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Full course notes for Nutrition 3090- Clinical nutrition... includes all lectures and labs
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NUTR 3090 EXAM STUDY GUIDENUTR 3090 MIDTERM 1
Jan 10th - Intro
Nutrition care process
- Nutrition Assessment
o Gathering and using information, Review chart data collected to date; medical diagnoses already made
o Conduct interview with pt
1. Anthropometric: Weight, weight change (% healthy body weight, usual body weight, time frame), Height, Waist
circumference
▪ Analysis: Calculation of BMI comparison to standards, Reference tables (ht, wt, skinfolds, wc)
2. Biochemical: Usually refer as lab values, Blood tests, urine analysis, etc.
▪ RD not typically involved in collection…Need to understand strengths and limitations of methods
3. Clinical: Underlying medical problem(s), Medical treatment. Medication and supplement/herbal use history,
Signs and symptoms?
4. Dietary: Various methods and variations
▪ Food frequency: May be quick to do, Does not affect the dietary intake of the client, May account for daily,
weekly and seasonal variation, May be time consuming, Literacy of client required, Relies on memory, May
be better at assessing general patterns than actual nutrient and kcal intake
▪ diet history : Asks about a usual (typical) day, Doesn’t require literacy, Quick and easy, Based on client’s
perception of their diet, Relies on client memory, Only gives a rough idea
▪ Recall: Quick and easy to do, Literacy of client not required, Doesn’t affect the dietary intake, Based on a
real day, Relies on memory, Estimated serving sizes, One day may not be representative of usual intake
▪ diet records: Does not rely on memory, Very accurate data collected, Considered the best method, May
affect the dietary intake of the client, burden on the client, Literacy of client required
▪ Short form methods… i.e. CHO Counting
▪ Analyse diet information
• Semi quantitative: Primary method in most clinical practice. Rough estimate of intake in
comparison to Canada's Food Guide (CFG). Focused on overall eating patterns
• More quantitative: Diet analysis with software approximate nutrient or food intake.
• Quantitative: Identification of likelihood of inadequate intake in comparison to the DRI. Multiple
days of dietary intakes required for reasonable estimate
5. Social history: Often these are assessed informally, Readiness, intention, Skills, Barriers; money, work
schedules, family responsibilities, Physical Activity, Family history
6. Additional information: Readiness, intention Skills, Depression screening, Barriers, Physical activity, Time,
Access to healthy food and HCPS, Confidence, Family support
- Nutrition Diagnosis (PES statement)
o P-roblem/diagnostic label : describes the human response to alterations in client’s nutritional status
o E-tiology : term applied to contributing factors to the existence of the problem. This links the etiology to the
diagnostic label… RELATED TO
o S-igns/Symptoms: defining characteristics identified during assessment phase; quantifies problem & describes
severity. AS EVIDENCED BY
o Example: Inadequate energy intake related to changes in taste and appetite as evidenced by average daily kcal
intake 50% less than estimated recommendations
- Nutrition Intervention
o Identify General Treatment Goals, Need clinical judgment for prioritizing, Be as specific as possible
o Often suggest multiple possible strategies, Work with client to prioritize
o Diet prescription
▪ Calorie level, Macronutrients, Fatty acid profile, Micronutrients
o Diet plan:
▪ Based on goals of client, Taking into consideration their lifestyle, Step wise changes to meet goals
- Monitoring & Evaluation
o Goal setting, Assess the effectiveness of the planned intervention, Assess the progress of the condition, Support
self-management, Adjust as needed
Jan 12th and 17th - Health Behaviour Change in Clinical Nutrition Practice
,Behaviour change practice
- Brief history in clinical nutrition
o From behavioural psychology i.e. Carl Rogers
o Two types of learning: cognitive (knowledge) and experiential (learning by doing)
o Transfer of learning is the result of training:
▪ Positive transference: occurs when the learners use the behavior taught in the course
▪ Negative transference: occurs when the learners no longer do what they are told not to do. Negative
transference results in a positive (desired) outcome
o Concepts also derived from addictions counselling and adult education→ “client centred counselling”
Behavior change theories
- Health Belief Model
o Psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs
▪ Based on the expectancy value theory (suggests that people orient themselves to the world according to
their expectations (beliefs) and evaluations)
o positive or negative: health behaviors of individuals are determined by the combination of beliefs and evaluations
that individuals have about a specific program/attribute/behavioral outcome
▪ If positive, it is likely that the individual would start or continue to use that choice
▪ if negative, then one would avoid it
o Assumptions…A person will undertake a health related behaviour if:
1. They believe their health is in jeopardy/ they are susceptible
2. They believe that the health behaviour will prevent or reduce severity of the disease
3. They can successfully carry out the behaviour (benefits outweigh costs)
o Constructs of the Health Belief Model
▪ Perceived susceptibility, Perceived severity, Perceived benefits, Perceived barriers
o Criticisms: Does not address long term maintenance, Difficulty associated with modifying beliefs, No strategies for
changes, Blames individual, Assumes person consciously thinks about behaviours
- Social Learning Theory
o Main Focus: behaviour is learned and modified by direct experience, External influences affect behaviour
▪ “Reciprocal Determinism”→Interconnectivity between cognitive, behavioural, and environmental factors
o 3 Distinct Features of SLT
1. Emphasizes the vicarious process in psychological functioning→Learning through modeling
2. Importance of symbolic functions*, which regulate behaviours and actions
3. Central role is assigned to self- regulatory processes self-efficacy
o 4 Processes for Effective Modeling to Occur
1. Attentional Processes→ The observer paying attention to the behaviour
2. Retention Processes→ Main variable: memory, Frequency of behaviour, “Rehearsal”
3. Motor Reproduction Processes→ Learn symbolically before performing
4. Motivational Processes→ Act as regulators to determine which behaviours to adopt
- Theory of Planned behaviour (aka reasoned Action)
o Explains the relation between attitudes, intentions and controlled behavior. Behavior is predicted by behavioral
intention. Behavioral intention is a combination of 3 factors:
1. positive or negative attitude toward performing action (behavioral beliefs)
2. person’s perception of what others expect (normative beliefs)
3. the perceived ease of performing the behavior (control beliefs)
▪ The more favorable the attitude and subjective norm, and the greater the perceived control, the stronger
should be the person’s intention to perform the behavior in question.
- Transtheoretical Model
o Studies of change: people move through a series of stages when modifying behavior
o 3 Dimensions: The time a person can stay in each stage is variable
1. Central Construct→Five stages of change
2. Dependent Variable Dimension→Decisional balance, Self-efficacy / temptation
3. Independent Variable Dimension→Processes of change
o 5 stages of change
1. Precontemplation (not ready)
2. Contemplation (getting ready)
3. Preparation (ready)
4. Action
5. Maintenance
, - Integrative Model of Behavioral Prediction
o incorporates intraindividual factors, self-efficacy, environmental factors known to influence health behaviors
o Attitude
▪ Experiential attitude… Feelings about behavior (short term)
▪ Instrumental attitude… Beliefs regarding behavior’s outcomes (long term)
o Perceived norm
▪ Injunctive norm… Normative beliefs / other's expectations
▪ Descriptive norm…Normative beliefs / other's behaviors
o Personal agency: individual's capability to originate and direct actions for given purposes
▪ Self-efficacy: individual's belief in his/her effectiveness in performing specific tasks
▪ Perceived control: individual's perceived amount of control over behavioral performance
o Developing Intention
▪ Believes the advantages of performing the behavior outweigh the disadvantages, Perceives more social
pressure to perform the behavior than not, Behavior is consistent with their self-image and personal
standards, Emotional reaction to performing behavior is positive, Have confidence they can execute
o There are five components that directly affect behavior:
1. The most important determinant is intention
2. An individual needs the knowledge and skills to carry out the behavior
3. The behavior should be salient to the individual
4. There should be few or no environmental constraints that make behavioral performance difficult
5. With experience performing the behavior, the behavior will become habitual for the individual – Habit
Patient Experience
- Principles of Andragogy: adult education
o have work and life experience, have a purpose for their learning, very motivated, view learning as a social process,
need to feel and be respected, may have some fear as past learning experiences may have been negative.
- Patient Perspectives: 5 Types of challenges
1. Self-discipline
2. Knowledge
3. Coping with every day stress
4. Negotiating with family members
5. Managing the social significance of food
- Behavioural Economics
o The effects of psychological, social, cognitive, and emotional factors on human behavior to explain the economic
decision making of individuals and institutions
o Using default choices—Nudge people toward what is better for them
▪ People require little information to make decisions
▪ Intentions are poor predictors of behavioural habits
▪ Habit is triggered by situational cues frequent performance in similar situations
o Changing habits requires different approaches
▪ Adding a new habit, Changing existing habits
o Some examples of nudge techniques
▪ Placement: Restaurants can design menus to emphasize healthier items by listing them first within sections
an columns with bigger or more colorful typefaces, cafeterias can move salad bars closer to entrances
▪ Words: lunchtime vegetable sales went up 99 percent in a school that offered “Silly Dilly Green Beans”
- Risk of bias
o Selection bias: Systematic differences between baseline characteristics of the groups that are compared
o Performance bias: Systematic differences between groups in the care that is provided, or in exposure to factors
other than the interventions of interest
o Detection bias: Systematic differences between groups in how outcomes are determined
o Attrition bias: Systematic differences between groups in withdrawals from a study
o Reporting bias: Systematic differences between reported and unreported findings
Jan 19th – Motivational Interviewing
Spirit of Motivational Interviewing
- 30- 60 minutes… Longer than any other behavioral change approaches
- Four General Principles Behind Motivational Interviewing
1. Express Empathy: involves seeing the world through the client's eyes, thinking about things as the client thinks
about them, feeling things as the client feels them, sharing in the client's experiences
, 2. Support Self Efficacy: counselors focus their efforts on helping the clients stay motivated, positive changes
3. Roll with Resistance: The counselor does not fight client resistance, but "rolls with it."
4. Develop Discrepancy: when people perceive a discrepancy between where they are and where they want to be
- Based on: Developing a partnership, Resolving ambivalence, Developing discrepancy, Eliciting commitment to change
- Client centered environments: Enhance communication and pay close attention to the values, priorities, and concerns of the
client. all clinical decisions and plans revolve around the client’s voiced concerns, needs, and preferences.
- Collaboration: A collaborative approach searching for ways to achieve a behavioral change
o The counselor brings a wealth of knowledge and experience, and the client is the expert on past failures, past
experiences, influencing pressures and personal beliefs and values
- Evocation: Assumes that individuals have the intrinsic desire to do what is truly important to them, and the counselor’s
responsibility is to facilitate clients to evoke that motivation and to bring about change
- Autonomy: Recognizes that decisions to change always need to come from the client autonomy
Guiding Principles of Motivational Interviewing
- Resist the righting reflex
o Roll with resistance, State what you see/hear, Acknowledge the resistance, Shift back in your chair and breathe,
Offer to let go, Invite working together, Explore/revisit readiness to change
- Understand and Explore Motivations
o Develop discrepancy →Allow the client to explore perceptions and see a discrepancy between current behavior and
their value, beliefs and concerns
o right track when your client is voicing concerns, giving reasons to change and expressing an intention to change
- Listen with Empathy
o Express empathy →Basic acceptance “You are OK” creates an environment for change
o If counselor does not communicate with empathy, clients are not likely to feel safe revealing discrepancies between
their current behaviors and their beliefs and values
- Reflective and Active Listening
o Acting as a mirror, Reflecting back your understanding of the intent or your interpretation of the underlying
meaning, Eye contact, Attentive body language, Vocal style: speech rate, volume and tone
- Empower the Client
o Support self-efficiency, Increasing self-efficacy
o Belief in the ability to change→ important motivator
o Stress the importance of the client, not the counselor, as the one responsible for selecting and carrying out changes
Basic Counseling responses
- Attending: active listening
- Reflection: empathizing [match intensity of your response to the level of feeling expressed by the client]
o Reflecting (empathizing): identify and reflect the feelings of your client, by matching the intensity of your response
to the intensity of the feelings expressed by the client
▪ Perhaps you are feeling…I imagine that you are feeling…It appears that you are feeling…It sounds as if…
- Legitimation: acceptance and validation of client’s emotional experiences
o Counselor: I can understand why you would feel like this. Anyone would, under the circumstances.
- Respect: explicit statements of appreciation
o Counselor: I am impressed that you are here searching for ways to lower your cholesterol levels through diet.
- Personal support: strategies are available, and you are there to help
- Partnership: collaborative relationship to solve problems
o Counselor: I want us to work together to find and implement strategies that will work for you.
- Mirroring: repeat to client what was said or with few words changed… repeat everything the client said
- Paraphrasing: Summarizing, Use when client is giving a story … not repeating everything they said… only key information
o Counselor: What I hear you saying is that you are looking for a way to put an end to eating the chips.
- Giving feedback (immediacy): tell client what you have directly observed
o Counselor: When you said you wanted to give up drinking so much coffee, you looked sad
- Questioning
- Clarifying: probing; prompting ask clarifying questions
o Counselor: Can you explain that in a slightly different way?
- Noting a discrepancy: Challenge-- do not use “but”
o Counselor: On the one hand, you say that you would cut off your right arm to lose weight; on the other hand, you
say that you do not want to exercise.
- Directing: Instructions
- Advice: suggest ideas to change a behavior if client is OK to hear them
o Counselor: I have some ideas for increasing your physical activity. Would you like to hear them?
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