Nutrition Counseling: From Clueless to Competent, Part 2

Seth Bilazarian, MD


March 10, 2015

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Useful Tips for Counseling Patients

For part 1 of Dr Bilazarian's commentary on nutrition counseling, click here.

This is Seth Bilazarian with part 2 of my nutrition and food counseling commentary. In part 1, I reviewed why this is a challenging issue. Here, I want to address some issues that I have struggled with, with the hope that it will prompt a conversation and others will share their own ideas.

One tip that I have found useful is to tell patients that they are likely to have some period of time where they "fall off the wagon" or experience some degree of recidivism following a good initial effort. I tell them that this is expected. It doesn't mean that they shouldn't make an effort to return to their successful period. I tell patients that this happens, in my experience, almost routinely at 11-12 months after a major adverse cardiac event. Patients come in after a myocardial infarction or stroke and say that they never want this to happen again. They have a huge, intense desire to make changes and they do a good job at first, but at around the 1-year mark they lose some of their gains. They may gain back some of the weight or they drift away from the will to lose weight. It is valuable to warn them up front that this is likely to happen. They tell me, "Oh, I remember you told me this would happen and I am trying to get back on track."

I also try to tell patients that if they indulge one day, it's okay and they should intensify healthy eating another day. It is the overall diet that matters most.

I tell patients that not all carbohydrates are the same. Giving patients a daily sugar limit is helpful because it helps them reduce their use of refined sugar. Just saying, "Cut down on sugar" is not as helpful, because patients have a hard time understanding what that means and acting upon that advice. I have found it useful to have a specific strategy.

I bought a book titled The Belly Fat Cure by Jorge Cruise (Hay House, 2009). I am not promoting the book. I have no connection to it. A used copy can be bought for a couple of dollars. It provides patients with a tangible look at sugar and carbohydrates and some strategies to try to move toward a low-carbohydrate diet.

In addition, I try to layer that advice with benefits from the Mediterranean diet and the DASH diet. These diets are most often recommended for cardiac patients, and providing some handouts on these diets can be very helpful.

Visual Aids and Varying Strategies

I also find it very useful to have a food product in the office. I have it on my desk and patients ask me about it. They say, "Why do you have this?" I show them the nutrition label and ask them to read it. For some patients I am using it for sodium instruction, but many patients don't know about how to review a nutrition label. They don't know how much sodium to restrict in their daily diets. They don't even understand the "servings per container" information. Showing them that this food has 410 mg of sodium per serving, when they believe that that is how much sodium is in the whole can, is a valuable instructional strategy.

Patients often say that they don't want to change their diets because they love certain foods. I use the phrase "Find foods that you love that will love you back" so they don't take a toll on their healthy choices. I also tell my patients that making a healthy food choice has two real benefits: If someone eats fish rather than red meat, for instance, the value in that swap is not just that fish is a beneficial food product, but that it is displacing a nonbeneficial food product. Eating nuts as a snack displaces the chips. Eating a piece of fruit displaces cake or candy as a dessert. These strategies are doubly beneficial.

I try to use a variety of teaching strategies, because patients have different learning styles. Sometimes I watch a video with a patient. I once watched with a patient, for smoking cessation, the Canadian Heart Association video titled "Social Smoking Is Like Social Farting." A year later, the patient told me that the day we watched that video together in the office, he quit smoking and never returned to smoking. It made a big impact on him for us to be connected in that way.

I also keep a brick in my office that weighs about 5 pounds. I use it to teach patients how much 5 pounds is. They say, "I only gained 5 pounds," but when they hold the brick, they really understand that if they are 5 or 10 or 15 pounds overweight, that is added weight not just on their hearts, but on their knees and backs. I have found such simple teaching tools to be very useful.

Much can be said about dietary recommendations. It is very difficult when the guidelines are not clear. There is consensus on avoiding trans fats, limiting saturated fats, and avoiding refined sugars. However, with respect to how much to limit refined sugar, the guidelines are all over the place. The recommendations for maximum refined sugar intake range from 24 g for women and 36 g for men (American Heart Association)[1] to 125 g (Institute of Medicine, 25% of calories).[2] It is difficult even for physicians, much less patients, to follow.

The Mediterranean Diet

The Mediterranean diet gets a lot of press. The PREDIMED trial (Prevención con Dieta Mediterránea), published in the New England Journal of Medicine,[3] used a 14-point scale to measure adherence to the diet, giving one point to each item (included in the Figure below).

Adapted from Estruch R, et al.[3]

This scale may be valuable for you to print off and give to your patients. In the study, they found that patients who had compliance of 9 points or greater on a regular basis had better outcomes—a 10% reduction in the composite endpoint of cardiovascular events. The four categories of food to avoid are red meats; butter, cream, and margarine; soda drinks; and cakes and sweets. Those are the displacement foods. Patients get one point for compliance and lose a point if they don't comply.

These diets work for some people. Some people are very fastidious and want to follow this kind of diet, but it can be very difficult to give them the necessary information in a short amount of time.

In summary, I would say that these problems with respect to physician literacy are difficult. I fully admit that I have concerns about my own nutritional and diet literacy, but it is very important and patients rely on us for it. It is worth the effort for physicians and it benefits patients. It is important to share this information with all patients. It is not just for coronary patients; there are benefits for atrial fibrillation, diabetes, cancer, and neurodegenerative diseases. Changes have been shown to be beneficial in patients who comply with the Mediterranean diet. This can have an enormous impact and can be very valuable for all of our patients.

Until next time, I would love to read your comments about other things physicians can do that are valuable for lifestyle modification.


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