Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

  ties for expanding their meal repertoire. While clients may see a necessary dietary change as negative, it can be reframed as an opportunity to experience new flavors and textures in the kitchen. For example, a client with a new diagnosis of celiac disease will be encouraged to switch from flour tortillas to corn tortillas to eliminate gluten. The client may discover that she enjoys quesadillas made out of corn tortillas more than flour tortillas.

  She may begin to try new recipes and foods that she might never have discovered had it not been for her new diagnosis.

  Many patients diagnosed with diseases are able to see the blessing in

  disguise; they often say that they appreciate the newfound motivation for eating well. An individual with diabetes may discover that, thanks to the dietary and exercise changes that were necessary for managing his blood sugars, he now has more energy. Clients will also appreciate hearing that taste buds change over time. Therefore, a reduction in table salt may make the food taste bland at first. However, in just a few weeks, the client may discover a new enjoyable flavor that was previously masked by the salt.

  Helping clients discover the silver lining of diet-based changes can

  reduce perceived barriers. However, when discussing these topics it’s easy to fall into the cheerleading trap. Within an MI session, these tips and tricks are provided gently and with a tone of empathy and autonomy, as in the following scenario:

  “Many of my clients, like you, are less than enthused about switching

  from whole milk to skim milk. There is certainly a significant differ-

  ence in taste. Can I share some tips that other clients have found use-

  ful? [“Yes.”] First, clients find this change easier to make in a gradual step-down fashion. They usually start by mixing whole milk and 2%

  for a few days, and then drink only 2%. Once they are accustomed to

  that, then they start mixing 2% and 1% and eventually switch to 1%,

  then mix 1% with skim, and eventually drink mainly skim milk. Also

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  they find that their taste buds adapt, and what at first seemed watery

  and bland becomes enjoyable. What do you make of this information?

  What do you think would work best for you?”

  If the practitioner can guide the client toward small, manageable

  changes that maximize taste and minimize preparation time, the client will be more likely to stick with the change. At times, dietary changes require significant adjustments in meal planning and cooking techniques. With the help of an MI practitioner, these dietary adjustments can be made gradually, in accordance with the client’s readiness to change. Often, even the most subtle dietary change results in a need to make adjustments in meal planning and preparation.

  MeAl PrePArAtIon And PlAnnIng

  Many of us attempt to manage full lives complete with work and family.

  We cram in as many activities as our lives will hold until our schedules are busting at the seams. We aim for more home-cooked, sit-down meals, but

  the barriers to achieving this goal are often immense. Many turn to the convenience of restaurants and packaged meals when in a pinch. While eating out can provide a break from the cooking and cleaning, frequent stops for takeout can be costly and can lead to overeating. Furthermore, it can be especially challenging to find a variety of options that meet the nutritional needs of your clients who may have necessary dietary restrictions for managing disease.

  Most dietary changes require a tweak in meal preparation, meal plan-

  ning, or both. Ultimately, a client’s ability to manage such changes depends on contextual skills. Child feeding expert and registered dietitian Ellyn Satter (2008) defines contextual skills as “skills and resources for managing the food context and orchestrating family meals” (p. 225). Developing strong contextual skills is about gaining the skills to prepare regular and reliable meals and snacks and eating those at times that honor internal hunger cues.

  Where is your client getting stuck

  when it comes to planning for eating?

  Where is your client getting stuck

  Is it that she hardly knows how to

  when it comes to planning for

  boil water and lacks confidence in the

  eating?

  kitchen? Or does she perceive cook-

  ing as something that requires a long,

  labor-intensive process? Is she paralyzed with fear because she worries that her meals don’t always include a perfect mix of all the essential vitamins and minerals? Perhaps she hasn’t found a grocery-shopping schedule that

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  easily fits into her busy week. Before any planning or goal setting can occur, it’s useful to explore her concerns. What are her barriers to meal planning and preparation? Only then can you provide her with the support she needs to be successful both at the grocery store and in the kitchen.

  the grocery store: Planning for eating

  Once your client expresses interest in making changes to her meal plan-

  ning strategies, it’s important to first assess her current skills and patterns.

  How often does she like to go to the grocery store? How does she decide which foods to purchase? Does she go with specific meals in mind, make

  up meal ideas while wandering the grocery store aisles, or does she buy random items and then later attempt to turn those items into meals? Specific evoking questions can be used to invite the client to explore which pieces of her current meal-planning strategy are working and which pieces are not. Here are some open-ended questions that may help her along in

  the process:

  “Describe your current grocery-shopping system. How do you deter-

  mine what you will eat for the week?”

  “What’s working well for you in how you plan your meals?”

  “What’s not working well for you in how you plan your meals?”

  “Which part, if any, of the way you plan your meals are you interested

  in changing?”

  “How do you see this change improving other areas of your life?”

  “What resources would you need to be successful if you were to make

  this change in the way you plan your meals?”

  These questions will help the client to home in on the real issue. In true MI fashion, when the client seems ready, invite her to devise solutions to her stumbling blocks. You are there to provide suggestions only if she gets stuck. We each have meal-planning strategies that work for us; however, these same strategies may not work for your client. In the script below, the practitioner puts the client in the driver’s seat to determine what might work best. The practitioner also helps the client when she gets stuck.

  pRactitioneR: You mentioned that you’d like to eat out less often.

  [reflection] What time of the day or which meals did you have in

  mind? [open-ended question]

  client: Definitely dinner. My boyfriend and I eat dinner out about

  four times a week. It was fun when we were first dating, but we’ve

  each put on a few pounds in the last 6 months, and we’re trying to

  save up money to go on vacation. [change talk—desire for change]

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  pRactitioneR: You’ve noticed the cost savings of preparing more

  meals at home. [reflection]

  client: Yes. Some nights, between the appetizer, drinks, and meal,

  we spend as much as $50 between the two of us.

  pRactitioneR: You’re finding that it adds up quickly. [reflection]

  client: It really does.

  pRactitioneR: What would need to change in order for you to pre-

  pare more meals at home? [open-ended question]

  client: We would need to get to the grocery store more often and

  maybe have mor
e of a plan when we go. Sometimes we say, “Oh,

  let’s stay home tonight and just fix something.” And then we open

  up our cupboards and can’t find anything to make, so we head

  out.

  pRactitioneR: You’d really like a fully stocked kitchen so that you’re

  less tempted to eat out. [reflection]

  client: Yes. I mean, we both know how to make a few things, so

  that’s not the issue. It’s just that we need to do a better job at the

  grocery store. [change talk—the need to change]

  pRactitioneR: You’ve got the cooking part down; you just want help

  on the meal planning and the grocery shopping. That’s where you

  see things could change for the better. [reflection of change talk]

  What ideas do you have? [open-ended question]

  client: I think I just need to make sure I make a list or something

  before I go. [change talk—activation]

  pRactitioneR: Yes, a list is something that works for some people.

  You want to be more organized when you go to the store. You

  want to have a plan. Would you be interested in hearing a few

  shopping list strategies that my other clients have tried? [asking

  permission]

  client: Sure!

  pRactitioneR: One idea is to write out a grocery list that includes

  food for a certain number of dinner meals each week . . . maybe

  four or five. Then go to the grocery store with both your list of

  ingredients and the meals you plan to make for dinner written

  down. Some clients prefer to go to the grocery store every 3 days

  or so, while others prefer once a week. Some like to buy major

  nonperishable items, like canned beans and canned tomato sauce,

  once a month and then only buy the fresh produce, dairy, and

  meat items once a week. [giving information] Which, if any, of these sounds more like you? [open-ended question]

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  client: I really don’t like going to the grocery store very often, so I could see how planning out my meals and only going once a week

  would probably work best.

  pRactitioneR: You’d like to change the way you’ve been doing things

  by being more organized and including meal ideas on your list

  before heading to the store. [reflection] Which days are best for grocery shopping each week? [open-ended question]

  client: I like going Friday nights because it’s quiet, so probably just on the way home from work.

  pRactitioneR: OK, Friday nights. [reflection] If you were to do your

  grocery shopping on Friday nights, when would be the best time

  to write up your list? [open-ended question]

  client: Probably Thursday night before I go to bed. Then I can just

  put the list in my purse and have it with me when I drive home

  from work on Fridays.

  pRactitioneR: All right, so what you’re thinking is if you can spend a

  few minutes coming up with certain meal ideas and writing those

  down Thursday nights, then it will be easy for you to shop Fri-

  days on your way home from work. [summary] How will your

  boyfriend feel about this change and how can he support you?

  [open-ended question]

  client: He’ll totally be on board with this. I think it might even be

  fun at first to test out our cooking skills. He can support me by

  giving me ideas for meals we can make together.

  pRactitioneR: You and your boyfriend seem excited about planning

  more meals to cook at home each week. [reflection] What sort of goal would you like to set in terms of the number of dinners you

  eat out each week? [open-ended question]

  client: I think if we could go from eating four meals out each week to

  eating one meal out each week that would be great.

  pRactitioneR: You’d like to shoot for eating out only one day a week.

  How confident are you on a scale from 0 to 10 that you can reach

  this goal, with 10 being very confident and 0 being not at all con-

  fident?

  In this conversation the practitioner uses consistent reflective listening to evoke and reinforce change talk. She also invites the client to take the lead in figuring out the pieces of the puzzle. The practitioner asks the client how and when, provides some information, but gives the client autonomy

  in deciding what might work best for her. She ends by summarizing the

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  specific goal the client has set and exploring confidence and any potential barriers that may arise as the client attempts this change.

  In the kitchen: Preparing Meals

  If your client expresses interest in expanding his repertoire of meals and snacks prepared at home, it’s important first to determine his baseline cooking skills and build from there. What does he already know how to

  make? What does he make regularly? What other foods, if any, would he

  like to be able to make? How much time does he prefer to spend in the

  kitchen preparing meals? Snacks? While assessing the client’s contextual skills in the kitchen, it’s easy to fall victim to the question–answer trap. As you gather this information, use open-ended questions that allow the client to tell his story.

  “Tell me about the foods you eat on a regular basis.”

  “What would you commonly eat for dinner?”

  “What are your go-to meals?”

  “What kinds of foods do you reach for when you’re in a rush?”

  “If you can remember, tell me what you had for breakfasts this past

  week.”

  “What other foods, if any, would you like to be able to make?”

  You can help increase your client’s self-efficacy for cooking by giving him quick and easy meal ideas, if needed. He may not realize that a balanced meal can be made in as little as 10 to 15 minutes. Handout 13.1 includes examples of meals that require minimal time and basic cooking skills.

  There are many resources available for expanding one’s meal ideas.

  We all get into cooking ruts and crave new and exciting food experiences.

  Nutrition counselors can provide tangible food ideas for clients within an MI session. The key is simply asking permission before providing these

  ideas and offering resources that best meet your clients’ needs.

  In order to provide relevant meal ideas, first assess your client’s preferred tastes and textures. In addition, consider that many clients have cultural food preferences that are important to understand. A common mis-

  take of nutrition counselors is to start spouting off meal and recipe ideas without checking in with the client first to determine food preferences. By asking these first, the client will feel respected and understood.

  Before providing new meal ideas, determine your client’s cooking

  skills. Recipes have very limited information to guide an actual cooking event. Encourage your client with limited cooking skills to start with very basic and simple endeavors. When discussing different recipes, assess the client’s interest in the recipe and perceived ability to prepare the recipe by asking open-ended questions. A scaling question may also be useful, such

  Handout 13.1

  FRuItS aND VEgEtaBlES MaDE EaSy

  10 Meals in 15 Minutes

  Are you hungry, but short on time? Here are 10 quick, easy meal ideas that include fruits and vegetables, along with a shopping list to take with you the next time you head for the grocery store.

  1. hummus Wrap

  Tortil a, fresh spinach, hummus, slice of cheese

  2. Chili Baked Potato

  Potato, canned chili (there are vegetarian options), shred
ded cheese

  3. Pita Pizza

  Pita bread, pesto or pizza sauce, mozzarel a cheese, toppings such as bell pepper, olives, mushrooms, and Canadian bacon

  4. Cottage Cheese or yogurt, Fruit, and granola

  Cottage cheese or yogurt, fruit, granola

  5. grilled Cheese and tomato or Vegetable Soup

  Bread, cheese, favorite soup

  6. Breakfast Burrito

  Tortil a, scrambled eggs, salsa, canned black beans, shredded cheese

  7. taco Bowl

  Canned beans, instant rice, canned or frozen corn, shredded cheese, tomatoes, avocado, salsa

  8. tomato tuna Melt

  Bread, bagel, or English muffin, sliced tomato, tuna with mayonnaise, cheese 9. Peanut Butter and Banana on Bread or tortilla

  Bread or tortil a, peanut butter, banana

  10. lettuce-Free Salad

  Canned beans of your choice (garbanzo beans work wel ), small vegetables such as peas and baby tomatoes, diced vegetables such as bell pepper, cucumber, and carrots, vinaigrette salad dressing of your choice

  gRoCERy lISt

  Produce

  Canned

  Refrigerated

  grain

  Misc

  Fresh spinach Chili

  Shredded mozzarella Pita bread

  Peanut butter

  Bel pepper

  Tuna

  Slices of provolone,

  Tortil as

  Mayonnaise

  Mushrooms

  Black beans (2)

  jack or cheddar

  Bread, bagel or

  Salad dressing

  Fruit of your

  Garbonzo beans

  Hummus

  English muffin Salsa

  choice

  Tomato or

  Pesto

  Instant rice

  Avocado

  vegetable soup Eggs

  Granola

  Tomato

  Corn

  Canadian bacon

  Cucumber

  Cottage cheese or

  Carrots

  yogurt

  ( continued)

  From Motivational Interviewing in Nutrition and Fitness by Dawn Clifford and Laura Curtis. Copyright © 2016 The Guilford Press. Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details). Purchasers can download a larger version of this handout (see the box at the end of the table of contents).