Current Guidelines, Barriers, and Strategies in Nutritional Counseling: A Q&A With Dr Amy Locke
Now more than ever, nutritionists, dietitians, primary care physicians, and other providers play a crucial role in educating patients about the risks associated with obesity and guiding them in making dietary and health-behavior changes.
In the United States, more than one-third of adults have obesity, according to the CDC.1 Annual medical costs associated with obesity have soared, reaching an estimated $147 billion in 2008. Conditions such as heart disease, stroke, type 2 diabetes, and certain types of cancer, all of which are heavily influenced by obesity, are among the top causes of preventable death in the United States.
With this in mind, Consultant360 spoke with Amy Locke, MD, FAAFP, who specializes in family and preventive medicine with a focus on nutrition and holistic medicine, and teaches at the University of Utah in Salt Lake City.
Dr Locke led a continuing medical education (CME) course titled “Nutrition Principles and Assessment: Turning Nutritional Guidelines into Patient Advice” on September 12, 2017, at the American Academy of Family Physicians Family Medicine Experience in San Antonio, Texas.
Consultant360: What are some misconceptions patients have regarding carbohydrates, proteins, and fats? How do practitioners overcome these barriers?
Amy Locke: Patients tend to lump macronutrients into categories of “good” or “bad,” but unfortunately, it is not this simple. While there are examples of good and bad in each category, encouraging patients to focus on foods and dietary patterns rather than on the components of foods can be better for some. For example, certain foods such as fruits, vegetables, legumes, and healthy fats like nuts, avocados, olive oil, and fish should be emphasized.
Patients should also be encouraged to consume whole grains, since they can slow down digestion, decrease inflammation, and help with weight loss. However, whole grains that are ground finely, like those found in light fluffy breads or pastas, should generally be limited, because they are digested similarly to products with white flour. “White carbs” such as sugar and processed grains like breads, pastas, and crackers should also be limited.
Furthermore, patients should be cautious of foods that are advertised as “health foods,” such as granola, granola bars, sweetened yogurts, and juice. While these types of foods can sometimes be healthy, they often contain a lot of added sugar and processed grains.
The biggest barriers, however, usually are not related to the knowledge of which foods are healthier. Many different types of barriers can impede patients’ abilities to consume a healthier diet, such as cooking abilities, access to healthy foods, family expectations, palate, time, and competing demands.
C360: What tools are currently available to nutritionists and primary care physicians to better provide nutritional counseling to their patients?
AL: A number of websites, CME events, and books are currently available to health care professionals. A few of my favorites include www.nutritionsource.org; the books Ending the Food Fight by David Ludwig, Mindless Eating: Why We Eat More Than We Think by Brian Wansink, and The Hunger Within: A Twelve-Week Guided Journey from Compulsive Eating to Recovery by Marilyn Migliore; and informational handouts from the University of Wisconsin Integrative Medicine group. In addition, receiving training in motivational interviewing or in similar techniques can revolutionize a practitioner’s ability to help patients make changes in their health behaviors.
C360: What role does dietary intervention play in treating patients with metabolic disorders, such as diabetes or obesity?
AL: Consuming a healthy diet is effective for both the primary and secondary prevention of numerous conditions. Patients who are able to modify their eating habits and consume a healthy diet can reduce their risks for diabetes, obesity, cardiovascular disease, cancer, inflammatory conditions, and brain diseases such as dementia.
C360: How can practitioners overcome obstacles when counseling patients who are resistant to dietary intervention?
AL: It is important to consider the stages of change. If a patient is pre-contemplative, merely noting its importance and offering to discuss dietary changes in the future may be enough. For patients who are contemplative, helping them explore their interest in a lifestyle change or their hopes of improving their health can help physicians find what might motivate their patients to make behavioral changes. However, it is a very slow process, and dramatic changes will not happen overnight.
C360: How can practitioners initiate fitness conversations with patients?
AL: I usually begin with a few brief questions to assess each patient’s current state. I will often ask, “How do you feel about your diet or the food you eat?” or “What types of physical activity or exercise do you engage in?” Then, I will follow up with questions about the frequency, intensity, and duration of physical activity. I usually also ask questions regarding sleep, stress, support systems, and screen time with electronics. If I am concerned about a patient’s fitness level, I might add the follow-up question, “Are you happy with how active you are currently?” or “Have you considered increasing your physical activity level?”
C360: Which method(s) work best for nutritional counseling?
AL: Intensive lifestyle counseling, meaning regular follow-up over the course of 6 to 12 months, has the best evidence for weight loss. Helping patients make very specific short-term goals and then following up with them allows them to be successful in the long term. There is also some evidence that [shows] focusing on short-term outcomes, such as how patients feel on a day-to-day basis, is better than focusing on long-term health outcomes. Although very short-term discussions about health behavior changes are rarely enough to lead to dramatic change, they can at least put the idea in the patient’s head, and he or she may later choose to engage in lifestyle changes.
C360: Do you think current clinical guidelines do enough to address the obesity epidemic in the United States? What do you think needs to change?
AL: Current guidelines are not the problem. The US Department of Agriculture (USDA) guidelines are overall pretty reasonable, although they are not as strong as existing evidence suggests they should be in terms of their over-emphasis on dairy and their lack of suggesting enough limits on sugar, processed starches (breads, crackers, potatoes, etc.), and processed and red meats.
The bigger problem is reimbursement and, therefore, the availability of programs that can help patients eat healthier. Health behavior changes are difficult, and as a country, we do very little to support patients in their efforts to make changes. Unhealthy food is cheap and widely available because of farm subsidies, and many companies market poor food choices as healthy ones. We rarely, if at all, reimburse for dietitians, exercise physiologists, or health coaches, and most places do not have the comprehensive lifestyle programs recommended by the US Preventive Services Task Force (USPSTF). If we actually manage to switch to a value-based model, these services may eventually be covered. However, it has been a very slow process.
From a physician’s perspective, these conversations take time. Pushing patients through very quick visits means that doctors are more likely to reach for a prescription pad rather than have a detailed conversation with patients about lifestyle and individual barriers. That being said, I am optimistic for the future. We are likely to reach a tipping point where chronic disease related to lifestyle choices becomes so pervasive and expensive that we need to reconsider our approach to prevention.
—Christina Vogt
Reference:
1. Overweight & obesity. Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/. Updated September 6, 2017. Accessed on September 18, 2017.