Doctors: How to Talk to Patients About Nutrition and Diet

Kerin Torpey Bashaw, MPH, RN, Senior Vice President, Department of Patient Safety and Risk Management, The Doctors Company

No more powerful an approach exists to preventing or even reversing heart disease than improving lifestyle, especially nutrition and diet. The challenge for physicians is finding an effective way to talk about nutrition with their patients, because the usual admonitions to eat better and exercise often do not work.

The American Heart Association estimates that 46 percent of U.S. adults have hypertension and, on average, someone dies of cardiovascular disease every 38 seconds. A 2018 report by the Centers for Disease Control and Prevention (CDC) showed the average U.S. adult is nearly obese. A 2017 study revealed that about 45 percent of deaths from cardiometabolic conditions were due to dietary factors.

Andrew M. Freeman, MD, FACC, co-chair of the Lifestyle and Nutrition Workgroup with the American College of Cardiology, explains that the drugs we use to treat heart disease can be wonderful tools, but they don’t really focus on a cure or reversal—they only control the disease.

But drugs aren’t the only option. Stephen Devries, MD, executive director of the Gaples Institute for Integrative Cardiology, stresses the wealth of research focusing on lifestyle and nutrition as the key component for curing or reversing heart disease. The data suggest that a diet filled with vegetables, fruit, whole grains, and predominantly plant-sourced protein offers the best chance for both prevention and treatment of heart disease, as well as benefits for reducing the risk of certain cancers.

Dr. Devries points to one landmark study, which found that a Mediterranean-style diet emphasizing more fish, vegetables, nuts, and whole grains yielded a 72 percent reduction in the occurrence of nonfatal myocardial infarction and death, compared to a control group. A more recent study of the Mediterranean-style diet found a 28 percent reduction in nonfatal myocardial infarction, cardiac death, and stroke, Dr. Devries notes.

The results that are possible with changes in nutrition and other lifestyle improvements make every drug and procedure pale in comparison, Dr. Freeman says. The Dietary Approaches to Stop Hypertension (DASH) trial showed that a diet rich in vegetables, fruit, and low-fat dairy prompted a significant drop in blood pressure in only two weeks.

Dr. Devries explains the compelling results of this research in a four-hour, self-paced CME program called Nutrition Science for Health and Longevity: What Every Physician Needs to Know, recommended by The Doctors Company.

Dr. Freeman believes there is no doubt we can significantly improve the quality of life for patients with heart disease through better nutrition, which promises benefits several magnitudes larger than nearly any medication.

The science is solid, but applying it is the challenge, he says. Unfortunately, cardiologists have almost no training in lifestyle approaches to disease. A survey of 646 cardiologists revealed that cardiologists are unprepared to talk to patients about the effect of nutrition on heart disease, with 90 percent receiving no or minimal nutrition education during fellowship training, 59 percent receiving little or no nutrition education during internal medicine training, and 31 percent receiving no nutrition education in medical school.

That means physicians face a significant challenge when trying to persuade patients to switch to a predominantly, if not totally, whole-food, plant-based diet. The switch is difficult for most patients, and physicians are not adequately prepared to talk about nutrition at all, much less such a daunting lifestyle change.

Most physicians have only brief conversations in which they tell patients to change their diets, possibly with a few specific suggestions. So one of the keys to making nutrition counseling work in a busy practice is making optimal use of the short period of time that physicians have available for nutrition counseling—a key component of the CME nutrition course.

Even when patients are eager for nutritional advice, they may find it difficult to sort out competing messages from the media and may not know how to follow their physicians’ advice to improve nutrition.

Effective communication requires a more interactive approach that uses data to back up the recommended changes. For example, Dr. Freeman asks patients what they had for lunch that day, what they had for dinner the night before, and how active they were in the past week for a snapshot assessment of nutrition and lifestyle. He then asks permission to be critical about the diet, which indicates whether the patient is receptive to the changes that are necessary to reverse the course of heart disease.

Dr. Freeman also assesses readiness for change through a technique called motivational interviewing, which helps identify what incentivizes a person to change behaviors. This approach recognizes how difficult it can be for some people to make lifestyle changes and helps them find successful strategies.

This approach and further conversation may reveal, for example, that the patient has an unhealthy diet but is unhappy about how he or she feels on a daily basis and wants to be able to dance at a daughter’s upcoming wedding. Such circumstances and goals can become the basis for meaningful change, supported by resources such as recipes and online links to resources, as well as support groups that let patients meet people who have successfully transitioned to better nutrition. Clinical scenarios that provide tips for motivational interviewing are also included in the nutrition CME course.

When patients are at least minimally receptive to the idea, the physician can show how research proves the value of improving their nutrition, comparing their own nutrition to the ideal versions and discussing the incremental steps for improvement. Physicians also can support patients making healthy lifestyle changes through programs like Walk with a Doc, which encourage doctors and patients to take walks together. Dr. Freeman runs the regional program and regularly takes walks, and talks, and educates patients.

Because the benefits of improved nutrition and lifestyle for heart disease are so compelling, clinicians must make a concerted effort to convey that information effectively and to work with patients to overcome any personal obstacles or hesitation. Simply telling patients to change their lifestyles does not work—a supporting hand through change is necessary.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.