CC BY-NC-ND 4.0 · Journal of Social Health and Diabetes 2018; 06(02): 72-74
DOI: 10.1055/s-0038-1675671
Review Article
NovoNordisk Education Foundation

Predietary Counseling in Ketogenic Diet: The 5R Model

Rahul Rosha
1   Department of Nutrition, Novique Healthcare, Pune, Maharashtra, India
,
Rajiv Singla
2   Department of Endocrinology, Kalpavriksh Healthcare, New Delhi, India
,
Bharti Kalra
3   Department of Gynaecology, Bharti Hospital, Karnal, Haryana, India
› Author Affiliations
Further Information

Address for correspondence

Bharti Kalra, MD
Department of Gynaecology, Bharti Hospital
Karnal 132001, Haryana
India   

Publication History

Publication Date:
12 November 2018 (online)

 

Abstract

A major determinant of success while following a ketogenic diet is the counseling that precedes and accompanies the dietary advice. Effective predietary counseling lays a strong foundation upon which successful outcomes can be built. Predietary counseling, an art as well as a science, is best understood through a bio-psychosocial viewpoint. This brief communication shares an alliteratively named model, the 5R rubric. Rapport, realistic realization, reliability, readiness to change, and relationship must be explored and improved during the process of counseling. These five R's remind one to practice continuous, holistic counseling, without forgetting any of the factors that may impact outcomes. Pre-ketodietary counseling is a theranostic intervention, as it helps in both assessment (diagnosis) and improving outcomes (therapeutics).


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Introduction

Ketogenic diet is an important, scientific method of treatment in diabetes and obesity.[1] Most literature on ketogenic diet relates to its use in epilepsy, and expert guidance on optimizing its weight loss benefit is scarce.[2] [3] One way of ensuring that ketogenic diet is used in a safe and efficient manner is to provide quality counseling. “Keto-counseling,” as we term it, is an ongoing process, which begins before institution of the diet, continues throughout the process of dieting and after it as well.

We share a 5R model ([Table 1]) to help ketogenic diet care teams ensure that optimal counseling is done prior to starting the therapy. Appropriate predietary counseling ensures correct patient selection, enhanced adherence, and persistence, and thus facilitates maximal therapeutic outcomes.

Table 1

Ketogenic counseling: the 5R model

Rapport

  With health care team

  With self (self–realization)

Readiness to change

  Benefit–cost ratio

  Major life events (job/family stress, concurrent illness)

Realistic realization

  Responsibilities and rights

  Resolve and resources

Reliability

  Keto–literacy

  Rebounding from relapse

Relationship

  With food

  With family/society


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Biopsychosocial Rubric

The domains of pre-ketogenic dietary counseling are best understood through a bio-psychosocial prism.[4] Counseling should be viewed as a theranostic and educative intervention, which aims to diagnose (suitability for ketogenic diet), educate (regarding the diet), and treat (enhance readiness, reliability, and resilience). These aims can easily be fulfilled if one is able to gauge the biomedical, psychological, and social fitness of the individual ([Table 2]). Such assessment helps in identifying strengths and limitations, as well as suggesting methods of improving dietary, metabolic, and overall health.

Table 2

Counseling in a nutshell

Biomedical issues

  Benefit–cost ratio

  Responsibilities and rights

  Keto–literacy

Psychological issues

  With self (self–realization) and resolve (rebounding from relapse)

  Stress from life events (family, job, concurrent illness)

  With food

Social issues

  With health care team

  Resources

  With family/society


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Rapport

The first step in counseling is relationship building.[5] Frequent friendly contact helps create a rapport between the person and her/his health care team. Exploratory discussion encourages the individual explore her/his health from a bio-psychosocial perspective. Current health status, current behavior, the need for change, and the reason for change must be analyzed by the person. This process of self-analysis, or self-realization, is promoted by ongoing dialogue with the health care team. Such conversation must be performed in an atmosphere of respect and relaxation. Modes of contact may include face-to-face meetings and telephonic and online conversations.


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Realistic Realization

During predietary counseling, information about the rationale, dos and don'ts, and caveats of the ketogenic diet is explained.[6] This discussion includes in-depth analysis of expected benefits, possible risks, and potential dangers of the intervention. Such an interview, conducted in a nonjudgmental and nonpaternalistic manner, allows the person to assess her/his risk-benefit ratio. Counseling also includes a description of an individual's rights and responsibilities following a ketogenic diet. Rights include, for example, the right to contact a health care team member for information or assistance when required. Responsibilities include self-management and creation/maintenance of resources required to practice effective self-management.


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Reliability

Readiness to change must be accompanied by reliability in managing change. This is ensured during predietary counseling, and afterward as well, by imparting education in the nutritional, dietary, and culinary aspects of ketogenic diet. Prior to starting the diet, the person should be aware of how to identify and source keto-friendly food, read nutritional labels, prepare healthy meals, measure protein sizes, and plan a satisfactory menu. Keto-literacy also covers issues such as dining out and troubleshooting. Troubleshooting may be required when one is faced with unfamiliar food choices or when one relapses into a carbohydrate-rich diet. Although such relapses are sound to occur, it is important that the individual be conditioned psychologically to rebound from these (temporary) setbacks.


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Readiness to Change

Predietary counseling is a theranostic (therapeutic + diagnostic) intervention. It aims not only to assess readiness to change dietary behavior but also to motivate the person to change. Thus, it serves a dual purpose. Readiness to change can be measured by assessing the resolve or firmness of the person understanding barriers such as stressful life events (e.g., family, job, concurrent illness), and by enquiring about the resources available to her or him. This helps assess if this is the right time for change.

The resolve to change is a dynamic concept and can be modified by an empathic explanation of the benefits of ketogenic diet. Other ways of building resolve are to foster peer motivation by people and families who have successfully managed a keto-diet and to provide counsel on stress management techniques and coping mechanisms.

Resource analysis includes enquiry regarding the availability, accessibility, affordability, and appropriateness of keto-friendly foods. Ability and willingness of family members to cook and serve keto-friendly meals is also a part of keto-resourcing.


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Relationship

Apart from the biomedical assessment and counseling, one must explore the psychosocial basis of obesity as well. This involves interviewing to understand the individual's relationship with food, including drivers for eating and drinking. This discussion will automatically evolve into an exploration of the relationship of food with family and society. The importance of food and specific foods in social interactions with the family and larger society must be considered. These insights will help identify potential obstacles to successful maintenance of ketogenic diet and suggest preemptive step to overcome them.


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Summary

The 5R model provides a simple, yet comprehensive, coverage of the essential components of predietary counseling. It is an essential learning tool for all health care professionals who deal with ketogenic diet.


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Conflict of Interest

None.

  • References

  • 1 Gupta L, Khandelwal D, Kalra S, Gupta P, Dutta D, Aggarwal S. Ketogenic diet in endocrine disorders: current perspectives. J Postgrad Med 2017; 63 (04) 242-251
  • 2 Forouhi NG, Misra A, Mohan V, Taylor R, Yancy W. Dietary and nutritional approaches for prevention and management of type 2 diabetes. BMJ 2018; 361: k2234
  • 3 Azar ST, Beydoun HM, Albadri MR. Benefits of ketogenic diet for management of type two diabetes: a review. Journal of Obesity and Eating Disorders 2016; 2 (02) Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980; 137 (05) 535-544
  • 4 Kalra S, Baruah MP, Unnikrishnan AG. Responsible patient-centered care. Indian J Endocrinol Metab 2017; 21 (03) 365-366
  • 5 Tips and advice. Available at: https://www.noviquehealth.com/blog/category/tips/ Accessed July 30, 2018

Address for correspondence

Bharti Kalra, MD
Department of Gynaecology, Bharti Hospital
Karnal 132001, Haryana
India   

  • References

  • 1 Gupta L, Khandelwal D, Kalra S, Gupta P, Dutta D, Aggarwal S. Ketogenic diet in endocrine disorders: current perspectives. J Postgrad Med 2017; 63 (04) 242-251
  • 2 Forouhi NG, Misra A, Mohan V, Taylor R, Yancy W. Dietary and nutritional approaches for prevention and management of type 2 diabetes. BMJ 2018; 361: k2234
  • 3 Azar ST, Beydoun HM, Albadri MR. Benefits of ketogenic diet for management of type two diabetes: a review. Journal of Obesity and Eating Disorders 2016; 2 (02) Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980; 137 (05) 535-544
  • 4 Kalra S, Baruah MP, Unnikrishnan AG. Responsible patient-centered care. Indian J Endocrinol Metab 2017; 21 (03) 365-366
  • 5 Tips and advice. Available at: https://www.noviquehealth.com/blog/category/tips/ Accessed July 30, 2018