Do dietitians feel that they have had adequate training in behaviour change methods?

Do dietitians feel that they have had adequatetraining in behaviour change methods?

L. Rapoport* & K. Nicholson Perry{*Health Behaviour Unit, Department of Epidemiology and Public Health, University College London and {INPUT Pain Management Unit,

Guy's & St Thomas' Hospital Trust, London, UK

Abstract

Correspondence

Lorna Rapoport,Health Behaviour Unit,

Department of Epidemiology and Public

Health,University College London,

2±16 Torrington Place,

London WC1 E 6BT, UK.

E-mail: [email protected]

Keywords

behaviour change, cognitive behavioural

therapy, counselling skills, dietitians,motivational interviewing, training.

Accepted

May 2000

Aim To investigate dietitians' perceived adequacy of pre- and

postregistration training in a range of behaviour change techniques,

current main approach to dietary treatment and perceived usefulness of

future training in five core behaviour change modalities.

Method A questionnaire was designed and distributed to all dietitians

registered in the BDA membership base (n = 4202).

Results Three hundred and ninety-four questionnaires were re-

turned. The majority of these respondents had obtained their degree

since 1982 (77%), since when courses were more likely to have

contained a psychological component. Despite the fact that facilitating

dietary behaviour change is a key dietetic role, respondents felt that

they had not received adequate training in behaviour change skills in

their dietetic training. Training was perceived to be most satisfactory in

active listening skills, but this was perceived as barely adequate.

Training was perceived as particularly poor in: applying theories of

cognitive and behavioural therapy (CBT); motivational techniques;

group work skills; and in both theory and skills of relapse prevention.

Although 40% of respondents reported receiving explicitly psycholo-

gically based training, skills-based training (mainly counselling) was

reported by only 25% and was limited by being mainly short 1- or 2-

day courses. Overall, where further training was obtained it was

perceived to be more adequate than that reported within preregistra-

tion dietetic training.

Conclusion Respondents felt that they had not received adequate

training in behaviour change skills in their dietetic training. The

application of CBT, motivational techniques and relapse prevention

was perceived as particularly deficient in training and the majority of

respondents felt that future training would be useful or very useful. In

the current health service climate, where evidence-based practice is

crucial for all practitioners with the emphasis on improved quality of

care with measurable outcomes, research must be funded and

undertaken to support attempts to improve dietitians' effectiveness as

behaviour change agents.

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 287±298 287

Introduction

Dietitians have traditionally functioned as nutri-

tional advice givers rather than behaviour change

agents. Dietetics originated as a hospital-based

profession with the traditional dietetic interview

being firmly based on the model of the doctor±

patient medical consultation which uses direct

persuasion to get people to change their behaviour

(Hunt, 1995). Dietitians focus on translating

scientific and medical decisions relating to food

and health into terms which everyone can under-

stand (BDA, 1997). In this context, dietitians are

trained how best to teach and advise people about

the important dietary changes that they need to

make rather than how to provide tools to help

people to implement these changes (Rapoport,

1998). Over the last 20 years there has been a shift

from the dietitian acting as a technician delivering

advice to a consultant with expertise in all aspects of

nutrition and dietetics (Judd et al., 1997). This has

been paralleled by a move from practising pre-

dominately within an acute hospital setting to a

more community-orientated base. As a result,

authors have recognized the need for competency

in counselling skills in the dietetics practitioner.

However, in spite of this most dietitians complete

their training without developing specific skills in

behaviour change. The process of facilitating

behaviour change has largely remained in the

domain of applied psychology.

The evidence in support of integrating behaviour

change theory and strategies into dietetic practice is

strong. Studies have shown that nutritional inter-

ventions based on the dissemination of information

are not very effective in bringing about behavioural

change (Glanz, 1985; Shepherd & Stockley, 1987;

Contento et al., 1995). In a review of 217 nutrition

intervention studies, it was found that setting

behaviour change as the goal is a significant factor

in improving dietary practices (Contento et al.,

1995). Effective programmes additionally incorpo-

rated communication and group educational stra-

tegies that were motivating, taught strategies for

behavioural change, included active involvement of

both the individual and the community and

attempted to build health-enhancing environments.

In a more recent review of 76 healthy eating

interventions, the HEA (1997) reinforced these

findings with recommendations that healthy eating

interventions should have a clearly stated theoretical

basis incorporating effective models of communica-

tion and behaviour change, and should adopt a

behaviourally based approach which includes active

involvement of individuals.

The research demonstrates the necessity of

including behavioural methods for effective inter-

ventions, but how important do dietitians perceive

training in behaviour change strategies to be?

Following a survey of dietetic practice, Gilboy

(1994) observed that whilst dietitians have adopted

some counselling strategies, they still lag behind in

the use of adherence-enhancing strategies recom-

mended for behaviour change. Increasingly dieti-

tians themselves have reported the need for

counselling skills training (Isselman et al., 1993).

Adopting a counselling approach and utilizing

counselling skills provides the fundamentals of a

process to help a person to identify problems, assess

needs and promote dietary change. In a BDA

preregistration working group survey examining

structure and content of preregistration education

and training for dietitians, participants perceived

counselling skills as largely absent in courses

(Rogers & Judd, 1996). Communication and

educational methods were considered to be allo-

cated too little time in training by over 50% of

respondents. This has led to recommendations from

the British Dietetic Association/Council for Profes-

sions Supplementary to Medicine Dietitians Board

Joint Working Party that more emphasis is placed

on developing skills in communication and coun-

selling. However, beyond this, specific behaviour

change methods are required to effectively treat

commonly encountered problems, such as obesity.

The British Dietetic Association recognizes that to

offer optimal obesity treatment dietitians must

possess the skills and confidence to help people

through the process of change and equip them to

prevent relapse (BDA, 1997), of which adequate

training is a prerequisite.

The need for training in these methods is

recognized by the profession and if dietitians

themselves desire further training in this area, core

behaviour change training has to be identified and

implemented based on the strengths and weaknesses

288 L. Rapoport and K. N. Perry

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 287±298

of current training. In the first instance, it is helpful

to identify perceived adequacy of current training in

core areas. Such core training areas may include

methods which facilitate the therapeutic alliance

(listening skills), methods which stimulate motiva-

tion for, and reduce resistance to, change (motiva-

tional techniques), strategies for optimizing

behaviour change (cognitive and behavioural ther-

apy) and strategies to help maintain new behaviours

once established (relapse prevention). This survey

aimed to assess how adequate currently practising

dietitians felt that their training in these behaviour

change methods both pre- and post- (where

received) registration had been as a starting point

for further recommendations.

Method

Subjects

In October 1997, a short self-completion question-

naire was mailed to all dietitians registered in the

BDA membership database (n = 4202). Of these,

4029 were based in the UK and 173 were based

overseas. Dietitians were asked to return the

questionnaire by the middle of November. Owing

to resource constraints, no self-addressed envelope

or reminder mailing or follow-up of nonrespon-

dents was undertaken.

Instrument

The questionnaire was designed to elicit informa-

tion regarding perceived adequacy of both pre- and

postregistration training in a range of behaviour

change techniques. The questionnaire consisted of

five sections (Appendix 1): (i) assessed dietetic

training history and any other training received in

psychological interventions; (ii & iii) assessed

perceived adequacy of training (rated on a four-

point likert scale) in five discrete areas of psycho-

logical behaviour change techniques pre- and

postregistration; (iv) asked respondents to identify

their main approach to dietary treatment (Hunt,

1995) eliciting an example of how they would apply

this approach in practice in order to assess the

degree to which this was used to consistently have

the same meaning; and (v) assessed perceived

usefulness (rated on a four-point likert scale) of

future training in the five core behaviour change

modalities addressed in sections two and three.

Statistical analyses

Statistical analyses were carried out using SPSS for

Windows, release 7.5. Valid percentages were used

for reporting results. Content analysis was used to

analyse data in section four.

Results

Questionnaire responses were received from only

394 dietitians, henceforth referred to as respon-

dents, representing 10% of the membership. Levels

of missing data in the different sections vary and so

actual numbers of respondents to each question are

reported.

Training history

Dietetic training

Locations of dietetic training were diverse. The

majority of respondents had been trained in Scot-

land (32%), southern England (28%) and northern

England (26%). The majority of individuals had

qualified by obtaining a BSc degree (39%), a

diploma (35%) or a BSc Hons degree (25%).

Dietetics obtained degree status in 1982 since when

courses were broadened, and were more likely to

have contained a psychological component. The

majority of respondents (77%) had obtained their

degree since 1982.

Perceived adequacy of preregistration dietetic degree/

diploma training

Table 1 shows the perceived adequacy of preregis-

tration training in a range of behaviour change

methods in the 394 respondents.

Perceived adequacy of preregistration dietetic training

in active listening. The modal response for both

reflecting and summarizing skills was barely ade-

quate. Only about one-fifth of respondents per-

ceived their training in this area to be at least

adequate.

Training in behaviour change methods 289



in cognitive and behavioural therapy (CBT). In

CBT, the modal response was not at all adequate for

seven of the specified techniques, and barely

adequate for theories of behavioural therapy.

Notable exceptions were perceived adequacy for

only two of the techniques: goal setting and self-

monitoring. Training was perceived to be least

adequate in exposure, stimulus control and challen-

ging negative thoughts related to eating.


in motivational techniques. In motivational tech-

niques, the modal response was not at all adequate

for all techniques specified. Training was perceived

to be least adequate in eliciting motivational

statements and confrontation of conflict regarding

change. It is notable that almost one-quarter of

respondents reported not receiving any training in

motivational techniques.


in relapse prevention. The modal response was not

at all adequate for all techniques specified. Nearly

half of the respondents perceived training in

theories of relapse prevention and actually mana-

Table 1 Perceived adequacy of preregistration dietetic degree/diploma training in behaviour change ± number and percentage in

parentheses (n = 394)

Not

at all

adequate

Barely

adequate Adequate

More

than

adequate

Not

applicable/

didn't have any

Listening skills

Reflecting skills 118 (30) 145 (37) 59 (15) 14 (4) 52 (13)

Summarizing skills 101 (26) 145 (37) 79 (20) 12 (3) 51 (12)

Cognitive and behavioural therapy

Theories of behavioural therapy 121 (31) 125 (32) 78 (20) 25 (6) 41 (10)

Theories of cognitive therapy 135 (35) 114 (29) 72 (18) 21 (5) 47 (12)

Exposure (progressive, planned exposure 180 (46) 89 (23) 23 (6) 4 (1) 92 (24)

to problem foods)

Response prevention (e.g. substituting 151 (39) 115 (30) 40 (10) 6 (2) 77 (20)

different behaviours for eating)

Stimulus control (e.g. reducing exposure to 161 (41) 118 (30) 29 (7) 7 (2) 72 (19)

cues for problem behaviour)

Reinforcement of new behaviours 136 (35) 133 (34) 51 (13) 7 (2) 61 (16)

Identifying negative thoughts related to eating 151 (39) 114 (29) 42 (11) 9 (2) 72 (19)

Challenging negative thoughts related to eating 169 (44) 111 (28) 24 (6) 7 (2) 76 (20)

Goal setting 90 (23) 110 (28) 113 (29) 25 (6) 50 (13)

Self monitoring (e.g. keeping diaries) 80 (21) 101 (26) 134 (34) 28 (7) 46 (12)

Problem solving 99 (26) 133 (34) 80 (21) 19 (5) 55 (14)

Motivational techniques

Theories of motivational interviewing 171 (44) 97 (25) 32 (8) 2 (0.5) 88 (23)

Eliciting motivational statements 184 (47) 90 (23) 24 (6) 2 (0.5) 90 (23)

Decisional balance (weighing pros vs. cons of change) 155 (40) 102 (36) 46 (12) 9 (2) 77 (20)

Confrontation of conflict regarding change 179 (46) 86 (22) 32 (8) 8 (2) 83 (21)

Theories of stages of change 174 (45.7) 75 (19.3) 43 (11.1) 12 (3.1) 85 (21.9)

Relapse prevention

Theories of relapse prevention 184 (47) 96 (25) 16 (4) 2 (0.5) 91 (23)

Identification of high-risk situations 166 (43) 101 (26) 31 (8) 3 (0.8) 87 (22)

Managing high-risk situations 184 (47) 95 (24) 15 (4) 3 (0.8) 92 (24)

Group treatment

Theories of group interactions 124 (32) 125 (32) 67 (17) 10 (3) 64 (16)

Group management skills 129 (33) 131 (34) 58 (15) 10 (3) 62 (16)



ging high-risk situations to be least adequate. It is

notable that almost one-quarter of respondents

reported not receiving any training in relapse

prevention.


in group treatment. The modal response was

barely adequate for training in theory and practice

of group treatment.

Other training

Just under half the sample, 195 (49%), completed

the question referring to other training in addition

to their preregistration dietetic training. Although

respondents were asked to name only their other

training in psychological interventions, 354 (90%)

reported having attended a wide range of other

training. This has therefore been included in the

analyses despite not necessarily being totally re-

levant to the question asked. Owing to requesting

course titles of other training received, in some

cases the degree of psychological content in the

named course was unclear as well as how it

compared with other courses. This made reporting

of these data particularly difficult. On the basis of

this limited information, types of training courses

attended were broadly categorized into nine differ-

ent subgroups (Table 2). Number of additional

training courses attended ranged from one to six.

On the basis of this categorization, 147 (42%)

respondents reported attending courses which were

explicitly psychologically related, with 92 (26%)

reporting having attended courses which included

explicitly behaviour change skills-based training.

It was notable that most further training courses

attended that were explicitly skill based were short

1-day or 2-day courses. Very few respondents

reported having attended in depth other training

in behaviour change-based interventions.

Perceived adequacy of dietetic postregistration/other

training

Table 3 refers to the perceived adequacy of further

training in the 195 (49%) respondents who

completed question 3 and reported having attended

this. The table reveals that the majority of

respondents who received other training received

Table 2 Training courses attended, other than preregistration dietetics ± number of all respondents attending each category and

percentage in parentheses

Type of course Example Reported attendance levels

Training in psychological interventions

Theory-based training BSc in psychology/health and

social studies, helping people

change

85 (24)

Counselling skills based certificate/diploma in counselling skills 60 (17)

Other psychologically based skills training groups work skills, eating disorder

training, Relate training

21 (6)

Motivational techniques and 16 (4)

motivational interviewing

Behavioural or cognitive behavioural therapy 14 (4)

Courses deduced to contain some 6 (2)

behaviour change skills and theory content

Miscellaneous

Non-psychologically based training BSc in Physiology/Biology/Biochemistry,

PhD/MSc in nutrition

54 (14)

Health education, education further degrees in Education/Health

Education Promotion, City And Guilds

teaching certificate, Community

Nutrition Group training

46 (13)

Not specified 49 (14)



this in active listening skills and were least likely to

have received further training in cognitive and

behavioural therapy or relapse prevention.

Perceived adequacy of other training in active

listening. The modal response for active listening

was adequate, indicating that the majority of

respondents who received additional training in

this area found this to be at least adequate. About

one-quarter perceived their training in this area to

be less than adequate.

Perceived adequacy of other training in cognitive and

behavioural therapy. Training in problem solving,

goal setting and self-monitoring were perceived as

having been covered particularly well. The modal

response for other training in CBT was adequate for

seven of the techniques and barely adequate for

exposure, stimulus control and challenging negative

thoughts related to eating. Similarly to dietetic

training, additional training in exposure, stimulus

control and challenging negative thoughts related to

eating were perceived as having been particularly

poorly covered.

Perceived adequacy of other training in motivational

techniques. The modal response to additional

training in motivational techniques was adequate.

The decisional balance and theories of stages of

change were perceived to be covered particularly

Table 3 Perceived adequacy of training other than preregistration dietetics in behaviour change methods ± number and percentage in

parentheses (n = 195)

Not

at all

adequate

Barely

adequate Adequate

More

than

adequate

Not

applicable/

didn't have any

Listening skills

Reflecting skills 14 (7) 40 (21) 66 (34) 62 (32) 12 (6)

Summarizing skills 16 (8) 39 (20) 66 (34) 60 (31) 13 (7)

Cognitive and behavioural therapy

Theories of behavioural therapy 33 (17) 40 (21) 68 (35) 22 (11) 31 (16)

Theories of cognitive therapy 35 (18) 49 (25) 61 (31) 18 (9) 31 (16)

Exposure (progressive, planned exposure to problem foods) 49 (25) 62 (32) 31 (16) 12 (6) 40 (21)

Response prevention (e.g. substituting different 37 (19) 52 (27) 54 (28) 18 (9) 33 (17)

behaviours for eating)

Stimulus control (e.g. reducing exposure to cues 43 (22) 51 (26) 49 (25) 18 (9) 34 (17)

for problem behaviour)

Reinforcement of new behaviours 35 (18) 42 (22) 55 (28) 32 (17) 29 (15)

Identifying negative thoughts related to eating 35 (18) 47 (24) 58 (29) 22 (11) 32 (16)

Challenging negative thoughts related to eating 37 (19) 55 (28) 49 (25) 22 (11) 31 (16)

Goal setting 26 (13) 23 (12) 71 (36) 52 (27) 23 (12)

Self monitoring (e.g. keeping diaries) 26 (13) 23 (12) 79 (41) 40 (21) 26 (13)

Problem solving 25 (13) 42 (22) 69 (36) 31 (16) 26 (13)

Motivational techniques

Theories of motivational interviewing 27 (14) 51 (26) 65 (33) 23 (12) 28 (14)

Eliciting motivational statements 38 (20) 47 (24) 62 (32) 20 (10) 26 (13)

Decisional balance (weighing pros vs. cons of change) 29 (15) 27 (14) 82 (42) 36 (19) 19 (10)

Relapse prevention

Theories of relapse prevention 36 (19) 44 (23) 61 (32) 16 (8) 36 (19)

Identification of high-risk situations 36 (19) 42 (22) 70 (36) 16 (8) 29 (15)

Managing high-risk situations 37 (19) 52 (27) 64 (33) 11 (6) 29 (15)

Group treatment

Theories of group interactions 33 (17) 47 (24) 58 (30) 27 (14) 27 (14)

Group management skills 35 (18) 47 (24) 59 (31) 27 (14) 24 (12)



well. On the other hand, theories of motivational

interviewing, eliciting motivational statements and

confrontation of conflict regarding change were

perceived to have been covered particularly poorly.

Perceived adequacy of other training in relapse

prevention. The modal response to additional

training in relapse prevention was adequate. Identi-

fication of high-risk situations was perceived to

have been covered slightly better than actually

managing high-risk situations or theories of relapse

prevention which was not covered at all for almost

one-fifth of respondents.

Perceived adequacy of other training in group

treatment. The modal response to additional

training in group treatment was adequate.

Main approach to dietary treatment

The majority of respondents reported using a

predominantly client-centred approach to dietary

treatment (43%). The next most popular approach

was discussing (29%), then advising (20%), teach-

ing (2%), nondirective (2%) and instructing

(, 1%). A multiple answer indicating the use of a

combination of responses was given by 47% of

respondents.

Three hundred and thirty-five (85%) respondents

gave an example of how they characterized their

practice, e.g. advising means taking a dietary history

and giving information about dietary change to a

patient. Fifty-eight (15%) gave no example. Those

who described `advising' as their main approach to

dietary treatment were more likely to mention

taking a diet history in their example of practice.

Other than that, no central theme emerged within

each category. Two main dilemmas for respondents

emerged across all categories: how to balance the

client's and professional's agendas and the degree to

which it is the dietitians responsibility to prioritize

offering information vs. other interventions when

time is short.

Perceived usefulness of future training

The majority of respondents reported that future

training in active listening, cognitive and beha-

vioural therapy, motivational techniques, relapse

prevention and group treatment would be very

useful (Table 4). Of these, the majority felt that

future training in CBT, motivational techniques and

relapse prevention would be particularly useful.

Discussion

The small sample size means the results must be

interpreted with caution. Compared with other

surveys of dietitians (Hauenstein et al., 1987; Judd

et al., 1997; Cowburn & Summerbell, 1998; Taylor,

1998), the percentage of respondents was low,

although actual numbers of questionnaires received

compare favourably. Results of this survey cannot

therefore be considered as representative of the

profession. Possible explanations of the particularly

poor response rate may firstly be methodological

considerations: the group targeted was not specially

selected for their potential interest in the survey

subject, no self-addressed, prepaid envelope for

return was included nor reminder letters or follow-

up mailings of nonrespondents sent. Secondly, the

recipients of the questionnaire may have been

unfamiliar with the topic and therefore did not

recognize its significance or comprehend what was

being asked. This explanation is supported by

Table 4 Perceived usefulness of future

training in behaviour change methods ±

numbers with percentage in parentheses

(n = 394)

Not at all

useful

Slightly

useful Useful

Very

useful

Active listening 15 (4) 65 (17) 145 (38) 156 (41)

Cognitive and behavioural therapy 9 (2) 40 (10) 117 (30) 220 (57)

Motivational techniques 5 (1) 19 (5) 90 (23) 274 (71)

Relapse prevention 6 (1) 23 (6) 96 (25) 261 (68)

Group treatment 13 (3) 52 (14) 141 (37) 177 (46)



written comments by several respondents who

commented that the survey did not apply to them

as they felt their training in this area was so

deficient.

Despite the fact that facilitating dietary behaviour

change is a key dietetic role, respondents felt that

they had not received an adequate training in

behaviour change skills in their dietetic training.

Training was perceived to be most satisfactory with

regard to active listening skills though this was

perceived as barely adequate. Training was per-

ceived as particularly poor in applying theories of

cognitive and behavioural therapy, motivational

techniques and group work skills and in both theory

and skills of relapse prevention. Although two-fifths

of respondents reported receiving explicitly psycho-

logically based training in addition to their

preregistration training, receiving further explicitly

behaviour change skills-based training (mainly

counselling) was reported by only one-quarter and

was limited by being mainly short 1- or 2-day

courses. Overall, where further training was ob-

tained it was perceived to be superior to that offered

within preregistration dietetic training. Certain key

areas were perceived as particularly deficient in

training across the board, notably the application of

CBT, motivational techniques and relapse preven-

tion.

Many respondents felt constrained by short

appointment duration and were confused about

whether their core role and responsibility was to

provide information, to establish and develop

patients' motivation for change, or to teach

behaviour change strategies which could be im-

plemented by the patient. In general, many

dietitians feel under pressure to see large numbers

of patients. In addition, some may feel that they do

not have adequate time to assist their patients in

effecting change. Dietitians need to find the balance

between size of caseload and clinical effectiveness

and to have the confidence to implement such a

strategy. Nonetheless, a skilful dietitian can opti-

mize effectiveness within even a very restricted

amount of time.

The majority of respondents felt that future

opportunities for training would be useful or very

useful. Most people reported `client-centred' as

their main style of treatment but there was no

consistency in the techniques reported in use under

this category. This suggests that respondents were

not familiar enough with the meanings of the

specified labels or that the terms were not essentially

valid to use. It is likely that education about the true

meaning of some of these approaches was absent

from their training.

In principle, should dietitians be trained in

counselling and behaviour change strategies? There

is enough suggestion from a broad range of research

that CBT is more likely to work than direct

persuasion. It is well known that compliance with

medical advice is poor and with dietary advice it is

often poorer (Glanz, 1979). Some suggest this may

be related to the limitations of the medical model

(Davidson et al., 1987). Using knowledge and

expertise to supply clients with a set plan to follow

is only likely to be adequate for a very small number

of people (Vickery & Hodges, 1986; Glanz &

Eriksen, 1993). Therefore, the information giving

and instructional aspect of dietetic practice should

incorporate motivational and behavioural compo-

nents.

Does the evidence support the case for training

dietitians in a range of different core behaviour

change methods specified in this survey? Most

evidence existing regarding the effectiveness of these

different methods comes from outside the dietetic

profession. A review of using a patient-centred

approach has shown positive health outcomes for a

range of different medical settings (although not

dietetic) in 16 out of 21 studies (Stewart et al.,

1995). This approach has been shown to increase

patient satisfaction after seeing a doctor, improve

compliance with medication, decrease patients'

concerns, decrease raised blood pressure, improve

postoperative surgery and decrease blood sugar in

people with diabetes mellitus (Orth et al., 1987;

Putnam & Lipkin, 1995; Stewart et al., 1995).

Training physicians in communication skills

through problem-defining skills or emotion-hand-

ling skills has been shown to improve the process

and outcome of care without lengthening the visits

(Roter et al., 1995). The evidence for the effective-

ness of CBT is mainly within the context of treating

mental health problems (American Psychological

Association, 1995) and obesity and eating disorders

(Wing, 1992; Fairburn et al., 1993; Wilson, 1995).



In the limited literature in which dietitians have

been trained in CBT, they have been shown to

achieve similar results in weight management as

behavioural psychologists (Paulsen et al., 1976;

McReynolds et al., 1976). The evidence for the

effectiveness for relapse prevention and motiva-

tional interviewing has mainly been demonstrated

within the field of addictive disorders (Miller &

Rollnick, 1991; Marlatt, 1995).

However, if we make the evidence the only

justification for the use of particular methods, we

are missing the importance of the moral and ethical

dimension of treatment. It could be argued that the

basic tenets of patient- or client-centred medicine,

which incorporates six key components (explora-

tion of both the disease and the illness experience,

understanding of the whole person, finding com-

mon ground between client and practitioner,

incorporating prevention and health promotion,

enhancing the relationship and being realistic),

constitute the fundamentals of good practice and

should be key in training any health professional

engaged in helping others change (Stewart et al.,

1995).

In principle, dietitians should be trained in

behaviour change methods and they themselves

recognize a gap in their skills and training. Limited

evidence exists as to whether, in practice, training

dietitans in these methods actually improves their

effectiveness ± the signs are promising, but only

with further research can the question confidently

be answered.

Recommendations

1 The role of the dietitian needs to be redefined as

an agent for behaviour change as well as a

consultant nutritional expert.

2 In the current health service climate, where

evidence-based practice is crucial for all practi-

tioners with the emphasis on improved quality of

care with measurable outcomes (Department of

Health, 1997), research must be funded and

undertaken to support attempts to improve dieti-

tians' effectiveness as behaviour change agents.

3 Consequently, dietitians should review the

degree to which the profession has an adequate

foundation in integrating behaviour change strate-

gies into dietetic practice both at pre- and

postregistration level.

Acknowledgments

We would like to thank Professor Jane Wardle and

Ms Gill Cowburn for their advice and support for

this survey and we are also grateful to all those who

took the time to complete and return the ques-

tionnaire to us.

References

American Psychological Association. (1995) Training and

dissemination of empirically-validated psychological

treatments: report and recommendations. Clin. Psychol.

46, 3±23.

British Dietetic Association (BDA). (1997) Obesity treat-

ment: future directions for the contribution of dietitians.

J. Hum. Nutr. Dietet. 10, 95±101.

Contento, J., Balch, G.I., Bronner, Y.L., Lytle, L.A., Maloney,

S.K., Olson, C.M. & Swadener, S.S. (1995) The effective-

ness of nutrition education and implications for nutrition

education policy, programs, and research: a review of

research. J. Nutri. Edu. 27, Nov./Dec. Special Issue.

Cowburn, G. & Summerbell, C. (1998) A survey of dietetic

practice in obesity management. J. Hum. Nutr. Dietet. 11,

191±195.

Davidson, C., Kowalska, A.Z., Nutman, P.N.S. & Pearson,

G.C. (1987) Dietitian-patient communication: a critical

appraisal and approach to training. Hum. Nutr.: Appl.

Nutr. 41A, 381±389.

Department of Health. (1997) The New NHS, Modern and

Dependable. Presented to Parliament by the Secretary of

State for Health by Command of Her Majesty. London:

HMSO.

Fairburn, C.G., Marcus, M.D. & Wilson, G.T. (1993)

Cognitive-behavioural therapy for binge eating and

bulimia nervosa: a comprehensive treatment manual. In

Binge Eating: Nature, Assessment and Treatment. eds C. G.

Fairburn & G. T. Wilson, pp. 361±404. New York: The

Guilford Press.

Gilboy, M.B. (1994) Compliance-enhancing counselling

strategies for cholesterol management. J. Nutr. Edu. 1,

228±232.

Glanz, K. (1979) Dietitians' effectiveness and patient

compliance with dietary regimens. J. Am. Dietetic Assoc.

75, 631±636.

Glanz, K. (1985) Nutrition education for risk factor

reduction and patient education: a review. Preventive

Med. 14, 721±752.

Glanz, K. & Eriksen, M.P. (1993) Individual and community

models for dietary behaviour change. J. Nutr. Edu. 25,

80±85.



Hauenstein, D.J., Schiller, M.R. & Hurley, R.S. (1987)

Motivational techniques of dietitians counselling indivi-

duals with Type 2 diabetes. J. Am. Dietetic Assoc. 87,

37±42.

Health Education Authority. (1997) Health Promotion

Interventions to Promote Healthy Eating the General

Population ± a Review. Melksham: The Cromwell Press.

Hunt, P. (1995) Dietary counselling: theory into practice. J.

Inst. Health Edu. 33, 4±8.

Isselmann, M.C., Deubner, L.S. & Hartman, M. (1993) A

nutrition counselling workshop: Integrating counselling

psychology into nutrition practice. J. Am. Dietetic Assoc.

93, 324±326.

Judd, P.A., Butson, S., Hunt, P., Lewis, B., Micklewright, A.,

Pearson, G. & Tredger, J. (1997) Pre-registration educa-

tion and training for dietitians. Report and recommenda-

tions from the British Dietetic Association/CPSM

Dietitians Board Joint Working Party, February 1996. J.

Hum. Nutr. Dietet. 10,157±162.

Marlatt. G.A. (1995) Relapse: A cognitive-behavioral model.

In Eating Disorders and Obesity. A Comprehensive Hand-

book. eds K. D. Brownell & C. G. Fairburn, pp. 541±545.

New York: The Guilford Press.

McReynolds, W.T., Lutz, R.N., Paulsen, B.K. & Kohrs, M.B.

(1976) Weight loss resulting from two behaviour

modification procedures with nutritionists as therapists.

Behav. Ther. 7, 283±291.

Miller, W.R. & Rollnick, S. (1991) Motivational Interviewing:

Preparing People to Change Addictive Behaviour. New

York: The Guilford Press.

Orth, J.E., Stiles, W.B., Scherwitz, L., Hennrikus, D. &

Valbonna, C. (1987) Patient exposition and provider

explanation in routine interviews and hypertensive

patients' blood pressure control. Health Psychol. 6,

29±42.

Paulsen, B.K., Lutz, R.N., McReynolds, W.T. & Kohrs, M.B.

(1976) Behaviour therapy for weight control: Long-term

results of two programs with nutritionists as therapists.

Am. J. Clin. Nutr. 29, 880±888.

Putnam, S.M. & Lipkin, M. (1995) The patient-centered

interview: Research Support. In The Medical Interview.

Clinical Care, Education and Research. eds M. Lipkin, S.

M. Putnam & Lazare, pp. 530±537. Berlin: Springer

Verlag.

Rapoport, L. (1998) Integrating cognitive behavioural

therapy into dietetic practice: a challenge for dietitians.

J. Hum. Nutr. Dietet. 11, 227±237.

Rogers, A. & Judd, P. (1996) Current and future training for

dietitians in the UK ± results of the BDA pre-registration

working group survey. J. Hum. Nutr. Dietet. 9, 387±411.

Roter, D.L., Hall, J.A., Kern, D.E., Barker, L.R. & Cole, K.A.

(1995) Improving physicians' interviewing skills and

reducing patients' emotional distress. A randomised

clinical trial. Arch. Intern. Med. 155, 1877±1884.

Shepherd, R. & Stockley, L. (1987) Nutrition knowledge,

attitudes, and fat consumption. J. Am. Dietetic Assoc. 87,

615±619.

Stewart, M., Brown, J.B., Weston, W.W., McWhinney, I.R.,

McWilliam, C.L. & Freeeman, T.R. (1995) Patient-

Centered Medicine. Transforming the Clinical Method.

London: Sage Publications.

Taylor, M.A. (1998) Evidence-based practice: are dietitians

willing and able? J. Hum. Nutr. Dietet. 11, 461±472.

Vickery, C. & Hodges, P.M. (1986) Counselling strategies for

dietary management: Expanded possibilities for effecting

behaviour change. J. Am. Dietetic Assoc. 86, 924±928.

Wilson, G.T. (1995) Behavioural approaches to the treatment

of obesity. In Eating Disorders and Obesity. A Compre-

hensive Handbook. eds K. D. Brownell & C. G. Fairburn,

pp. 479±485. New York: The Guilford Press.

Wing, R.R. (1992) Behavioural treatment of severe obesity.

Am. J. Clin. Nutrition 55, 545S±551S.

Appendix 1

Training in psychological interventions ± a survey

Dear Colleague,

The purpose of this survey is to identify the

psychological techniques that dietitians might be

trained in to help their client's change their eating

behaviours. These techniques are known by a

variety of terms so we have defined some of them.

We would be very grateful if you would complete

the questionnaire. We plan to publish the results

from this survey and to use them to help identify

training needs for dietitians. Thank you very much

for your interest, support and time in completing

this questionnaire,

Yours sincerely,

Lorna Rapoport and Gill Cowburn

PLEASE RETURN BY 15 NOVEMBER TO:

Lorna Rapoport, Health Behaviour Unit, Depart-

ment of Epidemiology and Public Health, UCL, 2±

16 Torrington Place, London WC1 E 6BT, UK.







Documents

Do dietitians feel that they have had adequate training in behaviour change methods?