Giving Good Nutritional Advice in Brief Clinical Encounters

April 27, 2010 — Editor's note: Lifestyle interventions aimed at reducing cardiovascular risk are a central part of cardiovascular disease management and prevention. Nurses are in a key position to help patients implement these interventions, according to a presentation at the Preventive Cardiovascular Nurses Association 16th Annual Symposium, held from April 15 to 17 in Chicago, Illinois.

To learn more about how nurses can give sound nutritional and lifestyle advice during brief clinical encounters, Medscape Nurses interviewed presenter Jennifer Ventrelle, MS, RD, LDN, CPT, a registered dietitian, certified personal trainer, and lifestyle counselor at Rush University Medical Center in Chicago, Illinois.

The discussion focuses on specific assessment and counseling tips that nurses can use regarding nutritional and lifestyle strategies, and addresses ways to improve nutritional compliance and coordination with other healthcare providers.

Medscape: What is the rationale for providing nutritional advice in nursing encounters?

Ms. Ventrelle: Nurses typically spend the most time and have the most frequent contact with patients. Patients need to be given simple, practical advice during these encounters to get started making behavioral changes. Therefore, it is important for nurses to understand this nutritional advice and to be able to communicate it to patients during office visits.

Medscape: Given the usual time constraints, how can cardiovascular nurses best assess a patient's nutritional needs?

Ms. Ventrelle: A great way for nurses to target what changes patients need to make for their cardiovascular health is by doing a quick assessment of their diet and exercise patterns. It is unrealistic to do an exhaustive interview on diet intake. Therefore, some simple questions can be asked to target modifiable behaviors that can have a significant impact on cardiovascular health.

[For example,] it can be useful to ask patients how frequently they eat out in restaurants, including takeout, fast food, sit down restaurants, and cafeterias. Foods eaten outside the home are more likely to be higher in fat, sodium, and overall calories.

Medscape: What advice can the nurse offer the patient to help address these modifiable behaviors?

Ms. Ventrelle: It can be useful to suggest to the patient to reduce the frequency of foods consumed away from home. One strategy can be to bring lunch and/or snacks to work 3 out of 5 days per week, assuming they are currently eating out more frequently than that.

Medscape: What sort of advice should nurses give regarding alcohol?

Ms. Ventrelle: Another great target can be alcohol intake. Alcohol has been shown to contribute to an increase in triglycerides, blood pressure, and body weight. If the patient consumes alcohol frequently, suggest reducing consumption to a certain number of days per week or a certain number of drinks per occasion.

Medscape: What type of assessment of physical activity and appropriate advice can cardiovascular nurses best offer?

Ms. Ventrelle: Physical activity is essential to cardiovascular health. The patient can be asked how many days per week they engage in some type of aerobic activity. It is important to stress to the patient that physical activity will only improve health if it is done at a level above what is currently being done. For example, if the patient says they walk 3 blocks from the train to work every day, that pattern is just maintaining their current health/weight.

If they expect to improve health and/or lose weight, they must do extra activity, above the current pattern. In this same example, the patient might get off the train 1 or 2 stops early and walk a farther distance to work. It is these types of small changes that get the patient on the road to sustained change.

Medscape: Generally speaking, how receptive are patients to nutritional interventions?

Ms. Ventrelle: Patient receptiveness is dependent upon the patient's willingness to make behavioral changes. Patients are unlikely to change their diet simply because their doctor or nurse told them they should do so. For some patients, a diagnosis that is potentially life-threatening, such as cardiovascular disease or diabetes, is enough to motivate them to change for fear that their condition could lead to more serious consequences.

Medscape: What can be done to improve compliance in patients who are less receptive to nutritional interventions?

There does exist a group of patients that appear to have a very low level of willingness to change, even in the face of potentially serious or life-threatening consequences. These patients will not be at all receptive to nutritional education. They will fail to "hear" what is being said, because their issue is less about lack of knowledge and more about lack of desire or motivation to alter their lifestyle.

To improve compliance in this group of patients, it is best to focus on the reasons why change should occur, rather than on how to make the changes. The appropriate time to educate exists when the person's level of motivation improves.

Medscape: How can the cardiovascular nurse help coordinate nutritional intervention with other treatments provided by various healthcare providers?

Ms. Ventrelle: Collaboration among healthcare providers is crucial to the quality of patient care. A great tool to allow providers to get a sense of other providers' interventions/recommendations is a patient's record keeping. Especially in the case of the patient with a chronic disease, such as diabetes, for example, it is helpful to encourage the patient to keep a diary of food and beverage intake, physical activities, and of weight and blood glucose self-monitoring.

If the patient is motivated and organized enough to keep these records, this information can be extremely useful across the continuum of care. For those patients who are less motivated, good record-keeping and charting on the part of the healthcare provider is crucial. Clinicians can also have referral forms available for a quick reference or reminder for patients to follow-up with their respective healthcare providers.

Medscape: How effective is nutritional advice offered during brief nursing interventions at improving cardiovascular outcomes?

Ms. Ventrelle: It is difficult for any provider (physician, nurse, or dietitian) to offer advice in one brief, isolated visit that will ultimately lead to improvement of cardiovascular outcomes. Improvement of such outcomes requires sustained change on the part of the patient. Nutritional advice offered during a brief nursing intervention can give the patient the initial information necessary to get started with their behavioral changes.

It is then useful to set up a system of accountability with the patient. This can be done through a referral to start a program with a dietitian or personal trainer, or even to follow up with the nurse/physician on a regular basis to keep the patient accountable and to monitor progress.

Medscape: What additional research needs to be done in this area?

Ms. Ventrelle: There is much research on what "works" for patients to make improvements in health and weight. Weight loss of as little as 5% of body weight [can] reduce or eliminate disorders associated with obesity (Obes Res. 1995;3(Suppl 2):211s-216s).

The National Weight Control Registry is a registry of individuals who have lost anywhere from 30 to 300 pounds and have maintained that loss for anywhere from 1 to 66 years. Ninety-eight percent of them follow a reduced-calorie diet and keep a food diary; 78% of them eat breakfast every day and consume several small meals instead of a few large ones; 75% of them weigh themselves at least once per week; 62% of them watch less than 10 hours of TV per week; and 90% of them exercise, on average, about 1 hour per day.

Therefore, the question is not what needs to be done to see improved cardiovascular health for patients; rather, it is how can we get these patients to make long-term sustainable behavior changes. Additional research needs to look at how physicians, nurses, dietitians, and other healthcare providers can work together, as a team, to help patients implement strategies that are known to be successful in reducing body weight and improving overall cardiovascular health.

Ms. Ventrelle has disclosed no relevant financial relationships.

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