“Y

ou can lead a horse to water, but you can’t make him drink.” Or can you? When I decided to become a registered dietitian (RD), I had visions of myself dispensing nutrition advice to eager patients who would listen attentively and then follow my instructions to the letter. It didn’t take long to find out that helping people change lifelong eating patterns was a little tougher than I had anticipated. In fact, I recall the exact day I was struck with this realization. I was in the cardiac care unit speaking to a man who weighed 267 pounds and had just undergone quadruple bypass surgery. I recall telling him I was the dietitian and that I had some material for him, which outlined his new dietary regimen. I was very enthusiastic and told him I was going to help him learn how to make better choices that would enable him to lose weight and lower his cholesterol. He looked at me with a big smile on his face and said, “Honey, I just got all new plumbing, so I am good for at least another 10 years, but thanks for coming.” I was crushed. I just couldn’t understand why someone would not want to improve his or her diet after enduring open-heart surgery.
       Shortly thereafter, I began focusing exclusively on long-term care and faced many different types of noncompliance in that environment. Residents with cognitive difficulties were trying to eat napkins, tablecloths, and an array of other nonedible items. These residents didn’t have the capacity to follow my instructions, so again, I felt at a loss. Other times, family members would visit and bring all sorts of goodies for my patients with diabetes, the dysphagia patients refused to drink their prescribed thickened liquids, and others just flat out refused to eat anything at all. The list can go on and on. In order to deal with these types of issues, we must understand the different causes of noncompliance, the stages of behavior change, and some techniques that can be used to overcome resistance.

Causes of Dietary Noncompliance

       Researchers have explored three categories of variables that appear to be associated with noncompliance. These categories include demographic characteristics, psychological variables, and social variables.¹
       Demographic barriers include educational level, financial considerations, and access to healthcare. Some patients may not have prior knowledge about proper nutrition, and others may not have the financial resources to purchase the 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 may be too depressed to try yet another intervention or fail at another diet. In long-term care, residents are often 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 noncompliance involves social variables. This might be lack of a support system, isolation, poor family relationships, and poor relationships with healthcare providers. Isolation has been linked with 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 Model 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.²
       The six steps are:
1. 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 or her awareness of the problem. For example, if a patient is at this stage, it may be useful to ask if he understands that there is a connection between thickened liquids and preventing aspiration. It would not be useful to instruct this patient on the types of thickening agents available, because he is not yet ready to accept that type of direction.
2. Contemplation: Once some awareness of the problem arises, 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 state that properly thickened liquids are one intervention that can help with managing swallowing problems. Don’t promise that if all liquids are thickened, the resident will never aspirate, because this will set up false expectations.
3. 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 a strategy that is acceptable. For example, the patient may state that he does not like the taste of thickened coffee and that it is not an acceptable beverage to him, but he is willing to drink less coffee and substitute juice for coffee.
4. Action: At this stage, the patient engages in the action that will bring about change.² The patient will actually make a change and request juice with meals and determine if it is acceptable to him. If not, other beverages can be taste-tested to help him find ones that he finds acceptable.
5. Maintenance: During this stage, the goal is to continue the changed behavior and not relapse.² For example, if the patient drinks coffee without any thickener, he can relapse back into past behavior the next day and drink more coffee or continue on the plan and resume drinking thickened juice instead of regular coffee.
6. Relapse: If relapse occurs, the patient’s task is to start the change process again rather than remain stuck in relapse. The goal is to resume action.² For example, if the resident never accepts the thickened juice again, it is helpful to determine why this occurred. Perhaps he was tired of it. Perhaps he didn’t see it helping his condition. Perhaps it wasn’t easily available or prepared properly. 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 long-term care, it is useful to have a permanent record of the approaches used to improve nutritional status. Noncompliance should also be documented. Residents have the right to refuse dietary interventions, but it should be noted that this right is reserved for residents with sufficient cognitive ability to understand the implications of their decision. If a resident is determined to disregard dietary advice, it is reasonable to have the resident 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

       There are many traditional counseling techniques and interpersonal skills that can be used to improve success when encouraging patients to modify their dietary habits.³ 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 a 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 with diabetes are often told to stay away from many foods and may look at the counselor as the “diet police.” 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, since most patients enjoy hearing that they are doing well and are on their way to success.

Putting It All Together

       The best approach for dealing with nutritional noncompliance is to use a combination of several approaches. The case example on page 6 shows how several techniques can be used together to improve outcomes. 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 that we not only know about nutrition but also about human nature and psychology. Nutritional counseling that is truly effective in facilitating actual behavior change must not focus on a diet or disease entity but on the patient.