Nutrition Counseling: Importance of a Two-Part Message

Jeanette Brooks: Hi there and welcome to Medicine With a Fork, produced by the nonprofit Gaples Institute. Today, we're exploring how clinicians can have better and more effective conversations with their patients about shifting to a healthier diet. I'm Jeanette Brooks, the Director of E-Learning Experience for the Gaples Institute.

We are an educational nonprofit with one goal, and that is to advance the role of nutrition and lifestyle in medicine. I'm here with our Executive Director, Dr Stephen Devries. He's a preventive cardiologist with over 30 years in academic medicine and, in addition to leading the Gaples Institute, he also lectures internationally on the intersection of patient health, diet, and lifestyle. Steve, welcome!

Dr Stephen Devries: Thank you, great to be with you.

Brooks: I'm glad that you're here. So, we know that in the last few decades, patients have really become a lot more proactive about how to take charge of their health. A lot of times they show up to an office visit expecting some advice and some answers about nutrition.

So, the first question for you today is, based on your experience, is there any key principle that you can share that clinicians should keep in mind when they're talking with a patient about diet?

Devries: Yes, absolutely. There's one that I think is really important and doesn't get nearly enough emphasis. That is, when we talk to patients about cutting back on—whether it be a nutrient or a particular food or food class—it's really important not only to talk about the thing that should be removed or reduced from the diet, but also what you need to replace it with.

Brooks: Okay, so it sounds like the key is really kind of a two-pronged approach, right? Talk about what to minimize, for sure, but just as much, to also focus on what the patient should add into their diet.

Devries: Exactly.

Brooks: Can you tell us a little bit more about times you've observed when this two-part message didn't get conveyed, and why that can really be a problem?

Devries: Yes. You know, it really was a problem in the United States overall, dating back in the seventies and eighties. At that time there was an especially big push to reduce fat in the diet, and a lot of advertising and a lot of messages from the media and from medical sources, that we should cut back on fat.

And in fact we did. But the problem is, as a nation, we cut back on fat, but we ended up substituting it for another problem—and that is, increasing our sugar intake.

Brooks: I actually recall those days! I remember all the fat-free products that suddenly started taking over the shelves at the grocery store. Let's talk a little bit more about why this made patients increase their sugar intake. Why do people tend to turn to carbs and sugar when they reduce fat?

Devries: Well, you know, it's really simple. There's three major macronutrients: carbs, fat, and protein. And when it comes down to your diet, unless you're going to be cutting down on your total caloric intake—which most people aren't really enthusiastic to do unless they're really, you know, in a concerted effort to cut down on calories—if you cut down on one macronutrient like fat, you've got to increase intake of one of the other two. Now, increasing protein intake is pretty tough for a lot of people to do. So it's really easy, when you cut down on fat, to increase intake of carbs—and that's exactly what happened in the United States.

And, I would say that the obesity epidemic is not only related to increased carb intake, because people are eating too much of all the macros. But in particular, when you cut down on fat, there's a tendency to increase refined carb and sugar intake. And that was definitely a problem that we're still dealing with today.

Brooks: Okay. So when a patient does that, what might that look like, practically speaking? How does it play out in their actual food choices?

Devries: Well, it could be, you know, think about low-fat ice cream. Ice cream ends up having reduced fat in the so-called healthier version, but it has increased sugar intake.

So one could be just looking at equally unhealthy portions of the same. But the studies are really clear—which is interesting, you know, with all the controversy about whether saturated fat is really as big of a problem as had been believed. We know now that there are things that are equally unhealthy to saturated fat, and that is if people do cut down on saturated fat and replace them with refined carbs and sugar, we know that that substitution does not reduce the risk of heart disease at all. So from a health viewpoint, if you were eating lots of saturated fat, you're no better off if you replace that saturated fat with sugar.

Brooks: So this certainly sounds problematic. Is there still some benefit since the patient is cutting back on saturated fat, even though they are increasing their sugar?

Devries: Well, this is where the whole kernel of important counseling needs to take place about, as we talked about, what to cut back on—in this case, saturated fat—but then the healthful replacements to suggest to patients in place of the saturated fat. So we do know, for instance, if you replace 5% of your daily calories, that used to be in the form of saturated fat, with whole grains, you can reduce the risk of coronary disease, in one really well-done study by 9%.

If you reduce saturated fat with an equal number of calories from monounsaturated fats, like in olive oil, you reduce the risk of heart disease by 15%. And if you replace saturated fat with polyunsaturated fats, like the healthy Omega-3s found in fish and some other vegetable products, you can reduce the risk of heart disease by 25%.

And that's replacing one type of fat—saturated fat—with a healthier version—polyunsaturated fat. So again, the replacement is really critical to add to your discussion with patients.

Brooks: Okay, great. So it sounds like there's a real opportunity here for physicians and other clinicians to really support their patients' health goals, just by getting more specific about the guidance that they give as far as healthy replacements—not just what to cut back on, but what to emphasize in their diet.

So Steve, you've talked about replacing saturated fat with some healthier options. Any other examples that you think might be helpful to clinicians who are seeking to help their patients make healthy swaps?

Devries: Yeah, absolutely. One that comes to mind that is actually surprising to a lot of patients and even clinicians. And that is, something like, replacing what we know is an unhealthy breakfast food, like a donut. We know that no one who eats donuts does so thinking that they're eating something healthful, but what people might want to do then, in thinking like, oh, I'd like to do something a little bit healthier, is to replace it with something that seems kind of similar, but perhaps, you know, not so sweet and not so sugary, like a bagel.

And what's really interesting is that if you make a replacement with a donut for a bagel, first of all, you could actually be getting more calories with the bagel. Many bagels have more calories. And also you actually increase the glycemic load. A bagel, being more dense, has more calories than a donut.

So, in terms of replacement, it wouldn't be enough to say, “Let's cut down on donuts.” It would be, “Let's replace a donut with something much healthier”—which is not a bagel—which might be something like oatmeal, or it might be something like a small English muffin made of a hundred percent whole grains, or half of an English muffin made of a hundred percent whole grains.

So something, you know, a healthier replacement. It might be a lowfat unsweetened yogurt, something like that. But again, just telling people to cut out the donut, you might find that they replace it with something that could be just as bad or worse, like the bagel. The best message, of course, is not too much of either of those, and more of the healthier substitutions.

So again, it's the substitution that's important. And it's so easy in clinical medicine, just to focus on the thing to avoid—the thing that sends out the danger signal. But what you really want to do is give people some advice about what else they can eat in place of it. Because if you don't give that substitution, they're going to come up with something on their own and chances are, it won't be exactly what you had in mind for them, or what's best for their health.

Brooks: Right. It sounds like in a lot of cases, the patient's go-to choices might intuitively feel to them like they're good choices, but in reality, they're maybe no better than the unhealthy choice that they had started with.

Devries: Exactly.

Brooks: So Steve, if a clinician feels like they need to boost their knowledge about some of these healthy substitutions and they want to get more intentional about the way they talk to their patients about diet, where can they learn more?

Devries: I suggest that they check out the course that is offered by our nonprofit, the Gaples Institute.

It's a course on nutrition that's interactive, it's self-paced, there's a special discount for AMA members available, and it offers four hours of continuing medical education. You can check it out at NutritionForDocs.org.

Brooks: Okay, so that is NutritionForDocs.org. Steve, thanks so much for being here today. This has been really helpful.

Devries: Thanks. It's been great to talk to you about this topic that doesn't get nearly enough attention and is so important for making a big impact with your patients.

Brooks: For sure. And thanks also to all of you who are listening in. Our hats are off to you, if you are championing healthy nutrition in your practice. It's really worthwhile—and in fact, it's crucial to patient health.

We invite you to follow the Gaples Institute on social media. You can find us on Twitter, on LinkedIn and on Facebook. And we look forward to connecting with you next time on Medicine With a Fork.

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Disclosure Statement: Dr. Devries is the salaried executive director and Jeanette Brooks is the salaried director of e-learning for the Gaples Institute, an educational nonprofit that offers accredited continuing medical education courses for sale to health professionals. Courses are developed entirely through philanthropy to the Gaples Institute, a nonprofit that does not seek or receive corporate support. Neither Dr. Devries nor Jeanette Brooks receive royalties or personal consideration of any kind from the sale of these courses.

Financial Support Disclosure Statement: This podcast was developed with no corporate support.