What is it?
Nutrition is a key determinant in three of the top four causes of death – cardiovascular disease, stroke, and cancer – not to mention a key component of most chronic conditions primary care clinicians treat: diabetes, obesity, hypertension, and hyperlipidemia. 3 4
One survey of 451 family physicians found that 58.1 percent believed that more than 60 percent of their patients would benefit from nutritional counseling. Yet few provided the counseling or referred their patients to dietitians. 5
Few doctors receive training on nutrition or nutritional therapy in medical school or residency. In addition, nutritional counseling is time consuming, nearly impossible to fit into the typical 10- to 15-minute visit, and limited in insurance coverage. 3 6
A nutritional consult typically begins with a one-hour evaluation to assess the patient and the patient’s diet. The nutritionist may also assess the patient’s sleep patterns, physical activity, and other lifestyle factors, as these can affect eating.
With this information, the nutritionist works with the patient (or client) to identify opportunities for change. This doesn’t always mean starting a diet. It could mean identifying one adjustment – such as giving up soda or adding more fish, nuts, and vegetables – that can have an impact on health and healing.
Next is formulating a plan. For instance, if the patient doesn’t have time to cook and shop, options could include utilizing a service that delivers healthy food to the door or providing patients instruction on food selection when eating out. If a patient eats because of stress, then the nutritionist works with the patient to identify the underlying eating urges and identify strategies to manage them.
What does the science show?
Numerous studies find that improving diet can provide the same, if not better, benefits as medical therapy with less risk, fewer side effects, lower costs, and shorter hospital stays. 3 7 8 Most major medical guidelines incorporate recommendations for nutritional interventions and changes as an integral part of managing chronic disease.
The U.S. Preventive Services Task Force found good evidence that medium- to high-intensity dietary counseling for patients with hyperlipidemia and other risk factors for cardiovascular disease can produce medium to large changes in the intake of the core components of a healthy diet, particularly if delivered by nutritionists, dietitians, and specially trained primary health care professionals. 9 Similar studies have shown benefits for obesity, diabetes, and hypertension. 10-12
Not only can nutritional counseling improve a patient’s health, it can improve your reimbursement. Insurance is increasingly paying for nutritional counseling. In this age of value-based reimbursement, maintaining a patient’s health and preventing emergency department visits and hospitalizations – as well as readmissions – directly impacts compensation, whether you are salaried or have your own practice.
Whom should I refer?
Overweight or obese patients are obviously candidates for nutritional counseling, as are patients with diabetes, hypertension, and heart disease, as well as others at high risk for cardiovascular disease. Pregnant women, patients with chronic kidney disease, and patients with cancer may also benefit from referral.
Also consider referring patients with conditions such as HIV, cancer, and chronic obstructive pulmonary disease, who are at risk for significant weight loss.
How do I find a quality practitioner?
Check to see if the nutritionist is licensed or certified to practice. The primary organization of qualified nutrition professionals is the Academy of Nutrition and Dietetics. They provide a search by zip code on their website of qualified practitioners:
Look for a registered dietitian or registered dietitian nutritionist (RDN), disciplines that typically require a four-year bachelor’s degree and 900 to 1,200 hours in a dietetic internship through an accredited program, as well as passing a dietetics registration exam and continuing professional education requirements. Some RDNs are certified in a specialized area, including pediatrics nutrition, sports dietetics, nutrition support, and diabetes education.
Make sure the nutritionist you choose provides regular feedback on your patient, including nutritional recommendations and progress reports. In one survey of 235 family physicians, 54 percent said a lack of feedback compromises patient care. 13
Does insurance cover it?
Most commercial and government insurances, including Medicare and Medicaid, cover medical nutrition therapy (MNT) for certain conditions. Under Medicare, for instance, patients who have had a kidney transplant, or who have diabetes or kidney disease, can receive an initial nutrition and lifestyle assessment, one-on-one nutritional counseling, and follow-up visits to evaluate the patient’s progress. Obesity screening and counseling is covered if it is received in a primary care setting. Medicare recipients in rural areas may receive MNT through telehealth.
Fad diets without evidence of benefit abound. Don’t let your patients be fooled by them. A large meta-analysis of major weight loss diets showed that over time (six to 12 months) all were equally effective if people adhered to them.14 The best diets to follow for general health are variations of the Mediterranean and DASH diets, which are based on the Alternate Healthy Eating Index. 15
Extreme dietary changes can harm your patients – both physically and psychologically. Cyclical weight loss and regain is bad for health and makes permanent weight loss more difficult. Implementing a major dietary change without medical monitoring and supervision can also get patients into trouble – especially if they are effective – as adjustments in medications or other therapies may be needed. Weight loss drugs and surgery are not recommended alone and should always be accompanied by diet and lifestyle changes. Thus, integrative health principles apply, such as person-centered care, shared decision making, and combining conventional medicine and self-care.