"I can't discipline myself, but I don't want to disappoint you" - Nutrition Medicine (Part III)

In this episode, Nate and Justin discuss the powerful technique of motivational interviewing to figure out how to help Tina inch closer towards her own goals.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Taking a Dietary History
3. Chapter 2: Motivational Interviewing
4. Conclusion

=== Learning Points ===

1. Changes in food habits and eating patterns can mean breaking patterns that have been ingrained over lifetimes
2. Fear and shame are not effective motivators, and so should not be used to persuade patients to change behaviors. Instead, emphasize the positive benefits that are present in the short term.
3. Taking a detailed hour-by-hour dietary history can uncover additional opportunities to change eating patterns. Be sure to ask patients how they prepare foods, dress foods with condiments, and so forth.
4. Empowering patients and removing judgment is critical. Motivational interviewing is a technique that frames change in an actionable, self-empowering manner, while uncovering reasons for changing eating patterns that are not solely weight-centered.
5. In addition to achieving weight loss goals, changing nutrition is an opportunity to help patients get excited about other health goals, such as improving their blood pressure or reducing their risk of developing diabetes.

=== Our Expert(s) ===

Dr. Justin Charles is a graduate of the Yale Primary Care Internal Medicine Residency Program.

His clinical interests are in Lifestyle Medicine, the use of evidence-based lifestyle interventions to not only prevent, but treat and reverse chronic disease from a root cause perspective. He has received training in Plant-Based Nutrition through the T. Colin Campbell Center for Nutrition Studies and eCornell, as well as Dr. John McDougall's Starch Solution Certification Course. 

=== References ===

Arab L, Tseng CH, Ang A, Jardack P. Validity of a multipass, web-based, 24-hour self-administered recall for assessment of total energy intake in blacks and whites. Am J Epidemiol. 2011 Dec 1;174(11):1256-65. doi: 10.1093/aje/kwr224. Epub 2011 Oct 20. PMID: 22021561; PMCID: PMC3224251.

=== Recommended Reading ===

1. Moshfegh, A.J., Rhodes, D.G., Baer, D.J., Murayi, T., Clemens, J.C., Rumpler, W.V., Paul, D.R., Sebastian, R.S., Kuczynski, K.J., Ingwersen, L.A., Staples, R.C., Cleveland, L.E. The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes. A J Clin Nutr. 2008;88:324-332
2. Johnston CA, Stevens BE. Motivational Interviewing in the Health Care Setting. Am J Lifestyle Med. 2013;7(4):246-249. doi:10.1177/1559827613485923
3. Hauser ME, McMacken M, Lim A, Shetty P. Nutrition—An Evidence-Based, Practical Approach to Chronic Disease Prevention and Treatment. Fam Pract. 2022;71((1 Suppl Lifestyle)). doi:10.12788/jfp.0292

*For more reading recommendations, check out our transcript!

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Nate Wood
Producers: Nate Wood, Helen Cai, August Allocco
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Patrick Patrikios, pATCHES, Myuu, VYEN, Reed Mathis, 

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

[00:00:00] Nate: hi, everyone. Welcome to primary care pearls. A podcast made by learners for learners, and most importantly led by our patients' stories today. We're continuing our discussion on food by focusing on nutrition counseling in the clinic. 

[00:00:14] Justin: and instead of us doing what we usually do, which is saying you should change this, here's how you should do it. We flip that and say, what would you like to change? And how do you think you'll be successful doing it mirroring certain things back to them to slowly nudge them along to a health outcome goal that's in line with what we both want.

[00:00:33] Nate: During our discussion today, we'll be joined by a patient, struggling with nutrition.

[00:00:37] Tina: Hi dr. Justin, this is Tina Westin

[00:00:43] Nate: we'll learn more about her experience with different eating patterns, her personal motivations for changing her nutrition plan and the emotional struggles she has faced. We'll also be joined by a resident expert from the Yale school of medicine. 

[00:00:57] Justin: I'm Justin Charles. I'm one of the residents in the Yale primary care program, really passionate, interested about nutrition and lifestyle medicine

[00:01:06] and excited to talk to Tina today about nutrition and her journey. 

[00:01:11] Nate: Our discussion today is part three of a four part series that will explore strategies for the primary care provider to help patients eat more healthfully regardless of their personal circumstances.

[00:01:22] And I know you all know me by now. My name's Nate wood, and I'll be your host for this episode. We hope that through this discussion, you'll feel more comfortable engaging your patients in comprehensive discussions about the foods they eat and how to help them make healthier choices. Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice.

[00:01:46] If you or a loved one is suffering from anything discussed in today's. Please be sure to discuss it with a medical expert. All right. Let's get started

Chapter 1: Starting the Conversation and Taking a Dietary History

[00:01:56] Nate: During the first two episodes in this series, we discussed Tina's background with food and the struggles she's experienced in changing the way that she eats while simultaneously working to find more joy in her life. If you missed it, I highly encourage you to check it out. Something Tina mentioned in our last episode is how much of the way that she thinks about food was developed in her childhood. And for many of us too, this is the. So keeping that in mind as providers, how can we help our patients change their behaviors? Like their eating patterns that they've been doing their whole lives.

[00:02:32] Justin: Underlying lifestyle changes is really some sense of spirituality and that doesn't have to be religion or God, it can really be anything that gives you a sense of meaning and purpose and love and the universe or what you want to call it. And not. Super hippie dippie and out there, but really having that sense of self.

[00:02:51] And I'm not going to lose weight because the doctor told me I'm going to lose weight because I deserve it because I deserve to feel good. Like other people feel good and I'm worth it. ' cause if, if fear and shame could motivate people to be healthy, there would be no chronic disease epidemic. There would be no, everyone has diabetes and heart disease and it's killing 500,000 people plus a year. But, but that's not the case, fear and shame and wagging our fingers. Doesn't motivate people. We need to help them cue into their own motivations and do it in a way where they. Except themselves. And that's what allows them to change and be a better version of themselves.

[00:03:30] Tina: I don't know. I got to try to do better. I know I had to try to do better. I am going to do better.

[00:03:36] Nate: All right. So the patient comes into your office and you've decided to discuss nutrition with them. 

[00:03:42] They seem engaged. You're doing this motivational interviewing and finding out more about them, what their goals are and what steps they think they can change in order to become a healthier version of themselves. Of course, with your guidance. My guess, is that in the data acquiring phase of that discussion, you may take a dietary history or do some dietary counseling. Um, so could you just break down for us quickly? Like what are the key steps of taking a dietary history that is both quick, because like you said, we are short on time, but also comprehensive.

[00:04:17] Justin: I'm so glad you bring that up. People can cherry pick all day long and tell you big generalities and tell you a bunch of stuff that's probably inaccurate and not helpful. So the 24 hour dietary recall is a really effective way to get a dietary history. The way I usually started is say from when you woke up yesterday to when you went to bed yesterday, tell me everything you ate and drank starting at the beginning. Then I go through that. I let them basically say that I'll give them a couple of cues. What was next? What was next until we get to the end of the day. That's the first pass. If you stop there, you'll get at least a decent amount of information. And that usually is pretty quick. You can even give patients a handout and have them write it down while they're being roomed. If you want to be a little more thorough while still being quick, there's a couple of extra steps. You want to be queuing the patient a lot because there's a lot of things they forget either willfully or accident. So focusing, um, on the forgotten food list. So there's nine categories of food. People often forget non alcoholic beverages, alcoholic, beverages, sweets, savory snacks, fruits, vegetables, cheese, breads, and rolls.

[00:05:31] Those are things that people say, oh yeah, you know, he did have that banana at this point. Or I did have that beer with dinner that they don't think is really a food. So they don't mention it. Oh, I had a sandwich. What was on the sandwich? How many slices of each of the different things were on it? What kind of bread? I had coffee. Okay. What did you put in your coffee? Oh, I put eight sugars and a gallon of cream. Okay. Well maybe that's why your diabetes is out of control instead of, oh, they drank coffee and you find so many hidden gems in that asking people how they prepare their food. If it's baked, if it's fried, if it's fried and slathered in cheese and gravy, as sometimes it is really getting that detailed review and that doesn't take long either. I had eggs for breakfast. How many eggs to, how did you prepare them fried with butter or oil? butter took what next two or three seconds. We have it on tape. We could record meaning exactly how much. Um, so that's getting a good amount of detail and that's really where we get so much of the information on what people can change.

[00:06:33] Maybe put two sugars in your coffee instead of of. four. And then the last step is final pass. going over it again, saying, did you have like any little small snacks or any new? Oh yeah. Well, I keep a granola bar in my desk and I I must have had two granola bars over the course of the day that I slowly picked at. So then you get those hidden items that are in there. And now you've gone through a couple of times and you've got a pretty comprehensive idea of what someone ate in the day. And then I like to ask them, is this a typical day for you? Oh no. This was the healthiest I've eaten in a while. This actually was pretty unhealthy.

[00:07:11] We had a holiday party at work. Most of the time I don't eat like that. And then you can ask some other questions. What else do you eat on a typical day? I like to ask. How often do you go out to eat versus cook, um, who cooks in the house? Who does grocery shopping? Where do you grocery shop a little bit more detailed because those, again are points that you can make changes on.

[00:07:32] If someone does not cook giving them recipes is really not a good idea. If their wife, their husband, their children, their parents cook involving them can be really helpful. So, so all of these areas of information are not extraneous, just so I can fill out some template that I made. It's all places that we can make tangible differences, and we can invite patients to make differences on. So it's very important to know what we're working with and be objective. 

[00:08:00] Nate: And I think this plays out in real life too. You know, we heard tina admit what she eats on a daily basis. Let's hear what she has. to say. 

[00:08:11] Justin: I know that you also work around food a lot. I do. How does that play a role in. Your food decisions and kind of your relationship with food. 

[00:08:22] Tina: Okay. Um, at work you can basically eat snacks all day long because you start seeing, they have the same exact food every day. So after a while that gets born, but the snacks change.

[00:08:34] So those are the things that changed the most is the snacks to novelty. Late today, we put out a bunch of candies. So I would say, I should have a Twix. Then I say, you know what, I'm going to get an ice cream for that ice cream tasted good. So I went and got another ice cream. So that was my day. 

[00:08:50] Justin: Well, if I just ask her what she ate for lunch yesterday, she might say, nah, you know, I skipped lunch and I write to no lunch. And I didn't ask what was between breakfast and dinner. I missed ice cream and ice cream and snack and cookie and pretzels. And that's really important. And I might give her really bad nutrition advice if I said. well, you ate a healthy breakfast. you had a healthy dinner. you skipped lunch. I don't know where all those calories are coming from.

[00:09:16] It must be genetic. That's probably why you're gaining weight. Instead of aha. We found it. We found all of those hidden gems that are in there, and that's what an effective dietary history does It allows us to really get a glimpse into those hour by hour. Meal decisions and snack decisions that our patients make 

[00:09:35] Nate: you know, you brought up something that I've seen play out over and over again, which is this additives in the coffees man. Like I had one patient come in and she wasn't eating breakfast or lunch. She was just eating dinner. Couldn't lose weight. Otherwise she was just having two cups of coffee a day detail in review is so important because in this patient we found out she was having two extra large Duncan coffees a day with extra cream. And like you said, literally I think eight sugars. And so she was having over 1200 calories a day just in her quote, unquote coffee the case of the hidden calories cracks.

[00:10:05] Okay, so let's take a quick pause here, just to summarize kind of this method for taking a 24 hour dietary recall because it seems so simple. Step one, like Justin said is the first pass where you just say, Hey. Tell me everything that you ate and drank yesterday. But of course it's not just that easy.

[00:10:25] Lots of studies have shown that even with proper technique, there's quite a bit of under reporting with 24 hour dietary recall. According to the NIHS national cancer Institute, 24 hour estimates of energy intake in Western populations like ours generally underestimate the true intake by anywhere from three to 34%.

[00:10:45] So of course that's a really wide range, but using the multiple past method, kind of narrows that range a little bit with under reporting, being somewhere between 12 and 23%. so even though this is an imperfect tool, we still like to use it because it's so easy and accessible for providers. And doesn't take a lot of time for patients to engage in it either.

[00:11:09] And this multiple pass method does improve the quality of data that we get from it. So keeping that in mind, the first pass done, you just ask the patient to kind of recollect everything that they ate or drank from beginning to end yesterday, starting with when they woke up and ending with when they went to.

[00:11:27] Then it's time for the deep dive. You go in and ask about any forgotten foods. So some of those common things that Justin mentioned, and this is not just a random list. This is a list of foods that was developed after nearly a hundred years of research by the

[00:11:52] U S D a and they include beverages, alcoholic, beverages, sweets, savory snacks, fruits, vegetables, cheese, and breads, and roll. The third step is collecting eating times and meal names, which may seem like a waste of time, but it really does help patients think through at every point during the day, what they were eating and allows you to go through and get more detail in a systematic and organized fashion.

[00:12:08] The fourth step is the detail cycle where you collect more food details and especially amounts. How many eggs did you eat? How many slices of bread or pieces of meat or slices of cheese in the sandwich, things like that. And then you take a, a further dive into asking more about how they prepared the foods.

[00:12:27] So was the sandwich cold or, you know, maybe was it fried some butter on a griddle, the coffee, how much cream, how much sugar? Did you take it plain? Was there any flavoring added and then like Justin mentioned the eggs, how many butter oil fried? All of this information is really important if you're trying to find those hidden calories.

[00:12:47] And then the last part is the final pass. So this is kind of the last chance to really get the patient thinking about everything that they ate yesterday. You know, by this point, they've given a really detailed review of what they ate and drank, but it's nice to ask them just one more time, if there was anything else and you'd be surprised how many extra calories you can catch with this simple final step.

[00:13:08] So, again, those steps for this multiple pass method and evidence based way of taking a 24 hour dietary recall, the first is the first pass or the quick list. The second step, those forgotten foods, the third step asking about the time and occasion. The fourth step is that detail cycle and that final or fifth step is the final pass or the final probe.

[00:13:31] As time allows, there are some more questions that you can kind of ask to get a better sense of their social situation and kind of how they come to eat the things that they eat. So you can say, okay, we just talked about all the things that you ate in the past 24 hours. Is this a. Typical 24 hours for you, or was it different in some way, and then digging deeper into their habits, you know, who does the cooking at home? How often do you eat out? Where do you like to eat out? Who does the grocery shopping? Where do you grocery shopping? All of these questions help you get a better picture of how your patients decide on what to eat on a day to day basis and can help guide your dietary counseling by knowing some of their limit. and the whole goal here is not just to acquire this data, but then to put it into practice, you know, after we analyze it, how are we going to make dietary recommendations for our patients? And as it turns out, it's a lot less about talking and telling and more about listening and inspiring. 

Chapter 2: Motivational Interviewing

[00:14:30] Nate: So for this next part of our discussion, we're gonna move into describing one of the most impactful methods that we as providers can employ in helping our patients to positively impact their diet.

[00:14:42] Justin: so what is it like when someone tells you, Hey, you should cut back on that or you shouldn't eat that, or you should eat that. What's your reaction to that? 

[00:14:49] Tina: Like anybody else, like a person in my life, like my boyfriend, he'll say, oh, you need to lose some weight. You're so fat, you know, this and this and that lose your stomach. But if you said it, the doctor, then I look at it as, you know, you're trying to help me, God, anybody else's being critical.

[00:15:04] Justin: Got it. So there's that critical aspect of, you know, is this person judging me versus being in an environment where someone's trying to help you? 

[00:15:13] Tina: Yeah. Like even when I see you at work and you're like, you know, don't eat this or eat that, eat that. So on those days I don't eat that junk because I saw you and you were making good food choices and I watched you.

[00:15:23] So then it makes me feel like, Hey, let me try this for this day. Then I do it the next day. And then, Hey, what did I last time I see him.

[00:15:30] Justin: So you're telling me that I should just come to the cafeteria to check up on 

[00:15:33] Tina: the office. Right? It's the pressure. It's just like, you don't want, I don't want to disappoint you.

[00:15:37] I can discipline myself, but I don't want to disappoint you 

[00:15:41] Justin: I'm not going to be offended if I don't do this, but what do you think.

[00:15:46] Is important when primary care doctors or other doctors talk to patients about nutrition, what do you think are some good things that they do that they need to do? And what are some things that we should avoid?

[00:15:57] Tina: I mostly just talked to you about it because a lot of them, like, they don't want to offend you.

[00:16:01] They don't want to say anything. So they just like, Hey, what are you here for? So let's treat that problem. I don't care about how you look, but you always tell me, you know, you can do it. So you talk to me. Acne, you don't make judgment calls on me. You don't say, you know, you could be looking a lot better than what you do.

[00:16:19] You say, this is what you can do to get to where you want to be at. And then, so I let myself down. You never let me down. I let myself down. That's why, when I see you, I get so embarrassed. You know, I get embarrassed. I say the pressure is on me. Like damn, you know, I'm letting him down. I know worried about me.

[00:16:35] I'm worried about you because. I shield the compassion. I feel the, you know, you want me to succeed and then I'm letting myself down and I'm embarrassed when I see you. 

[00:16:45] Justin: Well, and you know, the, the ultimate crux of this is you're not letting me down. I only want you to do this because I care about you and your health. And I know that a lot of times, you know, doctors make it seem like, oh, you need to do this for me, but really. I just care about your health and that's, that's part of my job and I'm helping you do it for you, right.

[00:17:11] Nate: Well, Dr. Charles, so nice. 

[00:17:15] Justin: Patients really value when you hear what they have to say. We are the experts in medicine, patients are the experts in themselves. And we can't forget that. 

[00:17:24] Nate: I think I can just imagine, you know, these other providers she's talking about who just kind of drop in, oh, Hey, I see you're up five pounds.

[00:17:31] You must not have been doing anything. I said, last time, you know, are you still drinking soda stopped doing that? See you in six weeks by, and it's no wonder she doesn't feel comfortable speaking with those providers about nutrition. Right? So what would be the exact opposite of that? 

[00:17:45] Justin: You'd be so surprised when you say, what do you think you could do to improve your health? The really creative things that patients say that you would have never thought of before?

[00:17:57] Nate: I love that. But as we kind of dig here into the nitty gritty and think about how you approach these conversations with your patients, how do you start the discussion with nutrition during an office visit? 

[00:18:08] Justin: The most important thing I find in any conversation with patients hearkens back to what we talk about in geriatrics or in the ICU, what is most important to you?

[00:18:18] And any conversation needs to start there? Otherwise we are not counseling our patients what's in their best interests, We're counseling them. and What's in our best interest and we really missed the boat and people disengage. So we might think that their diabetes is the most important to them or their weight or their A1C.

[00:18:38] What is most important to you about your health? How do you feel about the way you're eating currently? 

[00:18:45] The Thing about motivational interviewing is that you're really making this very patient centered.

[00:18:50] We talk about patient centered care a lot, but you're not saying what you think the patient wants. You're really talking to them. You're trying to figure out what their motivations, what their goals, what makes them tick, what are their barriers in a way that comes from them. And it really helps strengthen the relationship that you have with patients 

[00:19:12] and 

[00:19:12] allows us to have a connection that a lot of other physicians may have missed before.

[00:19:16] Tina: Um, what's gonna meet me, try to get, because I got the shock of my life. When I looked on line today about the, see if anything was on, um, is it, I had a message from my doctor from my chart and it said I'm pre-diabetic. And that I'm about to have that surgery, a surgery on my foot.

[00:19:34] And my sister was like, oh, you're going to probably lose your toe all behind food. Like I could probably, they told me now heal up. So I'm going to lose one of my limbs for food.

[00:19:45] Justin: You are worried about diabetes because your father and your grandfather had diabetes. I want to talk to you about a really effective, the most effective way that we can prevent you from getting diabetes and treat any diabetes that comes later.

[00:19:58] And so I'd like to talk to you about nutrition, is that okay? And then in a no-nonsense way, tell people what ideal is, teach a hundred percent, then meet people where they're at. Say we don't live in a perfect world, but the most ideal diet based on everything that I've learned in my is to eat a plant-based minimally processed, whole food. Plant-based whatever you want to call it, type of diet, the type of results we can see when someone follows that close to a hundred percent our reversal of their diabetes. Almost complete. reducing the risk by over 90% of developing diabetes in the first place, the potential to reverse coronary artery disease, the potential to lose weight meaningfully and keep it off, have better mood, increase your libido, have better blood flow, all of these different things, whatever it is that we can really get you to this optimal place.

[00:20:52] If you're interested in getting there, then I pull back and say, I know that was a lot. Where, where are you at right now? 

[00:21:01] Nate: I think you probably picked up also on this, in, in Tina's discussion, she seemed to be wholly focused on losing weight.

[00:21:10] Tina: I'm going to try it again and try to lose the weight seriously this time. Because when you think about it, I'm trying to be cute, but how cute am I going to be with missing limbs?

[00:21:19] Well, this isn't just a podcast because I said today, I'm going to commit. If I'm out here putting my voice out here, I'm going to like 10 years from now where somebody is gonna be listening to this and say, I wonder where she looks. And I want them to say, you know, I want to find this girl as he was like, let me be older.

[00:21:37] Yes. But I'm going to be also be thinner because there's weight on me makes my feet hurt. So like today I went to DSW to buy shoes, sneakers, and I said, I'm going to start walking every day. Because every day I get up, my feet hurt is because of the weight. It really is because of the way I could always tell when I gained weight because my feet hurt.

[00:21:56] So my excuse for not going out, exercise and walking is my feet hurt. So I'm never going to lose weight unless I like tried to lose like five pounds at least to take some of the pressure off my feet and then start walking. 

[00:22:08] Nate: And this is something we're all too familiar with in the clinic. Right. And that's a great goal for a lot of patients, but it is sometimes the only goal. Right? And I want you to talk more about this also, but I think this goal of improving the quality of our diet and losing weight for folks who need to do that, that can be done at the same time, one in the same with the exact same modality.

[00:22:30] So I'm curious if you could talk a little bit about that, but I also am curious to hear how you think we can get folks to see that, how can we get them amped about disease prevention and improving the quality of the diet and not just losing weight? 

[00:22:44] Justin: Great question. A lot of times we pitch to patients the way that we pitched to other doctors and it doesn't work saying your A1C has started to creep up a little bit.

[00:22:56] Now it's 8.3 and your ASC CVD risk score is 12, which means that you can have a 12% risk of having a heart attack in the next 10 years. So you really need to change your diet. 

[00:23:07] What does that even mean? How am I going to feel next week? I know if I go to Chili's next week that I'm going to feel real good and I'm not going to have a heart attack next week. So I can do this two weeks from now. So we have this whole, let's reduce the risk of negative later in the future. And the best way to get people motivated is to help them increase the positives in the short term, because that's what the food is doing. The food is giving them, making them feel better, make filling that emptiness that's inside them right now today. And we're competing with that. And we have to fight fire with fire when it comes to the weight loss issue. Again, it's really looking at what's important to the patient. Why do they want to lose weight? If they want to lose weight, to be held. There is you're in and helping them see that we can help them be healthy in other ways. And that Wade is an important marker of health, but it is not the only marker of health in those patients. I really try to focus on the process. Let's focus on eating healthy and keeping you healthy. The weight will come off. You don't even need to look at the scale. If you follow this way of eating, you will lose weight.

[00:24:23] Obesity is very complicated. I don't want to make it seem like it's just that easy, but from a patient standpoint, it's a good way to help them focus on the process, not the outcome, which is much more sustainable way to to change behavior. For people who maybe they don't care as much about their health and their prime goal is I want to look good. I know Tina had said that, finding more about why what's important to them.

[00:24:50] We just heard from Tina is practically an advertisement for motivational interviewing. We took that. I want to look good. I want to feel good about myself by losing weight. And if I have diabetes and I need to have an amputation, that's not going to really further my goal. Maybe I should try to lose weight in a way that's going to also help with my diabetes.

[00:25:12] My wonder what we could do. Have you ever heard anything like that before? And bam that's when you get someone engaged and not in a trickery way, but in a way that you're doing it with something they actually care about. And when they're at the cafeteria and thinking about, should I have another ice cream now they're thinking, do I want to lose my toe? And again, fear is a really poor motivator. If all of us were motivated effectively by fear and. shame. No one would be overweight. There would be no diabetes. We'd all be sitting in a circle, singing kumbaya, but, but fear and shame is not a sustainable long-term motivator. 

[00:25:48] Joy is you mentioned a tactic that I think is really important about meeting your patient where they're at, but then developing within them, the motivation I think, and the inspiration to actually make those changes. Because like you said, if you do believe in your patient, and if you walk alongside them on that path, they do have the power to make these huge changes that can really impact their health in a positive way.

[00:26:11] Nate: And so we put a name to that. You mentioned it briefly motivational interviewing, and I'm sure we could spend an entire episode talking about just this, but, um, for those listening, could you help us define what is motivational interviewing and how does it help with dietary counseling? Why is it so important? 

[00:26:27] Justin: So what is the essence of motivational interviewing? It's not a technique. It's a communication style that says patient knows best. They know what they care about. They know what their barriers are. They know what they are willing to do to change it. They know what works for them. And instead of us doing what we usually do, which is saying you should change this, here's how you should do. it. We flip that and say, what would you like to change? And how do you think you'll be successful doing it, mirroring certain things back to them to slowly nudge them along to a health outcome goal.

[00:27:01] That's in line with what we both want. So we're really trying to get elicit their own motivation and interviewing them in a way that gets them in the direction. We want them to go through guiding rather than pushing in order to get them to do something that they themselves know they can do. And again, all of the different techniques with that would be and should be a whole podcast episode in and of itself.

[00:27:27] we think it's going to take so much time, like, oh man, 30 minutes talking to patients, it actually gets to the root of things so much quicker that it can really save you time, especially if you're equipped with those skills, which I think is crucial to any primary care physician, any generalist, any medical professional, really any person.

[00:27:49] it's really just a good style of communication that helps both people get to the goals where they want to be.

Outro

[00:27:54] Nate: and I just like to add that motivational interviewing can be really fun, too, getting to the bottom of some of your patients motivations, the way they like to live their life and then partnering with them on their goals for improving their health is one of the reasons that I went into medicine in the first place. And I can say firsthand, it can be one of the most fulfilling things during a really long day in the clinic. 

[00:28:17] Here are some key takeaways that I took from the episode today and hope you can. before providing nutrition counseling, it's important to take a careful and detailed dietary history with a keen eye for those hidden calories in order to help our patients formulate plans that they are most likely to succeed with registered dietician, nutritionists are experts at this.

[00:28:39] So if the patient's finances allow a referral to one of these professionals can be extremely helpful. If not, this is definitely something that we, as primary care providers should have in our tool belt. Number two motivational interviewing is a communication style that recognizes the patient as the expert on their body and lifestyle, what their motivations are and what their barriers are.

[00:29:03] So getting comfortable with this tool is a crucial part of partnering with patients to work toward their health goals. and number three, many patients often look to nutrition to help them achieve their weight loss goals. But as providers, we should also use that same motivation as an opportunity to help patients get excited about other health goals, like improving their blood pressure or reducing their risk of developing diabetes.

[00:29:30] Be sure to tune in next time, wherever you listen to your podcasts to catch the finale of our four part nutrition series, where we'll discuss some of the external barriers that patients face when trying to make changes to their diet, including food environments and socioeconomic status. 

[00:29:46] Well, that wraps up our episode for today, which was made possible by contributions from our patient tina. We'd also like to thank Dr. Justin Charles, who served as our patient interviewer and expert, and who also provided peer review for this project special. Thanks to our producers. Madison swallow, August a Loco, Helen SI and Dr. Joshua Aygo as well as our faculty advisor, Dr. Katie gees. be sure to follow us at PC pearls on Instagram, where you can expect to get sneak peaks, additional learning content, and the most up to date details on show release times.

[00:30:22] Thanks again for joining us today. Farewell from all of us at the primary care pearls podcast. We'll catch you in the next one.

References: 

Re: multiple-pass method for taking a dietary history:
Steinfeldt L, Anand J, Murayi T. Food Reporting Patterns in the USDA Automated Multiple-Pass Method. Procedia Food Science. 2013;2:145-156. doi:10.1016/j.profoo.2013.04.022

Re: there being under-reporting of calories with dietary recalls:
Moshfegh, A.J., Rhodes, D.G., Baer, D.J., Murayi, T., Clemens, J.C., Rumpler, W.V., Paul, D.R., Sebastian, R.S., Kuczynski, K.J., Ingwersen, L.A., Staples, R.C., Cleveland, L.E. The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes. A J Clin Nutr. 2008;88:324-332

Re: National Cancer Institute citing that 24HR estimates of energy intake in Western populations generally underestimate true intake by 3% to 34% and that it’s 12-23% with the multiple-pass method:
https://dietassessmentprimer.cancer.gov/profiles/recall/validation.html 

Re: healthy diet diet reducing the risk of developing diabetes by >90%:
Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009 Aug 10;169(15):1355-62. doi: 10.1001/archinternmed.2009.237. PMID: 19667296.

Re: motivational interviewing: 

Johnston CA, Stevens BE. Motivational Interviewing in the Health Care Setting. Am J Lifestyle Med. 2013;7(4):246-249. doi:10.1177/1559827613485923

Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Australian Family Physician. 2012;41(9):660-667.

RE: evidence-based approach to dietary counseling:
Hauser ME, McMacken M, Lim A, Shetty P. Nutrition—An Evidence-Based, Practical Approach to Chronic Disease Prevention and Treatment. Fam Pract. 2022;71((1 Suppl Lifestyle)). doi:10.12788/jfp.0292

Claims/citations from episode 2 that make an appearance again in episode 3:

WFPB diet could reverse CAD:
Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998 Dec 16;280(23):2001-7. doi: 10.1001/jama.280.23.2001. Erratum in: JAMA 1999 Apr 21;281(15):1380. PMID: 9863851.

WFPB diet could put type 2 diabetes into remission:

Rosenfeld RM, Kelly JH, Agarwal M, Aspry K, Barnett T, Davis BC, Fields D, Gaillard T, Gulati M, Guthrie GE, Moore DJ, Panigrahi G, Rothberg A, Sannidhi DV, Weatherspoon L, Pauly K, Karlsen MC. Dietary Interventions to Treat Type 2 Diabetes in Adults with a Goal of Remission: An Expert Consensus Statement from the American College of Lifestyle Medicine. Am J Lifestyle Med. 2022 May 18;16(3):342-362. doi: 10.1177/15598276221087624. PMID: 35706589; PMCID: PMC9189586.

WFPB diet could be used as part of obesity treatment: