By Carolyn Feibig, MS, RD, CCTD

In medicine, nutrition is a science; but for people, it is a biography. What and when we eat can hold deep personal importance. Our life stories likely include shared experiences around food that could appear insignificant to the observer but often invoke feelings of family and love.

For me, that’s a spontaneous bacon cheeseburger. Occasionally, I’d get a call from my now-deceased dad saying, “Hey, your mom is out, let’s go grab a burger.” These are special memories for me, and, so, every now and then I’ll grab a burger and fries, smile, and think of him. In our clinics, we often see a patient’s diet as a list of data points. But if we ignore the emotional "burger and fries" in their lives, we miss the very core of who our patients are and why they eat the way they do.

As cardiovascular and pulmonary rehabilitation professionals, we occupy a unique vantage point. We often spend more time with patients than their other providers do. This is our window to move the lifestyle and nutrition needle. While daily cheeseburgers aren’t part of a healthy eating pattern, expecting a total overhaul to stick is unrealistic. By showing our patients that all foods can fit, we shift the focus from perfection to progress, making long-term change far more palatable.

Is This Working?

Traditionally, health care providers often rely on a provider-as-expert hierarchy. This authoritarian stance puts up a wall between the provider and patient. Research underscores that trust is a cornerstone of behavior change.¹ This trust is rooted in a patient’s belief that their provider genuinely cares and wants the best for them. This kind of compassion is hard to fake.

When patients feel seen and supported as individuals rather than just clinical cases, they are more likely to engage with their care. Sustaining complex lifestyle recommendations is incredibly difficult. It becomes more so when a patient feels their provider doesn’t understand their reality. Even the most medically sound lifestyle changes are hard enough to achieve and can feel unattainable when the patient doesn’t feel seen by their team.

Statistics on adherence are a sobering reminder of this reality. Even with a single lifestyle change, the success rate is only about 50% at the one-year mark. When we ask patients to juggle multiple shifts — activity, medications, smoking cessation, and complex food choices — the complexity of adherence grows exponentially. Many times, non-adherence isn’t because our patients don’t want to change, but because that change is simply out of reach. Fresh, nutritious foods are often too expensive, time-consuming to prepare, or physically inaccessible for our patients. If our communication style leaves a patient feeling accused rather than allied, we are inadvertently contributing to their non-adherence by ignoring the very real barriers they face daily.

The Scale vs. Reality

Weight loss remains a common benchmark in cardiovascular care, and for good reason. Organizations like the American Heart Association and the American College of Cardiology note that even modest reductions in body weight — around 3%–5% — can lead to improvements in blood pressure, glycemic control, and lipid levels. While larger weight losses of 10%–30% are linked to meaningful metabolic improvements, reaching this level is difficult through lifestyle modification alone and often requires medications or bariatric surgery.^4,5,6 While these data are important, they can create tension in everyday practice when weight becomes the primary marker of success.

The data tells a story. Patients in standard rehab programs rarely meet the 5% weight-loss goal. On average, men lose only 0.9 kg and women just 0.5 kg. If we define success by these metrics, we are labeling nearly every patient a failure before they even finish the program. The primary reason this advice fails is that it treats the human body like a simple machine: calories in versus calories out. However, weight is an interrelated and dynamic web of factors that are often entirely outside of a patient’s conscious control, including genetics, gut microbiota, fluctuating hormones like ghrelin and leptin, and social determinants of health.

Many patients in cardiac and pulmonary rehabilitation make meaningful improvements in diet quality, activity levels, blood pressure, and functional capacity even when the scale moves very little. Recognizing these gains allows clinicians to reinforce progress and sustain motivation while continuing to support long-term health goals.

Time for a New Approach: HAES and the Academy

A helpful framework for this shift is the Health at Every Size (HAES®) approach, which is often misunderstood in clinical settings. HAES® does not dismiss the importance of health or suggest that nutrition choices are irrelevant; rather, it encourages providers to focus on behaviors that improve health regardless of where a patient’s weight ultimately lands. The model emphasizes respectful care, reduction of weight stigma, and sustainable habits such as intuitive eating, enjoyable physical activity, and consistent medical follow-up. Research supports this narrative: fit obese individuals often have lower mortality risks than unfit lean individuals. For many patients, this shift can rebuild trust in the health care system and create a more durable foundation for lifestyle change.

The Academy of Nutrition and Dietetics (AND) also embraces this philosophy and is transitioning toward primary health outcomes that don't rely solely on weight management. The Academy’s Weight-Inclusive Education Toolkit (WITI) is a direct response to the need for "do no harm" curricula that prioritize the patient's lived experience and biomarkers over their BMI.

Flip the Script

This shift starts with our language. "Should," "would," and "could" often carry an unintended undercurrent of shame. To build a culture of trust and collaboration, we must replace directive commands with exploratory phrases that invite the patient into the decision-making process, thus building autonomy that will serve them for life.

• Flip "should" to "consider": Instead of "You should eat more vegetables," try "Would you be open to exploring how adding a vegetable to lunch feels?" This shifts the focus from a rule to a personal experiment.
• Flip "would" to "doable": Instead of "It would be better if you prepped meals," try "What feels doable for your dinner routine right now?" This identifies the patient's actual capacity.
• Flip "could" to "helpful": Instead of "You could try water instead of soda," try "Would it be helpful to talk through some alternatives to soda that you actually enjoy?" This positions you as a resource, not a judge.

The data is clear: shifting to a positive narrative isn't just about being nice; it is a clinical intervention. A research study in postoperative and asthmatic patients showed that conveying empathy and inducing positive expectations consistently reduces patient pain and anxiety, while improving physical function.² When we adopt this supportive care model, the patient-provider dynamic transforms from an authority figure to be feared to a practitioner who understands their unique situation, creating an effective partnership that fosters genuine change.³ This shift moves us from enforcers to partners in a patient's long-term health journey.

Redefining the Win

When we celebrate the small wins: choosing more vegetables, opting for water, or taking a short walk after dinner, we trigger a butterfly effect. These achievable goals empower patients to continue and expand the lifestyle changes, leading to improved labs, increased energy, and better blood pressure control. Although the numbers on the scale may not always move significantly, these healthy habits are more likely to become their baseline habits. A study out of the United Kingdom showed that while 80.8% of post-cardiac rehab patients maintained a heart-healthy diet, only 25% experienced weight loss.

A patient's progress is visible in ways a scale simply cannot capture. What does a win in rehab look like? A patient who can play with their grandchildren without worrying about becoming too short of breath. Someone who can take their dog for a 20-minute walk or make it through the workday with energy to spare. Sometimes even the smallest things represent achievements, like carrying the laundry basket up the stairs without needing help. When these everyday victories are combined with improvements in blood pressure, glycemic control, and six-minute walk test distances, that is what truly defines health.

Nutrition is science but, in the personal world, it is also biography. And if we want to move that health lifestyle needle, we must stop looking for perfection in a data point and start looking for progress in the person. By flipping the script and focusing on the power of food to connect and sustain us, we don't just change a diet: we help our patients reclaim their lives.

So, the next time a patient mentions a bacon cheeseburger, don't reach for the calorie tracker. Reach for the story behind it.

Carolyn Feibig is a thoracic transplant dietitian at Inova Schar Heart and Vascular in Falls Church, Virginia.

References:

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