The History Of Dietary Strategy Nursing Essay

Within this assignment the nutrition related disorder that will be discussed will be Coeliac Disease. Coeliac Disease is an autoimmune disease, which triggers an immune response when gluten is consumed. Autoimmune is defined as an immune response which enables an organism to attack its own cells as it fails to recognize these cells to be their own. Therefore, resulting in diseases like coeliac disease (Viljamaa,M et al,.2005).

Gluten is found in; wheat, rye and barley and therefore if gluten is consumed this can damage the inner lining of the small intestine (Coeliac UK, 2013). The symptoms of this disease can range from minor problems like excessive wind to more major symptoms like depression or osteoporosis (Coeliac UK, 2013). More of which will be considered later.

Coeliac disease is a debilitating disease that can cause many different health problems physical or mental. However, it can be treated by a dietary change of a gluten free-diet that can enable somebody suffering from this disease to consume a healthy diet without the complications that gluten can cause. It is thought that 1 in 100 people within the United Kingdom suffer from the disease. Therefore being an important disease to treat as soon as symptoms show. Without treatment it can cause further health problems like osteoporosis, bowel cancers or infertility (Coeliac UK, 2013). The fact that a dietary change can stop health problems in relation to this food intolerance makes a therapeutic approach to treatment an important consideration. A therapeutic approach to nutrition involves offering support for how the dietary change can be implemented as a debilitating disease like coeliac disease can be simply treated by this gluten-free dietary change. By offering support to a client it will enable them to control this disease avoiding further health problems. When considering the therapeutic approach the stages of change model is important to consider, if a client does not want to change then it will be difficult to persuade them to make the relevant changes and a therapeutic approach can also be used in order to prevent relapse having taken action to change (Porchaska J.O. & DiClemente C.C,1984).

Primarily it is important to consider the literature which underpins the dietary management of Coeliac Disease. The gluten-free diet leaves out the disease-activating storage proteins known as prolamins. It is known that these types of proteins are in wheat, barley, rye and oats. Prolamins activate the immune response that causes damage to the lining of the small intestine (intestinal mucosa) which results in inflammation releasing cytokines. Coeliac disease sufferers who consume gluten will result in mucosal damage therefore the only treatment that can be recommended currently is a lifelong gluten-free diet. Otherwise, further health problems like bowel cancers can result if this disease is not treated (Fasano and Cattasi, 2001;Kupper, 2005).

However, about 10% of people with coelaic disease have what is called refractory sprue or refractory coeliac disease. This happens usually as a result of undiagnosed coeliac disease severely damaging the inner lining of the small intestine over a period of time. As a result of this their bodies need help in reducing the inflammation caused by this. In this case dietary treatment will not work; therefore immune-suppressive therapy is needed. This will use medication called glucocorticoids, however clearly a gluten-free diet will still be required for the medication to be of any use (Miskovitz, P. F., & Betancourt, M., 2005).

Having researched literature in relation to treatment of coeliac disease it is clear that at this point in time the only treatment is simply a gluten-free diet. Other alternatives are being considered like enzyme therapy however at this moment in time nothing else can be offered for the treatment of the autoimmune disease (Rodrigo, L.2009).

Having considered the role of diet with in a nutritional related disorder it is now important to consider the role of diet within a therapeutic approach to individual treatment. Firstly, it is important to consider the basics of communication and counseling skills for nutrition there are 4 steps; assessment, diagnosis, nutrition intervention and finally monitoring and evaluation (Snetselaar,L. 2009). As well as considering the 4 steps for communication and counselling, it is also important to consider the stages of change. The stages of change are important to consider alongside necessary communication and counselling in order to get a positive result when implementing a dietary change. The stages of change include; pre-contemplation, contemplation, preparation, action, maintenance and possible relapse (Porchaska J.O. & DiClemente C.C.1984).The basics of communication and counseling and the stages of change coincide with each other, for example monitoring and evaluation is the final step of communication and counseling and this coincides with the final step of the stages of change being maintenance and possible relapse. A therapeutic approach means helping somebody through a difficult change within their life. Specialist counseling can help provide self-management emotionally and provide support or introduce personal coping strategies, this should make it easier for a client to come through a change within their life and change positively. For example, challenging negative thinking that a dietary change for coeliac disease will be more negative than not changing at all. By guiding and motivating somebody through a dietary change it can help them to stay within the maintenance phase as oppose to relapsing and causing more problems for themselves particularly when considering coeliac disease and possible health problems as a direct result of untreated coeliac disease. As with coeliac disease whenever gluten is consumed by a coeliac disease sufferer it will constantly damage the internal lining of the small intestine. Therefore the lifelong gluten-free diet is important; as if it is not adhered to it will increase the chances of major health problems like bowel cancers (Royal College of Nursing, 2010).

It is important to consider the stages of change as it is difficult to keep somebody at the maintenance stage, however it is important to also consider the precontemplation and contemplation stages. A precontemplator is somebody who is not seriously considering change due to many different reasons. These different reasons can include somebody not knowing a problem exists, not wanting to give up something they enjoy or not believing that they can achieve the change necessary. There are times were motivational interviewing as part of a therapeutic approach will be important as precontemplators believe that the advantages of continuing as they are out way the advantages of making the relevant change.

Therefore motivational interviewing will be important to consider. As it will enable a precontemplator to consider that change will benefit them. As it may enable them to become aware of a problem and its risks by providing education and support to try and turn precontemplation into contemplation. However, it is also important at this stage not to scare a client into change but instead use freedom of choice in order to hopefully make the client feel self motivated within this part of the change process, as oppose to telling them there is a problem. By using open questions and to focus on the consequences of not changing and hopefully produce a response emotionally to make the client feel the need to change. It is also important to use interviewing techniques as a health professional to understand at what stage a client is at in order to not push towards action too quickly, as this could negatively affect the therapeutic relationship between health professional and client.

Having hopefully moved across the stages of change from precontemplation to contemplation, it is now important when considering the therapeutic relationship to understand the client’s negative and positive feelings and move the balance across in the favour of change. It is important to consider a client’s uncertainty and it is the role of a health professional to understand this and motivate a client through it as oppose to confronting it. Doing this by providing accurate education and also feedback about the client’s current behavior, as inaccurate information from the media, for example, may hinder the chances of a client from making an important change within their lives as explained by Blaxter (1983). Considering the pros and cons of both the change and also not making the change is also important to consider. Doing this by getting a client to consider the positive effects a change will make it will hopefully make them see that changing will out way the negative effects of changing. For example ruling out a food an individual client enjoys is a negative part of the change; however by ruling this out it will also reduce the risks of further health problems like osteoporosis or bowel cancer like mentioned earlier. Therefore hopefully implementing a change and making the client feel motivated about changing. Self-efficacy will also help with the different stages of change, as it is more likely a client who feels self motivated to maintain the change is more likely to take the change onboard more effectively.

Having come past the contemplation stage the next stage is for the client to prepare for change having committed to it. Having come through contemplation uncertainty is still important to consider as clients may want to change but may not see an action plan that will help them change effectively. Therefore the therapeutic relationship between client and health professional is important in order to explore what possible course of action could be taken in order to choose the best option available to each individual.

Having chosen the best course of action it is then also important to strengthen their commitment and confidence in order for a client to then go on to put their feelings of wanting to change into action. Therefore educating the client in different ways to make the client understand how particular changes will make it easier for them to change and maintain the change as oppose to possibly leading into relapse and causing further problems for themselves. For example, with coeliac disease it is important to consider a dietary change is required for life in order for a change to work (Hunt, P and Hillsdon, M, 1996). Therefore like mentioned earlier it is important to consider the foods that a client may enjoy may have to be taken out of their diet, so as a result of this it is important to consider the 5 P’s; practical, positive, personalized, palatable and possible (Gatenby S.J., et al 1995). Without considering these 5 P’s there is an increased chance of a client relapsing due to it being difficult to maintain the change due to not enjoying the dietary change or it may be too expensive for a client to continue to buy gluten-free alternatives. This is also where a therapeutic approach can be considered as offering changes suitable for each individual is important. What one client may like another may not, or another client may have more time and money to prepare meals that they enjoy as oppose to somebody who struggles for time or money to make an enjoyable gluten-free meal. Therefore having considered the 5P’s it will then be important to put together an individual action plan.

Having taken action it is then important to maintain the change that has taken place, like on this occasion a dietary change. Therefore the therapeutic aim is to obviously maintain the change and prevent relapse. Therefore developing strategies for coping/dealing with high risk situations in order to avoid relapse. It is also important within the therapeutic approach as a health professional to increase self-efficacy or self-belief. It is important to make sure a plan is developed in order to cope with situations were a possible relapse may occur. Take for example with coeliac disease, temptation to eat something containing gluten whilst eating out at a restaurant. A client may willingly eat something containing gluten; however it is also difficult to know what foods may contain gluten when eating out at a restaurant. So, it may be helpful as a health professional to educate a client on foods that they will enjoy at a restaurant and reduce the risks of consuming gluten accidently. If a client understands the negative effects of this and also understands the other foods that they could enjoy whilst eating out, there is less chance of them relapsing as explained by Marlatt and Gordon (2005). If coping strategies are implemented within this therapeutic approach there is less chance of relapse and creating possible further health problems (Hunt, P and Hillsdon, M, 1996). However having considered these stages of change the maintenance phase sometimes does fail and does result in relapse. When this happens it is important for the health professional to support the client to re-enter the change cycle, therefore taking possibly harsher changes in order to succeed with the change and maintenance phase the 2nd time as explained by Porchaska J.O. & DiClemente C.C (1984). Having considered the therapeutic approach and how it can help support a client across the stages of change, it is also important to consider the stage of changes in relation to coeliac disease.

It has been made clear that a dietary change is important in order to treat coeliac disease. However, what is the role of a therapeutic approach when trying to implement this dietary change? It is important to consider lay beliefs as part of the therapeutic process. McClinchy, J., A. Dickinson, et al. (2011) explain that the general public (lay people) can sometimes consider nutrition as not being a medical issue. Therefore when a dietary change is needed lay people can consider their diet as being medicalised. So, as some lay people consider nutrition as not being a medical issue if they then believe that their diet has been medicalised, a positive outcome may not be produced. Therefore the client, as a lay person, may feel frustrated that a particular health problem is not being treated with drugs but instead is being treated by diet. With coeliac disease the usual treatment is a gluten-free diet, so considering this research relevant education may be need. This should then enable the lay person to understand why a dietary change is used as oppose to drugs. As mentioned earlier drugs like glucocortocoids can be used in certain cases of coeliac diseases. However this is also alongside a gluten-free diet. Therefore, it is clear that relevant education maybe required as part of the therapeutic approach. Inclusive of this McClinchy, J., A. Dickinson, et al. (2011) also found that trust is an issue when education is given to a client. Education is important as some lay people build their beliefs upon the media; whether it being a television program, newspapers or magazines for example as Blaxter (1983) explained. Therefore it is important to try and educate an individual with the correct information on a topic like coeliac disease. Otherwise like mentioned with the research by McClinchy, J., A. Dickinson, et al. (2011) clients may struggle to understand why a health professional may medicalise their diet by ruling out gluten containing foods.

Having considered the stages of change it is also important to consider the basics of communication and counseling skills for nutrition, like mentioned earlier alongside the stages of change and the therapeutic approach , there are 4 steps; assessment, diagnosis, nutrition intervention and finally monitoring and evaluation (Snetselaar,L. 2009). The 4 steps of counselling skills are important however inclusive of this it is important to consider what a client wants when they have a session with a health professional and Gable (1997) explains this. This will be important in order to begin to make an effective therapeutic relationship between client and health professional.

Patients firstly want to be welcomed and seen on time. This seems a simple requirement however depending on the location of a particular interview this can sometimes be difficult, in a doctors surgery or hospital setting it can sometimes be more difficult to stick to a planned timetable, however in a private setting not within the National Health Service (NHS) there may be more a private dietitian can do to stick to a timetable than in a public health setting within the NHS. In general clients also want to feel like they have been heard and understood and also given information they can understand and feels that relates to them. As well as this they also want to understand what the next steps are and what they will have to do to reach them; this is therefore all important when wanting to have an effective therapeutic relationship between health professional and client. Therefore as a nutritional therapist or dietitian it is important to have a variety of different skills. Firstly it is important to have the ability to communicate effectively, as it will be vital to be able to communicate complex information and treatment or dietary plans. As well as this it will be important to be sensitive to the needs of clients and having a genuine desire to want to help people. It will also be vital to have good listening and negotiation skills as well as having an interest and knowledge within the relevant fields of nutrition and dietetics. Without having a genuine interest in nutrition and dietetics as well as wanting to help people, it would be difficult to have an effective therapeutic relationship with clients. Other skills like keeping an emotional distance from clients and having a logical approach to problem solving would also be an asset within the nutritional or dietetic field were a therapeutic relationship is required to get the best results for the patient.

In conclusion, it is clear that a dietary change is the only form of treatment for coeliac disease. Therefore a therapeutic approach as a dietitian or nutritional therapist is important. As a result of a lifelong dietary change being required, it may be a lot for a client to take in or understand. Therefore motivational techniques will be important in order to make a client understand what the importance of the change is and the possible consequences if the dietary change is not adhered to. Inclusive of this, it is important to think of the stages of change and what stage an individual is at. This will then enable each session or interview with a client to be used most effectively. If a patient does not see the need to change or sees the change to be more negative to them than the benefits, then producing an action plan for them would be useless. The desire for change has to be present. Therefore, the different stages of change will be important to consider in order to try and motivate a client to change or motivate a client to maintain the change as oppose to relapsing. Having considered the stages of change it is also a requirement of a health professional to consider the needs of a client each and every time a health professional conducts a session or interview as explained by Gable (2007). Giving consideration to the stages of change and the steps of communication and counselling for nutrition it should enable a health professional to have an effective therapeutic relationship with each individual client. It is also important as McClinchy, J., A. Dickinson, et al. (2011) explain that relevant education is important as some lay people may have built their ideas from the media as oppose to a health professional. So, therefore if a health professional explains, clearly, to a client the need to change and the affects of not changing, along with why a change to an individual’s diet is used for treatment, as oppose to drugs, it should help towards a positive change. However, the needs of each client will vary, and some will be more difficult than others to address. But using motivational techniques and the stages of change it should provide for an affective therapeutic relationship with each client. Hopefully, having achieved this, each client will feel motivated enough to maintain the change or changes put in place. However, occasionally some clients may relapse and it is then important to support the client back into the change cycle. Sometimes alternative changes may be required at this stage to achieve a positive outcome.


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