the client to overcome adversity and to adjust to difficult situations.

Counseling Responses
Client and counselor respect each other and work together to find solutions
Personal Support
Making it clear that your are there to help them.

Counseling Responses
Paraphrasing –
Rephrasing content of what has just been said
Giving Feedback
Giving feedback to client on what you have just observed
Clarifying (probing, prompting)

Counseling Responses
Telling the client exactly what needs to be done.
Noting Discrepancy

Open questions
Closed questions

Developing a Nutrition Care Plan

Obtaining Diet History Information
Client Assessment
Address information about historical data:
Health History
Drug History
Psychosocial History
Anthropometric data
Biochemical analysis

Obtaining Diet History Information
Client Assessment Questionnaire
Clues to strengths and potential barriers
Provides good overview of client’s history
May appear invasive
May not be culturally sensitive

Obtaining Diet History Information
Food Diary -
Food intake record kept by the client for a specified period of time, usually 3 - 4 days.
Client assumes an active role
May get a good idea of the client’s life style and factors which affect food intake.
Does not depend on memory

Obtaining Diet History Information
Food Record or Food Diary
Requires a motivated client; time consuming
Conscious or unconscious changes in eating behaviors.
Poor compliance with record keeping
Requires ability to judge portion sizes

Obtaining Diet History Information
24 Hour Recall -
Consists of obtaining information on food and fluid intake for the previous day or previous 24 hours.
easy to obtain
takes less time than other methods
does not influence usual diet

Obtaining Diet History Information
24 Hour Recall
May not be a “typical” day
Difficulty in estimating portion sizes of food consumed
Difficulty in recalling foods eaten; relies on memory

Obtaining Diet History Information
Usual Diet
Clients are led through a series of questions to describe t ‘typical day’
May be more of a typical day than 24 hr recall
Not useful if diet pattern varies considerably.

Obtaining Diet History Information
Food Frequency Questionnaire -
Includes a list of foods or food groups. The client answers regarding the frequency with which s/he eats them and how often they are eaten, ie. servings per day/week/month/year.
It is often used in conjunction with a 24 hour recall.

Obtaining Diet History Information
Food Frequency
Good ‘cross’ check of other methods to obtain more complete information.
May include all foods groups or may be specialized to identify consumption of a specific nutrient, such as fat.

Obtaining Diet History Information
Food Frequency
Time consuming
Difficulty in estimating amounts eaten
Difficulty in estimating frequency of consumption of a particular food.
No meal pattern

Obtaining Diet History Information
Diet or Nutrition History -
Collects information about food intake and other factors influencing the client’s food habits.
Often includes a 24 hour recall, food frequency, and an extensive interview regarding food habits as influenced by socioeconomic, cultural and psychological factors.

Obtaining Diet History Information
Diet or Nutrition History
gives detailed information about food intake, activity level, shopping, appetite, eating out etc.
Time consuming
Relies on memory
Requires interview training

Obtaining Diet History Information
Tools for Determining Portion sizes:
Three Dimensional Measurement Aids
Household Measures
Real Food Samples
Food Replicas (Models)

Obtaining Diet History Information
Two Dimensional Measurement Aids
Food Photos
Computer Graphics
Food Package Labels

Methods for Evaluating Diet History Information
Data Analysis
Food Group evaluations
Tables of Food Values
Hand Calculated
Computer Calculated
Diabetic Exchange Lists

Methods for Evaluating Diet History Information
Interpretation of analysis
Comparison to calculated requirements
Food Guide Pyramid

Anthropometric Measurements

Adipose Tissue
Height Weight Tables
Hamwi Method:
Men: IBW = 106 + 6# for each in. > 60”
Women: IBW = 100 + 5# for each in. > 60”

Nutritional Assessment
Significant Weight Loss:
1 week 1-2% or greater
1 month 5% or greater
3 months 7.5% or greater
6 months 10% or greater

Anthropometric Measurements
Body Mass Index (BMI) -
Estimates total body mass.
Highly correlated with total body fat & is considered an indicator of body fatness.
BMI = weight (kg)/height (m2)
Kg = pounds/2.2 (e.g.. 130#/2.2 = 59 kg
Cm = inches x 2.54 (e.g.. 60” x 2.54 = 152 cm or 1.52 m)

Classification of Overweight and Obesity By BMI

Anthropometric Measurements
35-year-old-man who is 6’2” and weight 198#
72 x 2.54 = 183 cm or 1.83 m
198#/2.2 = 90 kg
BMI = 90 kg/1.832 (3.35) = 26.87

Evaluation of Body Weight
35-year-old-man who is 6’2” and weight 198#
178+ 10% or 160 – 196 #
% IBW?
111% of 178#

Waist-to-Hip Ratio
People whose fat is concentrated mostly in abdomen are at higher risk for health problems.
Apple versus pear shape.
Waist-to-hip ration measures waist at its narrowest point and hip at widest point.
Women with 35” waist and 46” hip =
35/46 = 0.76

Waist-to-Hip Ratio
Women with waist-to-hip ratio >0.8 and men with waist-to-hip ratio > 1.0 are at increased health risk because of their fat distribution.
The New York Times > Health > Vital Signs: Patterns: Apple-Shaped Danger for Women
Waist Circumference
High Risk:
Males > 40 inches
Females > 35 inches

Estimating Calorie Requirements
Harris Benedict Equation - Measure of resting energy expenditure
Men: 66+(13.7 x wt (kg)) + (5 x ht (cm)) - (6.8 x age)
Women: 655 + (9.6 x wt) + (1.7 x ht) - (4.7 x age)

Estimating Calorie Requirements
Men: 10 x wt (kg) + 6.25 x ht (cm) –5 x age + 5
Women: 10 x wt (kg) + 6.25 x ht (cm) –5 x age - 161

Harris Benedict Formula
Women: 5’6” tall; 130 #; 30 years
Works as a secretary
655 +( 9.6 x 59) + (1.7 x 167.6) – (4.7 x 30) =
655 + 566.4 + 248.9 = 1470.3 – 141 = 1329 Kcal

Mifflin-St. Jeor
Woman: 5’6” tall, 130#; 30 years
Works as secretary
(10 x 59) + (6.25 x 167.7) – (5 x 30) – (161) = 1327 kcal

Factors for Physical Activity Levels

Laboratory Values
Albumin (Visceral Protein Stores)
normal = 3.5 - 5.0 gm/dl
Serum Cholesterol
>200 mg/dl (Total) or <100 mg/dl (LDL)
Heart, Lung, Blood Institute

Serum Levels

Clinical Features
Problems with mouth, teeth or gums
Difficulty chewing, swallowing
Angular stomatis, glossitis
History of bone pain, fractures
Skim changes (dry, nonspecific lesions, edema)
Mental or cognitive changes

Medical Records Are Permanent Legal Documents Documentation Should Be Complete, Clean, Concise, Legible and Accurate.
Medical records usually contain various sections including: the history and physical, physician’s orders, progress notes, laboratory data, nurses notes, other consultations.

Charting and Documentation
Documentation in the medical record is made in the progress notes.
Documentation must be made in ink or type written.
All entries are dates and signed by the person making the entry with the full name and title, i.e... Virginia Bennett, RD, CD

Only approved abbreviations should be used. Avoid abbreviations with multiple meanings.
Documentation is usually made using the SOAP format.

Charting and Documentation
S: Subjective
Information provided by patient, family or caretaker
Significant nutrition history
Pertinent socio-economic, cultural information
Level of physical activity

Charting and Documentation
O: Objective
Factual reproducible observations
Height, weight, age
Laboratory data
Nutritionally pertinent medications
Desirable weight

Charting and Documentation
A: Assessment
Interpretation of patient’s status based on subjective and objective data.
Evaluation of nutrition history
Estimation of nutritional requirements
Projected rate of weight gain, loss
Assessment of motivation
Anticipated problems or difficulties for compliance or adherence.

Charting and Documentation
P: Plans
A specific course of action to be taken based on S, O and A to resolve the patient’s problem
Goals for nutrition therapy
Recommendations for nutrition care
Any referrals
Brief description of specific written or verbal instructions given
Follow-up plans

Charting and Documentation
S: Patient lives alone; has limited cooking facilities. 24 hr recall indicates only eats one meal per day.
O: Age: 73, Ht: 6’ , Wt: 140# , IBW: 175-185#
A: (1) Poorly nourished male 25-45# < IBW. (2) Dietary intake inadequate in calories, protein and most nutrients.
(3) Would benefit from participation in a senior services program like Meals on Wheels.

Charting and Documentation
P: Nutrition Goal: Eat three nutritionally balanced meals per day. (1) Provided patient with a number of easy to prepare food ideas, which he states he is willing to try. (2) Referred patient to social services and the Meals on Wheels food program. (3) Follow-up in three weeks.

Charting and Documentation
Significant History
Anthropometric data
Evaluation of pertinent prior intake
Evaluation of nutritional status
Recommendations for consultation or evaluation by other professionals
Implementation, monitoring of plan of care
Nutrition education given

Entries should always be legible. If an errors is made.
Never use white-out, correct tape or self-adhesive labels or obliterate an entry.
Never remove the original and replace it with a copy.

When making corrections:
The person who made the initial entry should correct errors.
A single line should be drawn through the error and the correction entered.

Or a line should be drawn through the entry or an X make through the paragraph or page in error. Note “error” plus the date and time.

For omitted information:
Beside the original entry, note “See addendum”, enter date, and initial.
Write addendum in chart sequence. Identify it as an addendum and reference to the original entry (e.g... addendum to nutrition progress note of 4/10/97).

Promoting Change

Strategies to Promote Change
Detailed Menus/Meal plans
Exchange Lists – Pages 234-249
Food Guide Pyramid
DASH Food Plan
Goal Setting

Adult Learners
Have experience
Readiness to learn dependent on necessity to learn
Are problem-centered
Are intrinsically motivated

We Learn and Retain
10% of what we read
20% of what we hear
30% of what we see
50% of what we see and hear
70% of what we say
90% of what we say and do

Examples of Interactive Education Experiences
Grocery store tour
Cooperative cooking
Practice selecting items from menu
Interpret food labels
Jointly modify recipes
Creating menus
Measuring and weighing portions sizes
Role playing

Getting the Message
Avoid technical jargon
Simplify directions
Information about actual choices
Incorporate self-help materials
Workbook activities
Repeat important points
Limit number of learning objectives per session

Behavior Change Strategies
ABCs of Behavior
A: Antecedent
Stimulus, cue or trigger
B: Behavior
Response, eating
C: Consequence
Punishment or reward

Behavior Chain Example
Negative Consequence
Positive Consequence

Behavior Change Strategies
Cue Management
Identify cues that stimulate a particular food response
Physical environment
Social environment
Eating behavior

Behavior Change Strategies
Exchanging healthy responses for problem behaviors
Foods which are healthier alternatives
Active diversions
Physical activities
Relaxation activities
Reinforcement or Rewards

Behavior Change Strategies
Goal Setting
Barrier or Obstacles

Choosing Education Materials

Grade Level
Use of white space
Use of Pictures and Graphics
Sources of Materials
Dairy Council; Meat Board
Food Companies
Make Your Own