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Nutrition 411: Dealing With Patients Who Disregard Nutrition Advice
“You can lead a horse to water but you can’t make him drink.” Or can you? In an ideal world, the registered dietitian (RD) dispenses nutrition advice to eager patients who listen attentively and then follow the instructions to the letter. In the real world, this usually does not occur.
The typical patient has fears, food beliefs, logistical concerns, cultural and religious ideals, and many other individual factors that all play a role in lifelong eating habits. This makes giving “simple” nutrition advice much more complicated than it appears.
Patients who do not follow recommendations are termed nonadherent. Although conveying the importance of adherence is relatively easy when the consequences are immediate (such as with an allergy that causes an anaphylactic reaction), adherence is much more difficult to achieve when the outcomes are 10 or 20 years down the road, as in diabetes. In other cases, such as patients with chronic wounds, it may be difficult to show how food and nutrition are connected to healing. In addition, patients may not believe that small changes such as a modest 5% weight loss can have any effect on their conditions. In order to deal with these issues, clinicians must understand the different causes of nonadherence, the stages of behavior change, and some techniques that can be used overcome resistance.
Causes of Dietary Nonadherence
Researchers have explored three categories of variables that appear to be associated with nonadherence: demographic characteristics, psychological variables, and social variables. Demographic characteristics include educational level, financial considerations, and access to healthcare. Some patients may not have prior knowledge of proper nutrition and others might not have the financial resources to purchase more costly fresh fruits and vegetables and lean cuts of meats.
Psychological variables include depression, anger, feelings of loss of control, denial, hostility, and embarrassment about being ill. A patient may feel that having an illness is his fault and that may put him on the defensive. Sometimes a patient may feel embarrassed about being overweight or allowing his blood sugar to get out of control. Quite often, a patient may feel that nothing is going to help and be too depressed to try yet another intervention or fail at another diet. In long-term care, residents often are depressed and feel they are at the end of life so why make the effort. Others may be very hostile and angry and attempt to exert control over the situation by challenging the advice given by the healthcare practitioner.
The third category of nonadherence involves social variables. These include lack of a support system, isolation, poor family relationships, and poor relationships with healthcare providers. Isolation has been linked to decreased meal intake; if a patient lives alone with limited ability to shop, prepare meals, and socialize, meal consumption may suffer. In long-term care, residents may isolate themselves because of the assistance they require and refuse to go the dining room.
Stages of Behavior Change
Eating behaviors are formed over the course of a lifetime and are not easily changed. People must be ready and motivated to make a change. The Transtheoretical Model2 is commonly used to define the stages of behavior change in a series of six distinct steps. It is important to remember that people cycle through different phases of changing and maintaining their dietary modifications and these steps may not be linear. Precontemplation. This is the point at which the patient has not even contemplated having a problem or needing to make a change.2 A person in the precontemplation stage needs information and feedback to raise his/her awareness of the problem. For example, it may be useful to ask a patient at this stage if he understands there is a connection between blood glucose levels and wound healing. It would not be useful to instruct this patient on carbohydrate counting because he is not yet ready to accept that type of direction.
Contemplation. Once some awareness of the problem is established, the patient enters a period of ambivalence or contemplation.2 The contemplator may swing between reasons for changing and reasons for staying the same. At this stage, it is helpful to show the advantages of changing but without making false promises. For example, it may be helpful to say that even a modest decrease in blood glucose may help the wound healing process. Don’t promise this will always or immediately heal the wound because that will set up false expectations.
Preparation. The preparation stage is a window of opportunity that either allows the patient to move forward or fall back into contemplation.2 At this stage, it is useful to help the patient set a realistic goal or identify an acceptable strategy. For example, the patient may state he is ready to learn about carb counting and get more information on what he would need to do if he were to utilize this technique.
Action. At this stage, the patient engages in the action that will bring about change.2 The patient will actually make a change and begin monitoring his carbohydrate intake.
Maintenance. During this stage, the goal is to continue the changed behavior and not relapse.2 For example, if the patient has a special occasion such a birthday party, he will either revert back to old behaviors or resume the new behaviors after the lapse.
Relapse. If relapse occurs, the patient’s task is to start the change process again rather than get stuck in relapse. The goal is to resume action.2 For example, if the patient never monitors his carbohydrate intake again and eats without regard to his blood glucose, it is helpful to determine why this occurred. Perhaps he was tired of the monitoring, ran out of testing supplies, or didn’t see it helping his condition. There can be many reasons for a relapse but the goal is to not remain in this stage.
Patients will not change their dietary habits until ready to make the change. It is helpful to identify which stage of change each patient is at and adapt the dietary strategies to that particular stage. 
Documentation Issues
It is necessary to document all nutrition education and counseling in the medical record. In the litigious environment that surrounds healthcare, it is useful to have a permanent record of the approaches used to improve nutritional status. Nonadherence also should be documented. Patients have the right to refuse dietary interventions. It should be noted that this right is reserved for patients with sufficient cognitive ability to understand the implications of their decision, especially when dealing with patients living in a long-term care facility. If a patient is determined to disregard dietary advice, it is not unreasonable to have the patient sign a statement documenting the education process, the medical risks involved, and the decision not to heed the advice of the nutrition professional.
Interpersonal Skills
Many traditional counseling techniques and interpersonal skills can be used to improve success when encouraging patients to modify their dietary habits. It is important to maintain eye contact when speaking with a patient — a lack of eye contact can signal disinterest or preoccupation. The voice level should be kept appropriate and enthusiastic — it is ineffective to speak in a monotone voice or scream at patients. It is important to be nonjudgmental and demonstrate empathy. Facial expression, tone of voice, body language, and gestures such as pat on the arm are all methods of communication. It is important that the patient be given adequate time to convey feelings and ask questions. This requires good listening skills. Sometimes diet advice can be seen as negative because of the manner in which it is presented. For example, patients may view the counselor as the “diet police” who forces them to stay away from many foods. It is better to ask questions to ascertain what knowledge the patient already has and build from that point. This requires effective use of open-ended questions such as, “Do you know what types of foods may help you achieve your blood glucose goals?” Asking is often much more effective than telling a patient what to do. Positive reinforcement can be a good motivator because most patients enjoy hearing they are doing well and are on their way to success. 
Putting It All Together
The best approach for dealing with nutritional nonadherence is to use a combination of several approaches. The case example in Figure 1 shows how several techniques can be used together to improve outcomes. Figure 2 lists strategies for dealing with patients in denial. In order for medical nutrition therapy (MNT) to be fully effective, we must not only instruct patients on the principles of good nutrition, but also build a relationship that will facilitate changes in behavior and improve outcomes.3 This requires knowing about human nature and psychology as well as nutrition. Nutritional counseling that is truly effective in facilitating actual behavior change must focus not on a diet or disease entity but on the patient.
Coming in August: Body Composition – How to Tell the Lean from the Fat
Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.
This article was not subject to the Ostomy Wound Management peer-review process.
1. Sherry DC, Simmons B, Wung SF, Zerwic JJ. Noncompliance in heart transplantation: a role for the advanced practice nurse. Prog Cardiovasc Nurs. 2003;18(3):141–146.
2. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition and Diet Therapy, 10th ed. Philadelphia, PA: WB Saunders Company; 2000;453.
3. Curry KR, Jaffe A. Nutrition Counseling and Communication Skills. Philadelphia, PA: W.B. Saunders Company; 1998;85.
