636616

research-article2016
AJLXXX10.1177/1559827616636616American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine

vol. XX • no X American Journal of Lifestyle Medicine

Antonio Herbert Lancha Jr, Gary A. Sforzo, PhD,

and Luciana Oquendo Pereira-Lancha, PhD

Improving Nutritional Habits With

No Diet Prescription: Details of a
Nutritional Coaching Process

Abstract: Thousands of dollars are conclusion, the nutritional coaching to health problems associated with
spent today with policies encouraging strategy detailed was effective at smoking. The need to lose weight is well
physical activity and healthy eating, helping our patient develop new eating understood; however, the process is
but nutritional consultation per se has patterns and improve related health difficult, and a recent estimate reveals
continuously failed to yield consistent parameters. less than 1 in 100 persons will be
and lasting results. The aim of this successful in achieving sustained weight
Keywords: health coaching; eating
case report is to detail and evaluate loss to normal weight.4 Ironically, Field
habits; nutritional education
nutritional coaching (employing and colleagues5 showed, on nearly
health coaching techniques) in 17 000 children ages 9 to 14 years, that

T
promoting lifestyle changes, enabling he onset of most modern diseases dieting was a significant predictor of
improvement of nutritional and body is associated with lifestyle habits, weight gain. Moreover, the risk of binge
composition associated parameters. and thus, the best way to prevent eating increased with the frequency of
The patient in this study had previously disease is through behavioral changes.1 dieting. The authors concluded, “In the
engaged in a series of different diet The enormous potential effects of health long term, dieting to control weight is
regimens, all of which failed in behavior changes on mortality, morbidity, not effective, it may actually promote
achieving the proposed aim. After 12 and health care costs provide ample weight gain.” Moreover, Mann and
nutritional coaching sessions (one motivation for the concept of lifestyle collagues,6 in their article “Diets Are Not
per week) with the strategy presented medicine, that is, evidence-based the Answer,” reviewed 31 studies of the
herein, reductions in body fat mass practice of assisting individuals and long-term outcomes of calorie-restricting
and in total body weight were attained. families to adopt and sustain behaviors diets and concluded dieting is a
Nutritional habits also improved, that can improve health and quality of consistent predictor of weight gain. They
as the patient showed decreased life.2 Treating type 2 diabetes3 is an noted up to two thirds of the people
total energy intake, decreased fat example of how developing new habits regained more weight than lost. Weight
intake, and increased fiber ingestion. can effectively improve health. regain or weight cycling is also
Daily physical activity and energy One of the most important associated with increased health
expenditure were enhanced. The contemporary health problems is the problems such as risk for myocardial
coaching program was able to induce global prevalence of overweight and infarction, stroke, and diabetes7 and
immediate health benefits using a obesity. In the United States, health lowered high-density lipoprotein
strategy with the patient at the core of problems associated with obesity are a cholesterol.8 Hence, not only is obesity a
promoting his own lifestyle changes. In leading cause of mortality, second only health threat but repeated unsuccessful

DOI: 10.1177/1559827616636616. From the Biodynamic Department, Physical Education and Sport School, University of São Paulo, São Paulo, Brazil (AHL); Department of
Exercise & Sport Sciences, Ithaca College, Ithaca, New York (GAS); and Vita Care, São Paulo, Brazil (LOP). Address correspondence to Antonio Herbert Lancha Jr, Universidade
de São Paulo, Escola de Educação Física e Esporte, Departamento de Biodinâmica, Av. Prof. Mello Moraes, 65, 05508-900 Cidade Universitária, São Paulo-SP, Brazil; e-mail:
[email protected].
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2016 The Author(s)

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 American Journal of Lifestyle Medicine Mon • Mon XXXX

attempts to lose weight apparently may setting. Health coaches educate and the prior 7 years, he was subjected to
contribute to further health problems. support patients to achieve their health varying and numerous nutrition
The practice of dieting often comes goals through lifestyle and behavior interventions in order to modify body
down to simply limiting caloric intake. adjustments. Rather than teaching a skill composition and blood biochemistry. He
Whether advised by a dietician or or prescribing a plan, this process had already succeeded in losing weight
self-induced, it forces people to follow a encourages individuals to explore inner many times (5 times), yet every time all
prescription and modify their daily strengths, thereby improving confidence weight was regained in a matter of 2 to 6
routine to conform to the diet. Such a and making improvements from within.12 months. On finishing a diet, he reported
plan might foster in the patient the In this study, we applied the concepts feeling “free to eat everything that had
notion that food is an enemy, thereby of health coaching in a strict fashion to been prohibited during the dieting
provoking dramatic food intake promote weight loss in an obese and period.” Therefore, it is clear that all
reduction. The patient may check in with treatment-resistant patient. The patient previous interventions failed in rendering
a dietitian every 30 or 45 days to monitor and coach entered the process sustainable nutrition modifications
compliance to the prescribed diet. The understanding weight loss is the goal adopted by the patient as a new habit.
traditional dietitian consultation, as well and other health behaviors (eg, stress,
as that of other health care professionals, smoking, etc). Yet it was understood that, Timeline Assessments
imposes an acute intervention strategy, in the long term, discussing nutrition and The patient was interviewed to evaluate
and the process usually results in an body composition might trigger a daily nutritional routines and also
unsuccessful attempt at weight loss. The synergistic effect rendering the patient submitted to anthropometric
importance of an intervention resulting prone to adopting other healthy measurements. Nutritional intake was
in new eating habits,7 forged in a behaviors. This nutritional coaching assessed by 24-hour recall at baseline,
relationship with a health professional model allowed the establishment of a after 6 weeks (POST 6), and after 12
but driven by the patient, is potentially coach-patient relationship using health weeks (POST 12). Body composition,
important to improving the success rate coaching tools such as motivational skinfolds, girths, and breadth were
of weight loss attempts. In such a setting, interviewing, wellness vision sharing, measured, and Kerr’s protocol was used
doctors do not simply give a pill to treat and goal setting. The hope is that to calculate muscle, fat, and residual
disease but actually help patients care for nutritional coaching helps a patient find mass at baseline, after 6 weeks (POST 6),
themselves and guide them to effectively inner motivation and tools to realize and after 12 weeks (POST 12). The plan
influence their own health.9 This helping self-determined goals empowering was to assess the quality of the body
relationship concept is based on theories achievement of better eating habits and composition change. Level of physical
of health coaching, in which a coach weight loss. Therefore, the aim of this activity and energy expenditure were
assists a coachee who is driving his/her study was to examine the effects of the assessed at 4, 8, and 12 weeks with a
own process of healthy behavior change. nutritional coaching process on the commercially available, wrist-worn health
Another feature of health coaching is eating habits and body composition of band (Nike FuelBand). This was done to
bringing in additional therapies to assist an obese, weight loss–resistant patient. see if nutritional coaching was prompting
with successful behavior change. A motivation for physical activity practice.
recent study with pediatric cancer
Methods Nutritional Coaching
survivors reported a strong association
between complementary medicine and This study was an in-depth, single case Intervention
lifestyle therapies identifying those with investigation on nutritional coaching After completing initial evaluations, the
commitment to general wellness. The intervention effects. Data, both clinical patient went through 12 nutritional
authors concluded that the use of outcomes and coaching results related to coaching sessions, scheduled for 45
one-on-one therapy may promote use of visioning and goal setting, were collected minutes each, 1 per week, over 12
other therapies, and this potential before, during, and after the coaching weeks. Half of the sessions were carried
synergistic effect should be targeted in intervention. The study was approved by out face-to-face and half were electronic
future interventions.10 the Ethic and Research Committee of (using the Internet—Skype). During
Health and wellness coaching involve a School of Physical Education and Sport nutritional coaching sessions, general
process facilitating healthy, sustainable (University of Sao Paulo). The patient coaching strategies and tools were
behavior changes by challenging a was informed of the experimental employed such as motivational
patient to listen to his or her inner procedures before he gave his informed interviewing, decisional balance,13
wisdom, identify personal values, and written consent to participate. positive psychology14 (gratitude, three
transform personal goals into action. blessing exercise), ambivalence,
Health coaching draws on the principles Presenting Concerns nonviolent communication,
of positive psychology and the practices The patient was a male, aged 42 years, mindfulness,15 and strategies to change
of motivational interviewing11 and goal and employed as a businessman. Over habits.16 No diet was prescribed by the

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 vol. XX • no X American Journal of Lifestyle Medicine

coach, and the patient continuously the patient’s strengths, values, and desires I am 25 pounds lighter, I play tennis
brought up questions and propositions are determined and then the vision is set in without losing my breath and I am
on how, where, and when he could start place. After this, specific short-term goals more physically active during my day.
to change his nutritional habits. The are set so that the patient is able to move in My motivators are to have physical
conditions to play my tennis, feeling
patient, rather than the coach, presented the direction of his newly formed vison.
more comfortable in my clothes and
arguments for change. An example of a nutritional goal-setting
also less anxious during meal time.
The coach conducting all sessions was coaching conversation is given in the
certified by Sociedade Brasileira de following: Patient also declare:
Coaching, a Brazilian school certified by
the Association for Coaching. She was Coach: What you would like to I am so tired about losing and
also certified as a Wellness Coach by change about your eating habits? regaining weight. I really want to lose
Wellcoaches through Carevolution. The Patient: I would like to reduce the and to keep my new weight for the
rest of my life, having better
coach had been practicing for 1 year at amount of fried food that I eat.
nutritional habits such as eating less
the commencement of this study and Coach: Ok, what is your intake today
fried food, drinking less alcoholic
worked at Instituto Vita. The patient was and what you would like it to beverages, enhancing the amount of
not charged any fee for coaching become? fruits in my diet. I also would like to
sessions as part of agreeing to Patient: Now a days I have once a be a more physically active person.
participation in the research process. day some fried food and I would
To further detail the nutritional coaching like to reduce to 2 per week. The patient started the program doing
process, one of the first steps was to Coach: Ok, on a scale of 0 to 10, how one class of tennis per week. He also
establish the readiness of the patient to confident are you that you can was used to driving to travel short
change, and with that purpose, we adopted reduce your fried food intake from distances, always using the elevator
the transtheoretical model.17 Understanding 7 to 2 times a week? besides other less active behaviors.
stage of change augments use of Patient: 7 to 8, because it is really During the program he increased the
appropriate coaching techniques and important to me, and I had already tennis classes to 3 per week, and we also
avoids prematurely encouraging new done this before. So I know that I hired a person to help him start running.
equivocal behaviors that might discourage can.
change. Another important first step was to Clinical Findings
establish a trusting relationship with the During the sessions, the coach worked As shown in Table 1, total energy
patient by building rapport using with motivational interviewing principles intake was reduced from baseline to 6
techniques such as genuineness, eye and avoided arguing for change while weeks, and this effect was even more
contact, good energy, warmth, good quality using open-ended questions, reflections, pronounced after 12 weeks of the
of voice, a feeling of connectedness, being and believing in the patient’s ability to nutritional coaching program. Similarly,
comfortable and relaxed, mindful listening, change. Between sessions the patient Figure 1 shows that fat intake was also
being supportive, and adopting positive and coach exchanged messages via email reduced, and protein, carbohydrate, and
body language and physical gestures. With and text message to update tasks. A fiber (Table 1) increased toward healthier
a relationship forming, a next step was to website called Coach Accountable was proportions in the diet.
create a wellness vision, which is a set up and used to remind the patient Table 2 illustrates the effects during the
statement by the patient revealing about what was discussed in the last coaching process on body composition,
aspirations to reach his highest potential. In session. If by 2 days after a session the weight, and fat mass over 12 weeks. A
the present context, the patient was asked patient did not send a message, the reduction in body weight was
to focus on nutrition, diet, and weight loss, coach would reach out with an email, or accompanied by a decrease in fat mass
but a complete wellness vision can include a text message, asking how he was while the percentage of muscle mass
physical, emotional, social, spiritual, and doing. Every goal accomplished by the increased (see Figure 2). The
financial realms of life. Motivational patient was recorded and available for intervention period was also
interviewing was a primary tool used and is the coach to view. This regular accompanied by a reduction in waist
characterized by a focus on the present communication between the coach and circumference. It is well established the
rather than the past. The emphasis is on the the patient was an integral part of the reducing waist circumference reduces the
communication, concentrating on internal strategy used. risk of cardiovascular diseases due to the
motivating factors, and on the exploration fact that this specific anatomical store of
of individual core values and goals. Finally, Results fat expansion is associated with
our coaching sessions heavily relied on inflammatory responses in the body.18
goal setting: a collaborative effort for Coaching Findings It was also evident that the nutritional
behavior change between coach and The patient’s wellness vision was the coaching period was also associated with
patient. Using motivational interviewing, following: a favorable modification in daily physical

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 American Journal of Lifestyle Medicine Mon • Mon XXXX

physiological endpoints (body mass

Figure 1. index reduction) and behavioral
Macronutrients Energy Intake Over Time. outcomes in terms of improved dietary
intake and physical activity, improved
quality of life, self-reported well-being,
as well as satisfaction outcomes.21 A
telephone-assisted counseling program
consisting of 4 coaching sessions and
offered to Rotarians (body mass index >
27) was valued highly with 83% of the
participants ready to recommend it to
other club members. In summary, our
results follow others demonstrating
successful weight loss is possible using
counseling, coaching, and educational
strategies. We have extended and
detailed these results by applying
coaching techniques specifically for
nutritional purposes and found it
produces beneficial health changes.
There are limitations to our work
particularly related to being a case study
Abbreviations: POST 6, after 6 weeks of coaching; POST 12, after 12 weeks of coaching. and not having long-term results to
report. Further research is needed to
elucidate best practices for generalization
of nutritional coaching and also for
determining effectiveness of the process
Table 1. in the long term. It is hoped that our
Dietary Characteristics. work is promising enough to help
stimulate such future study.
Baseline POST 6 POST 12 It was hoped that engaging in the
Energy intake (kcal/day) 2200 1850 1500 nutritional coaching process, with a
focus on eating behaviors, might trigger
Fiber (g/day)   8   25   30 a synergistic effect leading to adoption of
other healthy lifestyle changes. We found
Abbreviations: POST 6, after 6 weeks of coaching; POST 12, after 12 weeks of coaching.
this to indeed be the case as our patient
also enhanced physical activity habits
along with positive dietary changes. We
activities. Table 3 demonstrates that the resistant to traditional dietary did not set out to formally study
patient increased the number of steps intervention. This finding is supported by potential synergies between lifestyle
daily as energy expenditure increased. the work of King and colleagues,19 who changes but find it interesting and
This trend for greater activity progressed evaluated the effects of one-on-one informative that such a phenomenon
as the coaching process progressed. nutritional education and used goal occurs. The association between
Enhanced physical activity, though not setting, motivational lessons, and addressing nutritional goals using
suggested by the coach, verifies follow-up to improve lifestyle behaviors. coaching strategies and adoption of
synergies of the nutritional coaching A majority of patients showed other healthy lifestyle changes may be
process as the patient extended willingness to implement a healthy highly beneficial to changes in patient
behavioral change to other important lifestyle, leading the authors to conclude health status and is a topic worthy of
health practices. that personalized coaching tailored to a future study.
patient’s goal could be successful. Appel There is an emerging consensus
and others20 also demonstrated the among policymakers, professional
Discussion
effectiveness of health coaching for the organizations, clinicians, and payers
We detailed a nutritional coaching purpose of long-term weight loss, while across many nations that health care
process resulting in beneficial clinical another study demonstrated positive requires substantial change. Much of the
outcomes for a patient proven to be outcomes of a coaching program on money is directed to treat diseases

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 vol. XX • no X American Journal of Lifestyle Medicine

coaching service in promoting usage or

Figure 2. participation in prevention/wellness
Body Composition Over Time. services.9 Obesity, and related lifestyle
disorders, along with strategies for
weight loss are among the top
challenges facing employee wellness
programs and public health in general.
However, self-induced diets and dietary
professionals’ dependence on acute
prescriptive interventions do not favor
the emergence and sustenance of the
new eating habits in patients.22
Furthermore, the traditional physician
advice to “lose weight” often results in
more risk because of the likelihood of
weight loss-regain cycle.7 Moreover,
there are reports stating physicians often
lack the knowledge and skill to counsel
a patient about lifestyle interventions.23
Coaching, and nutritional coaching
Abbreviations: BW, body weight; POST 6, after 6 weeks of coaching; POST 12, after 12 weeks of coaching. specifically, holds promise for health
care professionals. This strategy provides
a technique intended to empower a
patient to make healthy lifestyle changes
bringing new potential for weight
Table 2. management success. Accordingly,
Body Composition Characteristics.
physicians should be encouraged to
refer obese and overweight patients to
Baseline POST 6 POST 12 those with nutritional coaching abilities
so their good advice for weight loss has
Body weight (kg) 111.0 106.0 102.2 a better chance of success.
BMI (kg/m2) 36.7 35 33
Waist circumference (cm) 107 103 99.3 Conclusion
To our knowledge, this is the first study
Abbreviations: POST 6, after 6 weeks of coaching; POST 12, after 12 weeks of coaching; BMI, body
mass index. detailing strategies for a specific
nutritional coaching intervention while
also reporting positive changes in
nutrition behavior and improved clinical
results. The strategy reported herein
Table 3. takes into consideration individual values
The Patient’s Physical Activity Characteristics. and aims, assessed in detail. The
coaching process supports development
Baseline POST 6 POST 12 of a helping relationship while
Steps per day 4872 7028 8371
encouraging a patient to identify his or
her vision, needs, and goals. Moreover,
Energy expenditure per day 950 1183 1400 coaching aims to help in organizing
routines and priorities, while putting the
Abbreviations: POST 6, after 6 weeks of coaching; POST 12, after 12 weeks of coaching.
patient in control of his or her health
destiny. Unlike dieting in the
conventional ways, which may make
associated with unhealthy lifestyles and coaching process with respect to people fatter,24 nutritional coaching
could be saved if companies had services to support healthy eating, appears to promote improved body
employees with healthier living habits. physical activity, and weight composition, beneficial lifestyle changes,
Others understand the potential of the management, and hope to use sustained and better health. AJLM

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 American Journal of Lifestyle Medicine Mon • Mon XXXX

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