Chapter 5

NUTRITION EDUCATION AND COUNSELING

Jamie Stang and Mary Story
One of the keys to effective nutrition education and counseling of teenagers is a good understanding
of normal adolescent psychosocial development (see Chapter 1). Adolescents are striving to achieve
independence yet they are highly influenced by the beliefs and behaviors of peers. They are
developing abstract reasoning skills, however they may revert to more concrete cognitive skills when
faced with new challenges or perceived stressful situations. These aspects of adolescent development
need to be integrated into all nutrition education and counseling efforts, whether they occur as
classroom nutrition education presentations or individual counseling sessions.
The capacity for more abstract thinking coupled with the changing psychosocial milieu of
adolescence provides both challenges and opportunities for health professionals when providing
nutrition education. Adolescence is an opportune time to train students to assess their own eating
behaviors and set goals for dietary change. Nutrition education has generally not taken advantage of
the social and cognitive shifts of adolescence that could be built upon to promote the adoption of
more healthful behaviors.
GENERAL CONSIDERATIONS FOR NUTRITION EDUCATION AND COUNSELING
Nutrition education involves teaching the client about the importance of nutrition, providing
educational materials that reinforce messages about healthy eating, teaching adolescents skills
essential for making dietary change, and providing information on how to sustain behavior change.
Information gathered during nutrition screening or assessment will provide the necessary information
on which nutrition issues need to be addressed during nutrition education and counseling sessions.
Prior to beginning the education process, it is helpful to assess what the adolescent already knows
about nutrition, how ready they are to adopt new eating behaviors, and if there are any language or
learning barriers that may need to be addressed in order to facilitate the nutrition education process.
Motivation to make behavior changes can be easily assessed using a 0 to 10 scale (see Chapter 4).
Once a teens motivation to make behavior change has been assessed, nutrition educators must
determine the best course of action to facilitate dietary change. Table 1 provides a model for nutrition
education and counseling based on stages of change. This model provides strategies for advancing
clients to the next level of readiness to change.

Stang J, Story M (eds) Guidelines for Adolescent Nutrition Services (2005)

http://www.epi.umn.edu/let/pubs/adol_book.shtm

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TABLE 1
Stages of Change: A Model for Nutrition Counseling

Stage
Precontemplation

Description
Is unaware of problem
and hasnt thought
about change.
Has no intention of
taking action within the
next 6 months.

Goal
Increase awareness of
need for change.

Strategies
Create supportive climate for
change.

Personalize information
on risks and benefits.

Discuss personal aspects and

health consequences of poor
eating or sedentary behavior.
Assess knowledge, attitudes,
and beliefs.
Build on existing knowledge.

Contemplation

Intends to take action

within the next 6
months.

Increase motivation and

confidence to perform the
new behavior.

Identify problematic behaviors.

Prioritize behaviors to change.
Discuss motivation. Identify
barriers to change and possible
solutions.
Suggest small, achievable
steps to make a change.

Preparation

Intends to take action

within the next 30 days
and has taken some
behavioral steps in this
direction.

Initiate change.

Assist in developing a concrete

action plan.
Encourage initial small steps to
change.
Discuss earlier attempts to
change and ways to succeed.
Elicit support from family and
friends.

Action

Has changed overt

behavior for less than 6
months.

Commit to change.

Reinforce decision.
Reinforce self-confidence.
Assist with self-monitoring,
feedback, problem solving,
social support, and
reinforcement.
Discuss relapse and coping
strategies.

Maintenance

Has changed overt

behavior for more than
6 months.

Reinforce commitment
and continue changes/
new behaviors.

Plan follow-up to support

changes.
Help prevent relapse.
Assist in coping, reminders,
finding alternatives, and
avoiding slips/relapses.

Source: Adapted from Glanz K, Rimer T. Theory at a glance: a guide for health promotion practice. Bethesda, MD:
National Institutes of Health, National Cancer Institute; 1995 and Sandoval WM, Heller KE, Wiese WH, Childs DA.
Stages of change: a model for nutrition counseling. Top Clin Nutr 1994;9:65-69.

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Adolescents often enter nutrition education and counseling at the precontemplation stage. They are
often not aware of the potential health risks associated with poor eating habits and have not thought
about making dietary changes. The initial goal of nutrition education and counseling therefore, will
be to increase the clients awareness of risks associated with current eating habits. In situations such
as the diagnosis of diabetes mellitus, adolescents may be aware of the need to change dietary habits
but may show resistance toward change. Identifying potential barriers to change and providing small,
achievable goals along with concrete strategies to facilitate necessary dietary modifications are often
the initial stages of nutrition education.
A variety of methods of nutrition education are used successfully with adolescents. Individuals learn
in a variety of ways and each individual responds differently to various methods of education. In
general, adolescents learn best when they are actively involved in nutrition education.

For general nutrition education topics such as making healthy food choices at fast food
restaurants, classroom presentations or group education sessions are an efficient and effective
way to reach a large audience of teens.

Small groups can be used to provide nutrition education to adolescents who are found to be at
nutritional risk and would benefit from modifying eating behaviors. Weight management,
vegetarian eating and sports nutrition are topics that can effectively be addressed in small
groups.

An individualized approach, such as one-on-one counseling, will be required for adolescents

who need a high level of nutrition guidance. Initial education related to diabetes, adolescent
pregnancy, hyperlipidemia or hypertension is best provided in an individualized setting.

Peer education on an individual level or in small groups can provide peer support for teens who
have undergone initial individualized nutrition education and may benefit from continued
nutrition education and support to improve compliance with dietary recommendations.

The initial component of the counseling session should involve developing a positive rapport and
getting to know the adolescent. Key aspects of an initial nutrition counseling session include:

Describe the role of the nutrition educator. Teens may be apprehensive about nutrition education
if their previous health education experiences have been negative or their perceptions are that
they will be told what not to eat and will not be offered choices or a chance to provide feedback
regarding dietary modifications. These concerns can be addressed if the health professional
provides a detailed overview of the events of the counseling session, including what specific
nutrition topics will be discussed.

Ask about any personal health or nutrition-related concerns that the teen would like to discuss.
Adolescents should be actively encouraged to add their own nutrition concerns to the list of
topics to be discussed during the education session.

Gauge the psychosocial development of the teen, in an effort to determine which types of
education and counseling methods may be most effective.

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A complete nutrition assessment should be performed prior to nutrition education and counseling (see
Chapter 4). Upon completion of the assessment, the health professional and teen should work
together to establish goals for improving dietary intake and reducing nutrition risk based upon the
findings of the nutrition assessment.
It is important to involve adolescents in decision-making processes during nutrition counseling.
Allowing teens to provide input as to what aspects of their eating habits they think need to be
changed and what changes they are willing to make achieves several important goals during the
counseling session.

The importance of the adolescent in the decision-making process is stressed and she or he is
encouraged to become involved in making personal decisions about health

A good rapport is established between the health professional and the teen, which may lead to
more interaction during the remainder of the counseling session

Behavior change is more likely to occur when adolescents have identified specific behaviors
that they feel need to be changed, thus expressing a willingness to change.

One or two goals during a counseling session are a reasonable number to work toward. Setting too
many goals in one session reduces the probability that the adolescent can meet all of the goals and
may seem overwhelming. For each goal that is identified and mutually agreed upon, several behavior
change strategies should be developed. These strategies should be concrete in nature and should be
initiated by the teen. The adolescent and the health professional should also work together to decide
how to determine when a goal is met. Follow-up sessions should be scheduled frequently in order to
provide feedback and monitor progress toward individual goals. The use of behavior change contracts
should be used with caution when working with teens. If the teens feel they have failed to meet their
goals, they may not return for follow-up nutrition education sessions.
PEER EDUCATION AND COUNSELING
Peer influence is very strong during adolescence. This aspect of psychosocial development can be
utilized to promote behavior change through the use of peer education and counseling sessions. In
peer education, teens who have mastered the skill of making dietary change and are willing to share
their experiences and knowledge provide nutrition education to other teens under the supervision of a
health professional.
Peer education is generally well received by adolescents and has many advantages:

Teens may be more willing to adopt suggestions provided by a peer than by a health
professional as they may perceive the suggestions to be more relevant to their personal lifestyle
and needs.

Peer educators are able to teach concepts using terminology and language to which other
adolescents can relate.

Peer educators can provide personal examples of changes that they have made and how they
were able to overcome perceived barriers to behavior change.

Chapter 5. Nutrition Education and Counseling

Peer education provides social support to teens. For issues such as overweight or diabetes,
where extensive changes in dietary habits may be required, peer support can help adolescents
overcome feelings of isolation and being overwhelmed by new information.

Practical suggestions and encouragement by older peers can help teens to feel empowered to
make behavior changes, while group support can help to sustain behavior changes through
positive reinforcement.

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It is important to choose peer educators carefully. Characteristics to look for in peer educators
include:

good communication skills

a mastery of skills that are being taught

an interest in working with other teens

the ability to identify teens who may need referral for more in-depth nutrition education

Because adolescents tend to look up to older teens, peer educators should be the same age or slightly
older than the individuals with whom they are interacting. All peer educators should have basic
training related to utilizing effective verbal and visual teaching methods, how to facilitate group
discussions, and how to identify individuals who may need referral for depression or chemical
dependency issues. On-going mentoring of peer educators is necessary to be sure they are providing
accurate information to teens as well as to maintain their interest in the peer education process.
GROUP EDUCATION METHODS
Group education can provide an effective means of reaching many adolescents with common
nutrition messages. Nutrition issues that are especially amenable to group education methods include
fast food and snack choices, vegetarian diets, sports nutrition, prenatal nutrition, and overweight. In
general, groups should be kept small when possible. Keeping groups to no more than 5-15 people
provides more opportunity for each member to participate and provide input. When larger groups are
necessary, utilizing small group activities that allow 2-3 individuals to work together encourages
participation by each adolescent.
Group education should begin with the identification of what nutrition concepts teens already know.
This can be accomplished by beginning an interactive discussion (not a lecture) about the topic to be
discussed. The inclusion of questions can assist group facilitators in determining the level at which
education should begin.
Group education should be as interactive as possible. It is important to build in opportunities for the
group leader to model desired behaviors or to demonstrate procedures in addition to verbally
describing them. It is also important to allow adequate time for group members to practice the skills
or behaviors they are being shown. Small groups can be effectively utilized for this purpose. One
scenario that works well with adolescents is to have them work in groups of 3. Two individuals in
each group can roleplay the desired behavior (such as how to choose low fat fast food choices when
they are with peers who they think may tease them about such choices) while the third person

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provides feedback. Allowing adolescents to practice a behavior as well as to assist others in learning
the behavior reinforces key concepts and empowers them.
It is important to provide each teen an opportunity to provide input during group education activities
so that he/she feels ownership in the group ideas. If 1 or 2 individuals dominate the conversation,
group leaders should ask each member of the group to provide an answer or personal reflection on the
issue being discussed. Alternatively, a group nomination process can be used. In this process, each
adolescent is asked to write down 1-2 suggestions or comments on a piece of paper. The group then
takes turns reading one of their suggestions as the group leader records each of them. Once all of the
suggestions have been read, and each person has provided at least one or more suggestions, the group
works together to group related suggestions together. The resulting groups of suggestions are then
discussed as potential ideas to facilitate dietary change.
Once the main points of a particular topic have been covered and desired behaviors have been
practiced, the group leader can introduce more detailed information that is tailored to the interest level
of the small group. Health professionals should remember that adolescents may only be able to learn
a few concepts at a time. Therefore information in initial sessions should be limited to what is most
necessary to know, while nice to know information should be added only when appropriate.
EFFECTIVE NUTRITION MESSAGES AND MATERIALS FOR TEENS
Health professionals need to give careful consideration to the types of nutrition messages that are
presented to adolescents. Many teenagers perceive that good nutrition means eating foods that dont
taste good and that eating healthy foods means not eating from vending machines or at fast food
restaurants.1 However, focus groups of teens have also found that many adolescents believe that
healthy eating gives them energy and helps them grow.1 More effective nutrition messages should
capitalize on these concepts and convey the idea that eating well will help the teen to have the energy
to do what s/he wants to do and to become the person s/he wants to become.
Most adolescents are present-oriented, which means they are generally not concerned about how their
current eating habits will affect their future health status, but are concerned about their physical
appearance, maintaining a healthy weight, and having plenty of energy. While teenagers should give
consideration to the potential long-term risks of an unhealthy diet and the likely benefits of healthy
eating habits, focusing on short-term benefits is more likely to make a lasting impression on
adolescents and facilitate dietary change.
Educational materials should be written using the style of language in which a person would speak.
Some key concepts to think about when developing education materials or messages include:

Use an active rather than passive voice when presenting information.

Use common language, phrases and words in place of medical terminology.

Provide illustrative examples for all key concepts presented. Remember, many adolescents are
concrete thinkers and cannot easily apply new concepts to current behaviors or situations.

Keep the reading level of written materials to the 5th 6th grade level.

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Be specific and concrete in examples. Avoid using value judgment terms such as too much or
not enough. These terms may be interpreted in many ways and are not valuable to concrete
learners.

Use many short sentences instead of a few long sentences.

Keep paragraphs short in written materials.

Include interaction whenever possible. Utilize concepts such as fill-in-the-blank worksheets,

open-ended questions, or checklists and quizzes whenever possible.

It is imperative that all educational materials and messages be pilot-tested with the population for
whom they have been developed. Ask several teens from a variety of grade levels to provide feedback
on educational materials or ideas for group counseling sessions. Peer educators can provide feedback
about nutrition education materials and messages or can help you to locate individuals who would be
willing to pilot test materials.

REFERENCES
1. Croll J, Neumark-Sztainer D, Story M. Healthy eating: what does it mean to adolescents? J Nutr Educ
2001;33:193-198.