Dietitians use most up-to-date public health and scientific research on food, health and disease which they translate into practical guidance to enable people to make appropriate lifestyle and food choices.¹ While there is much evidence and debate on what diet advice is the most effective to manage medical conditions, there is relatively little practical guidance on how this information should be provided in order to best facilitate a change in eating habits. 

What is a behavioural approach?

Behavioural medicine arose in the 1970s and is defined by the United States National Academy of Science’s Institute of Medicine as ‘the field concerned with the development of behavioural science, knowledge and techniques relevant to the understanding of physical health and illness and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation’.² It focuses on the effects of individuals’ health-related behaviours on their medical condition, and aims to enable individuals to change certain behaviours in order to achieve improved outcomes and prevent long-term complications. 

The burden of chronic disease related to lifestyle behaviours is increasing. In 2006, the World Health Organization attributed 60% of the disease burden in Europe to seven leading behavioural risk factors: hypertension, tobacco use, alcohol misuse, high cholesterol, being overweight, low fruit and vegetable intake and physical inactivity. 

Many people living in Ireland are affected by chronic diseases and disabilities related to lifestyle and behaviours such as poor diet, smoking, alcohol misuse and physical inactivity. It is estimated that by 2020, the number of adults in Ireland with chronic diseases will increase by around 40%.³

NICE⁴ recommends that health practitioners should deliver high intensity behaviour change interventions, typically lasting greater than 30 minutes and delivered over a number of sessions, for people who:

• Have been assessed as being at high risk of causing harm to their health and wellbeing (for example, adults with a BMI more than 40) 

• Have a serious medical condition that needs specialist advice and monitoring (for example, people with type 2 diabetes or cardiovascular disease)

• Have not benefited from lower-intensity interventions.

Frustrations in practice

Dietitians have many conversations about behaviour change during the course of a typical work day. These arise when either the dietitian or the patient is considering doing something different to benefit their health, for example changing diet, self monitoring blood glucose levels, or taking nutritional supplements. Sometimes, despite the best of intentions, these conversations are not as effective as they could be. 

In a study of 400 Australian dietitians, the most commonly reported gap in skills (47%) that limited respondents in providing dietetic treatment for obesity was behaviour therapy.⁵

Difficulties arise in consultations when patients are raising objections to the advice that is provided (even though it is evidence-based and will work for them). Dietitians face frustrations with patient’s commitment, compliance, motivation, treatment expectations, levels of responsibility and lack of acknowledgement of the health impact of their condition.⁶ Even when patients have the necessary knowledge and skills, they still struggle in changing their behaviour in the long term.⁷

This is because most people who need to make a change are ambivalent about doing so.⁸ Contemplation, or ambivalence, is a completely normal step in the process of change.⁹ When faced with this during a consultation, the temptation is to continue to offer the facts, make counter arguments, ignore the patient’s objections, dismiss concerns, and share our expertise. However, it has been shown that this does not result in significant behavioural change.¹⁰ 

The patient can end up feeling judged or criticised, may rationalise their current behaviour by providing arguments to maintain the status quo, stop engaging with the dietitian or silently resolve not to change. Even if patients are successful in making changes initially, they struggle to maintain them.¹¹

Key components

The way in which we talk with patients about their health can make a big impact on their motivation for behaviour change. The key components of delivering behavioural interventions are patient-centeredness, communication skills and specific behavioural strategies. 

Patient-centeredness is the underlying philosophy of a behavioural approach. While there are many interpretations of the precise meaning of this term, essentially it encompasses the following domains:¹²

• Exploring the patient’s experience and expectations of disease and illness

• Understanding the whole person 

• Finding common ground between patient and health professional regarding management of the condition

• Promoting health

• Enhancing the relationship between health professional and patient 

• Realistic use of time.

As well as the core qualities of empathy, sincerity and acceptance, a behavioural approach requires strong communication and interpersonal skills. Within dietetics, communication skills are explicitly included in dietetic professional competencies and code of professional conduct and ethics.¹³ Some communication skills necessary for delivering a behavioural approach include:

• Silence and minimal encouragers

• Verbally following or paraphrasing what the client says/means

• Affirming the positives

• Summarising your understanding of what the patient has said

• Asking open questions as appropriate

• Sharing expertise and advice with permission.

Patients report feeling valued by the dietitian when they believe they have been listened to (as demonstrated by paraphrasing and using reflective statements). Establishing rapport, demonstrating empathy, delivery of effective and reliable information, and providing a non-judgemental environment were valued as important by patients, who also reported that these factors create an environment where they would be more likely to talk openly.¹⁴ Indeed, a caring relationship involving active engagement, sharing and open communication is valued by patients as much as the clinical skills.¹⁵ 

Motivational interviewing

Motivational interviewing is a popular communication style which can be helpful in delivering behavioural approaches. It originally developed as a brief intervention for problem drinking in the 1980s and was subsequently used with other health problems, especially chronic diseases where behaviour change is important in treatment and patient motivation is a common challenge. It can be used clinically and non-clinically by any professional supporting others in changing their behaviours. 

It encompasses a spirit of collaboration, compassion, acceptance, and acknowledgement of an individual’s strengths, rather than deficits.¹⁶ Although it is a useful tool for addressing the specific problem of when a person may need to make a behaviour or lifestyle change and is reluctant or ambivalent about doing so, it is not intended to teach new skills, re-educate or correct erroneous beliefs and therefore is not a comprehensive tool or ‘panacea’ for behaviour change in dietetic practice. Motivational interviewing can, however, be combined with other treatment methods, and there is evidence that doing so increases the clinical impact of both.¹⁶

Working in a behavioural way

Within an atmosphere of patient-centeredness and strong communication and interpersonal skills, dietitians are better equipped to complete clinical and behavioural assessment and deliver evidence-based dietary treatment plans incorporating combined general and disease specific behavioural strategies such as:

• Goal setting and planning 

• Developing coping plans and managing relapse

• Monitoring or self monitoring of target behaviours and providing feedback on behaviour and outcomes (eg. blood results, weight checks, self reported measures)

• Developing social support networks for practical help or emotional support.⁴

Because most illnesses are multi-factorial in aetiology and treatment, behavioural medicine focuses on what individuals can do themselves to improve their condition, rather than relying solely on medical interventions such as medication or surgery, or factors which may be more difficult to alter such as genetics or the environment. 

Most patients are ambivalent or resistant to health behaviour change, so it is important to try to understand their perspective and experience, to reflect that understanding and create rapport, and then to provide new information that addresses their concerns and supports them to adopt new, healthier eating behaviours. 

Information giving and telling patients what to do simply does not work. A behavioural approach, encompassing patient-centeredness, strong communication skills and use of proven behavioural strategies is key for dietitians in translating dietetic knowledge and sharing expertise to enable patients to make changes to their eating habits and lifestyle, ultimately leading to better management of chronic conditions.

References

1. INDI (2015) What is a dietitian? Available at: https://www.indi.ie/what-is-a-dietitian/a-dietitian-is.html [Accessed May 17, 2016]
2. Schwartz GE, Weiss SM. Behavioural medicine revisited: An amended definition. Journal of Behavioural Medicine, 1978, 1, 249-251
3. Department of Health. Healthy Ireland - A Framework for Improved Health and Wellbeing 2013-2015. Available at: https://www.hse.ie/eng/services/publications/corporate/hieng.pdf [Accessed May 17, 2016]
4. NICE Behaviour Change: Individual Approaches. Available at: https://www.nice.org.uk/guidance/ph49 [Accessed May 17, 2016] 
5. Dietitians Association of Australia. DAA Best Practice Guidelines for the Treatment of Overweight and Obesity in Adults. Available at: http://daa.asn.au/wp-content/uploads/2011/03/FINAL-DAA-obesity-guidelines-report-25th-January-2011-2.pdf [Accessed May 17, 2016]
6. Campbell K and Crawford D. ‘Management of obesity: attitudes and practices of Australian dietitians.’ International Journal of Obesity Related Metabolic Disease, 2000; 24(6), 701–710
7. Fjeldsoe B, Neuhaus M, Winkler E, Eakin E. Systematic review of maintenance of behavior change following physical activity and dietary interventions. Health Psychology 2011; 30:99-109
8. Miller WR and Rollnick S. Motivational interviewing, Third edition: Helping people change. 3rd edn. United States: Guilford Publications 2014
9. Prochaska JO and DiClemente CC. ‘Stages and processes of self-change of smoking: Toward an integrative model of change’. Journal of Consulting and Clinical Psychology, 1983; 51(3), 390–395
10. The Look Ahead Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes, one-year results of the Look AHEAD trial. Diabetes Care, 2007; 30, 1,374-1,383
11. Naar-King S, Earnshaw P and Breckon J. ‘Toward a universal maintenance intervention: Integrating Cognitive Behavioral treatment with Motivational interviewing for maintenance of behavior change.’ Journal of Cognitive Psychotherapy 2013; 27(2), 126-137
12. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centred medicine transforming the clinical method. Thousand Oaks: Sage Publications, 1995
13. CORU Dietitians Registration Board Code of Professional Conduct and Ethics. Available at: http://coru.ie/uploads/documents/DRB_code_for_public_consultation.pdf [Accessed May 17, 2016]
14. Hancock RE, Bonner G, Hollingdale R, Madden A. ‘If you listen to me properly, I feel good’: A qualitative examination of patient experiences of dietetic consultations. Journal of Human Nutrition and Dietetics 2012; 25:275-284
15. Cant R, Aroni R. Exploring dietitians’ verbal and non-verbal communication skills for effective dietitian–patient communication. Journal of Human Nutrition and Dietetics 2008; 21:502-511
16. Miller B and Rollnick S. Ten Things that Motivational Interviewing Is Not. Behavioural and Cognitive Psychotherapy 2009; 37, 129-140 
17. WHO. The European Strategy for the Prevention and Control of Non-communicable Diseases. Copenhagen: WHO Regional Office for Europe, 2006