Asking Patients About Nutrition Can be as Sensitive as Asking About Sexual History

Experienced PA Shares Insights into How to Reframe Nutrition with Patients

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March 18, 2020

Healthcare providers know that good health starts with good nutrition. In PA school, students learn how to ask open-ended questions and talk about sensitive topics like sexual history. But there are some nutrition-related areas that may be equally as sensitive, like body-image and how people feel about food.

Nutritionist and diabetes educator Ellen Mandel, PA-C, DMH, MPA, MS, RDN, CDE, has been a PA for 24 years and a registered dietitian for nearly 40 years.

On the front lines with patients
Mandel has been on the front lines of working with patients and continues to delve into research on metabolic syndrome and other issues that produce hypertension, cardiovascular disease, diabetes and dyslipidemia. The incidents of overweight and obesity directly correlate with these types of comorbid conditions.

As Mandel was studying nutrition for the first time in college, she realized that people’s cultures and language and their choices of food were linked to nutrition. After becoming a dietitian, she worked in a teaching hospital which allowed her to be involved in morning rounds and surgical and medical cases.

“I began to notice patients’ nutritional needs, whether they were pre- or post-op and needed additional protein and calories or whether they were anemic. I became frustrated about constantly asking doctors, ‘would you mind ordering this lab’ and explaining why I wanted it. This drove me to consider either medical school or becoming a PA.”

Family practitioners, whether PAs, nurse practitioners, DOs or MDs, are the nutrition gatekeepers, she says. “We are going to see disorders such as diabetes, thyroid disease and osteoporosis right at the gate. A patient may walk in with fatigue and poor wound healing, and you’re going to say, ‘Oh, look at that. The A1c is elevated and you qualify for prediabetes.’”

Conversation with patients
PAs have an opportunity to initiate a conversation about nutrition with their patients, according to Mandel. “We know it’s not just selection or food availability that is contributing to poor diet and poor eating habits. If it were just food, we probably wouldn’t be in this predicament. There are very strong psychosocial components. Being affected by overweight or obesity or having diabetes or other types of morbidities or conditions, patients feel stigmatized. There’s been a lot of research, particularly in the area of diabetes, that patients will not go to diabetes educational programs because they don’t want to admit that they have problems with their health or eating or problems in general.”

Mandel has a unique and relaxed way to start the conversation with her patients. “I usually ask the patient, ‘Are you concerned at all about your nutritional intake or are you concerned about the way you feel? Is it possibly related to your activity level or even the body weight?’” Then she sits quietly to give them the authentic impression that she really wants to hear what they are going to say next.

“You want to know who they are, what they’re thinking and feeling and to know that you will be patient. It doesn’t take long for people to sense that and then they begin to open up. It works. I have seen it.

“I like to talk about potential and when I am sitting in an exam room with a patient, all I see is someone who has a window of opportunity. And I say, ‘Why don’t we crack the window and see the small or larger ways that we can impact this problem so that you can have many, many years of a healthy quality of life? What can you do to leave a positive, healthy legacy for your family?’ I can see that they’re thinking about being a role model for their kids.”

Training PA students
Mandel is currently the program director at the Johnson & Wales PA program. As a teacher, Mandel trains PA students to address overall patient health including nutrition and activity by asking questions.

“PA educators are quite expert at teaching PA students how to ask open-ended questions, how not to lead patients, and how to cover sensitive areas such as sexual history. We need to teach our students to ask questions about what is sensitive to their patients, such as body image, how they feel about food, and whether they are bullied.”

She also has students keep a food record to demonstrate the value of reviewing a 24-hour food record with a patient. The food record allows clinicians to point out areas of concern or to highlight good habits. Mandel says she is providing real-life training on how to have a diet recall analyzed in a setting that is very similar to what students might be doing when they graduate.

In addition to the real-life training, Mandel also recommends several resources to help improve clinicians’ nutrition conversations with patients:

• AAPA’s CME Central’s Nutrition Toolkit
• PA Foundation’s 2 podcasts on nutrition
• American Diabetes Association Practice Guideline Resources
• American Academy of Nutrition and Dietetics’ eatright.org
• HHS Dietary Guidelines for Americans
• HHS health.gov

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