Helping Patients Make Healthier Food Choices

[Lane Therrell FNP, MSN, RN, NP]

Nutrition is a significant part of everyday health for all ages. However, most nurses and healthcare providers don’t get much classroom or clinical instruction on nutrition and managing dietary change during their basic education. (DiMaria-Ghalili et al., 2014). And yet, in spite of our relatively weak academic foundation, we routinely advise our patients to “eat a healthy diet.”

Lasting dietary change begins with a patients’ ability to make healthy, or at least healthier, food choices. One of the foundational skills involved in making those healthier choices is reading food labels. But, if nurses and other healthcare providers have not learned these basics, who is teaching our patients this skill?

As an NP in primary care, I observed that most of my patients who would benefit from meeting with a dietician or nutritionist did not actually “qualify” for these types of specialist encounters due to insurance limitations. And many of those who qualified failed to make and keep “extra” appointments. So, food label reading remained an untaught, unlearned skill.

Do you feel confident enough in your own food-label reading abilities to teach your patients the basics? I had to do some extra studying to get myself there. Here’s how I’m leveraging what I learned.

The 3 Most Important Parts of a Food Package

I like to set the stage by pointing out 3 distinct parts of a food package—the front of the package, the nutrition facts panel or “label,” and the ingredients list. These three parts contain key pieces of information that work together to help consumers make healthier food choices. Here’s what to look for, understand, and decide for each part of a food package.

Front of Package

Food manufacturers know the front of the package is the first thing consumers see on a grocery store shelf, so it’s prime marketing real estate. That’s why you’ll want to take a close, thoughtful, look at the front of the package through the eyes of a skeptic.

Look for:

When you tune in and look carefully at the front of a food package, you’ll likely become aware of things you’ve never noticed before, even if it’s your favorite brand. Look at the names, descriptions, colors, images, designs. Be alert for key marketing words and phrases like reduced sodium, no sugar added, natural, low fat, or gluten free. What do these components suggest about what’s inside the package? And do the words and phrases really mean what you think they do?

Understand:

The big takeaway is that the front of a food package is designed to sell the product, not to tell you what’s in it. And when you understand that attractive is not the same thing as healthy, you realize that many packaged foods are not as healthy as they may seem at first glance.

The appealing colors, images, and words that make a food product look and sound attractive can also create a “health halo,” an intangible feeling of goodwill and good health associated with the product. Food manufacturers keep this idea in mind when they design packaging and advertisements, because marketing studies repeatedly show that when you think a food is healthier, you'll eat more of it. (Egan, 2019).

It’s also important to understand that marketing words may carry hidden meanings or implications. For example, the word “reduced,” as in reduced-sodium or reduced-fat, means the product has 25% less fat than the original version. (Egan, 2019). While that’s a step in the right direction, be aware that the total amount, even when reduced, may still be far more than ideal.

Furthermore, whenever an ingredient such as gluten is taken out of a food, something else—like extra sugar or salt—is generally added back in its place. These added ingredients may be more unhealthy than the original ingredient that was removed.

Decide:

The front of the package is your first stop in gathering clues for deciding whether the product supports your health or not. Notice what you’re drawn to, and what you’re looking for: Does what attracts you match up with what you know will support your health goals? Of course, if you aren’t sure what your health goals are stop and get clear about them before you go any further.

Nutrition Facts Panel

After you’ve looked at the front of the package with a critical eye, continue your quest for information by looking at the nutrition facts (NF) panel, also referred to as the nutrition facts label. This federally regulated piece of information tells you how much of which nutritional component is in the product.

The NF panel is your go-to resource for discovering how many calories are in your favorite foods. And it also reveals the percentage of fat, carbohydrates, protein, sodium, vitamins, and minerals that are present. The NF began appearing on food labels in the early 1990s, as required by the Nutrition Labeling and Education Act. (Egan, 2019).

Look for:

No matter what your dietary goals happen to be, or how they may change, the NF panel can help you make choices that support them.  Paying attention to the serving size, calories, percent daily value, added sugars and other nutrients listed on the NF panel will help you decide how consuming the product will affect your goals.

The FDA updated the appearance and requirements of the NF panel in 2016 to better assist consumers in making healthy food choices. The revised NF panel emphasizes total calories, makes serving size information more prominent, shows added sugars, and should be official on all US packaging by 2021 (Egan, 2019). Compare the original and new NF panels for more details. (Side-by-Bide Comparison: Original Label versus New Label, 2019).

Understand:

The numbers on the NF panel are most helpful to you when your personal intake goals are clear. Are you cutting calories? Reducing sodium? Reducing sugar? The NF panel shows you the extent to which consuming an individual product can help support your efforts to meet your goals.

And when you look at the NF panel for everything you consume, it can help you see your real-time and cumulative food intake in the context of your overall dietary goals. In fact, the NF can be used to help you see and track your “food numbers” in much the same way you may already be tracking other health numbers, like blood sugar and blood pressure.

The key here is learning to notice the numbers associated with food. It’s not so much about the numbers themselves as it is about the trends over time. The bottom line is: The NF panel cannot help you if you don’t have clear goals and sincere commitment to meeting them.

Decide:

Use the numbers from the NF to help you decide how the product supports or detracts from your daily intake goals. Ask yourself: Does this food support my health goals? How will choosing this food now influence my other food choices throughout the rest of the day? Use the numbers to help you decide whether to consume the food inside the package you’re looking at or make a different choice.

What are the options are available to you? Knowing the array of options available to you is a major step in making healthier choices. If you determine the product does not support your health goals, will you choose to consume this food anyway? Or will you look for a different, more supportive, option? Or might you choose to do something else, like schedule extra exercise to offset any over consumption of a specific nutrient? Ultimately, what action will you take?

Ingredients List

Finally, take a look at the ingredients list. Ingredients lists are printed in descending order by quantity. (Bjarnadottir, 2019). the item listed first on the list is the most prevalent ingredient.

Don’t let the ingredients confuse you. Instead, use the list as a way to spark your curiosity about what’s in your food, and start conversations with your health professionals and your family.

Look for:

When looking at the ingredients list, pay special attention to the number of items listed, the order in which they are listed, and any specific ingredients of interest. In general, shorter ingredients lists indicate a product has undergone minimal processing.

Look for shorter lists and ingredients you recognize. Be alert for allergens like dairy derivatives (whey protein), nuts, and shellfish. Avoid products listing sugar as a first ingredient. Pay attention to the order of items listed. Be alert for ingredients you cannot pronounce or are unfamiliar with, as these may indicate the presence of toxic chemicals and dyes, hidden sugars, non-nutritive fillers etc.

Compare the nutrients list to the nutrition facts panel to see how the two correspond. Let the comparison and your conclusions guide you to discover the best ways to support your health.

Understand:

Because ingredients are listed in descending order, the product contains the most of the first thing on the list. This helps you put the product’s nutritional value in perspective, in light of your health goals.  For example, if one of your health goals is to reduce the amount of sugar in your diet, and you’re deciding whether to eat a certain product, but the first ingredient listed sugar, you may decide to choose a different product.

The ingredients list also relates back to the front of the package. If something has been taken out, the ingredients list is where you can find out what has been added back instead.

Decide:

Ultimately, what’s in the package ends up in your body. Cross reference the ingredients list with the front of the package and the nutrition facts panel.

Ask yourself: Does this item contain ingredients that I wish to consume? What is the most prevalent ingredient in the product? Does this ingredient support your health goals? Is this product is as advertised, or is the marketing misleading?

Will you decide to consume this product? Do you feel confident and satisfied about your choice?

Additional Tips

Here are some additional helpful tips for teaching your patients how to make healthier food choices:

• Keep examples of food packaging in your clinic, exam room, or office so you can provide quick hands-on demonstrations with real products the patient is familiar with.
• Encourage patients to get familiar with food labels at home where they have time to practice reading them, coming up with additional questions, and figuring things out.
• Challenge patients to evaluate the packaged foods already in their home pantry to see whether they support their health goals or not. If not, offer support for small improvements such as looking for a low sodium version of a favorite brand, or trying a different brand with less sugar.
• Advise patients to take their reading glasses with them to the grocery store.
• Encourage patients to plan enough time in the store to read labels and make their healthiest decisions before they put items in the cart.

The bottom line is, your patients can’t eat a healthy diet if they don’t have the tools for making healthy choices in the first place. Learning how to read labels on packaged foods is a good first step toward making choices and decisions that support health goals. If you learn how, you can teach your patients whenever you have the chance. And you’ll be able to back up your instructions to “eat a healthy diet” with practical advice.

Question for Discussion

How can you use information about food packaging to help your patients manage dietary change?

References

1. Bjarnadottir, A. (2019). How to Read Food Labels Without Being Tricked. Retrieved 25 November 2019, from https://www.healthline.com/nutrition/how-to-read-food-labels

2. DiMaria-Ghalili, R., Mirtallo, J., Tobin, B., Hark, L., Van Horn, L., & Palmer, C. (2014). Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. The American Journal Of Clinical Nutrition, 99(5), 1184S-1193S. doi: 10.3945/ajcn.113.073536

3. Egan, S. (2019). How to Read a Food Label. Retrieved 25 November 2019, from https://www.nytimes.com/guides/well/how-to-read-a-food-label

4. FDA.gov. (2019). Side-by-Bide Comparison: Original Label versus New Label [PDF] (p. 1). Retrieved from https://www.fda.gov/media/97999/download

[Wuzzie]

Really great information Lane (and I do mean that) but... in nursing school I had one, one nutrition class. Right down the hall from me is a lovely young lady whose entire education was about nutrition. She has a masters degree in it. She is the expert and I will defer patient ed about this subject to her and her colleagues.

[RosesrReder, BSN, MSN, RN]

Great article; however, “good nutrition” is super subjective. For example, I have followed a very low carb style for 12 years and have lost and maintained 230 lbs off my body. Reversed so many comorbidities and have been living my best life (literally).

Still to this day, I get not only harshly judged, criticized and bullied by health care professionals I have established care with because of it. Not only do they spew hatred and misinformation but have been fired as a patient.

I get praised and applauded when I relate my weight loss and medical history up until “low-carb” or “ketogenic” comes out of my mouth.

I feel VERY some type of way about nutrition and nursing. More so because I have always preferred to see an NP over and MD and I now have PTSD lol

I do love the teaching aspect but I too will digress and let the pros handle this; especially, since more and more these folks are changing their mind sets and teaching the latest EBP from current literature.

[Orion81RN]

38 minutes ago, RosesrReder said:

Great article; however, “good nutrition” is super subjective. For example, I have followed a very low carb style for 12 years and have lost and maintained 230 lbs off my body. Reversed so many comorbidities and have been living my best life (literally).

Still to this day, I get not only harshly judged, criticized and bullied by health care professionals I have established care with because of it. Not only do they spew hatred and misinformation but have been fired as a patient.

I get praised and applauded when I relate my weight loss and medical history up until “low-carb” or “ketogenic” comes out of my mouth.

I feel VERY some type of way about nutrition and nursing. More so because I have always preferred to see an NP over and MD and I now have PTSD lol

I do love the teaching aspect but I too will digress and let the pros handle this; especially, since more and more these folks are changing their mind sets and teaching the latest EBP from current literature.

Same! I'm like my Ha1c is better than ever, same with cholesterol, BP etc...mind your business. I eat more vegetables than ever. I'm still in the process of losing a LOT of weight, so I am still overweight. I don't want to hear a word from anyone who doesn't know my progress attempting to "educate" me. Just bc Im not at my goal weight yet doesn't mean I haven't made tremendous progress.

I think the article is great in regards to teaching patients how to accurately read a label. I had the mother of a peds pt talking to me one time about her diabetes and her trying to get it under control. She was dangerously misinformed on how to read carbs. It was scary.

[Cowboyardee]

Just my humble opinion:

I suspect that among the kinds of functionally literate, independent people who we imagine having these kinds of conversations with as health care professionals, the problem has less to do with their lack of familiarity with nutritional information as written on food packaging and more to do with the confluence of a few major factors:

- lack of time. Convenience food, ready made food, food with a long shelf life all have a tendency towards being less healthful than less convenient food.

- lack of money. Same reasoning as above, especially for food that is both healthy and convenient.

- lack of a strong medical consensus about what healthy eating should look like. There's such a wealth of fad diets, each with just enough support in research to be plausibly a 'better way' of eating, that it's extremely easy to discount any sound nutritional advice on the basis of citing some diet (complete with it's own medically-qualified cheerleaders) that flaunts that particular advice and still seems to work fine for its adherents. Right now as a culture, we all seem to agree that trans fats and excess sugar are bad... and thats about it.

- lack of desire or willpower. Pretty self-explanatory, but its a tough nut to crack.

[Emergent, RN]

The medical profession is so behind the times on nutrition, it's a joke. In America, it's all about metabolic and inflammatory disorders resulting from the totally unnatural constant availability of carbohydrates in highly processed foods. Human beings did not evolve under these circumstances.

Instead, we've been advising low fat yogurt, laced with sugar, lots of pasta, which has very little nutrition in it, and diet soda, which is full of chemicals. Also, low salt, and salt is not a factor in the majority of people's htn.

Also, the industry has pushed drugs, drugs, drugs. Meanwhile, obesity is at all time highs. We are only maintaining life expectancy very expensively with advances in technology.

[vintagemother, BSN, CNA, LVN, RN]

Just this week, I had 2 pts with questions about how they could eat better to avoid hospital admissions in the future. I talked about good choices, but then remembered that our charting system, EPIC, has educational handouts that can be printed for pts. I printed out education for them, and documented that I provided it. One pt told me thank you as she read it. The other told me she can’t read big words and would have to ask her grandchild to read it to her. I also remember yet, another pt last week with dietary questions. That discharge was rushed and I felt bad I had to tell her basic info and refer her to her PCP for more information. These tasks are complex. Yet, pts deserve to be provided with good education, because what you eat has a big factor on your health. Bedside nurses like me are already consumed with so many tasks. But I think this education is important.

[labordude, BSN, RN]

On 12/4/2019 at 2:04 PM, Emergent said:

The medical profession is so behind the times on nutrition, it's a joke. In America, it's all about metabolic and inflammatory disorders resulting from the totally unnatural constant availability of carbohydrates in highly processed foods. Human beings did not evolve under these circumstances.

Instead, we've been advising low fat yogurt, laced with sugar, lots of pasta, which has very little nutrition in it, and diet soda, which is full of chemicals. Also, low salt, and salt is not a factor in the majority of people's htn.

Also, the industry has pushed drugs, drugs, drugs. Meanwhile, obesity is at all time highs. We are only maintaining life expectancy very expensively with advances in technology.

For every 5 articles blaming carbohydrates, there's 5 more blaming fats and 5 more blaming sugars. The lack of evidence (due to almost zero funding) has spewed more misinformation from guesswork and bad science than anything else.

Also, literally everything is "chemicals."

No mention of the increasingly sedentary lifestyle that has exploded for a variety of reasons? The reduction in recess and outdoor play for kids compared to 20+ years ago? Sure diet is a component, but it's definitely not the only one.

[Lane Therrell FNP, MSN, RN, NP]

On 12/4/2019 at 6:42 AM, Wuzzie said:

Right down the hall from me is a lovely young lady whose entire education was about nutrition. She has a masters degree in it. She is the expert and I will defer patient ed about this subject to her and her colleagues.

You are indeed fortunate to have easy access to a nutrition expert. Sure wish I had the same! ?

[Lane Therrell FNP, MSN, RN, NP]

On 12/4/2019 at 9:32 AM, RosesrReder said:

“good nutrition” is super subjective.

I get praised and applauded when I relate my weight loss and medical history up until “low-carb” or “ketogenic” comes out of my mouth.

Getting bullied by healthcare professionals is never ok... and it's beyond comprehension to me that it could happen when you're having good outcomes. In my humble opinion, if they truly cared about their work, they'd be asking you how you're making a low-carb/ketogenic lifestyle work for you instead of shaming you for trying it.

Your story is a testament to the value of individualized care: What works for one person doesn't necessarily work for someone else. I'm looking forward to a future where each of us will know what eating pattern works best based on our genetic profiles...no guesswork, and no wasted time trying things that don't work.

Meanwhile, since I don't usually have a dedicated nutrition professional with me in the exam room when the patient is asking questions and ready to hear some answers, I decided to learn some simple practical tips (like reading labels) to support my patients during those teachable moments. Sure, my "bag of nutrition tips" is a drop in the bucket, but we all gotta start somewhere.

I figure if I can just get my patients interested in learning a little more, it can be helpful. If we're lucky, a spark of interest can lead them to discover something that will work for them-- kind of like what happened for you.

[Lane Therrell FNP, MSN, RN, NP]

On 12/4/2019 at 10:18 AM, Orion81RN said:

I don't want to hear a word from anyone who doesn't know my progress attempting to "educate" me. Just bc Im not at my goal weight yet doesn't mean I haven't made tremendous progress.

You bring up a great point that far too many healthcare professionals don't understand the difference between "educating" and coaching/supporting a patient through a change.

Change is difficult, whether it's weight loss or something else. Any amount of progress toward a goal equates to victory that can be leveraged and expanded. As far as I'm concerned, all victories, no matter how small, are worthy of acknowledgement and celebration-- so, CONGRATULATIONS on all your good progress so far. ?

[Lane Therrell FNP, MSN, RN, NP]

On 12/4/2019 at 10:26 AM, Cowboyardee said:

Just my humble opinion:

I suspect that among the kinds of functionally literate, independent people who we imagine having these kinds of conversations with as health care professionals, the problem has less to do with their lack of familiarity with nutritional information as written on food packaging and more to do with the confluence of a few major factors:

- lack of time. Convenience food, ready made food, food with a long shelf life all have a tendency towards being less healthful than less convenient food.

- lack of money. Same reasoning as above, especially for food that is both healthy and convenient.

- lack of a strong medical consensus about what healthy eating should look like. There's such a wealth of fad diets, each with just enough support in research to be plausibly a 'better way' of eating, that it's extremely easy to discount any sound nutritional advice on the basis of citing some diet (complete with it's own medically-qualified cheerleaders) that flaunts that particular advice and still seems to work fine for its adherents. Right now as a culture, we all seem to agree that trans fats and excess sugar are bad... and thats about it.

- lack of desire or willpower. Pretty self-explanatory, but its a tough nut to crack.

I totally agree there's a "confluence of factors" that needs to be considered whenever nutrition/dietary/eating habits are concerned. I would add to the list of factors: hormonal changes, culture and belief systems, stress management, medication effects, and more. The more I think about it, the list of factors could go on and on and on.

And then it starts to feel overwhelming... And then it gets tempting to just say, "Oh, I don't have time for that, so I'll leave it to the experts." But then the patient never ends up in front of an "expert" (even if I refer them to go see one). So then I have to start asking myself what else can I do?

I've always been one to step up and try. So, the way I'm choosing to handle the reality of my patients' desperate need for nutrition education when I'm not a nutrition expert is to start small. Get curious. Use my critical thinking skills to learn what I can. Use my coaching skills with my patients. Ask them to be involved in setting their goals rather than handing there goals to them like homework assignments. Listen to them more than I talk. Pick a topic, like labels, and start a conversation. Empower the patient. Show them I'm still learning too.

To me, taking one small step at a time is better than doing nothing at all or ignoring the problem because there's no one "right" solution...