A qualitative study of adherence to nutritional treatment: perspectives of patients and dietitians

Figures & data

Table 1 Selected qualitative comments from focus groups presenting a comparison between the educational and informative approach and the counseling and treatment approach

Features	Educational and informative approach	Counseling and therapeutic approach
Professional description	Clinical aspect oriented: “When the profession began 30 years ago, it wasn’t like this. We knew that a person came in with a sickness and you had to tell him what he could and couldn’t eat.” (Dietitian)	Clinical and holistic behavioral aspects: “Today it is important for us to see how the patient relates to food, what it means to him, what need it fills. It might be an emotional need in reaction to boredom or stress […]. Some eating problems have a psychological basis and as a therapist, I need to take that into account and have the tools to address it.” (Dietitian)
Duration of the interaction	Short term and focused: “I treat it as counseling or guidance because it is short-term. She has to explain, give my instructions and see that it works and that’s it. Two or three meetings are enough. It is not therapy that requires continuity and close monitoring.” (Patient)	Sustained: “I feel it is like a psychology of food behavior, she is very understanding, and I feel I need ongoing support.” (Patient)
Relationship between dietitian and patient	Patient’s responsibility: “The dietitian tells me what’s good for me and what I should eat and that’s it […]. I’m the one that has to do it […]. So it’s not treatment […]. (Patient)	Partnership: “From the beginning I had the feeling of a partnership. She said, ‘Let’s try this together, let’s do it at your pace, I don’t want to dictate things that don’t suit you […]. I want us to succeed.’ As if it was about both of us.” (Patient)
Level of involvement	Dietitian as an expert advisor: “She has no enthusiasm; it’s just a job […]. She gives me instructions and I carry them out […]. I realized I needed a more enthusiastic temperament […]. To give me the feeling that we were working together, that my success was her professional success.” (Patient)	Dietitian as behavioral coach: “After I had plateaued for a while, she encouraged me not to give up and to keep at it and two weeks ago when I managed to lose a little weight, she was so happy, as if she had gotten good news, and she said ‘great, let’s plan how to proceed.’ Her enthusiasm gave me a lot of strength to go on.” (Patient)

Table 2 Selected comments from the focused groups regarding barriers to long-term treatment

When dietary counseling was seen as a one-time event rather than as a process

“What I wanted in the first place was to receive information, to know what is allowed, what is healthy and what is not […]. She guided me and that was enough for me. I did not see a need to go back to her.”

When the patient thinks that the issue was adequately addressed after one meeting

One patient said: “The patient does not return […] because he does not think that in future meetings he can learn anything more than he has already learned.” This argument was repeated in some of the interviews in a critical tone. For example: “After a month I said: ‘I went there twice and both meetings were the same.’ I said to myself: ‘It’s enough.”

Routine counseling

Some of the interviewees noted that they found the advice they received from the dietitian generic. For example: “They make a basic, standard menu of what you are and are not allowed to eat, don’t ask me how I am and what is good for me […]. It was just standard […]. Here is the menu and that’s it, as if handing out the menu were everything.” Patients reported that they terminated treatment when the diet offered was not adjusted to their lifestyle: “It is hard for me because I cook, I have a busy day and I just eat whatever there is, and she demanded I change everything […]. She wanted me to write down what I eat, when and why, and at the same time to give up a lot of things I am used to and like […]. It was more than I could handle […]. It was black and white.”

Incompatibility at the level of dietary counseling

One of the main reasons patients do not return to the dietitian after the first meeting is the patient’s feeling that the nutritional solution offered is not individualized: “She had a motto and I was supposed to go along with it […]. How could I eat every two hours at work? I did not feel there was an attempt to adjust the diet to my lifestyle.”

Lack of empathy

Some of the patients said they terminated treatment because the dietitian was too “business-like” and not supportive enough emotionally: “It was like working with a robot that weighs you and gives you a pass/fail grade.”

Lack of intensive follow-up

Some patients said they terminated treatment when their need for a more intensive framework was not met. For example: “Without an intensive regime I break down and that is what happened after I waited more than a month between appointments.” Some participants mentioned that scheduling appointments was difficult and that the appointments were too brief. Participants used the term “five minutes with the dietitian” to describe meetings that were too short to be satisfying or serious.