156 | LIVE From Today's Dietitian: 3 Nutrition Counseling Mistakes and What to Say Instead

I am recording this live from the hotel room of the Today's Dietician Nutrition Symposium. Welcome back to the Exam Room Nutrition Podcast. I'm Colleen Sloan, a PA and dietitian, and I'm really, really excited to share that I have finished my marathon of conferences this weekend. If you ran into me at the AAPA in New Orleans, thank you so much. It was so fun meeting you in real life. Or if we saw each other at the Today's Dietician Conference, I absolutely loved running into you and meeting you in person. Now, as you may know, I presented actually four times over this past weekend, and I wanted to share a few key takeaways from one of my presentations at the AAPA. And that talk was titled Nutrition Counseling, What to Say. And I feel like this is so applicable to dietitians, but also to PAs, because finding the right words can be so hard. I think about this even in real life things, like asking for a raise or telling an employer that you're leaving, or even admitting to a loved one that you wronged them and asking for forgiveness. But I think for all of you listening, it's really hard to talk about nutrition without feeling awkward or stigmatizing the patient. And I really think that's because nutrition and diet and body size is deeply personal. And a lot of us carry shame, blame, guilt, or past judgments from previous healthcare providers. So I just want to give you a few quick tips of how you can counsel your patients better without causing any harm. So I first want to talk about three common nutrition counseling mistakes that we've all probably been probably been guilty of. And the first one is that we assume knowledge changes behavior. Now, I ask this question, I kind of pulled the audience when I was doing this live. And so I will do the same for you, but please just message me on Instagram or LinkedIn at exam room nutrition and let me know your answer. So, true or false, when we know better, we do better. Do you agree with that statement or do you think it's false? Now I think it's false, and I will state my claim as to why. First of all, this assumes that if we tell people the negative health consequences of eating too much or exercising too little, that they will automatically change their behavior accordingly. And really, we know this is not true. What this can look like in practice is that we talk more than we listen, we don't ask enough open-ended questions, we don't assess what the patient knows already, we don't explore any past barriers. I firmly believe that our patients do not always lack information. They lack the ability to apply that information into their daily lives in a way that works for them. We are in the information age. You can literally find anything within less than a second, thanks to AI. And so our patients already are coming in with a lot of knowledge. And so, if knowledge alone changed behaviors, we really wouldn't have the amount of chronic medical conditions that we do have today. So when we give a handout and we explain the risks of not following a healthy diet, our patient may agree with us and they might even be really excited. But what happens is they don't lack information. They often lack environmental support, practical strategies, implementation planning, meaning helping the patient break up their goal into when and how they're going to do said goal, friction reduction, making that goal easier. And I believe that's the gap between knowledge and behavior. So we know that behavior change is not simple. If you've ever tried to change anything yourself, you know this. And yes, I believe that knowledge is the foundation. We do need to be educating our patients. However, it cannot stop there. Change requires more than information. And our food choices really don't happen in a vacuum. They're shaped by the environment in which the decisions are made. The second nutrition counseling mistake we make is using imperative language. PAs are really notorious for doing this. This is saying things like, hey, you need to cut out soda, or you should lose weight, or how about I want you to cut back on the sweets. Now, why do we default to this? I think a lot of it has to do with time pressure. We have limited time with our patients and we feel like we have to say something, and this might be better than nothing. We also might be unsure of what else to say beyond just giving black or white or a quick nutrition tip. And for PA specifically, it feels very natural to prescribe. We are trained in PA school to assess the patient, to come up with differentials, and then to determine our plan, which often involves writing a prescription for something. So it feels very natural to prescribe. But when it comes to nutrition, if you just prescribe a nutrition plan, often you're losing that personalization and the nuance that that patient needs. When we use imperative language like telling the patient what they should do, this immediately triggers resistance and defensiveness. It removes the patient's autonomy as well. I promise you, no one likes to be told what to do. And I like to think of my teenage daughter. If I tell her to do something, the immediate response is pushback. So if we can get their buy-in, they are far more likely to stick with the plan and kind of be excited about it. When we use imperative language, it also assumes that we know best. And this just isn't true. Our patients are living 23 and a half hours outside of our clinic walls. And sometimes we really don't have any idea of what's going on outside of clinic. When we tell a patient to do something, it also implies that the solution is just willpower. And if GLP1s have taught us nothing, we know that weight loss is far more than just about having more willpower. So rather than using imperative language, I would suggest you use more open-ended questions to open the conversation before you just make an assumption or make a statement of something that they should do. So rather than telling a patient, hey, you need to lose weight, I like to ask, would it be okay if we talked about how your diet might be affecting your health? Or if you're telling a patient, hey, I think you should cut down on the soda, why don't you be curious and find out what role does soda play in your day-to-day? Maybe this is the only time that they connect over lunch and a soda with their friend, and it's a deep connection and a deep emotional reason that they're choosing to drink soda. I also like to find out how do you feel about your soda intake? Maybe the patient does and has thought about cutting back. They just don't know how. I also like to have the patient have future me thinking. So I love to ask, what are you hoping your health looks like in one year? This really helps you determine what their goals are for their life, what they're trying to achieve so that you can better align your recommendations with their goals. And the last counseling mistake that we make, and I will be the first to admit I was guilty of this, is solving before understanding. Now, I'm gonna take you into the clinic with me really quickly. This was years ago. I was doing a checkup on like a nine or 10-year-old boy, and I had already gotten a diet recall, and we're doing his physical exam, and I was still chatting with them. Now, of course, I was rushed and already behind, and I felt like I needed to say something about nutrition and give them some kind of education. And so I had just suggested, hey, you know, you should eat more fruits and vegetables, because it doesn't sound like you're eating very many at all. And, you know, they're so healthy for you and they're so good for you. And there was an awkward silence in the room. And the little boy looked at his mom, she looked back at him, and you could feel the tension. And the mom looked at me and she said, you know, we would love to eat more fruits and vegetables, but we've been living in our car for the last three weeks. I had a huge pit in my stomach. I was so embarrassed that I tried to give a solution before I understood that family's reality. And that moment really changed how I practice. So, solving before understanding also looks like giving a patient a handout or telling them to try a diet that maybe worked for you or worked for some of your other patients. You really need to understand the patient's world. What is their financial barriers? What are their goals? Do they have any time constraints? What about the cultural and household context? What is their readiness to change and mental capacity? So rather than having assumptions, I recommend you replace those assumptions with curiosity. So here's what a few of those statements can look like. When were you successful? Or tell me about a time that you succeeded in the past. What has worked for you in the past? I love asking the patients what makes this hard. That's a wonderful way to problem solve what's going on rather than just assuming that they're non-compliant or non-adherent. And then just a blanket statement of tell me about blank really invites the patient to share their story so you can get to know them better. Well, I hope you enjoyed this quick episode. I know it's a little different than I normally do, but I've been having so much fun at these conferences. And so I will just leave you with this. If knowledge alone worked, we wouldn't have chronic disease. Our job isn't just to educate, it's to help the patient believe that change is possible. All right, my friend, thank you so much for carving out some time for nutrition, and I will see you next week.