Dietary interventions include brief nutritional counseling and education in the office such as negotiating with the patient to increase the number of servings of fruits and vegetables consumed each day. Again, take a look at the vegetable fact sheet provided as an example of a practical resource.

Complex medical nutrition therapies may require referral to qualified nutrition professionals such as registered dietitians who will usually spend at least 45 minutes to one hour on an initial visit with a patient to assess nutritional status, obtain a diet history, assess readiness to change dietary behaviors and negotiate a nutrition care plan that the patient will adhere to. This service to patients requires an in-depth knowledge of nutrition, counseling skills, and educational strategies for long-term success.

Follow-up is critical for the success of dietary intervention strategies to work. Just as in other medical problems and concerns, the physician needs to communicate concern regarding the successes and failures, and be able to trouble-shoot with the patient to maximize adherence. Telephone follow-up or sometimes postcards sent to the patients will trigger continued efforts to change eating habits.

Incorporating nutrition into office practice is not difficult if everyone involved (physician, receptionist, nurse, patient) thinks nutrition is an important issue in primary care. The algorithm provided below illustrates how the nutrition screening, assessment, diagnosis, prescription and follow up can be implemented in an office practice.

Algorithm for incorporating a food habits screen into your office practice The algorithm below briefly depicts an approach to utilizing the "How does Your Pyramid Stack Up Checklist" and "Food guide Fact Sheets" in an office setting. Since these materials are written at a fourth to sixth grade reading level, most patients should be able to read and understand the information being presented. We hope this example will encourage you to begin to use the materials today! Patient Check-In   ("Pyramid" Checklist distribution) Receptionist Reception Area Reception Area   ("Pyramid" Checklist completion) Patient Exam Room   (Checklist review and scoring) Patient/Nurse Food Habit Improvement Needs Identified Physician/Nurse, Patient (Fact Sheets distribution)   Patient's Office Visit Concludes Physician/Nurse ("Track Record" form distribution)   Subsequent Appointment(s) Patient/Receptionist Monitor Outcomes/Modify Interventions   (Identify additional "Tips" for implementation, Distribute additional "Fact Sheets," Refer to Registered Dietitian, when indicated) Physician/Nurse Used with permission from the Learning Center at the American Dietetic Association.

Here are some tips for physicians regarding facilitating dietary behavior change.

Learning the transtheoretical model of behavior change as it relates to diet

This model of health behavior change is also known as the stages of change and has been adopted by the Centers for Disease Control and Prevention, the National Institutes of Health, and other health organizations such as the American Association of Diabetes Educators as a primary tool to be used to assess a person's readiness to change. Why care about a person's readiness? Talk with some seasoned health professionals about how frustrating it is for them and their patients when "noncompliance" occurs. Many of our interventions are based on the belief that patients are ready to act upon the desired change immediately - behaviors such as smoking, abusing alcohol, overeating, and lack of exercise to name a few, require a person to be ready to change before success or "compliance" or "adherence" occurs. This is one reason why failure is so common in smoking cessation, weight control, and substance abuse programs - the interventions are not tailored to where the patient is in terms of readiness to change. Let's take a quick look at the transtheoretical model and how it applies to ambulatory medical practice.

This multidimensional model encompasses three major dimensions. The stages of change assess when a person is ready to change, the processes of change assess how a person changes, and decisional balance assesses why a person changes and weighs the pros and cons of changing. When these three dimensions are applied in tailoring interventions for dietary change, the success rate in improving specific health behaviors dramatically increases as has been shown by numerous studies over the past twenty years. For in-depth information on this health behavior change model and how it applies to clinical practice, go to the Cancer Prevention Research Center Transtheoretical Model at www.uri.edu/research/cprc/transtheoretical.htm. The University of Rhode Island's Cancer Prevention Research Center faculty are the original developers of this model and the website has a wealth of information to share.

Some patients will do very well when directed by a physician to "follow orders" but most people respond better when they feel they have a sense of responsibility and ownership in the decisions being made. There is a term called "therapeutic alliance" which basically means that the physician and the patient are partners in health care. Negotiation is a very important skill in patient counseling and education and it is your job as a health care provider to help the patient prioritize, set goals, and monitor progress for the various health behaviors that need attention.

Content questions should be directed to: Marilyn.S.Edwards, Ph.D., R.D.
or Maggie McQuiggan, M.S.
Copyright © 2004 - present, All Rights Reserved.
The University of Texas Health Science Center at Houston
Created by Beth Ardoin, M.Ed. in Academic Technology's Multimedia Scriptorium