The hospital is more than a place for treatment. It can be a place for learning. Picture this scenario:
A man arrives at the emergency room after an accident at a construction site. He has a compound fracture and a leg laceration with significant blood loss. After his initial treatment, he is admitted. His improvement is quick, and by day 2, he is medically stable and reasonably comfortable. His doctor arrives for a visit. After checking the wound sites and vital signs, the doctor sits down for a serious talk.
"You are going to come through this accident just fine," the doctor says. ''You'll be out of the hospital before you know it. I don't expect any residual problems at all. You're going to be fine." Then the doctor's expression turns more serious. "While you're here, let's tackle another problem. As I understand it, you've been smoking two packs a day for quite some time now. While you're here, let me help you stop. These injuries won't kill you, but tobacco very likely will, and this is as good a time as any to deal with it."
The patient bites his lip. But he realizes the doctor is right. He had wanted to quit, of course, and now - stuck in a nonsmoking hospital - that is exactly what is going to happen, whether he likes it or not.
Later on, the same doctor sits down with another patient, this one hospitalized for a hip replacement. The patient also has a long-standing weight problem, poorly controlled hypertension, and a high cholesterol level. He has had two prior heart attacks, but has not followed through on suggestions that he change his diet. The doctor's speech sounded nearly identical:
"You are going to come through the surgery just fine," the doctor says. "You'll be out of the hospital in no time. But while you're here, let's tackle a more serious problem. I am going to ask the hospital staff to help you learn some healthy eating habits."
In the chart, he orders a dietetic consultation and a vegetarian diet. He explains to the patient that this is a chance to try some healthful foods. Whether the patient keeps it up after discharge is his business. But the doctor is going to use the hospitalization to its full advantage.
None of this had anything to do with the man's hip, of course. But it had everything to do with what threatened his life over the long run.
Both patients told their families about what the doctor had said. And both families were mightily impressed.
These patients came to truly respect their doctor. Yes, they were a bit unsure about quitting smoking and rearranging long-standing eating habits. But, like most patients, they were well aware that they were not tackling their problems on their own. They appreciated a caregiver who looked beyond the presenting complaint to what really threatened their long-term health. The doctor saw the problems they had been unable to solve and helped these patients to address them.
Helping Patients Adopt Healthy Diets
Although the value of a healthy diets and lifestyles in preventing and treating disease is well established, too few healthcare providers raise these issues with their patients. The Behavioral Risk Factor Surveillance System surveyed approximately 13,000 obese individuals in 50 states, and found that only 42% had been advised by a health care provider to lose weight.1
Surveys show that physicians and medical students feel ill-prepared to address nutritional questions.2 Aside from a lack of information, physicians are often concerned about patients' ability to stick to lifestyle changes. They may also face a lack of reimbursement and significant time pressures, among other problems.1-3 Despite these reservations, the fact that patients seek out, respect, and are motivated by advice from physicians4 indicates that clinic visits present an important opportunity to effect major nutritional changes that improve health.
Partly in response to a growing consensus that practicing physicians and medical students should learn about nutrition, the National Institutes of Health developed the Nutrition Guide for Training Physicians.5 This publication is designed to help physician-educators integrate essential medical nutrition knowledge and behavioral skills into undergraduate and graduate medical curricula.
Hospitalization as a Teaching Opportunity
Every hospitalization is a chance to do more than treat a presenting complaint. It is an opportunity to help patients overcome additional problems that may be much more serious over the long run. Doctors do this every day:
An emergency physician treats a burn in a pediatric patient. But before closing the chart, he calls social services, because he suspects child abuse. That single action may have spared the child untold years of mistreatment.
An orthopedic surgeon treats a man's broken wrist. But before discharge, he has a frank talk about the alcoholism the led to the accident and arranges outpatient treatment.
A geriatric specialist can't find anything wrong with his patient's back. But with a few carefully chosen questions, he goes beyond the complaint of back pain. He discovers that the patient has no appetite, is sleeping poorly, and has lost interest in his usual activities. With the patient's permission, he arranges a psychiatric consultation for depression.
Child abuse, alcoholism, and depression are serious problems that are often hidden, and a physician who spots them makes a big difference.
If you are treating a typical North American population, you will confront equally deadly problems on a daily basis. Half of the patients in your practice will eventually die of cardiovascular disease. Many of the remainder will one day succumb to cancer. Along the way, diabetes, renal disease, chronic weight problems, and other serious health conditions will take their toll.
Depending on your specialty, these may not be your problems, of course. And, with ever-increasing time pressures, it is tempting to ignore the diet patterns that contribute to the presenting problems that you see. But hospitalization can be a time for a new beginning. You have the patient's attention, and with very little effort you can make a huge difference. The actions described below are the basic tools for getting the patient the help he or she needs.
Request a dietetic consultation. A registered dietitian can provide the nutritional counseling that you may not have the time or expertise for. If possible, extend the consultation into the post-hospitalization period. The process of diet change takes time, and patients always need continuing support.
It pays to work as a team. In a weight management program at 80 general practice sites, a combination of physicians, nurses, and dietitians specializing in obesity was able to achieve weight loss of 5% of body weight in one-third of the patients. In addition, roughly 50% of patients attended all clinic appointments, and 40% of this sub-group also maintained weight loss of 5% at 12 months.6 These results suggest that, while a team approach will not conquer all nutrition-related problems at the first attempt, a significant number of patients respond well to it. A team approach should be combined with the use of an effective diet prescription, as described below.
A team approach also provides more expertise on the topics of interest to patients and saves time for physicians. Although questions regarding weight loss are the most common nutrition questions asked of physicians, a wide range of other topics will come up routinely. Diet-drug interactions are a key topic. Unfortunately, physicians receive minimal training on informing patients about such interactions, in spite of this being a requirement of the Joint Commission on Accreditation of Healthcare Organizations.2 A registered dietitian can be a helpful consultant to both physician and patient.
Call the dietary department. At some point, call the dietary department manager to let him or her know that you will be ordering healthful meals frequently. Surprising as it may sound, hospital dietary services are not necessarily thinking about the fat and cholesterol of the foods they serve. Although they can easily fulfill your requests, the fact that you are now requesting healthful diets (see below) on a regular basis may come as a surprise. A single call or visit will help them understand your goals and let them know that you appreciate their help.
Talk to the patient. Explain to the patient that you are interested in providing good care, not only for the presenting complaint, but for all aspects of health during the hospital stay. A common complaint among patients is that doctors (1) seem to know little about nutrition; (2) favor pharmaceutical prescriptions over dietary interventions; and (3) underestimate patients' interest in nutrition and ability to change. Patients appreciate a doctor who helps them in this area, even if that help consists only of a special diet order and a referral to a knowledgeable dietitian. Patients are barraged by dietary messages of all kinds, from fad diet books to advertising claims. You can help them find their way through the thicket of information and misinformation.
Studies suggest that clinicians have the most success in helping patients modify diet, exercise, or smoking habits when they elicit and acknowledge patients' concerns, support their efforts to change, offer choices about treatment options, and provide relevant information-all while minimizing pressure and control.7 An authoritarian finger-wagging approach is likely to lead to rebellion, avoidance, or behavior changes that are only short-lived.8
For patients on medication, it is important to point out that medications work more effectively when combined with the diet prescribed. Poor food choices can negate the effect of medications. For example, foods high in sodium oppose the effects of diuretic medications, while eating foods high in saturated fat (eg, meat, eggs, and dairy products) oppose the benefits of statins. Many frequently prescribed medications designed for common ailments have additional benefits for patients. These include the anti-inflammatory benefits of statins9; the benefits of antidiabetic medications on endothelial dysfunction10; and the ability of ACE inhibitors and angiotensin receptor blocking drugs to significantly reduce the risk for type 2 diabetes.11 However, diets high in saturated fat and low in protective fiber and antioxidants can do the opposite by increasing inflammation,12 causing endothelial dysfunction13 and increasing the risk for type 2 diabetes.
At outpatient visits, it is useful to ask the patient about his or her diet, just as you would about smoking. A dietitian can be extremely helpful with follow-up.
Encourage an optimal diet. Diet studies show that patients sometimes follow their doctors' orders and sometimes do not, but the more significant the changes are that their doctors recommend, the more changes patients actually accomplish.14 If a doctor recommends as close to an optimal diet as possible, the likelihood of patients making at least some healthful changes is higher than if the doctor recommends only minor changes.
A contrary view is that, for many patients, recommended diet changes may be more effective if they are gradual, stepwise,15 and communicated with the understanding that perfection is not expected. This view is common among clinicians, but is at odds with clinical experience with other types of lifestyle changes, such as smoking cessation or substance abuse treatment, in which case flexibility often leads to failure.
A reasonable solution is to prescribe an optimal diet, while avoiding any semblance of moralizing when patients have lapses. It should be recognized that guilt and secrecy often characterize dietary behavior. A physician can coach patients through the routine difficulties of diet change, while helping patients set aside guilt and blame.
Give the patient a clear path to follow. It is easy to give vague advice about "eating right" or "trying to cut back on calories," but it is much more helpful to provide the patient with clear expectations and a specific diet plan. The receipt of a physician's advice to change diet and exercise habits strongly predicts attempts by patients to actually initiate and follow through with these changes.16 On the other hand, failure to communicate the purpose of treatment has been linked to noncompliance with therapeutic regimens. Compliance improves when physicians have better communication skills and when patients feel that they have more information and are actively participating in treatment planning.17 Most patients need to hear a health message several times before putting the new information into practice.4
Many patients are new to preparing healthful meals. They appreciate referrals to books, Web sites, health-oriented grocery stores, cooking classes, and supportive organizations. This volume provides those tools. The patient education pages are designed to be photo enlarged and given to patients. Dietitians also provide detailed and practical information. Hospital dietary or patient education departments may have nutrition or cooking classes, or can be encouraged to do so.
Welcome resistance. Mental health professionals know that when patients express resistance to change, it does not mean they are unwilling to change; it means they are expressing their concerns along the way. Many physicians misinterpret resistance as opposition, when, in reality, it is simply a way to discuss the challenges raised by the diet change. So when a patient says, "I don't like to cook," it is an opportunity for a dietitian to think through healthy simple meals or restaurant choices. A patient who says he could never give up this or that unhealthy food is showing a need for healthful alternatives. Resistance is a predictable stage in the process of change.
Clinicians often misjudge their patients' motivation.18 Many patients are far more motivated than their caregivers give them credit for. Although behavior change is an inexact science, change can occur through successive approximations of desired behaviors. Physicians can help by taking an interest in nutrition, by recognizing that patients' resistance is to be expected but is rarely deep-seated, and by providing a supportive relationship.
Provide healthful basic diet orders. If a special diet is not ordered, patients will be provided a standard hospital diet. However, a special diet can provide an opportunity to introduce healthful habits, albeit briefly.
To tackle patients' diet-related health problems, the most broadly applicable diet orders, and the orders recommended unless other considerations apply, are as follows:
- Vegetarian diet, low-fat, non-dairy.
- Dietetic consultation.
Although the dietary regimen may sound more demanding than the patient may need, it has been shown to be as acceptable to patients as other therapeutic diets.19,20 It is also the only dietary approach that removes all cholesterol and animal fat from the patient's diet. Evidence has shown this type of diet to be more effective for metabolic control, compared with other diets (see chapters on Coronary Heart Disease, Hyperlipidemia, Diabetes, Hypertension, and Obesity). Low-fat, vegetarian diets allow for weight reduction without a specific calorie restriction. This diet order will allow the patient to try out new foods and new tastes, without having to do any of the preparation.
Generally speaking, there are no contraindications to such orders. All hospitals are equipped to carry them out. However, some patients need additional orders, such as a sodium restriction for hypertension or a gluten-free diet for celiac disease.
Involve the family. After discharge, the family can either support or derail the patient's newfound eating habits. Ideally, they will serve as allies in the healing process. They are also at risk of the same diet-related problems the patient is displaying. With a single set of diet orders and dietetic follow-up, you can help them all.
4. Blackburn GL. Teaching, learning, doing: best practices in education. Am J Clin Nutr. 2005;82(1 Suppl):218S-221S.
5. National Heart, Lung, and Blood Institute. Nutrition Curriculum Guide for Training Physicians. Washington, D.C.: National Institutes of Health, 2002.
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8. Williams GC, Quill TE, Deci EL, Ryan RM. "The facts concerning the recent carnival of smoking in Connecticut" and elsewhere. Ann Intern Med. 1991 Jul 1;115(1):59-63.
9. Arnaud C, Burger F, Steffens S, et al. Statins reduce interleukin-6-induced C-reactive protein in human hepatocytes: new evidence for direct antiinflammatory effects of statins. Arterioscler Thromb Vasc Biol. 2005;25:1231-1236.
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14. Barnard ND, Akhtar A, Nicholson A. Factors that facilitate compliance to lower fat intake. Arch Fam Med. 1995;4:153-158.
15. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics. 1998 Sep;102(3):E29.
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19. Barnard ND, Scherwitz LW, Ornish D. Adherence and acceptability of a low-fat, vegetarian diet among patients with cardiac disease. J Cardiopulm Rehab. 1992;12:423-431.
20. Barnard ND, Scialli AR, Turner-McGrievy GM, Lanou AJ. Acceptability of a very-low-fat, vegan diet compares favorably to a more moderate low-fat diet in a randomized, controlled trial. J Cardiopulm Rehab. 2004;24:229-235.