The clinical practice of prescribing plant-based diets

Consumers reported in focus groups that their family doctor is the health professional they expect to advise them on diet. (1) Their function is to treat or prevent disease in their patients. Doctors are trusted, so it is acceptable for the family doctor to talk about diet, even if it seems remote from the presenting symptom. (2)

Health care professionals should ask patients on a plant-based diet about their dietary practices and assess for possible nutrient deficiencies through physical examination, periodic serum monitoring and perhaps bone mineral density (BMD) monitoring. (3)

Research has documented the high rate of compliance by patients treated with a plant-based diet, especially when physicians explain the rationale behind the treatment and specifically prescribe it to their patients. (4) It has also been shown to have good compliance, even in parts of the country that traditionally have a very meat-centered diet. (5)

The importance of talking to patients about their diet cannot be overstated. In a National Health Interview survey, 24,275 patients were surveyed. Only 30% reported receiving health promotion advice, and yet 88% of those patients complied with the advice they were given.  This led to 21% increased odds that patients who received and complied with the advice they were given reported an improved health status, compared with those who did not comply or were not advised. (6)

Talking about making dietary changes

One way to start the conversation with your patient about their nutrition status is to ask them to complete a Nutrition History Form at check in. (7) Alternatively, the patient could be asked to describe the previous or a typical day’s eating pattern, with the physician listening attentively and asking questions to be able to gather information similar to the form.

From this information, the physician can identify areas in the dietary pattern where changes would be most beneficial to the patient.  When discussing a patient’s treatment plan, diet can be included as a viable and affordable option.

Some key frames that can be used to create motivation for change are the following (8):

• Feedback: How unhealthy behaviors are harming the individual – based on interview and data.
• Responsibility: Emphasize that the patient has the responsibility and freedom to make the choice to change.
• Advice: Provide clear and direct advice about importance of making changes and suggest ways to accomplish them.
• Locus of control: Discuss different options and let patient decide which make most sense.
• Empathy: The patient needs to feel heard and their concerns understood
• Self-efficacy: Instill optimism and confidence in the patient, “you can do this!”

Examples of the types of questions that can motivate patients to make changes (9):

• Given your recent lab results, is there a specific lifestyle change you’ve been thinking about making?
• Would you be interested in hearing some of the changes others with this diagnosis make?
• On a scale from 1-10, how ready are you to make changes in your eating patterns?
• What benefits do you think you’ll get from a healthier diet?
• What concerns do you have about eating healthier?
• If you were to change, what would it be like?
• What things stand in the way of taking your first step?
• What barriers might impede your success?
• How do you think you’ll go about making changes?

The patient should be asked if they prepare their own meals. If not, they may rely on prepared or frozen meals, or may regularly eat at restaurants. A discussion on available plant-based options for meals, drinks and snacks is helpful.

For those patients where another family member prepares their meals, eliciting the support of those who do can be very helpful. (10) Further support can come from family and friends. The patient may gain greater support if they can explain to friends and family why they chose to be treated with a plant-based diet and what its advantages are.

Since the plant-based diet will be new to most patients, it is very helpful to write down dietary directions on stationary with doctor’s name on it which will give it the feel of a prescription.  This is what most patients are used to, and it can be shown to family and friends for help in implementation. Potential resources that could assist the patient in their transition can also be listed.

Charting the patient’s current dietary status and agreed goals, and enlisting other health care practitioners on the patient’s team to support and encourage the patient can help with compliance. If a dietitian with experience in the therapeutic use of a plant-based diet is available for referral, this may be an option for certain more complex cases.

Two potential strategies for treating patients with a plant-based diet are to counsel patients briefly at each regular visit, or to arrange a longer in-depth session with the patient. Five to ten minutes of each office visit can be used to gradually help the patient transition toward a plant-based, charting improvements as they become evident. This may be a good strategy for when the plant-based diet is prescribed as a prophylaxis.

Alternatively, it can be effective to spend one or two office visits thoroughly explaining the diet and working with the patient on the best implementation for them.  This will facilitate a more immediate implementation of treatment with a plant-based diet. This may be more appropriate as an interventional treatment with patients already with a pathology.

Medication titration

The treatment effects of the plant-based diet often take longer than drug therapy to become evident. Six weeks are frequently necessary for improvements to be noted. Effectiveness also depends on how quickly and completely the patient is able to implement their dietary transition. Medications should be titrated as clinical improvements become evident. Lab work should be scheduled in accordance with the pace of clinical improvement.

Since the plant-based diet treats common comorbidities, titration of any medications prescribed to treat those pathologies will be necessary as well. Likewise, labs for these pathologies should be ordered on a schedule that keeps pace with the expected pace of clinical improvements of comorbidities.

Improvements of signs and symptoms often continue for a few months. Therefore, it may take some time to judge the full efficacy of treatment. Patients, often used to the faster action of drugs, should be informed that the treatment may take a little longer but is well worth the wait.

Discussion

Vegetarian and vegan diets and food are not as uncommon as they used to be. The sales and availability of meat and dairy substitutes are have grown enormously in recent years. These products make dietary changes much easier in most cases, and when combined with a diet composed of vegetables, whole grains, fruits, legumes and nuts they can be very healthy.

Many people struggle with copayments and have high deductibles. With rising health care costs, treatment with a plant-based diet can relieve financial stress on the patient. Patients should be informed that it may save them money both in the short and the long term.

We live in an age of advanced medical technology. These advances have alleviated much suffering and saved countless lives. They have an unquestioned place in modern medicine. However, this can sometimes lead towards a kind of technological tunnel vision on the part of the patient. Little notice may be taken of treatments that, such as a plant-based diet, while lacking in technological sophistication, are nevertheless safe and quite efficacious. Patients should be told that while it’s a low tech treatment, it is still very effective.

As most physicians know, many patients these days attempt to gain health-related information and to treat themselves based upon what they read on the internet. Such information is often highly unreliable. (11) Most patients would rather get their health information and advice from their physicians, but turn to the internet when they can’t. Therefore, to serve the best interests and needs of their patients, physicians should familiarize themselves with this treatment. Physicians should warn their patients that nutritional information gained on the internet may be very unreliable.

Appendix: Nutrition History Form

References