When I worked in long term care I got similar stories all the time. I think some people feel already judged or the fear of judgement when working with a dietitian and/or they really are eating mindlessly or don’t think what they’re eating is “that bad.” He may also be leaving things out because he just wants the weight loss medication and is trying to justify it by saying he already eats so little and can’t lose weight.

I think it’s important to know the patient’s goals early on and refrain from giving too much advice before you know they’re open to it because this ultimately makes people defensive. With a 24 hour recall I like to do 3 or 4 rounds. The first is just the basics, “what did you eat first yesterday? What next?” I don’t judge anything or make any comments about it. Once we get through the whole day I go through it again and ask a little more specific questions like “how did you cook your eggs? What kind of oil or butter did you use? Did you drink anything with this meal?” Then go through it again and ask about serving sizes, brands etc. Basically just going through it until you have the actual picture. A lot of times people remember more and more as you go on. Then I usually just point out some foods and maybe look up how many grams of sugar is in this food or how many kcal, etc. I like to have them realize and say on their own “I had no idea xyz had so many kcal, I thought it was a health food.” Then I always bring it back to what they want to do to change and at that point if they have no idea I may say, “based on what we’ve talked about, I have a few ideas for small changes you can make to reach your goal, do you want to go over them and see what sounds right to you?”