Nutrition Lecture 3 (Counseling & Barriers in Nutrition)

Why might a patient know exactly what to eat and still be unable to do it?

Barriers

What are some considerations concerning barriers?

- Knowledge ≠ access

- Access ≠ affordability

- Affordability ≠ feasibility

- Feasibility ≠ cultural acceptability

- Recommendation ≠ behavior change

True or False: Nutrition counseling is ineffective unless barriers are addressed.

True

Barriers regarding nutrition knowledge

- Limited understanding of macronutrients, portion sizes, and dietary patterns

- Misunderstanding what constitutes a "healthy" food

- Difficulty translating general recommendations into meals

- Nutrition misinformation from social media, advertising,

influencers, family/friends

Barriers regarding health & nutrition literacy

- Difficulty interpreting nutrition labels

- Difficulty understanding serving sizes

- Confusion regarding carbohydrates, added sugars, sodium, fats, etc.

- Difficulty interpreting medical recommendations

Barriers regarding food preparation skills

- Limited cooking experience

- Limited meal-planning skills

- Difficulty shopping within a budget

- Reliance on convenience/prepared foods

What are other common barriers regarding time, convenience, and competing demands?

- Long work hours

- Multiple jobs

- Shift work

- Commuting

- Childcare/caregiving responsibilities

- School responsibilities

- Limited time for grocery shopping

- Limited time or energy for food preparation

- Irregular schedules

- Fatigue and decision overload

What are the implications of convenience strongly influencing food selection?

- Ready-to-eat foods require less planning

- Fast food may be geographically convenient

- Prepared foods reduce cooking and cleanup demands

Gastrointestinal barriers

- Nausea/vomiting

- GERD

- Gastroparesis

- IBS/IBD

- Constipation/diarrhea

- Malabsorption

Oral/swallowing barriers

- Poor dentition

- Xerostomia

- Dysphagia

- Ill-fitting dentures

Physical/function barriers

- Arthritis

- Mobility limitations

- Visual impairment

- Neurologic disease

- Difficulty shopping, opening containers, or preparing food

Medication effects barriers

- Appetite suppression/stimulation

- Nausea

- Taste changes

- Dry mouth

- Constipation/diarrhea

Psychological factors that may be barriers

- Depression → decreased motivation, appetite, meal preparation

- Anxiety/stress → appetite changes or emotional eating

- Trauma → altered eating behaviors

- Grief/loneliness → decreased intake or comfort eating

- Disordered eating/eating disorders

Behavioral factors that may be barriers

- Habitual eating patterns

- Emotional eating

- Reward-driven eating

- Restrictive dieting → overeating cycles

- Frequent distracted eating

- Low self-efficacy after repeated unsuccessful attempts

Why does sleep matter?

Sleep deprivation can affect appetite regulation, food preferences, energy, and the capacity to plan and prepare meals.

Barriers regarding preferences, beliefs, and culture

- Taste preferences

- Familiarity with foods

- Childhood eating patterns

- Cultural food traditions

- Religious dietary practices

- Beliefs regarding health and illness

- Vegetarian/vegan practices

- Family recipes and traditions

- Previous experiences with dieting

- Distrust of conventional nutrition recommendations

Regarding barriers concerning preferences, beliefs, and culture, what is the goal?

Modify dietary patterns within the patient's food culture whenever possible, rather than replacing culturally meaningful foods with a standardized "healthy diet"

Household influences that may be barriers

- Partner/children's food preferences

- Who purchases groceries?

- Who prepares meals?

- Shared household budget

- Family resistance to dietary changes

- Different nutritional needs within one household

Social influences that may be barriers

- Workplace eating

- Restaurants/social gatherings

- Alcohol-centered activities

- Peer norms

- Holidays and celebrations

In what population is social isolation important to consider?

older adults

How might social isolation be a barrier?

- Reduced motivation to prepare meals

- Eating alone

- Loss of spouse/partner

- Limited assistance in obtaining groceries

What do cultural norms drive?

preferences (e.g., large portions, high-calorie "go-to" items) and peer influence in adolescents

Why are school environments a barrier?

inconsistent policy enforcement, limited fresh items, vending near meals → default to empty-calorie choices; stakeholder engagement (parents, students) often minimal

How should you approach cultural & social barriers from a clinical angle?

ask about family roles (who shops/cooks), school meal participation, and "where snacks come from."

What are some healthcare system barriers?

- Insufficient visit time

- Minimal nutrition training among clinicians

- Conflicting recommendations from clinicians

- Generic dietary handouts

- Limited access to registered dietitians

- Insurance limitations

- Lack of culturally/linguistically appropriate resources

- Failure to screen for food insecurity

- Recommendations that ignore cost or access

What is neighborhood access to full-service grocery and fewer fast-food/convienence outlets associated with?

lower obesity/diabetes

the reverse environment worsens risk

What is the implication of schools with nearby fast food (

fewer fruits/veg, more soda, higher overweight in students

What do US literature reviews document?

disparities in access to healthy food ("food deserts"/"swamps") and their health impacts

What factors influence the US food environment?

- Distance to grocery stores

- Transportation

- Availability of fresh foods

- Density of convenience stores/fast-food restaurants

- Food pricing

- Farmers-market availability

- School/workplace food environments

- Food delivery availability

- Neighborhood safety

- Housing and kitchen facilities

True or False: Living near a grocery store automatically means nutritious food is affordable, culturally appropriate, high quality, or practically accessible.

FALSE; Living near a grocery store does NOT automatically mean nutritious food is affordable, culturally appropriate, high quality, or practically accessible.

What are USDA-ERS estimates used for?

mapping access gaps

Which neighborhoods have fewer large-chain supermarkets, requiring residents to travel farther to reach one?

Predominantly Black and Hispanic neighborhoods

What do low-income, rural residents face?

longer trips, fewer outlets, higher reliance on convenience stores; cost/time of travel compounds access barriers

What problems arise in rural areas?

longer distances, fewer supermarkets/gyms, reliance on convenience stores, strong presence of fast food (“food swamps”); community themes include cost, time, distance, and limited fresh options

What problems arise in urban areas?

density of fast food and marketing; time poverty; kitchen/storage constraints in shared/temporary housing

What is the bottom line when considering barriers in rural vs. urban areas?

Screen for where the patient gets food and how they get there; tailor support to geography

What barriers does low socioeconomic status add?

price sensitivity, limited store mix, lack of transport; smaller outlets often charge more for produce than large supermarkets

Statistically, what are the reported barriers to a healthy diet?

- cost is #1 (61%)

- time to cook (30%)

- transport (19%)

- storage (14%)

What barriers do families and teachers from US rural/low-resource schools and homes cite?

limited budgets, fewer healthy offerings, reliance on vending/convenience foods; students frequently bring/eat fast food due to cost and access

Considering income and financial resources, what are the socioeconomic determinants of nutrition?

- Food budget and food insecurity

- Rising food costs

- Competing expenses (housing, utilities, childcare, medications)

- Variable income/pay cycles → fluctuating food availability

- Limited ability to purchase food in bulk or absorb food waste

Considering employment, what are the socioeconomic determinants of nutrition?

- Shift work and irregular meal timing

- Multiple jobs/long working hours

- Limited meal breaks

- Lack of food storage/refrigeration at work

- Dependence on foods available near the workplace

Considering education and health literacy, what are the socioeconomic determinants of nutrition?

- Ability to interpret food labels and nutrition information

- Understanding of food preparation and storage

- Ability to navigate SNAP/WIC/community resources

- Exposure to nutrition misinformation

Considering the neighborhood food environment, what are the socioeconomic determinants of nutrition?

- Grocery-store availability and distance

- Quality/variety of available foods

- Convenience-store and fast-food density

- Farmers' markets and community food programs

- Food prices across neighborhoods

Considering transportation, what are the socioeconomic determinants of nutrition?

- Car ownership/access

- Public transportation routes

- Walking distance

- Ability to carry groceries

- Transportation cost and travel time

Considering housing, what are the socioeconomic determinants of nutrition?

- Housing instability/homelessness

- Refrigerator/freezer access

- Stove/oven/microwave access

- Food storage space

- Pest or food-safety concerns

Considering the built environment, what are the socioeconomic determinants of nutrition?

- Neighborhood safety

- Walkability

- Geographic isolation

- Accessibility for people with disabilities

What does true food cost include?

- Purchase price

- Transportation

- Time to shop

- Preparation time

- Cooking fuel/utilities

- Refrigeration/storage

- Kitchen equipment

- Risk of food waste

What are the broader social and structural conditions identified by the AHA that can shape dietary patterns and cardiometabolic risk?

- targeted food marketing

- residential segregation & neighborhood disinvestment

- structural racism

- food deserts

How does targeted food marketing shape dietary patterns and cardiometabolic risk?

- Disproportionate marketing of nutrient-poor foods and beverages to some racial/ethnic groups and children

- Digital media, television, product placement, sponsorships, and neighborhood advertising influence food preferences and purchasing

- Marketing exposure begins early and can shape dietary norms

How do residential segregation & neighborhood disinvestment shape dietary patterns and cardiometabolic risk?

- Historical and contemporary housing patterns have contributed to unequal neighborhood resources

- Can influence supermarket access, food quality, transportation, economic opportunity, and availability of healthy foods

- Neighborhood disadvantage can persist across generations

How does structural racism shape dietary patterns and cardiometabolic risk?

- Policies and institutional practices can produce unequal access to resources important for health

- Effects can occur through housing, education, employment, income, transportation, healthcare, and neighborhood investment

- These pathways can ultimately influence food security and dietary quality

Describe the statistics associated with redlining.

- Census tracts historically given poorer redlining grades had lower contemporary grocery-store food access than those receiving the highest grade.

- Historically redlined neighborhoods were more likely to have unhealthy retail food environments.

What quick screening can be used to assess access?

"How far is your usual grocery store? How do you get there?" (Food desert/transport flag) - disparities in U.S. access are well-documented.

What quick screening can be used to assess affordability?

"Is price the main thing shaping what you buy this month?"

What quick screening can be used to assess time?

"Which nights are you most rushed? Let's pick a 10- to 15-minute dinner."

What quick screening can be used to assess school/teens?

"Do vending or fast-food stops replace lunch?" (Adolescent risk prompts)

What are the US programs and policy levers?

- SNAP, WIC, senior meal programs

- Many farmers’ markets accept EBT

- GusNIP produces incentives for produce

- CDC Food Service Guidelines

- REACH community initiatives

What is SNAP (Supplemental Nutrition Assistance Program)?

Broadest major federal food-assistance program

How does SNAP provide benefits?

thorugh an EBT card

What can SNAP benefits generally purchase?

fruits/vegetables, meat, dairy, breads/cereals, snack foods, nonalcoholic beverages, seeds, and food-producing plants

What can SNAP benefits generally NOT purchase?

alcohol, tobacco, vitamins/supplements, hot foods at the point of sale, or nonfood household items

What is SNAP eligibility primarily based on?

income/resource based, with rules varying by household circumstances and state

How should we connect patients with SNAP?

- Screen patients for food insecurity and refer even when diet quality appears poor (food insecurity and poor dietary quality can coexist)

- Apply through Connecticut's ConneCT benefits portal

Whom does WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) serve?

pregnant, breastfeeding, and non-breastfeeding postpartum women, infants, and children through age 4

What does WIC require?

nutritional risk in addition to categorical and financial eligibility

What does WIC provide?

a defined food package, rather than unrestricted grocery benefits

What does WIC include?

nutrition counseling, breastfeeding support and referrals to health/social services

What are the foods WIC provides designed around?

nutritional needs of pregnancy, infancy and early childhood

What does WIC combine?

targeted foods with nutrition and maternal-child health services

Describe the WIC enrollment process.

- Connecticut WIC staff complete the enrollment process with the patient.

- Can start the process online, but they will need to go in for a nutritional assessment

What does CACFP provide?

Meals and snacks in childcare centers, family daycare homes, after-school programs, and participating adult-care settings

In CACFP, nutrition standards govern...

reimbursable meals

What is NSLP?

- Federally assisted school meal program

- Participating schools provide nutritionally balanced lunches (during the school year)

- Children may receive meals free or at a reduced price depending on eligibility/program structure

What does SBP provide?

breakfast during the school year; particularly important because food insecurity may manifest as children arriving at school without breakfast

What is the SBP reimbursement model?

similar federal reimbursement model

What does SFSP provide?

free meals/snacks to children in eligible low-income areas when school is out

What does SFSP help address?

loss of school-based nutrition access during summer

What is CSFP?

Commodity Supplemental Food Program

Who does CSFP primarily serve?

low-income adults ≥60 years

What does CSFP provide?

a monthly package of USDA foods

What is CSFP intended to do?

supplement, not provide the entirety of, an individual's diet

Who is CSFP particularly relevant to?

older adults experiencing fixed-income constraints

What is TEFAP?

The Emergency Food Assistance Program

How does TEFAP work?

- USDA purchases foods and distributes them through states

- Foods ultimately reach patients through organizations such as food banks, food pantries and community agencies

What does TEFAP support?

both household food distribution and prepared-meal programs

How is TEFAP unlike SNAP?

patients are receiving food commodities rather than purchasing benefits

What do food pantries provide?

free groceries directly to individuals or households experiencing food insecurity

Who might operate food pantries?

nonprofits, churches, community centers, hospitals, or other organizations

Where might food in food pantries come from?

food banks, USDA programs such as TEFAP, retailers, farms, and community donations

What might food pantries provide?

shelf-stable foods, fresh produce, dairy, meat, frozen foods, and household necessities depending on availability

How are food pantry eligibility and frequency of use defined?

vary by pantry

What is the client-choice model that some food pantries use?

allows individuals to select foods rather than receiving a predetermined box

What can culture influence?

- Staple foods and preferred ingredients

- Food preparation methods

- Meal timing and frequency

- Portion norms

- Who purchases and prepares food

- Family and communal eating

- Foods associated with celebration, comfort, illness, pregnancy, or healing

- Religious practices and fasting

- Beliefs about what constitutes a “healthy” diet

Why might an evidence-based nutrition prescription fail?

if it requires patients to abandon foods, traditions, or eating practices important to them

How can we be culturally sensitive?

ask better questions; don’t make assumptions

How can we tailor a diet while considering culture?

- Avoid unnecessary substitutions

- Target the nutritional problem, not the cultural food

*Modify, Don't Replace*

True or False: Broad cultural labels are dietary assessments.

FASLE; Broad cultural labels are NOT dietary assessments.

What can you ask to inquire about a patient's diet, while considering their culture?

- "What foods are staples in your home?"

- "Walk me through a typical dinner."

- "What type of rice/bread/grains do you usually eat?"

- "How are your foods usually prepared?"

- "Who cooks and shops?"

- "Which foods would you not want to give up?"

What should we not do when considering a patient's culture?

Don't prescribe based on ethnicity. Assess the actual diet.

Cultures include HOW people eat. What are different types of meal structures?

- Shared dishes vs. individually plated meals

- Large family meals

- Meal timing

- Number of meals

- Eating with extended family