Strategies for practitioners to support patients in plant-based eating

Successfully implementing a plant-based diet is attainable for patients, but the likelihood of achieving long-term, dietary maintenance can be increased by follow-up and support from practitioners. Practitioners, in particular physicians, are seen as nutrition authorities,[1] and are therefore well-positioned to deliver dietary advice and nutritional prescriptions.

Practitioners who are caring, empathetic, and who engage in participatory decision-making with the patient increase likelihood of patient adherence to recommendations.[2] During office visits, using the counseling style of motivational interviewing (MI) facilitates a collaborative conversation with the patient to evoke behavior change on his or her own terms,[3] and has been shown to increase health promoting behaviors among patients.[4] The MI guiding principles center on: (1) accepting the status of patient behavior in the present; (2) resisting the authoritative reflex to correct; and (3) focusing on the patient's own motivations for change. MI strategy is summarized with OARS: Open-ended questioning, Affirming efforts and strengths, Reflecting back what you hear, and Summarizing what comes from the patient as you go (particularly any thoughts of positive change).

Through open-ended questioning, practitioners and support staff can learn what is important to patients, how to approach next steps, and how to characterize their readiness to change. Open-ended questions avoid steering respondents towards simplistic, yes-or-no responses. This practice encourages active participation and has been shown to increase patient adherence.[2] Some of this probing can be delivered before the appointment either by dieticians or support staff, or with intake forms which can be paper-based or completed online before the visit. An open-ended question might be “What aspects of changing your diet would you be willing to start with now?” vs. “Do you want start changing your diet now?” Conversations during the office visit should positively affirm past successes and the patient's self-efficacy in achieving dietary change.[5]^,[6] Following patient readiness for change, the SMART Goals model (Specific, Measurable, Attainable, Relevant and Time-specific) can be used by the patient and provider together to effectively set goals for dietary improvements.[7]^,[8] Table 1 provides information and additional resources for training in MI. A Google search will easily locate these materials; alternatively, refer to the online version of this paper for direct links.

Table 1. Motivational interviewing education and training resources.

Resources	Description
Motivational interviewing: an introduction Steven Malcolm Berg-Smith	Overview and training manual, includes sample questions and questionnaires.
The effective physician: motivational interviewing demonstration	Six minutes Youtube video demonstrating effective myocardial infarction techniques in a brief appointment.
The ineffective physician: non-motivational approach	Five minutes Youtube video demonstrating confrontational suggestion in a brief appointment.
Motivational interviewing strategies and techniques: rationales and examples	Tip sheet for crafting effective messages in therapeutic contexts.
Motivational interviewing network of trainers	MI training network with live event calendar.
Motivational Interviewing: A Guide for Medical Trainees, 1st Editionby Antoine Douaihy (Editor)	Textbook on myocardial infarction specifically written for medical practitioners.
SMART goals from WebMD	WebMD describes SMART Goal setting using weight loss and fitness devices as an example.

Many patients will have questions and concerns about plant-based eating. Practitioners should be prepared to address some of these barriers and questions to a limited extent during a brief appointment with evidence-based responses but should also refer patients to resources for further learning. Clinicians who are able to speak from personal experience as someone who follows a plant-based diet will gain greater credibility through leading by example. Table 2 reviews common concerns with a suggested response and recommended resource to share with patients.[9]^–[20]

Table 2. Key discussion points for patient concerns about plant-based diets.

Concerns	Suggested response	Recommended resources
Worry about nutritional adequacy, such as getting enough protein, B12, vitamin D, iron, calcium or other nutrients.[9]	Reassurance that well-planned plant-based diets are healthy and nutritionally adequate; reframe question to remind patients that the majority of Americans (who are omnivorous) do not get enough vitamin A, vitamin D, vitamin E, folate, vitamin C, calcium, magnesium, potassium, or fiber.[10]	Position paper from Academy of Nutrition and Dietetics on vegetarian diets.[11]
Low self-efficacy due to unfamiliarity or lack of experience in shopping for or preparing plant-based foods.	Provide handouts with recommended cookbooks, recipe websites, and chefs to follow on social media.	Lighter.world StraightUpFood.com ForksOverKnives.com DrMcDougall.com Kaiser Permanente Starter Kit
Reluctance to eat more legumes because of the possibility of increased flatulence.	Increased flatulence may be temporary,[12] and adding more fiber-rich foods gradually, as well as soaking or sprouting legumes may help reduce flatulence;[13] remind patients of benefits of fiber consumption.	Winham & Hutchins comparison of 3 feeding trials to assess flatulence with increased fiber found complaints of flatulence subsided with time.[12]
Concerns about additional expense of buying plant-based foods or economic limitations for grocery shopping which are associated with highly processed foods.[14],[15]	Steer patients away from buying costly and highly processed vegetarian replacement meats and cheeses; suggest inexpensive frozen vegetables, buying items in bulk, such as legumes, brown rice, potatoes, and oatmeal; discuss nutritional value and nutrient-to-cost ratio of legumes as compared to meat.[16]	How to Soak & Sprout Nuts, Seeds, Beans, and Grains blog from Vegetarian Times.
Reluctance to try new foods or consume foods thought to be unpalatable (“I don't like vegetables…” or fruits, legumes, whole grains, etc.)	Explain that taste preferences are learned behaviors as opposed to personality traits, and preferences for high-sugar, high-fat, and high-salt foods often are addictions and will shift after a period of adjustment.[17],[18]	The Pleasure Trap by Alan Goldhamer and Douglas J. Lisle.[19] Breaking the Food Seduction by Neal Barnard.[20]

In addition to office visits, creating opportunities for regular follow-up contact is key. Increased frequency and total contact time with practitioners is associated with greater success in dietary change.[5]^,[6] Follow-up contact can take the form of individual appointments or group medical appointments. Groups led by the physician, staff dietitian, or educator can enable ongoing education to patients within the context of insurance coverage, with the added benefit of contact between patients engaged in similar dietary goals. For suggestions on using group appointment reimbursement codes, review the white paper issued by the American Association of Family Practice, check the Current Procedural Terminology (CPT) manual, and confirm with specific payers.[21] In addition to in-person follow-up, email and social media enable frequent contact with minimal time investment. For electronic communications, it is not necessary for the medical practice to generate original content, but simply to re-share recipes and relevant articles.

Predictors of long-term dietary adherence include social support and positive social norms affirming the intended behavior,[22]^–[27] a food environment that offers “healthy defaults”,[28] and a variety of intra-personal, cultural, and economic factors such as self-efficacy education,[29] convenience, food access, and others.[30] These elements cannot be delivered single-handedly by a physician in a short office visit; thus, establishing a framework for increased contact and referrals to outside recourses is critical. Integrating plant-based dietary practices into a patient's regular lifestyle will normalize the behavior and make long-term adherence more realistic. Table 3 provides suggestions for generating multiple avenues of support and ongoing engagement in plant-based eating.

Table 3. Strategies to increase patient engagement in plant-based education.

Goal	Practice	Tips for success
Reinforce seriousness of nutritional recommendations in the appointment	Write a “prescription” for the additional plant food supported by the patient's willingness to eat more.	Use the Plant Rx pads produced by the Plantrician Project.
Provide motivation and introductory education on the benefits of plant-based eating	Ask patient to watch the move Forks Over Knives following an initial discussion of diet.	Mention options for viewing – Amazon, streaming, or could offer DVD for purchase in the office.
Introduce patient to breadth of nutrition resources and recommended reading	Maintain a browsing library in the waiting room of videos, cookbooks, and plant-based nutrition books. Provide a handout listing these recommended titles for patients to take.	Arrange for comfortable chairs with a small table if possible to encourage browsing.
Encourage patient to make home food environment consistent with his or her goals	Explain importance of creating “healthy defaults”, avoiding purchase of junk food, and making healthy snacks accessible in the home, car, office, etc.[31]	Include suggestions for healthy snacks in handouts; could provide strategy session with group meetings moderated by a dietitian or educator.
Regularly disseminate nutrition and recipe content to patients	Ask patients to follow the practice on Facebook or Twitter; send daily updates.	Follow other plant-based recipe and nutrition sites; assign administrative assistant weekly task of scheduling re-shares using scheduler Hootsuite.
Foster community among patients to create social support for the diet	Hold monthly or bi-monthly potluck gatherings with patients.	Offer free cookbook giveaway drawings to incentivize attendance.
Generate buy-in from patient's friends and family to create social support for the diet	Invite patients to bring loved ones to medical appointments.	Speak directly to patient's friends/family to enlist their help as an integral member of the patient's medical team.

Providing ongoing education, referral to outside resources, and facilitating patient-to-patient interactions among those pursuing a similar diet will add to what can be delivered in a brief, individual medical appointment, and will increase likelihood of successful dietary adherence to a plant-based diet.