fter 21 years of nutritionally counseling patients in our clinics and implementing hundreds of nutrition counseling programs with doctors nationwide, most health care practitioners agree about the challenges we face with advising our patients on how to improve their lifestyles. The standard American diet is inflammatory, oxidative and high glycemic, and high in trans fats and sugar, promoting many diseases, pre-diseases and problems that your patients seek guidance for.1 The prevalence of hyperlipidemias, insulin resistance, weight gain, obesity, pre-diabetes, fatigue, arthritis and pain management are negatively impacted by a poor diet.2 As practitioners we are faced with contradictory research, and nutritional counseling is typically time consuming and it can be difficult to determine the best approach to guide patients to make short- and long-term lifestyle changes to achieve their desired results. Lastly, many practitioners have implemented various nutritional counseling programs in the past without adequate long-term effectiveness and many are disheartened with many nutritional counseling programs.
Interestingly, tougher economic times produce more job, environmental and relationship stresses, which often produce more emotional and comfort eating that result in consumers choosing less healthy foods.3 According to the Center for Science in the Public Interest (CSPI) it costs an average of $1,400 to lose 20 pounds of weight in the US. Most commercialized weight loss programs often use expensive packaged foods, meal replacements, diet products, and supplements and are not medically supervised. Nutritional programs incorporating a patient’s food preferences and incorporating healthy supermarket food are often less expensive for patients, and are more effective than most commercial weight loss programs (CSPI).4 Traditional approaches to nutritional counseling have typically used generic diet sheets and meal plans to instruct patients, which can be overwhelming and too restrictive for most people to follow. Furthermore, patients interpret programs using generic diet sheets, meal replacements and packaged foods as “dieting” instead of a true behavioral lifestyle program, which can also contribute to patients relapsing and lead to yoyo dieting syndrome.
The Psychology Behind Guiding Your Patients To Eat Healthy Food
Effective nutritional counseling programs should include a combination of components to facilitate patient compliance, including accurate assessment of individual metabolic profile, 5 personalized food preferences,4 patient education,6 contracts,7, 8 self-monitoring,9, 10 social support,11 telephone contact,12 and tailoring,13 for management of weight loss, wellness, disease management and prevention.
Nutritional Compliance, Metabolic Profiling and Patient Food Preferences
It is paramount for patient compliance to provide tailored sliding scale meal plans which can change the amount of carbohydrate, fat and protein for each patient’s metabolic profile and activity level. Using a sliding scale meal plan based on the patient’s metabolic profile, activity level and lean muscle mass assures we provide the patient with adequate carbohydrate for: glucose; muscle glycogen and energy utilization; protein for muscle anabolism; and healthy fat for anti-inflammation and satiety. This approach along with exercise has helped decrease the least insulin resistance, hyperlipidemias, fatigue, diabetes, and cardiac and cancer risk factors which are prevalent in America.17
This approach significantly decreases hunger, appetite, and fatigue and your patients will embrace your suggestions and look forward to learning more. Clients are substantially more motivated and receptive to learn how to properly balance their blood sugars rather than just counting calories or dieting. We encourage patients to become more aware of the improvement of their energy levels, stamina, and focus. As a result, overall well-being improves rather than just the number on the scale. By quantifying caloric expenditure based on lean muscle mass and anaerobic and aerobic calorie expenditure, you can be more effective with weight loss, insulin resistance, fatigue, and lean muscle mass increases.15
Most current and traditional metabolic equations used to perform metabolic assessments, such as Harris Benedict, World Health Organization (WHO) or Mifflin St Jeor equations, are often inaccurate because they are based on the body weight of patients instead of lean body muscle mass, which is significantly more metabolically active than adipose.5 When counseling clients with varying activity levels, genetic predispositions and metabolism profiles it is important to modify your nutritional recommendations accordingly for each patient.
By using a metabolic analyzer and customizing each patient’s nutritional program based on their specific muscle mass and including anaerobic and aerobic exercise, we can now provide a sliding scale of carbohydrates, fats and protein into the meal plan. We use a proprietary metabolic analyzer and simple software to provide custom meal plans which are based on a patient’s sex, height, weight, age, lean muscle mass and activity level. Having the ability to train your CA to act as a wellness coach to formulate custom meal plans and counsel the patients is the key to allowing the program to be much more cost effective in a busy chiropractic practice. Often, doctors or CAs do not have the time or the knowledge to formulate custom meal plans in a busy practice. However, technology and software have helped to quickly and easily provide meal plans such as Paleolithic, sports nutrition, vegan, South Beach, zone or even those for chronic fatigue or diabetes for patients based upon their food preferences. For example: a muscular, active, young, athletic patient will receive a very different nutritional program than a 45-year-old peri-menopausal insulin and weight loss resistant patient who is sedentary all day. A customized program based on lean mass activity level, age and specific exercises will reduce a patient’s hunger level and insulin overload without causing fatigue. Patients now adopt lifestyle changes in a positive way and look forward to their weekly nutritional sessions so they can incorporate long-term behavior modification, which is crucial to decreasing the likelihood for relapse.
By providing patients with exact name brand food suggestions to incorporate incrementally and strategically into their hectic lifestyles on a weekly or bi-monthly basis, and spelling out for them in detail what to do, patients are more receptive and achieve greater compliance than with generic diet sheets, carb or fat gram counting food groups or food pyramids which have been commonly used in the past for nutritional counseling. In order for patients to be successful each week, nutritional sessions should include succinct nutritional goals, exact name brand foods, shopping lists with enough detail so that it is 100% clear how and what a patient is expected to do. Each weekly nutritional session’s goals and food recommendations should change and build upon the prior week’s set of goals. Food preferences should be individualized for the doctor’s clinical philosophy and patient demographic. Some patients may require shopping lists with foods that can be purchased at a Whole Foods or Trader Joes Supermarket, and others may be purchasing foods at a Wal-Mart or Costco.
It is also important to point out to patients that being 100% compliant is unrealistic and not expected of them. If they eat healthy 80-90% of the week, this is acceptable and realistic. Patients also need to be reminded it’s not their fault they are faced with these nutritional challenges; it is a widespread problem throughout the US and a concern with most Americans living in our country. When patients realize and understand that capitalism and profits have changed the way we farm, grow, process and market our food in grocery stores and restaurants, they become more vigilant about the desire to understand nutrition and how it affects their overall health.
Understanding Nutritional Counseling Is a Psychological Process Is Key
The secret to implementing a nutrition counseling program in a clinical practice is to remember that guiding your patients to make positive lifestyle changes is a psychological process. Different patients are motivated with different concerns. Some patients are motivated by wellness or anti-aging. Some patients desire to eliminate a medication that may be giving them undesirable side effects, and others have self-esteem issues with their body and desire weight loss. Not all doctors and staff members are therapists, or have the time or skills to deal with these issues. It is imperative that the nutritional program you choose incorporates behavioral modification tools and has been used extensively by many doctors and patients from different cultural and socioeconomic backgrounds.
Explaining to patients up front that they need to commit to a series of 3-12 weekly or bi-monthly nutritional consultations focusing on food and exercise is also paramount for them to be successful and perceive the program as a lifestyle and not a diet. We require that our patients commit to a contract for a minimum number of visits based on their nutrition, medical goals and the typical food recall they provide us during their initial consultation. Signing a contract and making a commitment for a series of visits is very important for patients to be able to enjoy and comply with making strategic lifestyle changes incrementally at home, in restaurants and in social settings.7,8 The number of visits usually depends on the clinical and economic goals of the patient.
In our first nutritional session, we just focus on breakfast and snack foods and introduce regular exercise. We teach our patients how to food combine for their metabolic needs, and they learn the fundamentals of glycemic load by eating specific food combinations we suggest for them. In our second nutritional session we recommend various lunch and dinner proteins, detox soup, high fiber foods and teach the fundamentals of eating volumetric foods to decrease appetite in combination with the low glycemic load principles we covered in session I. Keep in mind that patients have not received a complete meal plan yet and are following our specific recommendations and making changes without having a meal plan. They are actually learning to decrease their appetites and fatigue while increasing their energy levels by eating the healthy foods we recommend, without having to measure, weigh or count calories. Studies show that by strategically adding higher protein, higher fiber breakfast and snack combinations, and eating every 3-4 hours, patients naturally on their own decrease their lunch and dinner portion sizes. By the time they receive their custom meal plan on their 3rd nutritional session, they already have incorporated 25-30 foods and food combinations based on their personal food preferences. By adding foods into a patient’s nutritional program initially, instead of restricting foods, they view their lifestyle program as a positive experience rather than one of deprivation.
During the third nutritional session (approximately the 3rd week of counseling) we present the patient’s meal plan to them. By now, patients have incorporated many lifestyle modifications and are ready to embrace their meal plan, instead of resenting it as they would with traditional approaches to nutrition counseling.
Our fourth nutritional session builds upon their meal plan with more food examples, explains how to eat in restaurants and airports, and recommends healthier fast foods and even suggests how to eat in a convenience store if necessary. At this point most patients are experiencing less hunger, cravings, decreased appetite and more energy and stamina, so we can begin to teach them how to intuitively eat using a hunger scale. This is when clients really start to understand the difference between biochemical eating because they are physically hungry and emotional eating due to stress, boredom, or for comfort or reward. We even provide our clients with a “Craving Satisfaction Hit List” if they need more suggestions. Clients realize our society, family, restaurants, and advertising companies often encourage us to overeat unhealthy foods and food combinations which create hunger and are truly motivated to live a healthier lifestyle.
A key component to relapse prevention following rapid weight loss detoxification programs, pharmacologic or HCG rapid weight loss is to provide patients with detailed guidelines as to the reintroduction of real food back into the their lifestyle, so patients do not revert back to old habits and regain the weight they lost. Often, lean muscle mass and metabolic profiles change after weight loss, so retesting a patient’s metabolism and lean mass is critical in order to provide the correct maintenance program.
Finding an Effective Program Will Be Personally and Financially Rewarding
Chiropractors have been well trained in musculoskeletal and neurophysiology systems of the human body, providing a strong foundation to effectively offer nutrition counseling to patients if they desire to do so. With advanced nutritional training and certifications available, many chiropractors have obviously added or specialized with nutrition in their chiropractic practices and have a competitive advantage over their peers.
An effective nutritional program should include behavioral and metabolic aspects and have the clinical flexibility to support and accommodate various patient backgrounds with different clinical needs. Long-term patient compliance will occur as a result, with periodic follow-up visits and/or telephone support. Taking the time to find and evaluate a nutritional program with most of the essential ingredients for patient assessment and compliance is paramount. You will find that introducing an efficacious nutrition counseling program to your patients and community will be a positive, lucrative, rewarding experience for you and your patients. Finally, lifestyle counseling programs based on patients eating real food are significantly less expensive to the patient, more profitable for the doctor, and market very well in today’s economic climate.
- Antioxidant nutrients and chronic disease: use of biomarkers of exposure and oxidative stress status in epidemiologic research. The Journal of Nutrition. 2011;93:284–296.
- Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature. 2006;444:840–846.
- Heightened sensitivity to cheap, high-calorie food is linked with obesity. Science Daily. 2012 Apr. 5.
- Food preferences: Influence on the dietary compliance of women with NIDDM. Topics in Clinical Nutrition. 1990 Apr;5(2):15-25.
- Validation of several established equations for resting metabolic rate in obese and nonobese people. Journal of the American Dietetic Association. 2003;103(9):1152-1159.
- Morisky DE, Levine DM, Green LW, Shapiro S, Russell RP, Smith CR. Five-year blood pressure control and mortality following health education for hypertensive patients. Am J Public Health. 1983;73:153-162.
- Oldridge NB, Jones NL. Improving patient compliance in cardiac rehabilitation: Effects of written agreement and self-monitoring. Journal of Cardiopulmonary Rehabilitation. 1983;3:257-262.
- Swain MA, Steckel SB. Influencing adherence among hypertensives. Res Nurs Health. 1981;4:213-222.
- Baker RC, Kirschenbaum DS. Self-monitoring may be necessary for successful weight control. Behavior Therapy. 1993;24:377-394.
- Edmonds D, Foerster E, Groth H, Greminger P, Siegenthaler W, Vetter W. Does self-measurement of blood pressure improve patient compliance in hypertension? J Hypertens Suppl. 1985;3:S31-S34.
- Daltroy LH, Godin G. The influence of spousal approval and patient perception of spousal approval on cardiac participation in exercise programs. Journal of Cardiopulmonary Rehabilitation. 1989;9:363-367.
- Taylor CB, Houston-Miller N, Killen JD, DeBusk RF. Smoking cessation after acute myocardial infarction: Effects of a nurse-managed intervention. Ann Intern Med. 1990;113:118-123.
- Haynes RB. A critical review of the `determinants' of patient compliance with therapeutic regimens. In: Sackett DL, Haynes RB, eds. Compliance With Therapeutic Regimens. Baltimore (MD): Johns Hopkins University Press; 1976.
- Interrelationships among postprandial satiety, glucose and insulin responses and changes in subsequent food intake. Eur J Clin Nutr. 1996 Dec;50(12):788-97.
- Glycemic index, glycemic load, and chronic disease risk—a meta-analysis of observational studies. American Journal of Clinical Nutrition. 2008 Mar;87(3):627-637.
Christopher Fuzy, MS, RD, LD is the Founder and President of Lifestyle Nutrition Inc. and PhysicianWellnessProgram.com, has a Master’s Degree in Clinical & Sports Nutrition with offices in Ft. Lauderdale and Boca Raton, FL. Over the past 20 years, he has trained over 700 physicians nationwide in the implementation of his Lifestyle Nutrition Counseling Program®. For more information or to try your own nutritional program, visit www.PhysicianWellnessProgram.com or call 800-699-8106.