Nutrition Counseling: From Clueless to Competent -- Part 1

Seth Bilazarian, MD


March 06, 2015

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Diet First -- Maimonides

Hi. I'm Seth Bilazarian, on on Medscape.

A blog on how to counsel patients on diet and nutrition is something I have been thinking about for a long time. I feel ill-equipped to talk about these things, but perhaps there's value in the poor preparation I have for talking with patients about diet and nutrition. I received 1 hour of nutrition counseling in my medical training—that's not an excuse, it's just a fact—and very little training in my residency or fellowship. So I'm largely self-taught in this area, and there may be obvious deficiencies in my knowledge base, but I make the best effort I can.

I want to talk a bit about some of the difficulties I have had counseling patients about diet and nutrition, and I want to share the things that have worked for me. They are anecdotal, and I hope others will also share ideas by clicking on the comments section below. I'm sure other community-based physicians have valuable strategies that streamline effective communication with patients about diet and nutrition.

Maimonides reportedly said, "No disease that can be treated by diet should be treated with any other means." Certainly treating by other means is largely what we're doing in the United States to reduce cardiovascular risks. We could potentially reduce those risks with better nutritional strategies. I think we all acknowledge that.

The Tailored Approach

It's known that the word "doctor" comes from the Greek, meaning teacher, but less than one third of doctors provide nutrition counseling—and I venture to guess that almost all physicians would say that good nutrition is important for health and disease prevention. There's clearly a disconnect.

Doctors are the teachers, and patients are the students. Yet we're not being very intentional or sensitive to their learning styles, and our lesson plans are probably not refreshed. I think we get into a habit of giving a certain brief comment about something and not evaluating whether it's connecting and not personalizing it.

We all know that there are different kinds of learning styles—there are auditory, visual, reading/writing, and kinesthetic learners. People learn in different ways, so probably trying a variety of strategies will be beneficial for different patients.

Challenges to Overcome

Of course there's this big challenge to improve health literacy in our 15-minute appointments. We have other priorities. There's not been anything removed—things are just being added. We certainly have to talk about statins, angiotensin-converting enzyme inhibitors, glycemic parameters, and manage a variety of health issues on top of doing a good job of diet and exercise counseling.

Part of the federal Electronic Health Record Incentive Program (EHRIP), requiring electronic reporting about patient visits, in the future may include counseling as a standard for quality and Meaningful Use Stage 2 and Stage 3 of EHRIP. Currently in our practice, to comply with Meaningful Use Stage 2, we just have to check off a box that says we did talk about diet. It's not very thorough; all you've got to do is mention diet to a patient to comply, and that's not very effective, obviously. Payers and quality measurements may eventually ask us to include diet and nutrition counseling, and that certainly would increase the pressure to provide them.

The challenges to be overcome are substantial. I mentioned those already. I think doctors actually feel ill-equipped. I feel about nutrition often the way I feel about health insurance literacy issues: Patients ask me questions about health insurance, and I know it's important, but I'm just not skilled at providing that information for patients.

Do We Believe That It Works?

I think many physicians, including myself, sometimes lack conviction about the value of the intervention—the amount of time I have to spend and the amount of time the patient has to spend for a 10% reduction, which is often what's seen in trials using surrogates such as low-density lipoprotein cholesterol or weight reduction.

Few randomized controlled studies actually show cardiac event reductions. The Lyon Heart study[1] for secondary prevention of coronary heart disease (CHD) and PREDIMED,[2] about nutrition and CHD, are two that do. Findings from the latter were published last year in the New England Journal of Medicine and got an enormous amount of press. The results of both trials are limited by problems of patient self-reporting, varying diet definitions, and differences in adherence. Both of those studies showed positive outcomes, but there have been problems with their adoption in the United States. Both studies were done in Europe—the secondary prevention study in France and PREDIMED in Spain—which may be part of it.

Problems With Dietary Guidelines

Which diet should we recommend? Mediterranean and DASH seem to be the most commonly recommended diets, but there's a fair amount of overlap—fruits and vegetables are a significant component of each. Guidelines are difficult to translate to patients. They're often in metric units, and patients in the United States obviously deal with nonmetric measures. And often the biggest problem is that the percent of calories in different food groups is what's defined.

In an article in The Atlantic on February 23,[3] the writer Olga Khazan wrote that adherents to the American Heart Association diet "should derive half of their calories from carbs, a fifth from protein, and the rest from fat—except just 7% should be saturated fat." I've always thought that this was very problematic: She quipped that perhaps the goal is to keep people busy doing long division so that they don't have time to eat food.

I think that the American Heart Association's diet[4] is very difficult for patients to follow. Of course, our incremental teaching strategy is also very unsatisfying. I think it's problematic as well, not feeling like you can provide the amount of information that's needed.

Many Questions, Little Time

There's really no reimbursement for nutrition counseling—outside of diabetic teaching or in cardiac rehabilitation—for patients who have already had cardiac events. It's very difficult. And although we have problems with this at our 15- or 30-minute visits as cardiologists, primary care physicians have it even worse because they have to do a variety of other teaching-oriented tasks like depression screening, domestic abuse screening, and a number of other things.

Patients ask us about nutrition, and I'm not sure how many of us are really capable of putting into context the things they ask about—organic foods, pesticide-free farming and antibiotic-free and grass-fed animals, extra virgin olive oil, stone-ground wheat, whole wheat, whole grains, plant-based diet, macronutrients, functional medicinal foods, junk foods, and fiber content. All of these things are difficult to explain.

In addition, patients often ask us questions about food at inopportune times. I have patients not uncommonly ask after a primary percutaneous coronary intervention, in the middle of the night, or when they come in with an ST-segment elevation myocardial infarction: "What kind of diet should I go on?" It's really an interesting thing: It's a lack of knowledge that that's not the time we're going to talk about it. It's the long-term benefits of these changes that are really critical.

What patients want, of course, are clear answers, and it's very difficult to implement this. There may be a future for this with mobile health. Perhaps there will be apps on phones that use food acquisition or barcode scanning to help patients and guide them. At this point, though, we really have not gotten very far.

The Roles of Empathy and Follow-up

What I really think patients want—and which is useful in my personal experience—is empathy. I think they really value that I acknowledge that it's hard to lose weight. I tell them that I struggle with it myself, and I think they find that to be helpful.

They value understanding that the hazards of obesity or poor food choices are really significant in terms of outcomes with regard to events like strokes and myocardial infarctions. They also want strategies and something that they can take with them. I think ultimately they want to know that we're looking in on them. Patients often will say—when I haven't gotten to it yet—did you see that I lost weight? Did you see that I made some improvements? They want their achievements to be lauded, and they want us to encourage them and re-engage when recidivism occurs—which, of course, it invariably does.

So, this is my struggle with the whole issue about diet and nutritional counseling. These are the problems.

This is a two-part blog, and I'm going to—at another time—go over specific ideas I have about what I do and hope that others will share their ideas about how to go forward. Please enter your comments below.

Thanks. Until next time: Seth Bilazarian on


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