Nut test 2

Identify four factors to consider when guiding clients in the use of rewards.

1) Rewards should be individualized. 2) Rewards should be well defined—what and how much. 3) Rewards should be timed to come after the behavior, not before. 4) Rewards should be given as soon as possible after the behavior is accomplished.

Exploration-Education Phase

In this phase a nutrition counselor and client work together to understand a client's nutrition/lifestyle problem, search for strengths to help address difficulties, assess readiness to take action, and the counselor provides educational experiences.

MyPyramid

● Easy to understand ● Flexible - ● Requires computer technology

Identify and explain four advantages of group counseling

1) Emotional support. Groups help clients feel as if they are not alone in dealing with their nutritional concerns. Sharing experiences with others who really know what it is like can provide a great deal of emotional support. 2) Group problem solving. Participants motivate each other to change as they share coping strategies and problem-solve together. Sharing supplies additional ideas and generates suggestions for finding solutions for over-coming obstacles to behavior change. 3) Modeling effect. Participants learn from each other by observing the accomplishments of others with similar problems. By observing and taking part in behavior changes of others who are experiencing similar problems, all group members are likely to feel hopeful for themselves. 4) Attitudinal and belief examples. As participants describe their attitudes and beliefs regarding health behavior challenges and perceived failures, other group members tend to reevaluate their own belief systems.

Identify and explain four disadvantages of group counseling.

1) Individual responsiveness. Some people do not easily share in a group setting, and as a result their issues may never be addressed. 2) Group member personalities. The dynamics of a group are heavily influenced by members' individual personalities. The ability of leaders to handle domineering, demoralizing, or needy individuals who may tend to monopolize time will impact on the counseling environment for all group members. 3) Possibility of poor role models. Poor role models can create additional burdens for a counselor to counteract. 4) Meeting the needs of all group members. It may be difficult to organize a group with similar issues and health concerns. Meeting the needs of participants who widely differ in age, gender, ethnic background, and specific health problems can be a challenge. There is limited opportunity to tailor an intervention for individual participant.

Identify four techniques for organizing a meeting for group decision making and problem solving.

1) Pair-Share works well with a large group. This process provides an opportunity for all participants to discuss their thoughts and feelings about a topic with another individual. When the topic is opened up for general discussion, the comments are likely to be more concisely and coherently formulated after sharing with small groups. 2) Corners tends to work well with a group when there are distinct tasks that need to be addressed. Participants are allowed to choose their task and move to the corner of the room that has the task posted. 3) ORID is a method encouraging discussion by providing a progression of questions that takes a group through four consecutive stages: Objective, Reflective, Interpretive, and Decisional. The facilitator asks probing questions that follow the natural sequence people generally utilize to contemplate an issue. This process is useful for reflecting on experiences and invites a variety of perspectives in a non-confrontational manner. The questions should flow naturally from one stage to the next. 4) Consensus is a method for making group decisions by encouraging members to share their thoughts, feelings, and suggestions. In order to develop a sustainable agreement, a group facilitator needs to lead the group through four stages: gathering diverse points of view; building a shared framework of understanding; developing inclusive solutions; and reaching closure.

Identify five topics a nutrition counselor can review with a client to provide guidance for record keeping.

1) Provide training. Clients gain a better understanding of the process when hands-on activities are included as well as complete instructions of how to keep a journal. 2) Use estimates. Sometimes clients can become very frustrated with writing down exact amounts of food consumed and then calculating caloric content and/or percentage of calories from fat, especially when consuming mixed dishes that the client did not prepare. 3) Set meaningful and achievable goals. Clients are more likely to be successful in record keeping if the first goal is modest, such as two days a week, and then gradually increase journaling activity in subsequent weeks. 4) Provide a variety of record-keeping options. Some clients prefer to use a pocket calendar with enough space to record a days worth of food intake. Others like to use 81/2 by 11-inch forms. At times clients will devise their own record-keeping system. 5) Provide nonjudgmental feedback. Clients should always be praised for their journaling work, and counselors should always review their clients' journals with no hint of criticism. Client thoughts regarding the journaling activity should be sought.

Describe nine topics that could be addressed in a final session with a client.

1) Review beginnings. Counselors could discuss issues that brought the client to counseling including initial assessments. 2) Discuss progress. Goals and progress in meeting them could be identified. 3) Emphasize success. A review of accomplishments could be discussed, particularly those that were difficult to overcome. 4) Discussion of the skills. Counselors should place emphasis on the skills a client used to bring about change. 5) Summarize current status. Counselors can highlight current biochemical and physical parameters, coping skills, social support, challenges, and environmental issues. 6) Explore the future. Counselors can explore how the changes that have been made will be maintained. 7) Discuss future involvement. Counselors can discuss the possibility of future interaction which could include personal meetings, phone calls, or e-mail. 8) Provide and elicit feedback concerning the significance of the relationship. Counselors can encourage a discussion of the meaning of the relationship has the counselor as well as the client. 9) Holding a ceremony and exchanging symbols. Mementos symbolic of work done together can be particularly meaningful. 10) Picturing your client. At a final parting counselors can tell their clients they will picture them doing something they have longed for or intend to accomplish. Such statements reinforce that the client's future welfare is important to the counselor

Explain the six steps of the group process.

1) Step 1: Establish an open, warm environment and productive leader-participant relationships. Facilitators need to show empathy, appear warm and genuine, and use relationship-building responses, attentive behavior, and effective body language. Counselors should radiate positive energy indicating that you are looking forward to your time with the group members. The counselor is a model of trusting behavior for all group members to emulate to promote openness and interpersonal communication. Counselors may wish to start each meeting with an expression of intent to create an environment conducive to acceptance and open expression. 2) Step 2: Balance facilitator-generated and group- generated information. The challenge for nutrition counselors is to cover a preset curriculum and integrate client needs and experiences and allow the group to generate solutions and problem solve. Often counselors have a list of tasks identified as essential for clients to understand, but the facilitator-generated information will fall on deaf ears if group members have other concerns on their minds. One way to handle this potential problem is to ask participants in the first session to identify their pressing concerns. Then cover the most pressing problems first. 3) Step 3: Design problem-solving strategies. Many opportunities for group problem solving should be provided rather than having the counselor tell participants what they need to do. Social disclosure is a powerful force for behavior change. Group counseling provides an ideal setting for coupling group problem solving with this process. Participants design goals with feedback from the group and disclose their intent to accomplish certain tasks before the next group session. 4) Step 4: Provide the opportunity for group members to practice new skills. In step 3, the group worked as a whole to problem-solve or develop new strategies. Opportunities for each member to rehearse the skill can occur if members are divided into groups of two or three. 5) Step 5: Use positive role models and pacing to keep the group motivated. Spending time reviewing and understanding the successes of group members can provide a model for other participants to make alterations in their lifestyle. Successful members inspire others to follow their example and stay in the group. However, clients who are having difficulty and appear to be monopolizing the group time with their problems can be frustrating for the rest of the group. If counterproductive behaviors emerge, the counselor needs to block them from disrupting the group process. If necessary, the counselor should tell the client to stay after the session to receive personal attention. 6) Step 6: Ask for evaluation and feedback. Throughout the counseling process and after trying out a new activity or strategy, the facilitator should elicit feedback from the group. For example, "Since we began meeting, what did you find particularly useful?" or "Did you find analyzing glucose records of previous clients useful?"

7. Explain the components of the FRAMES method for brief interventions.

1)Feedback: This includes providing feedback in a non-judgmental manner 2)Responsibility: The right to choose to change and client responsibility for change is emphasized. 3)Advice: With permission from the client, the nutrition counselor offers clear advice and a menu of change strategies. 4)Empathy: Throughout the intervention, the counselor interacts with the client in an empathic style displaying warmth, active interest, respect, concern, and sympathetic understanding. 5)Self-efficacy: The counselor offers hope for the future and enhances self-efficacy by expressing optimism for a client's ability to make a change

motivational levels

1)Not ready- is the first level and the goal is to raise doubt about the present dietary behavior and the major task is to inform and facilitate contemplation of change. 2)Unsure- is the second level and the goal is to build confidence and increase motivation to change dietary behavior and the major task is to explore and resolve ambivalence. 3)Ready- is the third level and the goal is to negotiate a specific plan of action and the major task is to facilitate decision making

Urges and Cravings

: The desire for immediate gratification can take the forms of urges, sudden impulses to indulge, or cravings, subjective desires to experience the effects of an indulgence.

SOAP (A)

A (Assessment): • This is the counselor's interpretation of the client's status based on subjective and objective information including nutrition diagnosis. • Information should be written in complete sentences as a paragraph. • The following can be the format for this entry: - Begin with a statement summarizing the client's nutritional status and concerns. - Reflect on subjective and objective data and their impact on concerns including evaluation of nutritional history, possible problems and difficulties with self-management and the effect of medications on nutritional status. - Provide possible approaches and interventions. - Assess degree of readiness, comprehension of information provided, and previous goal achievement. P (Plan):

Contracting

A contract documents an agreement between a counselor and a client to implement a particular goal. The contract can cover short- or long-term goals. Rewards are often used in conjunction with contracting.

Describe a goal attainment scale.

A goal attainment scale is used to quantify success in meeting a goal. The scale can be developed collaboratively with a client. A range of values are assigned to possible results, from a score of +2 for a most favorable result to a 2 for a least favorable outcome. A score of 0 represents the anticipated level of performance. This type of rating system is particularly useful for providing outcome results to funding agencies or for supplying useable numerical scores to determine levels of change for statistical analysis. The graduated level of desired outcomes has the added advantage of allowing success at several levels of performance.

(NCP) 3) Step 3 Nutrition Intervention

A nutrition prescription should be written which concisely states the patient/client individualized recommended dietary intake of energy and/or selected foods or nutrients based on current reference standards and dietary guidelines. The selection of an intervention is based on the nutrition assessment and needs be directed to the root cause (etiology) with the objective of relieving signs and symptoms of the diagnosis. There are four domains of nutrition intervention strategies including food and nutrient delivery, nutrition education, nutrition counseling, and coordination of nutrition care.

Stress Level

A person experiencing a high degree of stress is automatically generating negative emotional states, thereby creating high-risk situations. In addition, there is an increased desire to relapse and connect to the satisfying emotional states with previous unhealthy eating pleasures

Apparently Irrelevant Decisions (AIDs)

A series of seemingly harmless decisions can provide a conduit for a relapse. For example, buying a bag of potato chips for the "children" or a bag of cookies "in case guests stop by" creates conditions that can bring an individual to the brink of a relapse.

Food diary and daily food record

A written record of an individual's food and beverages consumed over a period of time, usually three to seven days P ● Does not depend on memory ● Provides accurate intake data ● Provides information about food habits C ● Requires literacy ● Requires a motivated client ● Recording process may influence food intake ● Requires ability to measure and judge portion sizes ● Time-consuming

Readiness-to-change scale question

Ask the following question: "On a scale from 1 to 10, with 1 being 'not at all' ready and 10 being 'totally ready,' what number would you pick that would represent how ready you are to make this change?"

Readiness-to-change graphic

Assess readiness by showing a graduated picture of a thermometer, ruler or chart. You begin by asking your client to look at the picture and identify a spot on the graphic that indicates how ready he or she is to make a change.

What are cognitive distortions?

Cognitive distortions are negative thinking patterns that have little in common with reality and hamper behavior change. They often include phrases such as "should, must, or have to."

Cognitions

Cognitive factors such as rationalization and denial set the stage for a relapse. For example, "I deserve a whole batch of brownies after this rejection." Here rationalization that the indulgence is justified adds to the creation of a relapsing environment.

What guides the facilitator choices regarding content and focus of questions?

Facilitators choose the content and the focus of a question by evaluating what is needed to move the discussion forward. . If the discussion appears disjointed, a process question may be in order asking participants to choose a solution, predict what will happen, or to compare and contrast two situations. If a need to address emotions arises, affective questions can be used probing for opinions, feelings, attitudes, or beliefs. Behavior questions are useful if a plan of action is under discussion while several members have indicated they are not ready for that step. If that is the case, the focus of questions should be on the application of new knowledge, what they learned from past experiences, or how they can solve a problem. Questions that put individuals "on the spot" by asking for justification for their actions or identifying blame are not likely to promote positive group dynamics.

Closing Phase

In this phase, counselors review what has occurred during the session, including a summary of the issues, identification of strengths, and a clear restatement of goals. In addition, an expression of optimism about the future and a statement of appreciation for any obstacles overcome are made to support self-efficacy.

(NCP) 4) Step 4 Monitoring and Evaluation

In this step, a practitioner evaluates the effectiveness of a nutrition intervention by engaging in monitoring, measuring and evaluating changes in nutrition care indicators. Counselors determine how much progress is being made toward goals or anticipated outcomes. The monitoring and evaluation terms used for ADIME charting are the same terms used for assessment except for those that would only be appropriate for an initial assessment.

ASSERTIVE

Is appropriately: emotionally honest, direct, self-enhancing, expressive

AGGRESSIVE

Is inappropriately: emotionally honest, direct, self-enhancing at the expense of another, expressive

Modeling

Many of our behaviors are learned by observing and imitating others. By observing others accomplish a goal similar to their own, clients' beliefs in their ability to imitate the behavior increases

SUBMISSIVE

May be emotionally dishonest, indirect, self denying, inhibited

SOAP (O)

O (Objective): •Information generally comes from charts and laboratory reports and includes factual and scientific information that can be proven. •Citations do not need to be in complete sentences. •Examples of possible information include: age, gender, diagnosis, nutritionally pertinent medications, anthropometrics, laboratory data, clinical data (nausea, diarrhea), height, weight, healthy body weight, changes in weight, and diet order, estimation of nutritional needs.

SOAP (P)

P (Plan): • Notations are generally short, concise statements written in complete sentences that can include the following: - Long-term goals and specific, measurable short-term goals - Need for additional diagnostic data—assessments, lab work, consultations - Therapeutic plans—changes in nutrition care plan, diet prescription, supplement recommendations - Educational plans to address dietary issues

Rewards

Reinforcement behavior change strategies provide incentives by addressing the end of the behavior chain—consequences. Rewards provide positive consequences, commonly thought to be more effective than negative consequences.

SOAP (S)

S (Subjective): •Information relayed to counselors from the client or the family. •Citations do not need to be in complete sentences. • Citations do not need to be in complete sentences.

Define SMART goals

S-Specific- Specific goals address the what, why, and how. M- Measurable-Measurable goals are concrete and observable. A- Attainable- Attainable goals usually mean small changes that are under the control of the client. They do not depend on another person. R- Rewarding (or Realistic) Rewarding goals are stated positively. T- Time bound -Putting an end point on a goal gives a clear target.

Readiness-to-change open ended questions

Simple open ended questions can be effective to assess readiness to change. • How do you feel about making a change now? • People differ in their desire to make changes. How do you feel? • When thinking about changing food habits, some people may not feel ready, others may feel they need time to think it over, and some people feel ready to start making changes. What are you feeling?

Explain the integrated approach to learning advocated by Funnell and Anderson

The integrated approach addresses psychosocial concerns and initiating behavior change strategies before concentrating on educational content. This method includes the following: • Review role of client as self-manager and role of counselor as a source of expertise, support, and inspiration. • Elicit client concerns and questions. • Discuss clients' experiences and understanding of their condition. • Identify what the client wants from the counselor. Ascertain educational topics client would like addressed. • Explore behaviors the client wishes to alter. • Present information to address concerns and questions. • Discuss strategies to address the behavioral aspects of the concerns

(NCP) 2) Step 2 Nutrition Diagnosis

The nutrition diagnosis is written as a PES statement. Generally a nutrition counselor only writes one PES statement but more than one can be written. The statementfollows a defined format: Nutrition Problem Label (using NCP nutrition diagnosis terminology) related to Etiology (root cause of the problem) as evidenced by Signs and symptoms (observable indicators that the problem exists). Simply written: "Nutrition problem label related to____ as evidenced by ____." There are three nutrition diagnosis domains including intake, clinical, and behavioral each having defined nutrition problems . After choosing a problem, next an etiology (root cause) needs to be identified. There are 10 etiology categories providing contributing risk factors for the problem to choose among. They include beliefs=attitudes, cultural, knowledge, physical function, physiolo9gica-metabolic, psychological, social-personal, treatment, access, and behavior The S part of the PES statement indicates the signs or symptoms. They can be measurable objective data, such as: decreased oral intake, consuming <25% of meals; or obesity, BMI > 30 or subjective (but quantifiable) symptoms including observations and statements from a client or caregiver (number of bowel movements).

Explain the physiological response to an anticipated stressor.

The physiological response stems from the stimulation of the hypothalamus from an imagined or real threat. The hypothalamus activates the sympathetic nervous system to increase heart rate and blood pressure in order to deliver extra nutrients to muscles and the brain. Also, blood sugar and lipids rise to meet the anticipated increase in needs for energy, while breathing accelerates to supply extra oxygen for energy metabolism. Blood supply is diverted from the skin to large muscle groups. The release of stress hormones from the adrenal glands prepares the body to be on a heightened alert to make a quick response by shutting down tissue repair, digestion, reproduction, growth, and immune and inflammatory responses. The body prepares for fight or flight. The observable symptoms can include sweaty palms, rapid breathing, dilated pupils, dry mouth, nervous or shaky speech, crying, and a feeling of butterflies in the stomach, or heart in the throat.

Resolving Phase:

The selection of activities involved in this phase is guided by the client's motivation category. The motivational interviewing algorithm found into Figure 4.2 provides three pre-action motivational levels. In the first and possibly the second level, the major issue related to motivation is the need to feel the behavior change as important. Those who pick a higher stage or higher number on a continuum are likely to feel behavior change is important, but are struggling with confidence in ability to make a successful change

(NCP) Step 1 Nutrition Assessment

There are two major components of the NCP assessment (1) collection of timely and appropriate data and analysis and (2) interpretation of the collected data, using relevant norms and standards. There are five major nutrition assessment domains in the NCP. These include food and nutrition-related history; anthropometric measurements; biochemical data, medical tests, and procedures; nutrition=focused physical findings; client history.

What do emotion-based counseling materials emphasize?

They aim to provide an engaging and memorable experiences by focusing on emotional "pulse points" to encourage behavior change

Involving Phase

This phase includes relationship-building activities such as greeting the client and establishing comfort by making small talk, opening the session by identifying the client's goals and long-term behavioral objectives, explaining the counseling process, and making the transition to the next phase.

Cue management (stimulus control):

This strategy deals with the antecedent component of a behavior chain by prearranging cues to increase a desired response or to suppress a detrimental one.

Problem solving

This strategy involves a counselor and client working together to identify a behavior chain, detecting barriers to change, brainstorming possible options, and weighing the pros and cons of the alternatives. The objective is to design an action plan by selecting as many breaks in the behavior chain as possible, especially focusing on the antecedents of the chain. The plan should include a reward.

Countering

This technique uses exchanging healthy responses for problem behaviors and addresses the B (behavior) portion of the behavior chain.

What are four immediate determinants of a relapse?

Threats to relapsing that are categorized as immediate determinants include the following: high-risk situations, a person's lack of coping skills, overly positive outcome expectancies, and negative reaction to a lapse

Encouragement

Words of encouragement generally increase a client's self-efficacy to perform a behavior change

Diet history interview

a conversational assessment method in which clients are asked to review their normal day's eating pattern P-● Provides clarification of issues C-● Relies on memory ● Requires interview training

24-hour recall

a dietary assessment method in which an individual is requested to recall all food and beverages consumed in a 24-hour period P- ● Quick ● Data can be directly entered into an analysis program ● No burden for respondent ● Does not influence usual diet ● Literacy not required C- ● Relies on memory ● May not represent usual diet ● Requires ability to judge portion sizes ● Under reporting and over reporting occurs

Food frequency

a method of analyzing a diet based on how often foods are consumed (that is, servings per day, week, month, or year) P- ● Furnishes overall picture of diet ● Not affected by season ● Useful for screening C- ● Requires ability to judge portion sizes ● No meal pattern data

Client assessment questionnaire and historical data form

a preliminary nutritional assessment form usually divided into sections for administrative data, medical history, medication data, psychosocial history, and food patterns ● Provides clues to strengths and potential barriers ● May seem invasive, may not be culturally sensitive

Stage of Change Algorithm

an algorithm containing questions to determine stage of change for adopting a low-fat diet. It can be easily modified to assess stages for other dietary factors.

Usual diet

clients are led through a series of questions To describe the typical foods consumed in a day P- ● May be more of a typical representation than a 24-hour recall C-● Not useful if diet pattern varies considerably

Explain the ABCs of eating behavior and behavior chains.

• Antecedents. Encountering antecedents to eating occurs normally throughout the day. Usually in nutrition counseling, we are particularly interested in cues that trigger unconscious eating or consumption of large quantities of certain types of food. Behavior change strategies addressing antecedents often concentrate on physical availability of food (cookie jar), social (parties), emotional (stress), or psychological (motivation; destructive thought patterns). • Behavior. Strategies dealing with the behavioral response to an antecedent 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 slice of lemon). • Consequences. Consequences can be positive reinforcers or punishment; such as a reward or losing a privilege.

Explain ways in which nutrition counselors can assess their own effectiveness.

• Client Evaluation of Counselor. An evaluation form such as The CARE Measure can be used to evaluate client interactions with counselors. • Assessing Client's Nonverbal Behavior. Throughout a counseling session a client's non-verbal behavior can be a key to his or her emotional state and can indicate how the counseling session is going. • Checking. Counselors can provide periodic summaries, and asking client's reaction to the summary can help counselors to evaluate whether they are on target during a counseling session. • Counseling Checklists (Interview Guides). Previously prepared counseling guides can be reviewed to assess whether all planned counseling interventions were addressed. • Charting. Charting can be a valuable tool to evaluate counseling effectiveness as well as client progress. • Videotape, Audiotape, or Observation Evaluations. Counselors can conduct self-evaluations of their skills by using a video- or audiotape or have a colleague or mentor conduct an assessment. An assessment instrument can be used to guide the evaluation.

3. Name the three steps involved in completing a dietary evaluation.

•Step 1: Food Intake Data Collection (ie-typical day or 24 hour recall- or combined approach, 5 step multiple pass methodology) •Step 2: Data Analysis (compare to UDSA guidelines if during interview or computer software if after interview) •Step 3: Interpretation of Analysis (Compare intake with standards)

Detailed menus/meal plans

● Clearly defined ● Useful for someone who expresses a need for a lot of structure ● Useful for someone who has complex dietary requirements who is not ready or not capable of following a food group plan - ● Does not allow for spontaneous events ● Food items needed for the plan may not be available ● May be difficult to design so as to complement a client's lifestyle

Goal setting

● Easy to understand ● Flexible ● Designed to take into consideration a client's lifestyle - ● Approach may move too slowly when aggressive intervention is needed

DASH Food Plan

● Easy to understand ● Flexible ● Rich in various nutrients believed to benefit good health - ● Some of the foods may not be part of a client's usual intake (e.g., nuts, beans, and seeds)

Exchange lists

● Offers choices ● Provides structure ● Allows for variety ● Meal pattern is individualized - ● May be too complex for some individuals

Meal Replacements

● Simplify food choices ● Reduces exposure to temptation ● Portion size is clear - • Some may not find taste acceptable • May interfere with social plans