How to Counsel Patients About Diet

"Do I need to watch my salt if I don't have high blood pressure?" "What can I do to bring my cholesterol down without using medications?" "I've heard that some carbohydrates are not good and that I should pay special attention to something called the glycemic index. Is this important for me?"

Do you have the answers to these questions? And just as important-can you communicate them in a way that motivates patients to apply the information? You need to be able to answer yes on both counts if you want to help your patients prevent and manage chronic illness.

Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for about two thirds of all deaths in the United States. An unhealthful diet is one of the major risk factors for these diseases.

In this 2-part series, we provide practical suggestions for counseling patients with various needs and conditions, ranging from a simple desire to eat more healthfully ("preventive nutrition") to requirements for dietary interventions that combat hypertension, dyslipidemia, obesity, and diabetes. Here we offer tips on motivating your patients to make changes in their diets, and we discuss strategies that promote weight loss. In part 2 on page 185, the focus is on specific recommendations for patients with hyperlipidemia, hypertension, diabetes, and the metabolic syndrome.

STRATEGIES TO ENCOURAGE LIFESTYLE CHANGE

Simply providing patients with nutritional information is not enough-they need to know how to incorporate your suggestions into their lives. Communication that accomplishes this objective has been called "patient-centered communication," "relationship-centered communication," and "shared decision making." All 3 terms suggest that the physician and patient should work as partners, developing strategies that give the patient the best chance to control his or her own medical problem.

Motivational interviewing. This is one of the most useful techniques for facilitating behavioral change.¹ In motivational interviewing, the main focus is on helping patients explore and resolve their ambivalence about changing a specific behavior. Consider, for example, the recommendation to a patient to incorporate more fruits and vegetables into his diet. This sounds simple enough. However, achievement of long-term behavioral change in this area will first require determination of why the patient has eaten few fruits and vegetables in the past and then the development of strategies that will encourage him to eat more.

Is the patient simply unaware of the importance of eating fruits and vegetables, or (more likely) does he live alone and think that produce will spoil before he can eat all he buys? Does he not shop often enough to purchase fresh produce? Has he never developed a taste for these foods, or does no one else in his household eat fruits and vegetables? Keep in mind that the reasons the patient provides should not be regarded as excuses but as explanations.

Knowing why a patient does or does not do something leads directly to targeted, individually tailored strategies to change behavior. Depending on the reasons a patient gives, solutions might include purchasing canned or frozen items, making more trips to the grocery store, choosing fruit as a snack, adding a side salad to meals, or introducing one new vegetable into the diet each week. Active recommendations such as these address the "how," "what," and "when" of behavioral change and need add only a few minutes to the office visit.

Principles of effective dietary advice. Recommendations about a patient's diet will prove more helpful when you keep these points in mind:

• Be positive: emphasize what to add to or include in the diet rather than what to take away, cut back on, or avoid.
• Aim for progress and small changes rather than perfection and a complete makeover.
• Encourage the patient to enlist the support and encouragement of family, friends, and coworkers; change is difficult to sustain on one's own.
• Make sure your recommendations are practical, achievable, and consistent with the patient's lifestyle.
• Document all suggestions in the medical record, and follow up at the next office visit.

These principles apply whether you are providing preventive dietary counseling or specific advice about diet for patients with obesity, hyperlipidemia, hypertension, or diabetes. For additional nutrition education and guidance, regardless of the health concern, consider referring patients to a registered dietitian.

PREVENTIVE NUTRITION

According to the

Surgeon General's Report on Nutrition and Health,

"for the 2 out of 3 adult Americans who do not smoke and do not drink excessively, one personal choice seems to influence long-term health prospects more than any other: what we eat."

²

Although many patients get information from friends, coworkers, family, and the media about what constitutes healthful eating, most still want advice from their physician.

What recommendations should you give patients interested in preventive nutrition? The recently updated Dietary Guidelines for Americans³ and new Pyramid Food Guidance System are a good place to start (Table). These guidelines can seem unreachable and overwhelming at first. Aim to individualize the recommendations and translate them into actionable steps by focusing on a patient's particular needs, risk factors, lifestyle, and eating habits.

One useful recommendation is to "colorize" the diet. Telling patients to colorize their plate encourages them to eat more orange, yellow, green, purple, blue, and red fruits and vegetables. An increase in color adds powerful plant-based antioxidants and phytochemicals that can help maintain and improve health. Colorizing the plate will improve the nutritional value of meals for most patients. Also, this recommendation is in keeping with the basic principle that, for most people, it is much easier to add foods than to take them away.

Other practical suggestions include:

• Choosing 100% whole-grain, high-fiber (at least 3 g of fiber per slice) breads instead of white bread.
• Trying new grains, such as quinoa or triticale.
• Adding fruits and vegetables.
• Eating fish several times per week.
• Incorporating low-fat dairy foods as snacks.

WEIGHT MANAGEMENT

In the United States, 31% of the adult population is obese and another 34% is overweight.⁴ Thus, the majority of your patients are probably carrying excess weight. Most overweight patients know they need to decrease their caloric intake and increase their physical activity; these are not new concepts. It is not enough to instruct such patients to reduce portions or watch their calories--you need to establish realistic target behaviors for each patient. In turn, implementation of these behaviors can be used to gauge the patient's success in making permanent lifestyle changes.

One of the most useful tools for promoting behavioral change in the area of weight management is a food log. The patient is instructed to keep track of everything he or she eats and drinks, including types of food and beverage, portion sizes, and times of meals and snacks. Keeping a food log may be difficult for patients; however, those who keep such records tend to be more successful at weight loss than those who do not. Food logs increase awareness; help patients monitor, plan, and evaluate their food and meal patterns; and lead to constructive problem solving. Ideally, patients should bring the log to follow-up visits for you to evaluate and discuss with them.

Another tool that can help patients control portion sizes and incorporate balance into their diet is the "plate method." By showing patients a 3-sectioned 9-inch plastic plate (Figure), you can visually demonstrate what portion of each meal should be devoted to vegetables (50%), whole grains (25%), and protein (red meat, pork, poultry, and fish) (25%). Patients can readily see that vegetables, rather than protein and starches, should be the main focus of the meal. You can recommend that patients use a picnic plate as a template to reorganize their serving sizes until new habits are developed.

Meal replacements can also assist with calorie and portion control. Meal replacements are prepackaged frozen meals, bars, and shakes that contain between 220 and 350 calories, less than 4 g of saturated fat, and 10 g or more of protein. A variety of such products are available in grocery stores and pharmacies. Research has shown that meal replacements can safely and effectively produce sustainable weight loss as well as a reduction in obesity-related risk factors.⁵ Recommend that patients substitute meal replacements for 1 or 2 of their meals each day and add unlimited vegetables and a piece of fruit for additional fiber and fullness. The other meal(s) for the day should be low in fat and rich in colorful fruits and vegetables.

Increasing physical activity can seem to patients to be a daunting task and an expensive investment. Emphasize that an increase in activity can be achieved by spreading it throughout the day; it does not have to happen all at once. One practical way to build more activity into the day is to use a pedometer as an inexpensive incentive to increase movement. Worn daily, a pedometer not only tracks accumulated steps, it also serves as a reminder to take the stairs instead of the elevator, park the car further away, walk the dog, or take a walk at lunchtime. Recommend that patients calculate a baseline number of steps the first week they wear the pedometer and then increase steps by 10% per week-or a weekly increase of 500 steps per day. The ultimate goal is 10,000 steps a day.

References:

REFERENCES:

1.

Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review.

Patient Educ Couns.

2004;53:147-155.

2.

US Department of Health and Human Services.

The Surgeon General's Report on Nutrition and Health.

Washington, DC: Public Health Service, DHHS; 1988. Publication 88-50210.

3.

US Department of Health and Human Services and US Department of Agriculture.

Dietary Guidelines for Americans 2005.

6th ed. Washington, DC: US Government Printing Office; January 2005. Available at: www.health.gov/dietaryguidelines/ dga2005/document/. Accessed December 15, 2005.

4.

Flegal KM, Caroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000.

JAMA.

2002;288:1723-1727.

5.

Heymsfield SB, van Mierlo CA, van der Knaap HC, et al. Weight management using a meal replacement strategy: meta and pooling analysis from six studies.

Int J Obes Relat Metab Disord.

2003;27:537-549.