Dietary Counseling

Definition

Dietary counseling is individualized nutritional care and advice for modifying eating habits. It includes patient education and meal planning and can help prevent or treat nutrition-related illnesses. Dietary counseling for chronic diseases is sometimes called medical nutrition therapy (MNT).

Purpose

Dietary counseling that includes education, motivation, and meal planning geared to the individual is most effective for engaging active patient participation. Individualized dietary counseling can provide patients with important insights into food-related illnesses and education regarding how various macronutrients (proteins, carbohydrates, fats) and alcohol affect obesity and illness. Dietary counselors are also concerned with the intake of micronutrients, especially vitamins and minerals. Intakes of certain vitamins and minerals that are too low or too high can lead to a nutrient deficiency or nutrient toxicity, respectively. Dietary counseling may be tailored to the needs of patients diagnosed with specific conditions. It can also help reduce complications and/or side effects of treatments and improve general well-being.

Although dietary counseling is most often used to treat obesity and obesity-related conditions, as well as conditions such as diabetes and eating disorders, it can be useful for a wide range of circumstances. For example, hospice agencies routinely provide dietary counseling for their patients. The U.S. Preventive Services Task Force recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other risk factors for cardiovascular and other diet-related chronic diseases. This intensive counseling may be provided by primary care physicians or through referrals to other specialists such as registered dietitians.

Precautions

Dietary counseling—whether provided by a registered dietitian (RD), a nutritionist, a physician, or other healthcare provider—has consistently been shown to be much more effective when it is tailored to the individual. “One size fits all” approaches to dietary counseling, such as are sometimes offered by commercial weight-loss programs and meal plans, are rarely effective for permanently modifying dietary habits. Furthermore, dietary counseling that is effective with one group of people may be less effective with other groups, especially underserved or economically disadvantaged populations or clients with different cultural beliefs and practices. Age, gender, health status, and various psychological factors also affect how dietary counseling should be pursued with different individuals.

Description

There are numerous goals that must be considered when planning appropriate dietary counseling:

Resources

Dietary counselors often use the dietary reference intakes (DRIs) developed by the U.S. Department of Agriculture as a guide for macronutrient and micronutrient recommendations. The DRIs also include safe upper intake limits for each nutrient. The guidelines provided by the National Cholesterol Education Program are often followed for achieving and maintaining optimal or satisfactory blood lipid levels (total cholesterol, low-density lipoproteins [LDL], high-density lipoproteins [HDL], and triglycerides).

Both dietary counselors and self-counseling individuals utilize various other U.S. Government sources, including the Dietary Guidelines for Americans, 2015 and Healthy People 2020. The Guidelines include 23 key recommendations for choosing an overall healthy diet, as well as six additional key recommendations for specific populations such as pregnant women. The three major goals of the Guidelines are:

Approaches

Dietary counseling that is tailored to individual needs and tastes is more helpful and appropriate than general dietary advice. However, the best ways to encourage patients to follow dietary recommendations and elicit beneficial changes are often unclear. Positive feedback or implementation of a reward system helps some patients comply with dietary advice. It is often easier to introduce new behaviors than to eliminate established ones. For example, recommending that a patient start exercising regularly for weight loss may be more effective than trying to make dramatic changes in current dietary habits. Multiple simultaneous changes may be easier than a single behavior change, since multiple smaller changes can yield faster, more perceptible results. Dietary counseling should stress that lifestyle changes are not an all-or-none phenomenon and that clients should not give up because of setbacks. Counselors should stress the importance of persistence, since behavioral studies have shown that lifestyle changes are often characterized by abrupt forward and backward cycles, as well as periods of spiraling and stasis. Finally, prioritized goals are a critical part of dietary counseling, as is ongoing assessment of progress.

The transtheoretical (stages of change) model is one of the most popular models for changing health behaviors. This model 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 skill training and advice at different stages and has shown promising results for dietary modifications.

Cognitive-behavioral strategies are also used in dietary counseling. In cognitive-behavioral therapy (CBT), the counselor interacts with patients as individuals; conveys interest, understanding, and acceptance; and provides ample opportunity for patients to express themselves. The counselor identifies the patient's readiness to change behavior, using empathy to identify less desirable dietary practices, and helps the patient recognize circumstances and scenarios that contribute to the undesirable behaviors. Next, the patient must come to understand and accept the need for changing behaviors that may be linked to stressful situations, work, family, economics, education, social, and various other factors. The counselor must then help patients develop independence and self-motivation to overcome inertia and make ordinary daily efforts. Finally, the counselor must help patients handle resistance to change and deal with recidivism.

Excess weight is a significant problem among American children and adolescents, and dietary counseling is one component of a multi-faceted intervention that includes promoting physical activity, parent training and modeling, behavioral counseling, and nutrition education. Family-based programs are geared toward children ages 5 to 12, and school-based programs are usually aimed at teens.

Availability

In the United States, the Affordable Care Act of 2010 (ACA) and new regulations have required that new health plans offer obesity screening and prevention and control of obesity-related diseases, as well as dietary counseling from physicians for promoting sustained weight loss, all without copayments. It was assumed that these provisions would significantly increase utilization of dietary counseling. However, as of 2018, relatively few physicians referred their patients for dietary counseling. For example, one study found that only about 15% of obese patients received recommendations for dietary counseling. Among overweight and obese patients enrolled in the Cholesterol Education and Research Trial, only about 15%–20% were referred for nutrition counseling. For the ACA provisions to have a significant impact, physicians need to take the initiative and either perform dietary counseling themselves or refer their patients for counseling.

MNT is nutritional diagnostic, therapeutic, and counseling services for disease management provided by RDs. Medicare, the U.S. healthcare program for seniors, has covered outpatient MNT for beneficiaries with diabetes, chronic renal insufficiency/end-stage renal disease, and kidney transplants. Many private insurance companies also cover MNT for various diseases and conditions. Patients generally receive three hours of MNT in the first year and two hours in subsequent years. Medicare has covered additional hours when a diagnosis, condition, or treatment changes.

Preparation

Selecting an appropriate approach to dietary counseling first requires a comprehensive assessment of the individual's health, nutrition, lifestyle, and goals:

KEY TERMS
Body mass index (BMI)—
A measure of body fat; the ratio of weight in kilograms to the square of height in meters.
Cholesterol—
A fat-soluble steroid alcohol found in animal fats and oils and produced in the body from saturated fats; high blood levels of low-density lipoprotein (LDL) or “bad” cholesterol increase the risk of heart disease, whereas high-density lipoprotein (HDL) or “good” cholesterol may protect against cardiovascular disease.
Cognitive-behavioral therapy (CBT)—
A treatment that identifies negative thoughts and behaviors and helps develop more positive approaches.
Dietary Approaches to StopHypertension (DASH)—
A flexible, balanced eating plan to help lower blood pressure.
Dietary assessment—
An analysis of food and nutrients consumed over a particular time period, including food records, dietary recall, food frequency questionnaires, and diet histories.
Dietary reference intake (DRI)—
A system of nutritional recommendations used by the Institute of Medicine of the U.S. National Academy of Sciences and the U.S. Department of Agriculture.
Hyperlipidemia—
Excess fats or lipids in the blood.
Macronutrients—
Carbohydrates, proteins, and fat that are required in relatively high amounts in the diet.
Medical nutrition therapy (MNT)—
Dietary counseling for treating chronic disease.
Micronutrients—
Nutrients, such as vitamins and minerals, that are required in minute amounts for growth and health.
Obesity—
Excessive weight due to accumulation of fat; usually defined as a body mass index of 30 or above or body weight greater than 30% above normal on standard height-weight tables.
Overweight—
A body mass index between 25 and 30.
Registered dietitian (RD)—
A health professional with at least a bachelor's degree in nutrition who has undergone practical training and is legally registered.
Saturated fat—
Hydrogenated fat; fat molecules that contain only single bonds, especially animal fats.
Trans fat—
Fat that is produced by hydrogenation during food processing; trans fats increase bad cholesterol and decrease good cholesterol.
Triglycerides—
Neutral fats; lipids formed from glycerol and fatty acids that circulate in the blood as lipoprotein. An elevated triglyceride level is a risk factor for diabetes.

There are various dietary assessment tools. Among the most common are food records, dietary recall, food frequency questionnaires, diet histories, and biochemical indices. A scientific assessment of nutritional status combines information from clinical evaluations, biochemical tests, and dietary assessment. The clinical evaluation includes anthropometric measurements—height, weight, body mass index (BMI), and percentage body fat as determined by the skin-fold test or hydrostatic weighing. A clinical evaluation may also include any signs of nutrient deficiencies in the mouth, skin, eyes, or nails. Biochemical tests provide a comprehensive picture of the patient's current nutritional status and relative risk factors.

Aftercare

Permanent modifications in dietary habits are the desired end-product of dietary counseling and are ultimately the responsibility of the patient. Minimal weight loss, or none at all, or minimal reduction in serum lipids is usually due to the patient's failure to comply with recommendations and instructions.

Complications

Over the long term, behavior changes, such as making healthier food choices and increasing physical activity, are much more successful—and more pleasurable—than dieting. Furthermore, most people cannot permanently follow a restrictive diet, so their food intake and weight eventually increase unless energy expenditure is increased through exercise or other means. Dieting can encourage “yo-yo” weight loss and gain, in which, typically, more weight is gained back than was initially lost. In addition, regained weight is often even less favorable because it may have a higher fat-to-muscle ratio. Because muscle is metabolically active tissue, it utilizes more calories even while at rest. This is only one of the reasons why exercise is so important for maintaining body weight.

Results

Results of dietary counseling vary greatly and depend on a number of factors, especially the patient's commitment to set goals. In general, the success of dietary counseling is limited, particularly with regard to weight loss and control. Nevertheless, studies have found that MNT improves patient outcomes and quality of life and lowers healthcare costs for those with or at risk for chronic diet-related conditions and illnesses.

Healthcare team roles

Dietary counseling is generally performed by RDs and registered dietary technicians, who have sufficient knowledge and training to accurately assess the nutritional adequacy of a patient's diet. Although some RDs call themselves nutritionist, the term “nutritionist” is not regulated by law in some states, so that anyone can call herself or himself a nutritionist. Some physicians with adequate backgrounds specialize in nutritional counseling. However, medical school training in nutrition is limited, and physicians' visits are usually too brief to include nutritional counseling.

RDs and dietary technicians perform counseling in both clinics and community and public health settings. MNT is usually performed by an RD as part of a medical team in a hospital, clinic, health maintenance organization, or other healthcare facility or in private practice. RDs also advocate for funding and the inclusion of dietary counseling in programs and policies at all levels and play an important role in researching improvements in dietary counseling.

QUESTIONS TO ASK YOUR DOCTOR

See also Academy of Nutrition and Dietetics ; Adult nutrition ; American Heart Association No-Fad Diet ; Body mass index ; Childhood nutrition ; Dietary guidelines ; Dietary reference intakes (DRIs) ; Infant nutrition ; MyPlate ; Obesity ; Senior nutrition .

Resources

BOOKS

King, Kathy. The Entrepreneurial Nutritionist. 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott William & Wilkins, 2010.

Lee, Robert D., and David C. Nieman. Nutritional Assessment. 6th ed. New York: McGraw-Hill Science/Engineering/Math, 2013.

Samour, Patricia Queen, and Kathy King. Essentials of Pediatric Nutrition. 7th ed. Sudbury, MA: Jones & Bartlett Learning, 2013.

PERIODICALS

Appelhans, Bradley M., et al. “Time to Abandon the Notion of Personal Choice in Dietary Counseling for Obesity?” Journal of the American Dietetic Association 111, no. 8 (August 2011): 1130–36.

Colleran, Heather L., and Cheryl A. Lovelady. “Use of MyPyramid Menu Planner for Moms in a Weight-Loss Intervention during Lactation.” Journal of the Academy of Nutrition and Dietetics 112, no. 4 (April 2012): 553–58.

Louzada, Maria Laura da Costa, et al. “Long-term Effectiveness of Maternal Dietary Counseling in a Low-Income Population: A Randomized Field Trial.” Pediatrics 129, no. 6 (June 2012): e1477–84.

Masheb, Robin M., Carlos M. Grilo, and Barbara J. Rolls. “A Randomized Controlled Trial for Obesity and Binge Eating Disorder: Low-Energy-Density Dietary Counseling and Cognitive-Behavioral Therapy.” Behaviour Research and Therapy 49, no. 12 (December 2011): 821–29.

Niinikoski, Harri, et al. “Effect of Repeated Dietary Counseling on Serum Lipoproteins from Infancy to Adulthood.” Pediatrics 129, no. 3 (March 2012): e704–13.

WEBSITES

Academy of Nutrition and Dietetics. “What Services Do Registered Dietary Nutritionists Provide?” http://www.eatrightri.org/wp-content/uploads/2014/12/Value-and-Services-of-the-RDN.pdf (accessed March 23, 2018).

Franklin, Barry A. “Counseling Patients to Favorably Modify Dietary and Physical Activity Practices.” Professional Heart Daily, July 12, 2010. https://professional.heart.org/professional/ScienceNews/UCM_432570_Counseling-Patients-to-Favorably-Modify-Dietary-and-Physical-Activity-Practices.jsp (accessed May 1, 2018).

MedicineNet. “Medical Definition of the National Cholesterol Education Program.” https://www.medicinenet.com/script/main/art.asp?articlekey=24145 (accessed March 23, 2018).

National Heart, Lung, and Blood Institute. “DASH Eating Plan.” National Institutes of Health. http://www.nhlbi.nih.gov/health/health-topics/topics/dash (accessed March 25, 2018).

U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. “USDA National Nutrient Database for Standard Reference.” http://www.ars.usda.gov/Services/docs.htm?docid=8964 (accessed April 2, 2018).

U.S. Department of Agriculture. “MyPlate.” Choose MyPlate.gov . http://www.choosemyplate.gov (accessed March 25, 2018).

U.S. Department of Agriculture, National Agricultural Library. “DRI Tables and Application Reports.” Food and Nutrition Information Center. https://www.nal.usda.gov/fnic/dri-tables-and-application-reports (accessed March 15, 2018).

U.S. Department of Health and Human Services. Healthy People.gov . http://www.healthypeople.gov/2020/default.aspx (accessed March 25, 2018).

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. December 2015. https://health.gov/dietaryguidelines/2015/guidelines (accessed March 15, 2018).

ORGANIZATIONS

Academy of Nutrition and Dietetics, 120 South Riverside Plz., Ste. 2000, Chicago, IL, 60606-6995, (312) 899-0040, (800) 877-1600, amacmunn@eatright.org, http://www.eatright.org .

Food and Nutrition Information Center, National Agricultural Library, 10301 Baltimore Ave., Rm. 105, Beltsville, MD, 20705, (301) 504-5414, Fax: (301) 504-6409, fnic@ars.usda.gov, http://fnic.nal.usda.gov .

International Food Information Council Foundation, 1100 Connecticut Ave., NW Ste. 430, Washington, DC, 20036, (202) 296-6540, info@foodinsight.org, http://www.foodinsight.org .

U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC, 20201, (877) 696-6775, http://www.hhs.gov .

Crystal Heather Kaczkowski, MSc
Revised by Margaret Alic, PhD

  This information is not a tool for self-diagnosis or a substitute for professional care.