THE IMPORTANCE OF HEALTH COACHINGIN NUTRITION PRACTICE
by nutritionist Dr Danielle Crida MBChB, Dip Nutr.
As healthcare practitioners, taking a full case history and giving expert advice is often the straightforward part of the job. Getting clients to implement your recommendations can be much more difficult. The reason is clear – information overload and hectic lifestyles make advice easy to access but challenging to put into practice. Too often clients get caught in the vicious circle of stress and health issues coupled with not making time for self-care and health-promoting practices. The best assessments, advice and supplements may be ineffective without consistent behaviour supporting nutrition, sleep, stress reduction and appropriate exercise - leading to unwell, unhappy clients and unfulfilled practitioners. In this article, we’ll look at how you can help your clients set health goals, establish focus areas and choose SMART action steps, as well as track their achievements and adjust their action steps with time.
Expanding the role of health expert to include that of behaviour change coach and ally may not come naturally to some of us if it hasn’t been part of our training. However, once we have made the shift, the consultation process is enhanced, the client becomes empowered, leading to a greater chance of success, and the emphasis is taken off us, as practitioners, being solely responsible for a client’s health outcomes. Hopefully, the enhanced practitioner-client relationship also leads to more follow-up appointments and even word-of-mouth referrals.
Change is difficult, and clients often need a helping hand to get going and persist with changes. Statistics bear this out, with only 8% of people following through with their New Year Resolutions and 80-95% of people who lose weight, gaining it back. Why is change so challenging? Brutal honesty is required in examining one’s life, finding it wanting in supporting optimal health, and generating enough willpower and motivation to shift behaviour. Transformation may create a sense of fear or loss as habits providing temporary pleasure may need to be eliminated. There are many competing priorities – looking after ourselves requires more time and energy than grabbing the most convenient processed foods and not making time for exercise and relaxation. Stress and sleep deprivation affect decision making, increasing the likelihood of poor choices and giving in to the temptation of foods that appear to provide temporary relief- high in sugar, salt, fat and caffeine. We don’t like being told what to do – some might resist change and become defensive, while others, maybe the majority, may know that they need to make changes but do not get going due to a lack of motivation, willpower or self esteem.
Fortunately, small changes can have a big impact. For example, research shows that replacing 30 minutes per day of sedentary time with light physical activity reduces all-cause mortality by 11% and deaths from cardiovascular disease by 24%, whereas replacing just 10 minutes of inactivity with moderate to vigorous physical activity decreases cardiovascular mortality by 38% over a 14 year period.
It has been suggested that a reason some of us struggle with behaviour change is through lack of engagement with our ‘future self’. We identify more with the current version of ourself, who enjoys instant gratification and lacks willpower, than with our future self, an ideal version of ourself who makes the right decisions in terms of health-promoting behaviour. The goal, then, is to adapt our behaviour to move slowly but steadily towards becoming our ‘future selves’.
Experiencing setbacks is natural, and most people move through several cycles of adopting a health-promoting practice then giving it up, before changes become permanent. Anticipating relapses can limit the damage caused by them, as shame over deviating from planned behaviour actually sabotages health goals by causing disinhibition, eroding willpower and increasing the indulgent behaviour in a misguided attempt to blunt feelings of guilt. Clients should regard these setbacks not so much as ‘falling off the wagon’ but rather stopping then restarting the wagon! Under research conditions, it is shown that participants given self-compassionate messages about occasional deviance from healthy behaviour self-regulate more in terms of limiting indulgences.
Motivation to change behaviour can be external or internal and consists of three components: activation (involving a decision to initiate a behaviour), persistence (continued effort towards a goal despite obstacles) and intensity (the amount of commitment and vigour that goes into pursuing a goal). Extrinsic motivators such as fear of illness, pressure from a loved one, financial rewards or recognition are often short-lived. Instrinsic motivation comes from a place where the reason for change is self-love and care and the reward for engaging in the health promoting comes from the feelings of joy and stimulation that the behaviour itself provides. In other words, one pursues health-promoting behaviours simply because they make one feel good, regardless of perceived health benefits. If motivation is external rather than internal, all is not lost, however, as once a client starts pursuing a new way of eating, exercising or relaxing, they may find that they enjoy it enough to continue, as well as having their self esteem boosted by initial small successes. Ideally, we should help clients to get in tune with their own internal motivators, modifying their reasons for change to self-compassion and care and their rewards to intrinsic satisfaction.
Before jumping headlong into a plan of action with a client, it is wise to first assess their readiness for change. According to Prochaska and DiClemente’s Stages of Change Model, all change occurs in a series of predictable steps. In pre-contemplation, clients are not considering changing. They may be in denial, dealing with feelings of loss or shame, or may have given up due to past failures. Coercive tactics with this group are usually met with resistance, and the goal should rather be to get them thinking about changing behaviour. Maintain a positive practitioner-client relationship, pose thoughtful questions and instil hope about the positive effects of behaviour change without applying pressure. Encourage dialogue about the emotional impact of health concerns and position yourself as a compassionate ally.
Clients in contemplation are ambivalent about change. They know that they should adopt positive habits, but are weighing up perceived gains against a sense of loss caused by giving up enjoyable habits. Barriers may seem insurmountable. A successful approach requires practitioners to remind clients of difficult changes they’ve successfully made in the past and discussing ways of overcoming obstacles. In the preparation phase, clients are preparing to make a change in the next month. Cutting preparation short lowers chances of success which may cause clients to give up on transitioning, so clients should be encouraged to ensure they have support and resources in place and any obstacles are addressed. Making their intentions public is also an important step for some clients.
The action phase is one in which we’d love all our clients to be! This is the most obviously busy period, requiring the most time and energy. As such, it is demanding and draining, and any actions taken should be praised. Once changes become routine habits, the period of maintenance and relapse has been reached. Setbacks are bound to happen, and by anticipating these and using them as opportunities for learning, clients can strategise to prevent similar setbacks in future. For example, ex-smokers may learn to avoid smoke-filled environments and clients trying to lose weight may learn to order off the menu and not go to a buffet. Focusing on successes rather than failures provides encouragement to continue health-promoting behaviours over the long haul.
Once a client is ready to make changes, they should identify their health goals. Goals may be quite specific, such as losing 5kg in 3 months, or more general such as reducing stress, sleeping better or having more energy. Rating current symptoms on a scale of 1-10 can be a useful barometer for measuring future progress. After setting goals, the next step is to look at focus areas which would help achieve these goals. Clients may have some ideas of their own based on previous experience or general knowledge and it would be good to elicit some ideas from them before making suggestions, so that they take ownership of the process.
Focus areas can be nutrition-based (such as decreasing sugar, refined carbohydrates, alcohol & caffeine, or increasing vegetables & fruit, nuts, seeds & legumes) or non-nutritional, such as improving sleep, exercise, stress management, relationships, stopping smoking or improving relationships. The ‘Wellness Wheel’ is a useful tool which assists clients to rate various areas of their life on a scale of 1-10, giving a good indication of areas which would benefit from improvement.
Choosing goals and focus areas leads on to the brainstorming of possible SMART action steps. These should be SPECIFIC (e.g. walking 5 times per week for 30 minutes rather than ‘exercising more’), MEASURABLE (should be trackable for a sense of achievement, such as eating 3 vegetables with dinner 4 nights per week, rather than ‘increase vegetable intake’), ACHIEVABLE (taking into account resources and barriers), REALISTIC (the client must be willing and able to perform the action) and TIME-BOUND (all actions should be framed with a duration and number of days per week).
If the brainstorming session has gone well there will be more ideas than feasible to adopt right away. To decide which to implement immediately, ask your client to rate each on a scale of 1-5 as to how ready they feel to take each action, where 1 is not at all ready and 5 is completely willing and able to make the change. Choose, for example, 3 nutrition-based and 3 non-nutrition-based action steps to move forward with. Explore barriers to implementation, and provide tips to overcoming these. Double check with the client that they feel that the action steps agreed are manageable or whether they need tweaking.
Finally, I find it immensely helpful to use a tool which provides concrete accountability – a tracking sheet, which is almost like a star chart for grown-ups! It helps clients to commit to which days of the week they will perform a specific action. It is useful in terms of thinking of how the action steps will fit into their lifestyle – some practices may be impossible to carry through on some days but easier on others. It also gives clients a bit of ‘wiggle room’ as actions do not need to be committed to on every day of the week. The tracking tool can include a line below each item where one marks off which day the behaviour was achieved, so that even if it was missed on the planned day, it can be ‘made up’ another day. And finally, it provides a visual reminder for the client of what they’re aiming to achieve each week – it can be stuck up on the fridge or another prominent place.
In addition to the tracking tool, consider additional needs, such as referrals (to another practitioner or an exercise group), information sheets/recipes and/or supplement recommendations.
Regular follow-up is key to success in implementing behaviour change. Agree how you’ll make contact – another face-to-face appointment, online or telephone consultation. In the beginning, regular, brief follow-ups are often more successful than longer consultations spaced further apart. Key at follow-up appointments is to focus more on successes than failures. Revisit the motivations for the behaviour change, and discuss whether the client’s health goals and focus areas are still the same. For those action steps that were achieved, give praise and consider whether those steps can be built upon or new steps added. For those steps not achieved, emphasise that the client did not fail but rather that the step needs to be adjusted to make it more manageable, or discuss ways of overcoming barriers faced. Encourage the client to keep weekly tracking sheets even if they make their own new sheets between consultations.
PUTTING IT ALL TOGETHER
• Establish if the client is ready to make changes (which stage are they in: Pre-contemplation / Contemplation / Preparation / Action / Maintenance and Relapse)
• Explore goals and motivators – what does the client want to achieve and why?Try to find internal motivators
• Discuss focus areas: Changes in what areas will help achieve goal? (nutrition and non-nutrition)
• Brainstorm SMART action steps by focus area
• Narrow down action steps based on readiness to change, e.g. 3 nutrition and 3 non-nutrition steps
• Discuss barriers and tips to achieving action steps
• Make a tracking sheet
• If applicable: other tools, referrals, supplement recommendations
• Plan follow up – how? when?
We have a common aim – creating sustainable, long-term behaviour change for tangible client benefits and practitioner fulfilment. Hopefully, applying these simple yet powerful tools with your clients will lead to success in the process of behaviour change.
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