- Email: [email protected]
Time for Food—Including Nutrition on Physiatrists' Tables
PM R 8 (2016) 388-390
www.pmrjournal.org
Emerging Issue
Time for FooddIncluding Nutrition on Physiatrists’ Tables Rani Polak, MD, MBA, Marie L. Dacey, EdD, Edward M. Phillips, MD
Abstract Unhealthy nutrition is a leading factor in various rehabilitation diagnoses such as stroke and several musculoskeletal complications. Further, the association between nutrition, pain management, and brain plasticity support the importance of having rehabilitation patients follow healthy nutrition guidelines. The goal of this brief report is to emphasize the importance of nutritional counseling to physiatrists and to briefly describe recommended communication skills, behavioral change strategies, and opportunities for interprofessional collaborations. Potential next steps aimed at prescribing nutrition within physiatry clinics are provided. Incorporating healthy nutrition in the physiatrist’s personal and professional life presents an opportunity for a meaningful change. Physiatrists can lead the way one bite at a time. The time for a healthy approach to food is now.
Introduction Unhealthy nutrition is a leading factor in all-cause mortality and the preponderance of noncommunicable chronic diseases [1]. Robust positive correlations exist between nutrition-related risk factors such as hypertension and stroke [2] and between obesity and various musculoskeletal complications [3,4]. In fact, poor eating behaviors were found to be highly prevalent in patients with chronic pain who underwent long-term opioid therapy [5], and evidence shows that select dietary factors are important modifiers of brain plasticity and can help reduce the consequences of neural damage [6]. This evidence supports the importance of having patients who are undergoing rehabilitation follow healthy nutrition guidelines. Although environmental and community factors have crucial roles in creating and sustaining appropriate health behaviors, they do not eliminate the duty of physicians to assist patients in making health behavior changes [7]. The goal of this brief report is to emphasize the importance of nutritional counseling to physiatrists and to provide them with a preliminary set of skills and tools for prescribing healthy nutrition. Communication Skills and Behavioral Change Strategies Numerous strategies have been developed to aid patients in their efforts to adopt and maintain healthier
eating behaviors. However, a few communication skills and behavioral change strategies warrant particular consideration for physiatrists, who have unique opportunities as a result of their close relationships with patients that often have developed over many years. These skills and strategies are presented in Table 1 [8-13] and include food language, motivational interviewing, frequent contact, delivery modes, goal setting, and self-monitoring. Interprofessional Collaboration A model of care has been suggested for delivering nutrition education in which the physician is a coordinator of an interprofessional health care team [14]. The physiatrist is uniquely suited to be effective in this environment because (s)he is the multidisciplinary manager of patients with stroke or other patients who require complex rehabilitation care [15]. Although physiatrists routinely refer patients to dieticians and behaviorists such as rehabilitation psychologists, the impact and uptake of nutrition education can be improved by working with other specialists who traditionally are not included in a health care team, such as health coaches and chefs. Health coaches are professionals who facilitate positive changes in mindset and behavior by applying principles such as patient-directed goal-setting, guided self-discovery, self-monitoring, and expectations of accountability [16]. Physiatrists can collaborate with
1934-1482/$ - see front matter ª 2016 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.09.026
R. Polak et al. / PM R 8 (2016) 388-390
389
Table 1 Communication skills and behavioral change strategies for prescribing nutrition Strategy
Description
Examples
Communication for prescribing nutrition Food language Messages that focus on food rather than nutrients [8] Motivational interviewing
Directive, individual-centered counseling style for eliciting behavior change with a central purpose of helping individuals to explore and resolve their ambivalence [10]
Frequent contact
Follow up after each meeting and/or generate a system for regular provider-patient communication
Delivery modes
Media messages, printed materials, and other nonindividualized strategies (more effective when added to physician counseling) [12]
Behavioral change strategies Goal setting
Self-monitoring
SMART goals that are specific in outcome, proximal in terms of attainment, and realistic in terms of the individual’s capability [13] Consistent recording of progress and challenges while working toward goals; self-monitoring facilitates recognition of progress made toward the identified goal, thus providing direct feedback
well-trained professional health or wellness coaches who can spend adequate time working one-on-one with patients in their journey toward behavior change [17]. Culinary programs delivered by chefs have recently emerged as a way to improve adherence to nutritional guidelines [18]. These programs, which augment nutritional knowledge with skills such as shopping, food storage, and meal preparation, have been described for patients with disabilities and have resulted in demonstrated dietary changes in both patients and caregivers [19]. Potential Next Steps Physiatrists will require dedicated training to gain the knowledge necessary to develop nutritional counseling expertise [20]. When choosing a continuing medical education (CME) program, it is worth noting that although Web-based nutrition education programs such as Nutrition in Medicine [21] have become popular, the most popular nutrition CME programs still have a live inperson lecture format [22]. Live nutritional CME programs vary in how nutritional content is presented: they might focus primarily on nutrition [23], include nutrition as part of a comprehensive Lifestyle Medicine program [22], or discuss nutrition as a component of the management of specific health conditions such as hypertension [24]. Interactive modules and small group training are particularly efficacious compared with the traditional didactic delivery style [25]. Physiatrists help build skills and facilitate behavior change, but they can further help their patients
Increase vegetable consumption to 5 servings per day; eating family meals >3 times weekly [9] Eliciting and selectively reinforcing the person’s own self-motivational statements, concern, intention, and ability to change; ensuring that resistance is not generated by jumping ahead of the individual; affirming the person’s freedom of choice [11] Face-to-face, telephone, e-mail, or through the social media (the frequency of subsequent contact is important) [11] Interactive computer modules, brochures, posters, nutritional displays, and social marketing [11]
Eating a home-cooked dinner every Wednesday
Pencil and paper, online modules (with or without feedback), scripted telephone messages or Internet e-mail reminders, commercial and free-of-charge Internet-based programs for monitoring dietary intake [11]
(and help themselves, as well) in yet another way: by serving as positive role models. Providers who are in the process of improving their own behavior may be more likely to encourage their patients to adopt a similar way of eating [26], and their patients are more likely to adopt it [27]. Conclusions Nutrition has moved from being just a preventive modality to being a disease management tool. Physiatrists have unique opportunities to promote healthier food choices because of their close relationships with their patients, which often have developed over many years. Incorporating healthy nutrition in both our personal and professional life presents an opportunity for a meaningful change. Physiatrists can lead the way, one bite at a time. References 1. Ford ES, Zhao G, Tsai J, Li C. Low-risk lifestyle behaviors and allcause mortality: Findings from the National Health and Nutrition Examination Survey III Mortality Study. Am J Public Health 2011; 101:1922-1929. 2. American Diabetes Association. Standards of medical care in diabetesd2014. Diabetes Care 2014;37(suppl 1):S14-S80. 3. Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part II: Focus on micronutrients and supportive nutraceuticals. PM R 2012;4:S155-S168. 4. Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part I: Focus on fatty acids and macronutrients. PM R 2012; 4:S145-S154.
390
Nutrition and Physiatry
5. Meleger AL, Froude CK, Walker J 3rd. Nutrition and eating behavior in patients with chronic pain receiving long-term opioid therapy. PM R 2014;6:7-12. 6. Gomez-Pinilla F, Gomez AG. The influence of dietary factors in central nervous system plasticity and injury recovery. PM R 2011;3: S111-S116. 7. Lianov L, Johnson M. Physician competencies for prescribing lifestyle medicine. JAMA 2010;304:202-203. 8. Mozaffarian D, Ludwig DS. Dietary guidelines in the 21st centuryda time for food. JAMA 2010;304:681-682. 9. Behan E. Health care providers: What to say to your patients about diet in 30 seconds. Am J Lifestyle Med 2012;6:448-451. 10. Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother 1995;23:325-334. 11. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation 2010;122:406-441. 12. Pomerleau J, Lock K, Knai C, McKee M. Interventions designed to increase adult fruit and vegetable intake can be effective: A systematic review of the literature. J Nutr 2005;135:2486-2495. 13. Moore M, Tschannen-Moran B. Coaching Psychology Manual. Philadelphia, PA: Lippincott Williams and Wilkins; 2010. 14. Mitchell P, Wynia M, Golden R, et al. Core principles and values of effective team-based health care. Washington, DC: Institute of Medicine; 2012. 15. Laskowski ER. Action on obesity and fitness: The physiatrist’s role. PM R 2009;1:795-797. 16. Wolever RQ, Simmons LA, Sforzo GA, et al. A systematic review of the literature on health and wellness coaching: Defining a key behavioral intervention in healthcare. Glob Adv Health Med 2013; 2:38-57. 17. Frates EP, Moore MA, Lopez CN, McMahon GT. Coaching for behavior change in physiatry. Am J Phys Med Rehabil 2011;90:1074-1082.
18. Reicks M, Trofholz AC, Stang JS, Laska MN. Impact of cooking and home food preparation interventions among adults: Outcomes and implications for future programs. J Nutr Educ Behav 2014;46: 259-276. 19. Wilneff MA, Wolf KN, Havercamp S, Nahikian-Nelms ML. A pilot study: Effectiveness of basic cooking skills and nutrition education for adults with disabilities and caregivers. J Acad Nutr Diet 2013; 113:A80. 20. Weinstein SM. Maintaining health, wellness, and fitness: A new niche for physiatry? PM R 2009;1:793-794. 21. Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: Nutrition education for medical students and residents. Nutr Clin Pract 2010;25:471-480. 22. Dacey M, Arnstein F, Kennedy MA, Wolfe J, Phillips EM. The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors. Med Teach 2013;35:e1149e1156. 23. Eisenberg DM, Myrdal Miller A, McManus K, Burgess J, Bernstein AM. Enhancing medical education to address obesity: “See one. Taste one. Cook one. Teach one”. JAMA Intern Med 2013;173:470-472. 24. Drexel C, Merlo K, Basile JN, et al. Highly interactive multi-session programs impact physician behavior on hypertension management: Outcomes of a new CME model. J Clin Hypertens (Greenwich) 2011;13:97-105. 25. Davis D, Davis N. Selecting educational interventions for knowledge translation. CMAJ 2010;182:E89-E93. 26. Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians’ prevention-related practices. Findings from the Women Physicians’ Health Study. Arch Fam Med 2000; 9:359-367. 27. Frank E, Dresner Y, Shani M, Vinker S. The association between physicians’ and patients’ preventive health practices. CMAJ 2013; 185:649-653.
Disclosure R.P. Institute of Lifestyle Medicine, Physical Medicine and Rehabilitation, Harvard Medical School, Joslin Diabetes Center, Suite 344, One Joslin Place, Boston, MA 02215. Address correspondence to: R.P.; e-mail: [email protected]. edu Disclosures related to this publication: grant, Maccabi Healthcare Service, Harvard Medical SchooldPM&R Department, Israeli Cancer Association (money to author) Disclosures outside this publication: royalties, Penn publication (money to author) M.L.D. Department of Behavioral and Social Sciences, School of Arts & Sciences, MCPHS University, Boston, MA Disclosure: nothing to disclose
E.M.P. Institute of Lifestyle Medicine, Physical Medicine and Rehabilitation, Harvard Medical School, Joslin Diabetes Center, Suite 344, One Joslin Place, Boston, MA 02215 Disclosure: nothing to disclose Supported by educational grants from Maccabi Healthcare Service, Harvard Medical SchooldPM&R Department, and the Israeli Cancer Association. Submitted for publication September 11, 2015; accepted September 24, 2015.
www.pmrjournal.org
Emerging Issue
Time for FooddIncluding Nutrition on Physiatrists’ Tables Rani Polak, MD, MBA, Marie L. Dacey, EdD, Edward M. Phillips, MD
Abstract Unhealthy nutrition is a leading factor in various rehabilitation diagnoses such as stroke and several musculoskeletal complications. Further, the association between nutrition, pain management, and brain plasticity support the importance of having rehabilitation patients follow healthy nutrition guidelines. The goal of this brief report is to emphasize the importance of nutritional counseling to physiatrists and to briefly describe recommended communication skills, behavioral change strategies, and opportunities for interprofessional collaborations. Potential next steps aimed at prescribing nutrition within physiatry clinics are provided. Incorporating healthy nutrition in the physiatrist’s personal and professional life presents an opportunity for a meaningful change. Physiatrists can lead the way one bite at a time. The time for a healthy approach to food is now.
Introduction Unhealthy nutrition is a leading factor in all-cause mortality and the preponderance of noncommunicable chronic diseases [1]. Robust positive correlations exist between nutrition-related risk factors such as hypertension and stroke [2] and between obesity and various musculoskeletal complications [3,4]. In fact, poor eating behaviors were found to be highly prevalent in patients with chronic pain who underwent long-term opioid therapy [5], and evidence shows that select dietary factors are important modifiers of brain plasticity and can help reduce the consequences of neural damage [6]. This evidence supports the importance of having patients who are undergoing rehabilitation follow healthy nutrition guidelines. Although environmental and community factors have crucial roles in creating and sustaining appropriate health behaviors, they do not eliminate the duty of physicians to assist patients in making health behavior changes [7]. The goal of this brief report is to emphasize the importance of nutritional counseling to physiatrists and to provide them with a preliminary set of skills and tools for prescribing healthy nutrition. Communication Skills and Behavioral Change Strategies Numerous strategies have been developed to aid patients in their efforts to adopt and maintain healthier
eating behaviors. However, a few communication skills and behavioral change strategies warrant particular consideration for physiatrists, who have unique opportunities as a result of their close relationships with patients that often have developed over many years. These skills and strategies are presented in Table 1 [8-13] and include food language, motivational interviewing, frequent contact, delivery modes, goal setting, and self-monitoring. Interprofessional Collaboration A model of care has been suggested for delivering nutrition education in which the physician is a coordinator of an interprofessional health care team [14]. The physiatrist is uniquely suited to be effective in this environment because (s)he is the multidisciplinary manager of patients with stroke or other patients who require complex rehabilitation care [15]. Although physiatrists routinely refer patients to dieticians and behaviorists such as rehabilitation psychologists, the impact and uptake of nutrition education can be improved by working with other specialists who traditionally are not included in a health care team, such as health coaches and chefs. Health coaches are professionals who facilitate positive changes in mindset and behavior by applying principles such as patient-directed goal-setting, guided self-discovery, self-monitoring, and expectations of accountability [16]. Physiatrists can collaborate with
1934-1482/$ - see front matter ª 2016 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.09.026
R. Polak et al. / PM R 8 (2016) 388-390
389
Table 1 Communication skills and behavioral change strategies for prescribing nutrition Strategy
Description
Examples
Communication for prescribing nutrition Food language Messages that focus on food rather than nutrients [8] Motivational interviewing
Directive, individual-centered counseling style for eliciting behavior change with a central purpose of helping individuals to explore and resolve their ambivalence [10]
Frequent contact
Follow up after each meeting and/or generate a system for regular provider-patient communication
Delivery modes
Media messages, printed materials, and other nonindividualized strategies (more effective when added to physician counseling) [12]
Behavioral change strategies Goal setting
Self-monitoring
SMART goals that are specific in outcome, proximal in terms of attainment, and realistic in terms of the individual’s capability [13] Consistent recording of progress and challenges while working toward goals; self-monitoring facilitates recognition of progress made toward the identified goal, thus providing direct feedback
well-trained professional health or wellness coaches who can spend adequate time working one-on-one with patients in their journey toward behavior change [17]. Culinary programs delivered by chefs have recently emerged as a way to improve adherence to nutritional guidelines [18]. These programs, which augment nutritional knowledge with skills such as shopping, food storage, and meal preparation, have been described for patients with disabilities and have resulted in demonstrated dietary changes in both patients and caregivers [19]. Potential Next Steps Physiatrists will require dedicated training to gain the knowledge necessary to develop nutritional counseling expertise [20]. When choosing a continuing medical education (CME) program, it is worth noting that although Web-based nutrition education programs such as Nutrition in Medicine [21] have become popular, the most popular nutrition CME programs still have a live inperson lecture format [22]. Live nutritional CME programs vary in how nutritional content is presented: they might focus primarily on nutrition [23], include nutrition as part of a comprehensive Lifestyle Medicine program [22], or discuss nutrition as a component of the management of specific health conditions such as hypertension [24]. Interactive modules and small group training are particularly efficacious compared with the traditional didactic delivery style [25]. Physiatrists help build skills and facilitate behavior change, but they can further help their patients
Increase vegetable consumption to 5 servings per day; eating family meals >3 times weekly [9] Eliciting and selectively reinforcing the person’s own self-motivational statements, concern, intention, and ability to change; ensuring that resistance is not generated by jumping ahead of the individual; affirming the person’s freedom of choice [11] Face-to-face, telephone, e-mail, or through the social media (the frequency of subsequent contact is important) [11] Interactive computer modules, brochures, posters, nutritional displays, and social marketing [11]
Eating a home-cooked dinner every Wednesday
Pencil and paper, online modules (with or without feedback), scripted telephone messages or Internet e-mail reminders, commercial and free-of-charge Internet-based programs for monitoring dietary intake [11]
(and help themselves, as well) in yet another way: by serving as positive role models. Providers who are in the process of improving their own behavior may be more likely to encourage their patients to adopt a similar way of eating [26], and their patients are more likely to adopt it [27]. Conclusions Nutrition has moved from being just a preventive modality to being a disease management tool. Physiatrists have unique opportunities to promote healthier food choices because of their close relationships with their patients, which often have developed over many years. Incorporating healthy nutrition in both our personal and professional life presents an opportunity for a meaningful change. Physiatrists can lead the way, one bite at a time. References 1. Ford ES, Zhao G, Tsai J, Li C. Low-risk lifestyle behaviors and allcause mortality: Findings from the National Health and Nutrition Examination Survey III Mortality Study. Am J Public Health 2011; 101:1922-1929. 2. American Diabetes Association. Standards of medical care in diabetesd2014. Diabetes Care 2014;37(suppl 1):S14-S80. 3. Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part II: Focus on micronutrients and supportive nutraceuticals. PM R 2012;4:S155-S168. 4. Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part I: Focus on fatty acids and macronutrients. PM R 2012; 4:S145-S154.
390
Nutrition and Physiatry
5. Meleger AL, Froude CK, Walker J 3rd. Nutrition and eating behavior in patients with chronic pain receiving long-term opioid therapy. PM R 2014;6:7-12. 6. Gomez-Pinilla F, Gomez AG. The influence of dietary factors in central nervous system plasticity and injury recovery. PM R 2011;3: S111-S116. 7. Lianov L, Johnson M. Physician competencies for prescribing lifestyle medicine. JAMA 2010;304:202-203. 8. Mozaffarian D, Ludwig DS. Dietary guidelines in the 21st centuryda time for food. JAMA 2010;304:681-682. 9. Behan E. Health care providers: What to say to your patients about diet in 30 seconds. Am J Lifestyle Med 2012;6:448-451. 10. Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother 1995;23:325-334. 11. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation 2010;122:406-441. 12. Pomerleau J, Lock K, Knai C, McKee M. Interventions designed to increase adult fruit and vegetable intake can be effective: A systematic review of the literature. J Nutr 2005;135:2486-2495. 13. Moore M, Tschannen-Moran B. Coaching Psychology Manual. Philadelphia, PA: Lippincott Williams and Wilkins; 2010. 14. Mitchell P, Wynia M, Golden R, et al. Core principles and values of effective team-based health care. Washington, DC: Institute of Medicine; 2012. 15. Laskowski ER. Action on obesity and fitness: The physiatrist’s role. PM R 2009;1:795-797. 16. Wolever RQ, Simmons LA, Sforzo GA, et al. A systematic review of the literature on health and wellness coaching: Defining a key behavioral intervention in healthcare. Glob Adv Health Med 2013; 2:38-57. 17. Frates EP, Moore MA, Lopez CN, McMahon GT. Coaching for behavior change in physiatry. Am J Phys Med Rehabil 2011;90:1074-1082.
18. Reicks M, Trofholz AC, Stang JS, Laska MN. Impact of cooking and home food preparation interventions among adults: Outcomes and implications for future programs. J Nutr Educ Behav 2014;46: 259-276. 19. Wilneff MA, Wolf KN, Havercamp S, Nahikian-Nelms ML. A pilot study: Effectiveness of basic cooking skills and nutrition education for adults with disabilities and caregivers. J Acad Nutr Diet 2013; 113:A80. 20. Weinstein SM. Maintaining health, wellness, and fitness: A new niche for physiatry? PM R 2009;1:793-794. 21. Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: Nutrition education for medical students and residents. Nutr Clin Pract 2010;25:471-480. 22. Dacey M, Arnstein F, Kennedy MA, Wolfe J, Phillips EM. The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors. Med Teach 2013;35:e1149e1156. 23. Eisenberg DM, Myrdal Miller A, McManus K, Burgess J, Bernstein AM. Enhancing medical education to address obesity: “See one. Taste one. Cook one. Teach one”. JAMA Intern Med 2013;173:470-472. 24. Drexel C, Merlo K, Basile JN, et al. Highly interactive multi-session programs impact physician behavior on hypertension management: Outcomes of a new CME model. J Clin Hypertens (Greenwich) 2011;13:97-105. 25. Davis D, Davis N. Selecting educational interventions for knowledge translation. CMAJ 2010;182:E89-E93. 26. Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians’ prevention-related practices. Findings from the Women Physicians’ Health Study. Arch Fam Med 2000; 9:359-367. 27. Frank E, Dresner Y, Shani M, Vinker S. The association between physicians’ and patients’ preventive health practices. CMAJ 2013; 185:649-653.
Disclosure R.P. Institute of Lifestyle Medicine, Physical Medicine and Rehabilitation, Harvard Medical School, Joslin Diabetes Center, Suite 344, One Joslin Place, Boston, MA 02215. Address correspondence to: R.P.; e-mail: [email protected]. edu Disclosures related to this publication: grant, Maccabi Healthcare Service, Harvard Medical SchooldPM&R Department, Israeli Cancer Association (money to author) Disclosures outside this publication: royalties, Penn publication (money to author) M.L.D. Department of Behavioral and Social Sciences, School of Arts & Sciences, MCPHS University, Boston, MA Disclosure: nothing to disclose
E.M.P. Institute of Lifestyle Medicine, Physical Medicine and Rehabilitation, Harvard Medical School, Joslin Diabetes Center, Suite 344, One Joslin Place, Boston, MA 02215 Disclosure: nothing to disclose Supported by educational grants from Maccabi Healthcare Service, Harvard Medical SchooldPM&R Department, and the Israeli Cancer Association. Submitted for publication September 11, 2015; accepted September 24, 2015.