Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

  • Only exercise to lose weight for a wedding and then stop exercising

  when the wedding is over.

  • Only allow himself to have a 300-calorie meal if he burns 300 calo-

  ries according to his heart rate monitor device.

  • Go to an exercise class because she will feel guilty and anxious if

  she skips it.

  Setting up external rewards for physical activity is not inherently bad.

  In fact, it is often the initial dominant form of motivation when clients begin an exercise routine. It may be helpful, at first, for the client to set up a reward system to get started. Using MI, the conversation may sound something like this:

  pRactitioneR: Some of my clients have found it helpful to set up

  a reward system when getting started with a new activity plan.

  Would you be interested in hearing more about this strategy? [ask-

  ing permission]

  MI in Fitness Counseling 221

  client: Yes, that might help.

  pRactitioneR: There are many ways to do it, and you can decide

  what might work best for you. [supporting autonomy] One way is to set a weekly goal such as going for a walk three days a week.

  And then for each week you are successful in reaching that goal,

  you treat yourself to an inexpensive reward, such as a magazine

  in the grocery store checkout line or downloading a new song to

  listen to. Others prefer setting up rewards based on total minutes

  or steps per week or per month. [giving information] What do you

  think of this approach? [elicit]

  client: I like that. I love going to the movies, so I think I’ll take myself to the movies at the end of the month if I’ve met my monthly goal.

  Maybe I could set a monthly goal of going for a walk 12 times.

  pRactitioneR: You found something that could get you excited about

  your new plan.

  However, if controlled motivation remains the dominant force, it is

  more than likely to waver, especially once the external reward is removed (Deci, Koestner, & Ryan 1999). This is seen in employee wellness programs that offer financial incentives for increasing physical activity. It can be the catalyst that gets people active, but it also can result in employees focusing only on the reward and not the intrinsic benefits of the physical activity.

  When clients focus only on external rewards and feel that they are not

  totally free to make their own decisions, the activity becomes unsustainable. To illustrate this further, consider the following example:

  Tracie, a part-time bank teller and mother of two children is starting

  an aerobics class with her friend Jessica. She feels compelled to join the class because Jessica wants to lose weight and has asked Tracie to help by going with her to the class. If it were entirely up to her, Tracie would do something outside of the gym that included her family.

  Tracie is motivated by the desire to support her friend, and she

  would feel guilty if she didn’t try to help. They do a few weeks of the class together and Tracie isn’t very good at it. She feels unskilled and uncoordinated, leaving her feeling slightly humiliated. After 2 weeks

  Jessica gets a cold and cancels. Tracie then doesn’t go by herself and

  never gets back into it.

  Both Tracie’s and Jessica’s motivation would be categorized as con-

  trolled. Jessica was exercising for the external reward of perceived weight loss, and Tracie was stuck in an activity she didn’t really enjoy and was only going to support her friend.

  Figure 14.1 highlights some of the common extrinsic reinforcers that

  motivate people to be physically active. Although these may be the reasons

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  MI IN NUTRITION AND FITNESS INDUSTRIES

  • Monetary rewards for reaching personal activity goals.

  • Rewards from winning a competition (honors, trophies, etc.).

  • Changes to physique (weight loss, muscle tone, weight gain, etc.).

  • Pressure from friends or family.

  • Compliments from friends or family.

  • Money or incentive for physical activity.

  • Rewards for attendance to a workout class or sport practice.

  • Punishment for missing a workout class or sport practice.

  • Improved lab values such as cholesterol, blood sugars, and blood pressure.

  • Decreased risk of disease.

  FIgure 14.1. Common extrinsic motivators for physical activity.

  why people start exercising, it is important to help clients make a shift from initially focusing on an external reward to realizing the intrinsic benefits.

  In fact, when people are given external rewards for activities that are intrinsically interesting, the amount of intrinsic motivation regrettably diminishes (Deci et al., 1999). Other factors that decrease intrinsic motivation are the threat of punishment (Deci & Cascio, 1972), surveillance (Plant & Ryan, 1985), evaluation (Deci & Ryan, 2008), and negative feedback (Vellerand & Reid, 1984).

  selF-eFFIcAcy And exercIse

  Adopting a new physical activity routine can be daunting, especially if the client is hoping to explore a new sport or style of exercise. For some, the risks of looking silly, having poor coordination, or being uncomfortable can be enough to scare them away from trying fun and physically challenging activities.

  Even if a person doesn’t yet have the skill to master a particular activity, with time and perseverance, the skills often develop and more of the intrinsic benefits surface. The question, though, is how to help clients to persevere through the awkward initial trial period when starting a new

  activity.

  The answer is found in building client self-efficacy, otherwise known as self-confidence in one’s abilities for a specific task or activity. For example, a client may have high self-efficacy for running after being on the high school cross-country team, but have low self-efficacy for tennis. Therefore, when clients start new activities, they will commonly have low self-efficacy.

  To help them get over this hump, emphasize “starting small.” Urge your clients to set up goals they feel confident in meeting. A good scaling question can help you gauge their readiness and confidence: “On a scale of 0 to 10,

  MI in Fitness Counseling 223

  with 0 being not confident at all and 10 being 100% confident, how con-

  fident are you that you can correctly use the strength-training machines at the gym?” If the client reports low confidence, discuss ways to increase self-efficacy, such as meeting with a personal trainer, going with a friend who knows how to use the machines, or finding instructional videos online.

  Guide your client to come up with a small, manageable goal. No goal

  is too small for the purpose of increasing self-efficacy. Perhaps your client sets a simple goal of asking a friend to join him at the gym. The main goal is to help your client find success, even if he reaches a very small goal. You can help your clients see their own potential when they accomplish small goals, and ultimately it will build their self-efficacy for maintaining the activity.

  Other ways to build self-efficacy involve having your client examine

  his or her beliefs about what physical activity is and what it is not. Many clients have preconceived notions about physical activity that set them up to select unreasonable goals. For example, it is a common belief that physical activity only benefits you if it’s continuous at a gym or an organized workout class. This is simply untrue. Small bouts of physical activity have been known to generate significant benefits as well. Once your clients realize that small amounts of physical activity spread throughout a typical week can improve health and well-being, they will be more willing to set smaller, more realistic goals. Handout 14.3 has examples of quick, easy ways clients can sneak physical activity into their week.

  Before pr
oviding your clients with ideas for increasing physical activ-

  ity, find out more about your clients’ previous experiences. Be sensitive to their past experiences with exercise and dieting. There will be times when your clients may voice feeling intimidated or humiliated during certain activities. Those experiences and underlying beliefs about physical activity may be what have been keeping your client from being active up until now.

  AddressIng BArrIers to BeIng PhysIcAlly ActIve

  Clients often cite many different barriers to being physically active on a regular basis. When researchers evaluated 56 structured exercise programs, they discovered that 50% of people who start exercising drop out within the first 6 months (Dishman, 1991). According to the Centers for Disease Control and Prevention (2014), 52% of adults do not meet the 2008 Physical Activity Guidelines. Figure 14.2 includes several commonly reported barriers to physical activity.

  Like any behavior change, clients express ambivalence in their deci-

  sion to start or continue exercising. Straightforward discussions about specific barriers can help clients evaluate what is keeping them from being active. The following are a few open-ended questions that could help you get started in discussing this topic:

  Handout 14.3

  FIttINg IN FItNESS: CREatIVE WayS

  to SquEEzE PhySICal aCtIVIty INto youR Day

  It’s often chal enging to find time to exercise. Many believe that exercise has to look a certain way or be a certain length in order for it to “count.” The truth is that any time you move your body it counts as physical activity.

  If you’re feeling too busy to work out, consider incorporating these quick little bursts of physical activity into your day:

  • Park in the farthest spot in the parking lot and walk.

  • Take the stairs instead of the elevator/escalator.

  • Take a 10-minute walk on your lunch break or during a rest period.

  • Walk or bike to work, or drive halfway to work and walk or bike the rest of the way.

  • Walk or bike to the store for light groceries.

  • Take a stretch break every 2 hours to get your blood circulating.

  • Walk around the perimeter of the field while your child is at a sports practice.

  • Walk over to a coworker’s office instead of cal ing, texting, or emailing to ask a question.

  • Initiate walking meetings at work when meeting with two or three people.

  • Walk to the mailbox instead of picking it up in the car on your way in or out of the driveway.

  • Walk around the block with your family after dinner.

  • When watching a television program do strength-building activities during the commercial break (such as push-ups or sit-ups).

  • Clean the house or garden.

  • Turn on some music and dance in your living room.

  Which of the strategies above, if any, sound like feasible ways to add more activity to your day?

  ____________________________________________________________________________

  ____________________________________________________________________________

  ____________________________________________________________________________

  ____________________________________________________________________________

  What other ideas do you have?

  ____________________________________________________________________________

  ____________________________________________________________________________

  ____________________________________________________________________________

  ____________________________________________________________________________

  Based on Kowalski (2010).

  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).

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  MI in Fitness Counseling 225

  • Perceived lack of time.

  • Perceived lack of convenience.

  • Fear of injury.

  • Poor self-efficacy.

  • Unrealistic expectations.

  • Negative self-talk.

  FIgure 14.2. Common barriers to consistent physical activity.

  “What most concerns you about being physically active?”

  “What tends to get in the way of being active?”

  “How do you feel about being physically active?”

  “If you decided to start working out tomorrow, what would need to

  happen?”

  “When you see yourself being active, what kind of activities do you see yourself doing?”

  “What’s not working well with your current physical activity routine?”

  Depending on the client’s perceived barriers to being more physically

  active, a number of MI strategies can be used to evoke change talk and

  support the client in coming up with viable solutions. The following sections include an in-depth look at common barriers clients report to being physically active.

  Perceived lack of time

  The number-one barrier to being physically active in healthy adults is a perceived lack of time (Chinn, White, Harland, Drinkwater, & Raybould, 1999). People make time for the things that are important to them. It may be that your client has not made time for exercise before now, but would be able to if priorities changed. However, the perception of having no time has immobilized him. It can be helpful to explore this perception with your client to gain insight into how having no free time interacts with other possible barriers.

  For example, having no free time

  may be linked to a belief that physi-

  People make time for the things

  cal activity only counts if it is for 1 that are important to them.

  hour at the gym, 5 days a week. It

  is reasonable, therefore, for physical

  activity to be too time consuming for some. Alternatively, by exploring the preconceived notions of physical activity, you can clarify any misinformation and help your clients set goals that fit into their busy lives. The following script highlights a client and practitioner exploring physical activity while reviewing an exercise frequency questionnaire.

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  MI IN NUTRITION AND FITNESS INDUSTRIES

  pRactitioneR: It says here that you are physically active once a week,

  and you’ve written in the margin “if I’m lucky.” What do you

  mean by “if I’m lucky”? [open-ended question]

  client: Well, I have a lot going on. If everything comes together I’ll

  be able to steal away to the gym for a while. But it rarely happens.

  I used to go three to five times a week before my husband and I

  had our kids.

  pRactitioneR: You have a pretty hectic schedule, which tends to push

  getting to the gym to the end of the list. [reflection]

  client: It’s not that it’s not a priority for me. It’s just that when I’m home in the evenings and the kids get home it’s all homework and

  dinner. There’s always something else that needs my attention.

  pRactitioneR: Physical activity would need to be something that fits

  easier into your life and involve your family. [reflection] If you

  were to start doing more activities that didn’t impose on your

  family life, what would they be? [open-ended question]

  client: Well, sometimes I take our dog for a walk. [change talk] It’s

  usually my son’s responsibility, but I do it when he’s too busy with

  homework. Sometimes we do it together, but I don’t break a sweat.

  pRactitioneR: Since you don’t break a sweat, you’r
e wondering if it

  still counts. [reflection]

  client: It’s just not the same as when I work out. We’re just walking

  around and having fun.

  pRactitioneR: And when you think of exercise, you don’t think about

  having fun. [reflection]

  client: When I think of exercise, I think of sweating, like running or

  something.

  It is no wonder the client has not made time to go to the gym. She

  doesn’t connect exercise with enjoyment or pleasure. She sees exercise as a chore or a punishment. People rarely make time for things they hate, but if the activity could involve things she already loves doing and perhaps include the people she enjoys spending time with, she might find a physical activity she looks forward to doing. Furthermore, if practitioners can guide clients into breaking activities up into short bouts that easily fit within a busy schedule, clients may be more successful squeezing activity in during their regular routine.

  lack of enjoyment

  Many find exercise boring or tedious—something you have to do, but don’t want to. Therefore, they sign up for a gym membership that goes unused as

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  they voice many legitimate reasons why they can’t go. The fact is, they have other more pressing issues, or they simply don’t want to go, and that’s OK.

  Helping clients make fitness goals starts with finding out what they

  like to do. As with people, physical activity comes in many shapes and

  sizes; one size doesn’t fit all. It is with this attitude that the spirit of MI comes alive in your counseling through the use of empathy. Expressing

  empathy means looking at a situation through your client’s eyes and understanding how he or she would feel, not how you would feel in the same

  situation. Allow your clients the autonomy to come up with their own goals and ideas that make being active enjoyable.

  exacerbation of a health condition

  Another common barrier that may arise revolves around the perception