1. Collins, Nancy PhD, RD, LD/N

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Q: I encourage my patients to follow a healthy diet that will support optimal wound healing. Unfortunately, most of them neglect my instructions. How can I help ensure patients' adherence to my nutritional recommendations?


A: As health care professionals and educators, we know what our patients should do to improve their overall health. Medical nutrition therapy (MNT) is an important component of the wound healing process, but many patients consume inappropriate diets despite our recommendations. Before we can change their behavior, we must understand the different causes of nonadherence, the stages of behavior change, and some techniques that can be used to overcome resistance.


Causes of Dietary Nonadherence

Researchers have explored 3 categories of variables that appear to impact nonadherence: demographic characteristics, psychological variables, and social variables. 1


Demographic barriers include educational level, financial considerations, and access to health care. For example, a wound care nurse advises a patient that he or she should take a multivitamin, vitamin C, and an arginine-enriched powdered beverage twice daily to enhance wound healing. If the patient is on a fixed income, he or she may be unable to afford these supplements.


Psychological variables include depression, anger, feeling out of control, denial, hostility, and embarrassment about having a wound. A patient may believe that having a wound is his or her fault, prompting defensive behavior. Suffering with a nonhealing wound for several months can be disheartening. A patient who thinks that nothing will help may become too depressed to try another intervention. Others may exhibit hostility and try to exert control over the situation by challenging the advice given by the wound care professional.


The third category of nonadherence involves social variables, such as a lack of a support system, isolation, and poor relationships with family and health care providers. Isolation has been linked with decreased meal intake. Thus, if a patient lives alone and has limited ability to shop, prepare meals, and socialize, his or her meal consumption may suffer.


Stages of Behavior Change

Eating behaviors develop over the course of a lifetime and are not easily changed. Individuals must want to make a change. The Transtheoretical Model is commonly used to define the stages of behavior change as a series of 6 distinct steps. Remember that people cycle through different phases of changing and maintaining their dietary modifications, so these steps may not be linear. 1


The 6 steps are:


Precontemplation: The patient has not even contemplated having a problem or needing a change. 2 He or she requires information and feedback to raise awareness of the problem. For example, ask the patient if he or she understands the connection between protein intake and wound healing. This will raise awareness that diet impacts wound healing. That patient, however, is not yet ready to receive instruction to consume 6 to 8 ounces of protein daily.


Contemplation: Once some awareness of the problem arises, the patient enters a period of ambivalence or contemplation. 2 He or she may fluctuate between reasons for changing and reasons for staying the same. At this stage, it helps to show the advantages of changing, without making false promises. For example, explain that increased intake of high-quality protein is 1 factor that helps with wound healing. But do not offer false hope by promising that increased protein intake will make the wound heal.


Preparation: This stage is a window of opportunity: The patient will either move forward or fall back into contemplation. 2 Help the patient set a realistic goal or identify an acceptable strategy. For example, a patient who prefers not to eat meat may be willing to try a sample of protein powder.


Action: The patient engages in the action that will create change. 2 For example, the patient will try the protein powder and determine if it is acceptable. If the patient likes the protein powder, he or she can continue adding it to meals. If not, another strategy can be identified to increase protein consumption.


Maintenance: The goal of this stage is to continue the changed behavior and avoid relapse. 2 For example, if the patient runs out of protein powder, he or she can purchase more of it or relapse into past behavior.


Relapse: If relapse occurs, the patient's task is to restart the change process rather than remain in relapse; the goal is to resume action. 2 For example, determine why the patient did not purchase another can of protein powder. Perhaps he or she was tired of it or didn't see it helping the wound. The powder may have been too expensive. There can be many reasons for a relapse, but the goal is to emerge from this stage.



Patients will not change their dietary habits until they are ready. Help patients by identifying which stage of change they are at and adapt their dietary strategies accordingly. Remember to document this information in the patient's medical record. Litigation frequently arises from nonhealing wounds; a permanent record of the strategies used to encourage improved nutritional status can be beneficial.


Interpersonal Skills

Many traditional counseling techniques and interpersonal skills can help improve adherence to dietary modifications. 1 Always maintain eye contact when speaking with a patient. A lack of eye contact can signal disinterest or preoccupation. Voice level should be kept appropriate and enthusiastic-never speak in a monotone or a voice raised in anger. Remain nonjudgmental and always demonstrate empathy. Facial expression, tone of voice, body language, and gestures (such as a pat on the arm) are all methods of communication. Give the patient adequate time to convey his or her feelings and ask questions. This requires good listening skills.


Nutritional advice can be perceived as negative if presented the wrong way. For example, patients with diabetes are often told to avoid many foods and may view the counselor as the "diet police." Instead, first ascertain the patient's nutritional knowledge base. This requires effective use of open-ended questions such as, "Do you know what types of foods may help your wound heal faster?" Asking is generally more effective than telling a patient what to do. Positive reinforcement motivates patients because most enjoy hearing that they are doing well and are on their way to success.


Case Example

SR is a 76-year-old man with a diabetic foot ulcer of 6 months' duration. He visits an outpatient wound clinic to receive his wound care. The clinic's nurse has instructed him on several occasions to monitor his blood glucose level more closely and to stop eating so many sweets, but this approach has not worked.


Using her new understanding of dealing with nonadherence issues, the nurse decides to ask questions to determine why SR is not checking his blood glucose level regularly or following his diet. Using open-ended questions, she learns that he is having trouble paying for his diabetic testing equipment. The nurse and SR agree that he can test his blood once a day rather than 3 times a day. Then they plan a rotating schedule of testing times, while they investigate reimbursement options.


Reviewing the stages of behavior change, the nurse is surprised to discover that SR is in the preparation stage. He would like to reduce his intake of concentrated sweets but needs a workable strategy to satisfy his sweet tooth. The nurse suggests sugar substitutes and sugar-free desserts that can be enjoyed in moderation.


The nurse's expressions of empathy and understanding of how difficult it can be to eliminate some favorite foods from SR's daily routine strengthens the relationship between the two. Her positive reinforcement of SR's first step further builds his confidence and support.


Putting It All Together

The best strategy for dealing with nutritional nonadherence is a combination of several approaches. The case example illustrates how techniques can be combined to improve outcomes. For MNT to be fully effective, we must not only instruct patients on the principles of good nutrition but also build a relationship that will facilitate changes in behavior and improve outcomes. 3 This requires us to understand human nature and psychology, as well as nutrition. Counseling that facilitates actual behavior change will focus on the individual patient, not just the diet or disease entity.




1. Zerwic JJ, Sherry DC, Simmons B, Wung SF. Nonadherence in heart transplantation: a role for the advanced practice nurse. Prog Cardiovasc Nurs 2003; 18( 3): 141-6. [Context Link]


2. Mahan LK, Escott-Stump, S. Krause's Food, Nutrition & Diet Therapy. 10th ed. Philadelphia: WB Saunders; 2000. p 453. [Context Link]


3. Curry KR, Jaffe A. Nutrition Counseling and Communication Skills. Philadelphia: WB Saunders Company; 1998. p 85. [Context Link]