Dietitians are a counselling-based profession. This means their role is as teacher-supporter-behavioural interventionist, but the actual work (the hardest bit) is up to the individual. Compare this for example with a physiotherapist, a physical-based profession, where in the 15 or 20 minute consultation the "problem" can be alleviated. The work is "done" on the spot, and the person exits with a clear gain in physical health. Similarly, a doctor will write a prescription, you take that prescription, head to the pharmacy, decision-making is limited to which pharmacy (usually the closest) and then whether you choose a "cheaper brand" of the specific medicine. Sure, you have to take the medicine....but how hard is that? Rhetorical. This is not a test.
I expect any dietitian reading this is hoping I clarify two things I've written in that opening paragraph. Lets sort these out first so we can clear our heads for the real message.
1. What "dietitians do"
Dietitians do lots of things. Heaps. One-on-one consultations is one service that is simply "classically" representative of our profession. Given Australia's chronic health statistics and projections for getting worse, one-on-one food and behaviour counselling is, and probably should be, the main service people see in the community as representative of the profession of dietetics. But sure, we do lots of other stuff...research, policy, legislation....highly trained, smart, funny etc...
2. "Food prescription"
Writing out a "food prescription" for a client is a strategy, one strategy of many, that may be what the person in front of us needs at a particular time in their health journey. Like many professions, dietitians don't want to be labelled or boxed into terms like "food nazi" or giving a "prescriptive diet". But in fact, thinking about our service in these terms is what led me to draw parallels between what we (dietitians) do, and what other professions, like doctors and physios, do. So, food is a dietitians intervention, our medicine.
When someone is not at their healthiest, making healthier food choices can help to alleviate or manage the problem: a dietitian "prescribes" foods that will make the person healthy. We give a "food prescription" and then that person has to go out and get those foods and "take" the medicine prescribed. Sounds easy, but, compared with the [two] decisions for getting a prescription (i.e which pharmacy and which brand of medicine), making decisions about food are far more challenging. There is so much noise in the process from knowing what to eat, and actually eating it. In every moment a decision is made about food, the process is a series of trade-offs influenced by many things, the price of food is just one of these. There is the HARD bit, consistently sticking to the prescribed foods when the path to anything except the prescribed foods is more appealing.
What do we know for sure? Australian's are in the worst shape ever. You know the stats: just over two in three Australian adults are above a healthy weight; ranked in the worlds "worst third" for body weight; diabetes set to increase and has some pretty awful associated health problems (AIHW 2012; Baker IDI 2012). Dietitians, the experts in what to eat to be healthy, are well positioned to make a significant contribution to halting and reversing these health statistics.
Right. Here is me, one of these experts, trained to know and subscribe to the scientific evidence of what to eat to be healthy: eat two fruit, five veg, drink water (no other drinks), have a body mass index (BMI) at or below 25kg/m2, and do 60 minutes of moderate exercise every day. The only one of these health benchmarks I meet is the BMI *yay genetics*! Here is what bothered me when I was doing one-on-one consultations: if I can't achieve the health benchmarks, what chance do others have? I could see my own inability to achieve what I should influenced what I did with clients. If they said "I don't have breakfast", I'd say "yeah neither do I". If they said "gosh its too hot to exercise" I'd say "yeah I KNOW! It's outrageous".....or similar. So I stopped doing, took a step back, and started questioning.
I became my own personal experiment: what is it about my decisions that divert me from the evidence? This series of self-critique was the start of my work on the cost of healthy eating, the economics of decision-making to prioritise healthy eating, and a series of short vignettes on eating economics (to go into my thesis). And of course, the trolleys! I've written about these preliminary ideas previously on my website (remember websites?) - but not in a blog....
It is this questioning of my own evidence-based prescription that brought me to my PhD - Can dietitians turn around the obesity epidemic? I really did wonder. And given how far Australians are from healthy eating (note the trolleys), is it reasonable to expect we CAN turn this around? I believe we can, and there is evidence to support my belief. It's coming....promise.
Epilogue
I know about stuff and I still struggle to eat to the evidence - but doing this research has allowed a "story" on decision-making about food that will contribute to what we know about the HARD bits, so we can be more effective.
What's that? Yes my eating is better thanks for asking. I'm at one fruit, maybe four veg, and erm...one dairy. Twenty minutes of intentional exercise a day....is it my fault I'm a fast runner? And some incidental exercise - yes I take my housework seriously.
Tips du jour:
Erm....
Other blogs by me
[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month
The story of dietitians for professional integrity
What is professional integrity?
[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together
March is [unofficially] professional integrity month
The story of dietitians for professional integrity
What is professional integrity?
[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together
[Other stuff]
Australian Institute of Health and Welfare (AIHW). Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra: AIHW Available online at www.aihw.gov.au/publication
Australian Institute of Health and Welfare (AIHW). Australia’s food & nutrition 2012. Cat. no. PHE 163. Canberra: AIHWAustralia's Food & Nutrition Available online at www.aihw.gov.au/publication
Baker IDI. Diabetes: the silent pandemic and it's impact on Australia 2012 Available online at www.diabetesaustralia.com.au
National Health & Medical Research Council (NHMRC). Australian Dietary Guidelines 2013. Canberra NHMRC Available online at www.nhmrc.gov.au Note the analysis for the "trolleys" were based on the earlier Australian Dietary Guidelines 2003, which are now superseded by the 2013 version. However, the 2013 revision would make little change to the "healthy spend" trolley.
Thanks Melanie, I've been doing it for over 20years (yikes, wrinkles) and its still hard, exactly because of the things you've identified. As a counselling based profession we probably don't teach counselling enough - I didn't when I trained. Enjoyed the read, thanks. And thank goodness for lattes - thats how i get my daily dairy!
ReplyDeleteDefinitely not enough counselling - and I'd go so far as to say not enough on primary care and managing chronic illness in general. Hoping this will change so new grads feel like they have choices in where they might work.
ReplyDeleteMany of the dietitians who've participated in my study have gone on to do hours and hours of further study. Its quite impressive. I'm sure you have done this too - and all sorts of courses, business, health coaching, behavioural change, motivational techniques...
One of the things I did with my calculator is to look at the production economics of our profession: how much does it "cost" to produce one new graduate, and then, what is the output of that new grad for the cost in health benefits? There are a few gaps in my model so I am not sure if I will get to publish this work, but it is an important model for us.
Keep in touch. mv
Hi Melanie, I love your blog! I too have been similarly frustrated with 1:1 consults and really questioning what I am doing! Knowledge and behaviour are two very separate things. Helping people to change can be very challenging, especially when they aren't confident to change or really can't be bothered. I've had numerous clients referred to see me on EPC's who attend all of their appointments, but make NO changes. So who is to blame? And would any other kind of intervention really of made any difference to these clients at that point in time? They did as their GP asked of them and saw the Dietitian. I provide them with education- information that is evidence based and tried my hardest to work towards some goals. But at the end of the day, nothing has changed. As a colleague of mine said, that if you are consistently working harder than the client, then it's probably not worth either of your time. I think that it's really important work that you are doing.
ReplyDeleteI am LOVING your colleague! "if you are consistently working harder than the client, then it is probably not worth either of your time" - there's a bit of like left over for you too MJ because everything you have said in your post here is super important as well.
ReplyDeleteThere is defs much work to be done. And I guess I do feel a sense of urgency in getting this work done and published and the next phase started. When I get comments on and off line via any forum, it makes me want to work harder on behalf of all dietitians.
I really am convinced dietitians are VERY well-placed to lead in the food-health arena, but equally, we are accountable for the privileged position we are in, and must not take it for granted. We protect our credential through what we do - each of us as individuals, and collectively. We can do this through data and reporting systems that mean something to policy, but also mean something to us as practitioners, as business and marketing people, as a health profession with a pure intent for a healthy planet. Yes? Who's in?