Introduction
Chronic disease management is the foundation of general internal medicine. In my ninth year as an academic primary care physician treating a variety of chronic diseases, I am increasingly drawn to their underlying root cause. Diet is the primary risk factor for death from chronic diseases, such as cardiovascular disease, cancer, and diabetes.1 This becomes evident in speaking with patients—many have harried lives, are too busy to cook, and consequently eat highly processed, convenient foods on the go.
Many studies have shown that lifestyle change interventions yield tangible health benefits: two examples are the Diabetes Prevention Program (DPP) study and the Portfolio Diet study. The DPP study compared the effect of lifestyle changes to metformin and placebo in halting the progression from prediabetes to diabetes. Participants who underwent lifestyle changes facilitated by coaching sessions and nutrition classes, exercised 150 minutes weekly and achieved 7% weight loss, ultimately resulting in nearly twice the reduction in risk when compared to metformin (58% v. 31%).2 In the Portfolio Diet study, a dietary pattern emphasizing viscous fiber (from oats, barley, psyllium), soy, nuts, and plant sterols showed a similar reduction in LDL as lovastatin 20mg.3
Given that diet is the most important risk factor for death from chronic diseases in the United States and the evidence that changing diet reduces risk of disease and promotes better chronic disease management, this should be the cornerstone of medical practice. However, for various reasons, it is not. Busy general internists in primary care cite two main barriers—a lack of knowledge and lack of time. This article will provide actionable information and skills to address nutrition counseling in a busy primary care visit.
Lack of Knowledge
In his excellent 2016 review, Dr. Dariush Mozaffarian gives an overview of the current evidence base for nutrition recommendations. General internists should recommend that patients consume more of the foods that have been shown to be beneficial: fruits, vegetables, legumes (beans, chickpeas, lentils), whole grains (oatmeal, corn, brown rice, and others), nuts, seeds, unsaturated oils (olive, avocado, canola), fish, and fermented dairy. Patients should be advised to eat less red meat (beef, lamb, pork), processed meats (bacon, sausage, deli meats), and foods high in refined carbohydrates, sugar, and salt. Specific hazards from these foods include an increased risk of diabetes and colon cancer with red meat. Processed meats have been classified as carcinogens by the World Health Organization. Other foods, including unprocessed poultry, eggs, and dairy products like milk and cheese, should be consumed in moderation.4 To summarize, patients should focus on a primarily whole food, plant-based diet—consuming 90% plant foods near their natural state.
Patients come to the office with ideas from social media about what constitutes good nutrition. There are fad diets that focus mainly on what someone should exclude from their diet. This leads to fractious “diet wars” between different camps, such as vegan, keto, and paleo. Many focus on macronutrients, or “macros,” like carbohydrates, fat, and protein. This terminology is unhelpful and confusing for patients and doctors alike. Carbohydrate-rich foods include fruits, vegetables, and whole grains which are clearly health-promoting. Protein sources heavily emphasize animal-based sources and neglect plant-based, like beans, which are associated with longevity and less disease. Finally, foods labeled as low fat, particularly processed foods, can have more refined grains and sugar. I recommend talking to patients about specific foods rather than using these umbrella terms.
Lack of Time
Assessing a patient’s nutrition status and providing tailored counseling during a busy office visit can seem daunting. Utilizing a brief nutrition intervention modeled after those for substance use counseling can be helpful. This method consists of taking a dietary assessment using the 24-hour dietary recall then employing behavior change techniques, culminating in an action plan for change.
The 24-hour dietary recall is a validated tool used by registered dietitians to assess a patient’s dietary status. This tool can take up to 30 minutes to administer in the most detailed form; but, for general internists, I recommend utilizing a brief version. It is a multi-pass method consisting of five passes summarized in the table. Key points are to ask open-ended questions, such as “what was the first thing you ate after you woke up?” rather than leading questions “what did you have for breakfast?”. These allow for more flexibility for patients who have different work schedules, cultural beliefs, and backgrounds. To introduce the concept, one could say “The foods that you eat can play a big role in your health. To help me get a better understanding of your nutrition, would it be OK to discuss this?” This phrasing demonstrates a core principle of motivational interviewing and behavior change techniques—respecting the person’s autonomy. One may also want to connect nutrition to a specific health concern.
As noted in the table, the fourth step can be adjusted as desired depending on time. Often a more general overview is sufficient for patients who have many areas for improvement. Those who eat healthily but struggle with weight loss, for example, may need a deeper dive.
Taking a dietary history in this way also allows for more opportunities for personalization, especially if one can gain an understanding of culturally important foods or dietary preferences to make more appropriate recommendations. Understanding how food fits into a patient’s daily routine and who obtains food and prepares meals is also critical.
After obtaining a dietary history, it is important to assess the patient’s readiness for change. Those familiar with the Transtheoretical Model of Change will recognize the stages of pre-contemplation, contemplation, preparation, action, and maintenance.5 For patients ready to make a change (preparation), one can focus on setting a SMART (Specific, Measurable, Attainable, Relevant, and Time-based) goal. The difference is highlighted here: a patient saying “I will eat more vegetables” compared to “I will eat ½ cup of steamed broccoli three days a week for the next month.” The first is non-specific while the second has all those SMART elements. This could also be thought of as a positive nutrition prescription. These may be more accessible to patients than being told to avoid or limit certain foods without offering healthier alternatives. Making recommendations to increase the healthful foods consumed will provide health benefits and over time displace the more harmful foods.
SMART goals will become action plans. Once the patient and physician agree, the action plan should be written out; I utilize the EMR visit summary. The physician should follow up with the patient on their plan at an agreed time. This could consist of sending the patient an electronic message or having a team member such as a nurse or health coach call them. Action plans should also be revisited at the beginning of the next visit.
My article lays out one approach for addressing nutrition during a busy office visit. General internists play a crucial role in focusing patients on nutrition as a driver of the chronic disease we see every day. Although this approach focuses on what an individual provider can do, it is essential to continue to advocate for a more health-promoting environment in our communities.