By Anna Horner | News & Views

Cardiac rehabilitation (CR) practitioners spend a lot of time with patients during their rehab regimen, which means patients often go to them with nutrition-related questions. Whether a registered dietitian or other nutritional professional is readily available depends on the facility, says Tara Schmidt, M.Ed., RDN, LD, a registered dietitian and instructor of nutrition at the Mayo Clinic in Rochester, Minnesota, making it important for CR providers to have the confidence and the tools to answer at least basic questions about nutrition and behavioral modifications.

There are several evidence-based tools CR practitioners can utilize, such as motivational interviewing. Schmidt says motivational interviewing is a four-stage process of “helping patients move from ambivalence to change.” It involves, according to Schmidt:

• Engaging: Establishing rapport with the individual, expressing empathy, and setting the agenda
• Focusing: Identifying and prioritizing the key issues from the individual’s perspective
• Evoking: Encouraging the individual to express their motivation for change
• Planning: Collaboratively setting an action plan to guide the individual

“We help the patient come up with scenarios, habits, or goals. We want the motivation to come intrinsically from the patient,” she says. “I always tell people that my job is not to tell you what to do. I want to hear about what you’re doing, what motivates you. I want to help you come up with lifestyle changes that you’re interested in and help you find reasonable, realistic ways to make those changes.”

Schmidt says providers also should have a basic understanding of the various evidence-based diets that may be appropriate for patients in cardiac rehab — like the DASH Diet, the MIND Diet, and the Mediterranean Diet — and be able to recommend the regimen that would best meet their patient’s needs. “It’s important for them to feel confident in recognizing what those evidence-based dietary patterns have in common,” she notes. “They don’t have to know which one is best because in many scenarios, there is no best diet outside of which one the patient is most likely to adhere to.”

Additionally, CR practitioners can ask open-ended questions to learn more about the patient’s diet and eating patterns. According to Schmidt, “Providers, especially in cardiac rehab, are equipped enough to give patients meaningful, accurate dietary advice, but it’s hard to know where to start. We don’t just start by educating, saying, ‘You have hypertension; here’s a pamphlet. Here’s what you should and should not eat.’” To start the conversation, she says providers can ask patients: Do you struggle with eating for reasons other than hunger? What are some lifestyle and nutrition goals you’re interested in working on? Do you have any experience tracking your food and beverage intake? Such questions, Schmidt says, can give the provider clues about where the conversation should go.

However, she stresses that these questions should be unbiased. “We in the medical field, unfortunately, are guilty of having obesity- or weight-related bias. People who live in larger bodies or have a diagnosis of obesity face bias in all facets of life, including in medical facilities,” notes Schmidt. “It’s important that medical professionals recognize their unintentional bias and learn how to discuss weight and diet, especially with patients who have a diagnosis of obesity, so that they can come across as unbiased.”

According to Schmidt, providers should not assume that someone who has excess weight also has a need or desire to lose weight, and they should not make assumptions about their eating or exercise habits. It’s also important to ask permission to talk about someone’s weight, she says. “Looking at someone gives you absolutely no detail into their actual daily habits,” Schmidt explains, “so we really need to check ourselves before we start to make assumptions.”

Furthermore, CR professionals need to know when referral to a dietitian makes the most sense. “Most CR practitioners recognize that it’s out of their scope when the level of detail a patient seeks involves math equations,” she notes. Patients may, for example, ask how many calories they should be eating, how many grams of protein are ideal, what their sodium intake goal should be, etc. “Registered dietitians have the tools to calculate that,” Schmidt says. “It’s not that CR professionals can’t use the calculator in the medical record, if such a tool exists in their facility, but when math becomes part of the equation, the patient may be better suited by medical nutrition therapy.”

Schmidt explains that medical nutrition therapy is involved when a diagnosis or health condition has a nutrition component and there are specific nutritional guidelines that should be followed. “Dietitians can step in when the conversation moves from general healthy eating into hot topics that dietitians stay up to date on, like seed oils, supplements, and protein shakes, among other things,” she adds.

Overall, Schmidt says the goal is for CR providers to increase their knowledge about nutrition and collaborate with patients on dietary and behavioral changes. “CR professionals can help patients with targeted nutritional interventions, which might be helping them improve self-regulatory skills and monitor their exercise, weight, and nutrition. Or it might be an actual nutritional intervention, like decreasing or increasing their intake of X, Y, or Z,” she emphasizes. “They can help patients determine whether they are motivated at this time for change or need a more appropriate weight loss expectation.” Schmidt concludes that CR professionals can be instrumental in helping patients overcome barriers to change and in improving patient outcomes.