Dietary Counseling

Definition

Dietary counseling provides individualized nutritional care for encouraging the modification of eating habits. It may also assist in prevention or treatment of nutrition-related illnesses such as cardiovascular disease, cancer, obesity, diabetes, and hyperlipidemia.

Purpose

Today's major health care problems are increasingly the result of acute and chronic conditions related to poor nutrition and/or overconsumption. A large proportion of coronary disease and cancer can be attributed to unhealthy eating habits and obesity. Chronic diseases continue to increase due to such factors as the rise in obesity in the American population.

Individualized nutritional counseling can provide the patient important insight into food-related illnesses and education regarding how various nutrients (protein, carbohydrate, fat, alcohol) affect illnesses or obesity. Alternatively, dietary counseling can assist in prevention of nutrition-related conditions such as the need for weight management. Dietary counseling can be tailored to meet the treatment needs of patients on diagnosis of specific illnesses, can help reduce complications and/or side effects, and can improve general well-being. Prevention at all levels: primary (preventing disease), secondary (early diagnosis), and tertiary (preventing or slowing deterioration) requires active patient participation and guidance and support from the dietician or physician. Education, motivation, and counseling are needed for effective patient participation. In addition to patient education, dietary counseling often includes meal planning.

Consumption of too little or too much of certain vitamins and minerals may lead to a nutrient deficiency or a nutrient toxicity respectively. A guide to the amount an average person needs to remain healthy has been determined for each vitamin and mineral as well as macronutrients. In the United States, this guide is called the Dietary Reference Intakes (DRI). Dietary counselors may use the DRI as a guide when providing counseling. A dietitian can advise the patient about any vitamin or mineral inadequacy concerns during the dietary counseling session. The DRIs have replaced the Recommended Dietary Allowance (RDA), but encompass both the RDAs and the upper intake limits for each nutrient.

Precautions

When providing dietary counseling, registered dietitians and nutritionists should recognize the benefit of individualizing nutritional care and that a "one-size-fits-all" approach to modifying eating habits cannot be effective.

Description

Effective dietary counseling includes a comprehensive evaluation that considers presence of disease, lipid profile, blood pressure, and weight history and goals. In addition, factors such as lifestyle, time available for food preparation, work schedule, and personal food preferences must be considered. Food choices are driven not only by the physiological necessity for nutrients, but also by the social aspects of food consumption, for example, gathering with friends at a restaurant. This complex relationship concerning food choices often makes dietary counseling a challenge for managing specific nutrition-related disease or conditions. For example, a patient with cardiovascular disease may need to select low-fat foods when attending a social dinner or party.

There are many goals that need to be considered when planning appropriate dietary counseling. When considering the appropriate counseling approach for an individual with a specific illness, particular attention needs to be given to usual food choices, food likes and dislikes, learning style, cultural issues, and socioeconomic status.

Other factors that may be assessed during dietary counseling include:

• medical history, including assessment of any nutrition-related illnesses, and biochemical and anthropometric measures
• dietary assessment (dietary analyses)
• psychosocial evaluation, including food-related attitudes and behaviors
• sociological evaluation, including cultural practices, housing, cooking facilities, financial resources, and support of family and friends
• nutrition knowledge
• readiness to learn or change; as well as learning style analyses
• current exercise and activity level

Preparation

A dietary assessment is often conducted to determine the macronutrient content (energy/or calories, protein, carbohydrate, and fat) and the micronutrient (vitamin and mineral) content of the diet to assist in providing dietary counseling. The validation of dietary assessment instruments is important to evaluate the diet in terms of chronic disease risk factors such as a high fat diet or a diet low in antioxidants and/or fruits and vegetables.

Some of the most common dietary assessment tools that assist in providing dietary counseling include food records, dietary recalls, food frequency questionnaires, diet histories, and several other methods, including biochemical indices. A scientific assessment of nutritional status may be made by using a combination of the information collected from clinical evaluations, biochemical tests, and dietary information. The clinical evaluation includes measurements of various anthropometric parameters such as height, weight, and percent body fat (determined by skinfolds or hydrostatic weighing). In addition, a clinical evaluation may also include observations for signs of nutrient deficiencies in the mouth, skin, eyes, and nails. The information collected from a clinical evaluation can be compared with that obtained from the dietary assessment and biochemical tests to provide a comprehensive picture of the patient's current nutritional status and relative risk factors for diet-related illnesses.

Aftercare

Dietary counseling is only effective if the individual is willing to implement the necessary dietary modifications. If patients do not follow the recommended dietary guidance, they will not receive a benefit from counseling. Typically, modest effects seen in weight loss or reduction in serum lipids are often due to failure to comply fully with the dietary recommendations provided.

Complications

Systematic problems exist in the quantification of food intake using self-reported measures (when patients subjectively report their own food intakes). This is due to the fact that these methods rely on the patient's ability to recall or record food intake accurately. Therefore, selection of the appropriate method for dietary assessment is important to meet the goals of dietary counseling.

Results

Goals of dietary counseling for preventative nutrition or treatment of nutrition-related illness:

• Providing adequate calories for attaining reasonable weights for adults, ensuring normal growth and development rates for children and adolescents, and meeting increased metabolic needs during pregnancy and lactation or recovery from catabolic illness. Reasonable weight for adults is defined by considering weight history and is a weight that both the individual and health professional determine is attainable and can be maintained long term.
• Achieving optimal lipid levels. The guidelines provided by the National Cholesterol Education Program can be followed for maintaining optimal blood lipid levels (total cholesterol, low-density lipoproteins [LDL], high-density lipoproteins [HDL], and triglycerides). Nutrition intervention plays an important role in reaching recommended lipid levels through maintenance of a low-fat diet.
• Ensuring the diet contains appropriate or reasonable amounts of protein, carbohydrates, fat, vitamins, and minerals.
• Preventing, delaying, or treating nutrition-related risk factors and complications.
• Improving overall health through optimal nutrition.

What methods are most helpful for dietary modifications?

Clearly, dietary advice tailored to suit individual needs and tastes is more appropriate than general dietary advice. The issue is how to elicit a beneficial change in dietary habits and how to encourage a patient to stick to the dietary recommendations provided. Typically, dietary modifications have demonstrated limited success especially regarding weight control. Various methods have been used to induce behavioral change in individuals, two of those include:

• Positive feedback or implementation of a reward system. This method may be advantageous in helping some patients follow dietary advice.
• Transtheoretical (Stages of Change) Model. This model is one of the most popular models of health behavior change that classifies individuals into stages according to their degree of readiness to consider change, and identifies the factors that can induce transitions from one stage to the next. It utilizes different types of skills training and advice at different stages and has shown promising success with dietary modification.

In general, it may be easier to introduce new behaviors than to eliminate established behaviors. Therefore, if weight loss is a concern, recommending the patient start exercising regularly may be more effective than trying to make dramatic changes regarding current dietary habits. Changing behaviors, such as making healthier food choices and increasing exercise, will be much more successful and pleasurable in the long-term than dieting. Furthermore, an individual cannot live on a diet permanently; therefore, when food intake increases, weight gain will follow unless energy expenditure is increased through exercise or by other means. Dieting may encourage a "yo-yo" weight loss or gain where typically even more weight is gained back than was lost in the first place. Moreover, the weight regained is often in less favorable fat to muscle proportions. When weight is lost, muscle and fat are both lost. Sometimes the weight that is regained after weight loss has a higher content of "fat" (adipose tissue) than the weight previously lost (which may have contained a significant percent of skeletal muscle). This is only one of the reasons why exercise is so important in maintaining body weight. In fact, because muscle is metabolically active tissue, the body actually needs more energy or calories to feed the muscles even when at rest (for example, sitting still or sleeping). Dietary counseling may help reinforce dietary modifications and assist in achieving permanent weight control.

Other sources that can be used for dietary reference and self-counseling for individuals are The Dietary Guidelines for Americans, which is published by the U.S. Department of Agriculture and Health and Human Services. The Dietary Guidelines for Americans, can provide a broad overall view of good nutrition. They provide science-based guidance to promote health and reduce risk for major chronic diseases through diet and physical activity. These guidelines include basic recommendations:

• Eat a variety of foods; let the food pyramid guide your food choices.
• Control weight.
• Be physically active each day.
• Eat a diet low in saturated fat (less than 10% of total calories) and cholesterol (less than 300 mg/day), and moderate in total fat (20-35% of total calories).
• Limit intake of fats and oils high in saturated and trans-fatty acids.
• Eat a variety of vegetables and fruits, and whole grains.
• Eat a variety of whole-grains.
• Eat sugar in moderation.
• Use salt in moderation.
• If you drink alcohol, do so in moderation; no more than two drinks per day of wine, beer, or spirits.
• Keep food safe to eat; follow the government safety precautions as outlined on the food package.

Two examples of eating patterns that follow the Dietary Guidelines are the U.S. Department of Agriculture (USDA) Food Guide and the Dietary Approaches to Stop Hypertension (DASH) Eating Plan. These examples are designed to integrate dietary recommendations into overall healthy eating patterns and are not weight loss diets. Rather, they are examples of plans that adher to the Dietary Guidelines. Other programs to look for dietary guidance are the National Cholesterol Education Program guidelines, which may be followed to assist in controlling weight. The guidelines provided by the National Cholesterol Education Program can be followed for maintaining optimal blood lipid levels (total cholesterol, LDL, HDL, and triglycerides).

KEY TERMS

Dietary assessment— An estimation of food and nutrients eaten over a particular time point. Some of the most common dietary assessment methods are food records, dietary recalls, food frequency questionnaires, and diet histories.

Dietary counseling— Individual nutritional advice provided to a patient by a registered dietitian, nutritionist, or doctor for encouraging modification of eating habits.

Dietitian— A dietitian is a health professional who has a bachelor's degree, specializing in foods and nutrition, and undergoes a period of practical training in a hospital or community setting. Many dietitians further their knowledge by pursuing master's or doctoral degrees. The title "dietitian" is protected by law so that only qualified practitioners who have met education qualifications can use that title.

Macronutrient— A nutrient such as protein, carbohydrate, or fat.

Micronutrient— An organic compound such as vitamins or minerals essential in small amounts and necessary to the growth and health of humans and animals.

Nutritionist— A general term for someone who works with the principles of nutrition. Some dietitians call themselves "nutritionists," but the term "nutritionist" is not protected by law, and therefore anyone can call themselves a nutritionist.

Health care team roles

In general, only registered dietitians (R.D.s) have sufficient training and knowledge to accurately assess the nutritional adequacy of a patient's diet. The term "nutritionist" is not regulated by law; therefore anyone can call themselves a nutritionist. A doctor may also have a nutrition background or specialization and may thus be able to provide general nutrition counseling. However, one research study demonstrated that even though most doctors admitted they had ready access to a publicly funded dietician, 50% of doctors refer less than a quarter of their patients to dieticians. Major barriers to improving dietary counseling for patients include short visit times, limited nutrition coursework in medical schools, and poor compliance with physicians' dietary prescriptions.

For effective therapy to occur, all health care team members and the patient in particular must commit to the goals of counseling. Prioritized goals are critical when developing a nutrition treatment plan. Continuous assessment is made by the patient and health care team members to evaluate the importance of these goals. Dieticians and physicians must listen to and understand the dietary habits of a patient, and to consider these when providing dietary counseling. Any dietary guidance that does not fit well with a patient's lifestyle will not likely be adhered to.

Resources

BOOKS

Bronner, Felix, ed. Nutritional and Clinical Management of Chronic Conditions and Diseases. Boca Raton, FL: CRC Press, 2005.

Eskin, N. A. Michael, and Tamir Snait. "Dictionary of Nutraceuticals and Functional Foods (Functional Foods & Nutraceuticals Series)" Boca Raton, FL: CRC Press, 2005.

Institute of Medicine, ed. Dietary Reference Intakes for Energy, Carbs, Fiber, Fat, Fatty Acids, Cholesterol, Protein, And Amino Acids. Washington: National Academies Press, 2005.

Lutz, Carroll, A., and Karen Rutherford Przytulski. Nutrition And Diet Therapy, 4th ed. Philadelphia, PA: F. A. Davis Company, 2006.

Temple, Norman J., Ph.D., et al. Nutritional Health: Strategies For Disease Prevention, 2nd ed. Totowa, NJ: Humana Press, 2005.

PERIODICALS

Cristina, F. "Mediterranean diet health benefits may be due to a synergistic combination of phytochemicals and fatty-acids." British Medical Journal 331 no. 7508 (2005): E366.

Price, S. "Understanding the importance to health of a balanced diet." Nursing Times 101 no. 1 (2005): 30-1.

Westman, E.C., Yancy, W.S. Jr, Vernon, M.C. "Is a lowcarb, low-fat diet optimal?" Archives in Internal Medicine 165, no. 9 (2005): 1071-72.

ORGANIZATIONS

American Dietetic Association. 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606-6995. (800) 877-1600. 〈http://www.eatright.org/〉.

American Heart Association National Center. 7272 Greenville Avenue, Dallas, Texas 75231. (800) AHAUSA1. 〈http://www.americanheart.org/〉.

Food and Nutrition Information Center, Agricultural Research Service, USDA. National Agricultural Library, Room 105, 10301 Baltimore Avenue, Beltsville, MD 20705-2351. (301) 504-5719. Fax: (301) 504-6409. 〈http://www.nal.usda.gov/fnic/〉. fnic@nal.usda.gov.

International Food Information Council. 1100 Connecticut Avenue, NW, Suite 430, Washington, DC 20036. (202) 296-6540. Fax (202) 296-6547, 〈http://www.ific.org/〉. Email: foodinfo@ific.org

U.S. Department of Agriculture (USDA), Agricultural Research Service. 5601 Sunnyside Avenue, Beltsville, Maryland 20705. "USDA Nutrient Database for Standard Reference, Release 18." Nutrient Data Laboratory Homepage 2005. 〈http://www.ars.usda.gov/ba/bhnrc/ndl〉. USDA home page 〈http://www.usda.gov/wps/portal/usdahome〉.

USDA Food and Nutrition Service. 3101 Park Center Drive, Alexandria, VA 22302 〈http://www.fns.usda.gov/fns/〉.

U.S. Department of Health and Human Services. 200 Independence Avenue, S.W., Washington, D.C. 20201. (202) 619-0257 or (877) 696-6775. 〈http://www.hhs.gov/〉.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). 1600 Clifton Rd, Atlanta, GA 30333. (800) CDC-INFO. 〈http://www.cdc.gov/〉. Email: cdcinfo@cdc.gov

U.S. Department of Health and Human Services, CDC, National Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD, 20782.(866) 441-NCHS (6247). 〈http://www.cdc.gov/nchs/〉. Email: nchsquery@cdc.gov

OTHER

Center for Nutrition Policy and Promotion. 〈http://www.usda.gov/cnpp/index.html〉.

Dietary Guidelines for Americans, 2005. 〈http://www.healthierus.gov/dietaryguidelines/〉.

Finding Your Way to a Healthier You〈http://www.health.gov/dietaryguidelines/dga2005/document/html/brochure.htm〉.

Healthy People 2010. 〈http://www.healthypeople.gov/〉.