Marion Nestle recently tweeted her followers, alerting us to a you tube video titled “So You Want To Lose Weight“, mocking a nutrition counseling session. Gable Kermit, the creator and a registered dietitian, claimed he was creating an amalgam of his patients. Did he realize he was also creating an amalgam of dietitians?

The patient depicted the most demanding, opinionated, resistant, clueless, and defended patient I can imagine. Every request was met with defiance, every suggestion was met with opposition. I hope this is a parody.

It was the comments that gave me pause. There are only a few, but many of the participants are registered dietitians. They see their patients and howl with the release of pent up frustration. I wonder if they realize that patients will view this and probably both laugh and cry. How many of them will relate to the behavior of the dietitian?

THE DIETITIAN ON A MISSION

The dietitian is focused and unwavering. His job is to help this woman lose weight. The robotic nature of the voices only serves to underscore the robotic nature of his mission. This dietitian has no clue.

In the first few sentences his patient tells him in her tone, words and behavior that she is ambivalent. She tells the dietitian she wants to lose weight, but then blocks him at every angle. He never relents. For 10 agonizing minutes the dietitian continues the good fight, trying to extract damning information from her, use that information to illustrate what she is doing wrong, and tell her what she could do differently. It’s old school nutrition counseling.

I know, this is how I was trained over 30 years ago. I mentor young dietetic interns, and I know that nutrition counseling is taught differently today. The sad reality is that these young and bright interns hit the hospital floor and soon find out that there is little application of more sophisticated skills in the real world. Too often practicing dietitians are using the old textbooks.

IS THE PATIENT HEARD?

To be fair, most dietitians working in hospitals and clinics don’t get an adequate opportunity to do their jobs well. At UCLA, the diabetic patients are routinely allowed four 15 minute visits with a dietitian a year. That is hardly enough time to establish rapport and find out what is happening with the patient much less provide them with information and guidance. It is even more impossible with a resistant, oppositional or ambivalent patient, even if you have the skills.

Too often nutrition counseling is all about the dietitian doing their job. The expectations come from administrators, insurance companies, physicians, and sometimes the patients themselves. Just tell me what to eat.

While the dietitian may listen, it is often to identify what needs to be done or what the patient can do differently. I wonder what we would find out if after every nutrition counseling session the patient was asked, “Did you feel heard?”

I squirmed watching So you want to lose weight? Xtranormal. I felt tense for the dietitian, I ached for the patient.

READINESS, WILLINGNESS, ABILITY TO CHANGE

Mostly I wanted to step in and say something. Maybe I would recap the exchange and ask, “I’m not sure what you are looking for. I hear that you want to lose weight, but I am also hearing that you don’t think you eat very much. What do you think is going on?” or maybe I would say, “It sounds like you feel you are doing everything you can. How can I help you?” Possibly I would venture, “I wonder why you are seeing me today. When I am working with a patient, I always listen for words that tell me you are ready or willing to do something different. I am not hearing those kinds of words.”

And then I would let the patient fill in the space.

DIFFERENT, MORE EFFECTIVE COUNSELING SKILLS

Overall, I am most disturbed by the dietitian’s inability to stop and reflect on the patient’s resistance. Some level of ambivalence, resistance or opposition can be expected . It comes with the territory, the business of change.

Not all patients are so intensely stuck (I really do want to believe this is a parody). But for the ones who are, dietitians need to be able to shift gears. Different counseling skills or training in motivational interviewing could go a long way.

Too many patients come because their doctor sent them, their spouse threatened them, their children begged them. Sometimes they feel desperate one moment and make a call, and by the time they step into the office, they are not in the same place.

WHO SHOWS UP?

I always wonder who is going to show up at an appointment. A willing, ready patient or the darker twin who is defended as they walk through the door. Not every patient is truly ready or willing to be told what to eat. Not every patient comes to the visit honestly looking to change right away. Sometimes they only wish they were.

The challenge of nutrition counseling is to support, guide and facilitate the patient’s journey to cultivate an approach to food that works. This takes more than nutrition science and biochemistry. This takes more than counting calories, grams of carbohydrate or fat. This takes more than 15 minutes four times a year.

There is an opportunity here to explore the nature of nutrition counseling today. What is your experience as a dietitian, as a nutrition consultant? as a patient or client?