To help determine the client's readiness to change and move them forward to self-efficacy, Spahn, et al. (2010) broke down the use of the transtheoretical model for nutritionists. They can use motivational interviewing, reinforcement, self-monitoring, goal setting, social support and stimulus control to help clients maintain a healthy lifestyle while walking them through the transtheoretical stages. (Spahn, et al., 2010)

Life Style

READINESS FOR CHANGE

To help determine the client's readiness to change and move them forward to self-efficacy, Spahn, et al. (2010) broke down the use of the transtheoretical model for nutritionists. They can use motivational interviewing, reinforcement, self-monitoring, goal-setting, social support and stimulus control to help clients maintain a healthy lifestyle while walking them through the transtheoretical stages. Other models of nutrition counseling include cognitive behavior theory and social learning theory (Spahn, et al., 2010).

Precontemplation

Before adults make any change to their health they are in the precontemplation phase. Most people go to their annual wellness visit with their general practitioner and even though the physician will warn them of health concerns they deny it or choose not to do anything with the information. Someone may have high blood pressure, but they do not have all the information about the long term health concerns of high blood pressure. They may not understand their poor eating habits and sedentary lifestyle are one of the causes of high blood pressure. This is a good time for clinicians to educate the patients/ clients on why it is important for them to make changes for their health (Summerfield, 2015).

Contemplation

When an adult leaves the doctors office they begin to understand that there are some health concerns. Their high blood pressure is most likely a result of excess weight and poor nutrition. They may ask the physician for further information about the signs, symptoms and prognosis of high blood sugar. During these stages adults may decide to take further measurements. For example get their blood drawn for cholesterol, weigh themselves regularly, and research gyms or new recipes. Adults become aware that they need to start making behavior changes, but this can take up to six months before they start to make lifestyle changes (Summerfield, 2015).

Preparation

During the Preparation phase the adult starts to read labels, seek out a gym or even hire a personal trainer/ health professional. They begin to make small goals to adjust their diet or add exercise into their activities of daily living. They begin to believe that they have control of the situation and they accept that they are the ones that need to change their behaviors in order for them to lower their blood pressure. Some positive actions that may occur in this phase. They are finding positive and supportive social groups and activities, overcoming denial, adjusting their attitudes towards change and entering self reevaluation about their current behaviors (Summerfield, 2015).

Action

After adults begin to make small changes in their activity level and nutrition it becomes more natural and they adapt to a new lifestyle. The action phase typically takes six months for consistency with their healthy behaviors. If an adult reduces his red meat and increases his vegetables consistently for 6 months and his blood pressure begins to drop, he is in the action phase. Adults that are in the action phase are positive about their behavior changes and become more self-sufficient. They are tracking their own foods and making independent choices for their health. They continue to make goals and attain them. During the action phase adults stop speaking negatively about themselves and to themselves. They are no longer defensive and in denial, but have a positive mindset of slow and consistent change (Summerfield, 2015).

Maintenance

When adults are able to lose weight and lower their blood pressure and they are self-sufficient they move into the maintenance phase. The behavior changes are self-monitored and consistent. If an adult lapse into old habits, they are able to quickly adjust their behaviors and shift back into their healthy lifestyle. Many adults find a sport, social group or form of exercise that they enjoy and do regularly (Summerfield, 2015).

Termination

During the final phase adults are exiting a set program, because they have maintained a healthy weight, eating habits and exercise program. Adults need to adapt to a new lifestyle that is flexible but does not cause relapse. The focus of nutrition counseling strategies is to change the long-term behavior of the client through education and positive reinforcement.

In a study completed by Karintrakul & Angkatavanich (2017) 60 obese women participated in a twelve-week weight loss study. Group one had weekly counseling based on the transtheoretical model and the other group was only given an information flyer at the beginning of the study. The group that had counseling based on the transtheoretical model lost significantly more weight, body fat percentage and lowered their circumference measurements. Consistent counseling, goal setting and education are vital to a successful weight loss program. Adults are able to move into the maintenance and termination phases with support from health professionals and an outside support group ( Karintrakul & Angkatavanich, 2017).

SCIENCE!

WHAT ARE CALORIES?

Here are some basic definitions that will help you better understand nutrition:

1. Calories (Kcal): Kcal is a unit of energy that comes from food intake. We need calories for our organs to properly function and expend energy.

2. Resting Metabolic Rate (RMR): The number of calories you expend to live and for your organs to function. It does not include walking or even sitting up in bed. RMR is combined measurement of lean body mass, height, weight, sex, and genetics.

3. Total Energy Expenditure (TEE): The amount of energy you burn in a 24-hour period- including your RMR, movement, and exercise (Jeukendrup & Gleeson).

Energy Metabolism

A rapid increase in calorie intake can cause an increase in body fat. If a reduction in food intake occurs too fast, like many diets require, your body will store more calories versus using them for energy. People reduce their daily calorie intake unintentionally or intentionally with the desire to lose weight, lifestyle changes, or as they age. Commonly, people reduce their calorie intake too fast to reduce weight, but when they lose discipline, desire, or drive, they go back to their old patterns of overeating or binge eat. When they decrease their food intake too quickly during their diet, their RMR decreases. They need less energy each day to fuel their activities. When they return to their old eating habits, they may quickly gain extra pounds on the scale. Other side effects of eating too little, or a rapid reduction in calories include: becoming fatigued, lose sleep or poor sleep, poor brain function, poor exercise performance, and possibly suffer from nutritional deficiencies.

Practical Application

When determining TEE, your daily activity level and body size largely effects the number of calories you burn. A larger person will burn more calories than a lighter female. As you lose weight your metabolism slows due to less calorie intake, but the leaner mass a person gains or the stronger they become the more their metabolism increases. Therefore, current research recommends strength training for weight loss. Increase your lean body mass to increase your RMR and the more food you can eat without gaining weight (Jeukendrup & Gleeson).

Determining how to make nutrition changes begins with self-monitoring and nutrition education:

1. Log your food

2. Eat three (proportional) meals per day

3. Learn how to tailor your macronutrients for sport and lifestyle

4. Exercise 30-60 minutes a day

BEHAVIOR CHANGES

Behavioral assessment: Do you relate to any of these?

Nutritionist, personal trainers, primary health care providers, dietitians, and psychologist can work together to give a well-rounded treatment plan with the best life-long changes for improvements in health, fitness, and performance. It typically takes six months to change a lifestyle, which is more effective then diets or rapid changes in eating patterns.

Clients who are learning to adopt healthier eating behaviors benefit from Social- cognitive theory.

Social- cognitive theory: people adapt to new behaviors that they feel confident about performing and the reward reinforces long-term changes and results. It is often beneficial for people to change behaviors through a multi-faceted approach to change. Certified Sports

Set positive and realistic goals: Examples-

"I am going to add these delicious and nutrient dense foods" versus " I have to stop eating bad food!"

I can pair carbs (Sugar, fruit, bread, etc) with a protein (meat, nuts, cheese, milk, protein products) most of the time.
I can exchange processed/ low-nutrient-dense food for a food that better fuels my body or promotes long-term health benefits.
When you restrict or categorize foods into " good" or "bad" they can become triggers that lead to binge eating or negativity. Negativity or shame does not promote behavior changes.

Below are examples of positive psychological changes in a person's internal and external dialog versus trying to restrict foods or start different diets:

Reinforcement: perform and get a return
Self-efficacy: The confidence in themselves to continue to perform when they feel successful- they do the behavior changes on their own for their own reward and benefit- not external rewards.
Reciprocal determinism: reciprocal interactions among personal, behavioral and environmental factors affect behavior change. Make sure your partner and friends are ready to support you and provide a positive environment for change.
Goal setting: decide on reasonable and biologically attainable directions for change. Progress slowly. ( We looked at your current eating, your lifestyle, and your goals to make attainable goals each week)

Contingency contracting and reinforcement:

Self- monitoring:

3-day food logs and physical activity assessment
Tools for increased awareness - looking through the food graphics I sent you.
Visual reminder of behaviors. Ex: leaving postcards around the house of reminders or moving nutritious foods to the front of the fridge or cupboard. A photo that you love of yourself or your family.
Provides evidence that setbacks in behavior are controllable. ex: you had birthday parties and 4th of July but you were able to clear out the house and go grocery shopping for healthier food options and plan out meals for the week.

Stimulus control:
- Initially avoid situations that promote problem behaviors. Avoid places and spaces that trigger negative behavior or thoughts about yourself and food. ( we quickly discussed stress and pot/alcohol being a trigger)
- Modify the environment to promote behaviors. (Clean out the house. Avoid bringing in food that triggers binge eating. Possibly avoid alcohol or other substances that cause inhibition towards behaviors- poor health habits)
- Altering behavior within the environment- once you have altered your behavior within your environment you can expand and reintroduce triggers.