The Day I Nodded and Said, "I Understand": Dietary Guidance

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When I opened the chart screen, the HbA1c from six months ago and today's blood test results were side by side.

8.2%... It hasn't changed.

It was 8.4% a little while ago... I wanted to lower it gradually, so we talked about diet, discussed exercise, and then the day we met again six months later arrived.
That person sat in the chair in the examination room and said, looking a bit apologetic.

That person sat in the chair in the examination room and said, looking a bit apologetic.

"I really was doing it, though..."

There was a small sense of frustration deep in their eyes. They had tried their best, but the numbers hadn't moved—that regret seeped into the edge of their voice.

The day I nodded and said, "I understand"

I remember the consultation from six months ago clearly.

During the first dietary guidance session, they received careful explanations from the nutritionist. To prevent post-meal hyperglycemia, reduce the amount of rice just a little, be conscious of the order of eating vegetables first, and switch sweet juices to water or tea.

"I understand."

That person nodded with a serious expression. They also accepted the paper materials and took them home.

—We medical professionals tend to take this "I understand" literally.

But as I continue my clinical practice, I realize. Between nodding and saying "I understand" in the examination room and actually continuing that at home, there is
a deeper gap than one might imagine.

Until they can say, "Actually..."

That day, faced with the fact that their HbA1c hadn't moved, that person was silent for a while. I waited without rushing them.

It happens often in the examination room, but when asked, "How was your diet?", an answer doesn't come out immediately. Admitting to "things not being done" is awkward for the person themselves.

After a silence of several dozen seconds, that person said quietly.

"Actually, my wife keeps buying sweets."

That was the beginning of a story I hadn't been able to tell anyone for six months.

"Even if I try to restrain myself, when I open the fridge, there's cake inside. When I come home tired from work, I end up eating it."

"My wife doesn't mean any harm. In fact, she buys it for me thinking, 'Eat something sweet and cheer up'—that's the kind of feeling she has..."

"I just can't bring myself to say, 'I have diabetes, so please don't buy it.'"

Six months ago, when he nodded at the nutritionist's explanation and said, 'I understand.'
He was thinking about a world he could change solely through his own efforts alone.

But in reality, the dining table was not something he created alone.
The contents of the fridge, the dinner menu, the frequency of eating out...
most of life is not determined by one's own will alone.

Looking at the data: 'Not continuing' is the standard, not the exception

Failing to continue dietary therapy is not because the person has a weak will.

Various studies both in Japan and abroad have reported that after diabetic patients receive nutritional guidance, about half are not following the original plan 6 to 12 months later.

This is not limited to diabetes. Whether it's quitting smoking, reducing salt intake, or exercising—long-term adherence rates for any lifestyle intervention remain at around 30-50%—a common challenge in every field.

In other words, 'not continuing' is not an exception, but a standard phenomenon.

Furthermore, the presence of 'family' has a major impact on whether one can continue.

Overseas meta-analyses have repeatedly reported that groups where cohabiting family members understand and cooperate with dietary therapy tend to have significantly lower HbA1c levels compared to those that do not. The difference is about 0.3-0.7%. This is an effect comparable to one oral hypoglycemic agent.

A study in Japan also reported that the group whose spouse attended the nutritional guidance session had a higher rate of dietary behavior adherence six months later than the group that attended alone.

Dietary therapy is not a battle for the individual alone.

And, Japanese food culture itself also has a quiet effect.

According to the Ministry of Health, Labour and Welfare's National Health and Nutrition Survey, the frequency of eating out is higher for men than for women, and it is not uncommon for those in their prime working years to eat out several times a week or more. Work social events, business entertainment, ramen on the way home from overtime—there are many situations where one feels that refusing would lower their standing.

Single-person households tend to have lower vegetable intake than households living with family. Reliance on convenience stores and pre-made meals increases, making it easy to fall into a carbohydrate-centered diet.

Meals exist within the 'context of life'.
Simply saying 'please eat your vegetables first' without looking at that context naturally won't get through.

'Context,' not 'willpower,' determines behavior

In recent years, the concept of "Social Determinants of Health (SDH)" has become widespread in the medical world.

Health is not determined solely by individual choices. Family, workplace, community, economic status, culture—the sum of these environments shapes our daily actions.

Diet is exactly the same.

"Since you have diabetes, you should just not eat."
"If you have a strong will, you won't give in to temptation."

—Such words are spoken by those who do not know life outside the examination room.

People eat what is in the refrigerator.
They eat what their family buys.
They eat what is served at work.
When they have no time, they eat what is available at the convenience store.

Actions are determined by context, not by willpower.

Changing how I ask questions in the examination room

After accumulating these realizations, I gradually changed how I ask about diet in the examination room.

Previously, I used to ask, "What are you eating?"
Now, I try to ask, "Who, when, and how are you eating?".

Do you eat breakfast alone or with your family?
Who cooks dinner?
How does the dining table scene differ between weekdays and holidays?
How often do you have work-related social engagements?
What kind of things are usually in your refrigerator?

When I started asking questions like this, the scene I see in the examination room began to change.

The true nature of "overeating" can be "a family's expression of love", "workplace relationships", or "fatigue and loneliness".

Once that becomes visible, the options I can propose change.

"Could you have your wife listen to the nutritionist's advice with you?"
"Why not adjust your breakfast the next day when you have a social dinner?"
"Would you like to try preparing just a little bit of food in advance on the weekend?"

Instead of a uniform "dietary therapy," I am gradually moving toward proposals that are like narrow alleys, tailored to the context of that person's life.

From a place of blame to a place of observation

At that time, when I reunited with that person after half a year and they said, "I was doing it properly, though...", I did not point at the numbers and lecture them.

Instead, I said this:

"You have worked hard and kept coming here for half a year."

Then, slowly, I had them tell me about their life.
About their family. About their work. About their refrigerator. When they find themselves reaching for sweets.

When they finished talking through everything, that person smiled a little and said,

“I wonder if it’s okay to tell a doctor things like this.”

I replied, “Of course it is!!”

“How you eat” is the most important information, hidden behind your lab results.

The examination room is not a place for blame.
It is a place to look at your life together.

On that day when I nodded and said, “I understand,” perhaps what I should have really handed over wasn't the nutritional material.

“Do you think you could share what we talked about today with someone at home?”
“Could you show this material to your family as well?”

Perhaps it was a single remark like that.

Meals are not something you make alone.
Health is not something you build alone, either.

Our reunion after half a year taught me that once again.

Reference Information

・Japan Diabetes Society, "Diabetes Clinical Practice Guidelines" (Long-term continuation of nutritional guidance)
・Glasgow RE, et al. Behavior change intervention research in healthcare settings (Long-term adherence to lifestyle interventions)
・Rintala TM, et al. Family member support and diabetes self-management (Meta-analysis of family support and HbA1c)
・Ministry of Health, Labour and Welfare, "National Health and Nutrition Survey" (Frequency of eating out and nutritional status of single-person households)
・WHO: Social Determinants of Health
・Marmot M. The Health Gap (The relationship between social environment and health)

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※This article is intended for general information purposes only and does not indicate individual treatment policies. The patient profiles appearing in this article have been constructed based on multiple clinical experiences with privacy in mind.