For the more than 10 percent of Americans who are living with diabetes, making educated changes to their diet—often along with using the latest pharmacological options—is an important part of an effective treatment strategy. Clinicians play a significant role in “prescribing” this approach to help people keep their condition under control.
Yet many medical professionals find it challenging to appropriately address nutrition with their patients, according to A. Enrique Caballero, MD, faculty director of diabetes education through Harvard Medical School’s Postgraduate Medical Education and course director for our Prevention and Management of Diabetes Complications course.
Caballero, who also directs the Latino Diabetes Health Program within the Division of Endocrinology, Diabetes, and Hypertension at Brigham and Women’s Hospital, says that when working with minorities and underserved populations, the challenges can be magnified, due to things like language barriers, traditional cultural food preferences and food availability.
Helping Patients Navigate Nutrition Information Overload
“As a clinician and researcher, I recognize that counseling patients on nutrition is an area that most health care professionals struggle with,” he says. “I also realize that providing information on healthy eating and nutrition is important, but we don’t know how to do it well yet,” he stresses.
Compounding the problem for clinicians and patients alike is the overload of information around dieting that exists and the conflicting messages that can be very confusing—not only for the public but also for health care professionals, Caballero says.
“How the research gets translated in the media is where there can be some confusion,” explains Kathy McManus, MS, RD, LDN, who serves as director of the Department of nutrition and the director of the dietetic internship at the Brigham and Women’s. “You can see headlines that say butter is bad for you, butter is good; eggs are bad, eggs are good. People say why bother trying, then. They are confused and decide just to eat what they want until they figure it out,” she says.
Many people are also looking for a quick fix, so fad diets appeal to them. But eliminating food groups sets them up for failure since they are not a sustainable way of life, she adds.
Tips for Clinicians to Use Nutrition to Treat Cardiometabolic Disease
What does work, both McManus and Caballero agree, are slow and steady changes to diet that people can incorporate into their current lifestyle. Here are some of their tips that clinicians can use to help their patients to get diabetes under better control.
1. Translate the science into meaningful steps
Caballero says that clinicians need to be able to translate the science into practical recommendations that fit the patient’s specific circumstances—including biological, psychological, social, financial, educational and cultural factors that impact their food choices. Yet in order to do this, clinicians must have a good understanding of the patient’s background and family situation. This is easier said than done, since health care providers have very limited time during a patient visit and must review the medical history and blood tests, which doesn’t leave much chance to delve into the patient’s lifestyle.
“Clinicians need to know how to optimize their time and understand how to communicate in a culturally appropriate way,” he says. This is essential, especially since people’s access to food and their preferences could vary based on their background and where they live.
“Even if someone has enough money for food, is the food we recommend available in their community? There’s huge food insecurity in the U.S., and in some neighborhoods you just can’t find healthy foods,” Caballero says. This causes stress for patients if they can’t get what the doctor recommends.
2. Keep an eye on the bigger picture
When giving a patient nutritional counseling, clinicians also need to think of the patient’s circumstances and ability to prepare healthy foods. When the clinician suggests that the patient eat something that is different from what he or she makes for the rest of the family, they will feel overwhelmed and are likely to just ignore the recommendation.
McManus suggests that in such a case, a clinician can suggest one meal that the patient can make for the entire family and then if needed, modify the dish for their own specific needs. “Also, if patients need financial assistance and have not applied for [the Supplemental Nutrition Assistance Program], the clinician needs to be able to help them do this. Patients should not have to go find their own resources. We, as clinicians, should support them in the effort,” Caballero adds.
By taking into account the biggest picture, providers can make suggestions that will be feasible for the patient to act on.
3. Focus on balance, not extremes
Many patients may want to try more extreme diets, such as intermittent fasting. But McManus points out that they only hear the hype about the diet, not the details. “For certain people, like those with type 1 or type 2 diabetes, intermittent fasting may not be the most healthful approach,” she says.
In addition, diets like Keto, Paleo and Whole 30 can look appealing because there are many social media stories of people achieving results on these. But the science isn’t there to back up the claims, she points out. Further, none of these extreme diets that eliminate major macro nutrient groups can be maintained over the long term, she adds.
“The challenge is to share what science we do have and help support the clinician,” she says. The Mediterranean Diet, DASH and Flexitarian are diets that have good data behind them and take a more balanced approach to eating.
“The key is that your patients are going to ask you about diets. They are exposed to a lot of information today. It’s essential that physicians know how to answer. All health care professionals need to be prepared to discuss the pros and cons of different diets,” Caballero adds.
“For people with cardiometabolic disease, diabetes and prediabetes, we want to encourage lifestyle changes for good health, since we know these can have a significant impact. It’s never too late to start making modifications in diet and reaping the results,” he stresses.
4. Using diet to complement pharmacological options
“There are lots of new medications that can help patients lose weight and control their blood sugar," McManus says. While these pharmacological options can be appealing, she stresses that these should be prescribed along with a healthy meal plan. It’s important to include both elements in a treatment strategy.
“While the latest data shows the new medications bring about significant weight loss, there are still patient side effects that have to be considered. Like every medication, it has to be tailored to the patient and has to fit into their lifestyle. We also need to support patients and families over time to help behavioral changes [such as healthy eating] become a regular habit,” she adds.
The good news is that it isn’t an all-or-nothing proposition. “There is some recent research out there that shows that taking positive steps in the right direction can build healthy habits,” she says, adding that one way to help patients be more effective in this endeavor is to connect them to community groups or support systems.
5. Make a personal connection
Clinicians should also practice what they preach and strive to be role models. Some research shows that if the health care provider is overweight, a discussion on weight loss is less likely to happen with the patient than if the health care provider is not overweight. Caballero says. “It may be that the clinician doesn’t want to bring up the subject of weight, but that shouldn’t be the case.”
McManus adds, “A lot of patients trust the health care provider. Therefore, if the clinician does not address weight in a sensitive way and discuss some of the real issues, they think it is okay and that their weight must not be that important.”
Caballero suggests that when clinicians struggle with their own weight, sharing that fact can actually build a stronger bond with patients and just may help to motivate patients toward healthful change.
“You could share a recipe you just tried with their family and say this worked for us,” he says. When medical providers approach their patients on a more personal level and make a deeper connection with them, understanding who they really are and what their strengths and challenges are that can impact their nutrition choices, this can increase the likelihood of helping them eat a more balanced diet. This will help them manage their diabetes—or better yet, prevent it—and ultimately result in improved outcomes.
Written by Lisa D. Ellis