Promoting Nutrition Counseling as a Priority for Clinicians

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By Kellie Casavale, PhD, RD, Nutrition Advisor, and Richard D. Olson, MD, MPH, Director, Division of Prevention Science, ODPHP

The evidence is clear that nutrition plays a vital role in maintaining good health and helping to prevent chronic disease. And yet when people visit the doctor, they’re unlikely to receive nutrition counseling as part of their medical care.

In their recent JAMA article, Nutrition Counseling in Clinical Practice: How Clinicians Can Do Better, Drs. Scott Kahan and JoAnn Manson discuss why diet gets left out of the conversation during office visits — and offer feasible and accessible ways to incorporate nutrition counseling into clinical practice.

From Treating Symptoms to Addressing Causes
While treating people with diabetes in her endocrinology practice, Dr. JoAnn Manson noticed a pattern. “I could see from my experience with patients that nutritional factors were playing a major role in blood sugar control, weight gain, and general health,” she says. She saw the same nutritional factors at play in other patients’ blood pressure and cholesterol problems.

JoAnn E. Manson, MD, DrPH, Chief, Division of Preventive Medicine, Brigham and Women’s Hospital

That’s why Manson decided to pivot from a focus on clinical practice to a focus on population health and prevention research in an effort to address the risk factors of chronic disease rather than just disease management. “I’ve been impressed by the compelling evidence that nutrition and lifestyle drive the risk of the major chronic diseases in the United States — type 2 diabetes, cardiovascular disease, cancer, and down the line. The evidence for this has reached a critical mass.”

Challenges in Addressing Nutrition in Clinical Settings
Why isn’t nutrition more frequently addressed in clinical settings? Manson traces part of the problem back to medical school, where very little time is spent learning about nutrition. “Physicians often come out of medical school and residency with limited training in nutrition and lack of confidence in their ability to provide nutrition counseling to their patients,” she says. And it doesn’t help that patient interactions are often brief and focused on acute conditions rather than prevention and lifestyle changes.

“As a clinician myself, I know there are lots of time pressures,” says Manson. That’s why she stresses that clinicians can discuss dietary changes gradually over time, setting aside just a few minutes of each visit to talk nutrition. “This isn’t a one-time event where you counsel a patient and expect it will transform their life,” she says. “This needs to be one step at a time with good follow up.”

Practical Advice for Clinicians
The JAMA article offers concrete suggestions for counseling patients on dietary behavior change. “Focus on small steps — and make use of the available resources in your practice,” says Manson. She stresses that nutrition counseling is a team effort. Larger practices can bring on dedicated health coaches or dietitians to help support patients, but even small practices can get support staff involved in screening patients and keeping track of their dietary change progress.

For example, an assistant can give patients a dietary screening questionnaire before the visit. The clinician can then engage patients with evidence-based techniques like motivational interviewing, which draws on patients’ self-reported dietary habits to ask questions and suggest small changes. Manson says an exchange might go like this: “I see that you’re having 3 glasses of sugary soda every day. That’s been linked to increased risk of diabetes.” Then the clinician could suggest the small step of swapping one of those daily sodas for water or another calorie-free beverage.

And positive messages are a must. “It’s not just saying ‘don’t do that,’ because that doesn’t work,” she says. “The strategy is to suggest substitutions.” Patients could trade a bag of chips for a handful of nuts, or a sugary dessert for a bowl of fruit.

Clinicians looking to start the conversation about dietary changes can find a helpful table in the JAMA article with examples of realistic substitutions to suggest to patients. Manson also points to the Dietary Guidelines for Americans as a main resource for clinicians. The Dietary Guidelines offers evidence-based nutrition recommendations for Americans ages 2 and older. In addition to the guidelines, ODPHP provides a toolkit of handouts in English and Spanish to help clinicians communicate with patients about healthy food choices. ODPHP developed these resources based on research with providers to address the challenges of nutrition counseling in clinical settings. Patients and clinicians may also find helpful advice through MyPlate, the American Heart Association, and the American Cancer Society.

A Call to Action
Manson emphasizes that boosting nutrition counseling in the doctor’s office will require action from various players — and says she sees signs of progress. “Medical students are calling for more instruction in nutrition, for example. Some of this may really be grassroots.”

Manson also cites the important role of reimbursement. Consistent coverage for nutrition counseling and clear policies in insurance plans encourage clinicians and patients to make nutrition counseling a priority. “It has to be really clear what’s covered and what isn’t,” she says, “and hopefully clinicians will be able to get reimbursed for these interactions.”

Overall, she says, more work is needed. “This is still the first step of a call to action,” Manson says, “where clinicians recognize their key role in helping patients modify behavior and improve their nutritional status.”

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