Dietary Assessment

Although most aspects of diet are more properly characterized as behaviors, the need remains to understand patients' tastes and the macronutrient composition of their usual array of food choices. This information is a tool for suggesting behavioral changes that will comport with the patient's preferences and lifestyle. Although the physician can and should get some idea of these things in talking with the patient, a formal dietary assessment is best done by a dietitian using either a prospective or retrospective food diary.

The results of a food diary must be interpreted with caution, as both retrospective underreporting and prospective restrained eating are common. Despite these shortcomings, the information gathered can be very useful. For example, the macronutrient composition of a patient's diet will often be weighted towards fats, simple carbohydrates, and protein. By cutting fat and increasing intake of complex carbohydrates, especially vegetables and fruit, such patients can considerably increase the volume of food they consume as they attempt to reach and maintain a lower weight.

A helpful tool in altering the composition of the patient's diet is the technique of gradual change. For example, a patient reluctant to switch from whole milk to skim milk could first try 2% milk (which is actually 35% fat), get used to this for a month or two, then move on to 1% fat milk for another month. At this point, the patient should notice something interesting: the once-favored whole milk will now taste too oily. At some later date, the final step to skim milk can be made with few or no feelings of deprivation, demonstrating that taste preferences are acquired and eminently changeable even in later life.

Recommend scouring the supermarket aisles (at a time when the patient is not hungry) for tasty, low fat, or fat-free alternatives to favored foods. Encourage the patient to explore the wide variety of foods now available and to focus on the good taste of the new choice rather than comparing it with the "real thing." The presentation of nutritional information on food labels is becoming more and more useful, listing not just g of fat, for example, but also the percentage of the daily dietary fat allotment those g represent. The patient should be taught (usually by the dietitian) to read labels and to stay within the fat and calorie "budget."

This is also a good time to improve the dietary habits of the patient's family, something that is particularly easy to do when the patient is the primary cook and food shopper. Including the family in this process not only improves their diet but also makes it easier for the patient if at least the house can be a temptation-free zone. Even if other members of the family must have junk food, they can be instructed to partake outside the home or to put only individually packaged items in the cupboard. Small-size purchases of rich deserts and the like are desirable in general; the smaller the dietary indiscretion, the less severe the consequences. Unfortunately, portions have risen greatly in the

United States in recent years, especially in meals consumed outside the home. Specific recommendation of types of diets is listed under "Types of Diets."

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