Nutritional counseling can be a challenge. A substantial barrier to effective patient counseling is lack of consideration of patients' resources. Clinicians need to have a keen awareness of the constraints of access, time, and cost of healthier choices. Access to affordable groceries (supermarkets, supercenters, and grocery stores) may limit patients' nutritional resources. The United States Department of Agriculture (USDA, 2017) measures these "food deserts" (neighborhoods that lack healthy food sources) by access such as distance to a store and whether a family needs a vehicle for access or by the number of stores in an area. According to the United States Census (n.d.), there are approximately 44,500 supermarkets in the United States, making the ratio of fast-food restaurants to supermarkets approximately 6 to 1. However, in neighborhoods designated as food deserts, this ratio becomes even more skewed. Patients' neighborhoods should be considered when counseling about nutrition.

Real or perceived time constraints may further frustrate counseling. Fast food is identified as easy and cheap. Thorough nutritional counseling includes asking about which restaurants the patient frequents. Some fast foods are healthier than others. Patients may state flatly that preparing meals takes too long and is an additional chore in their day. The clinician's role is to examine that perception. Even small changes can have a big impact and a planned home-prepared meal is less costly and more nutritious than restaurant meals. There is an incorrect perception that fast food is always cheaper. Although it is true that per calorie, fast food is cheaper, it is not necessarily so per meal. Comparing cost of chicken dinners for four at a fast-food chain to a home-cooked chicken with vegetables can be very instructive. Foods that are fast, healthy, and less costly than eating out include peanut butter, lentils, rice, yogurt, eggs, bananas, and apples.

Patients who routinely derive most of their food from chain restaurants, may simply be inexperienced with meal planning. Without a plan, the patient has no alternative and so defaults to fast food for dinner. Asking, "What are you planning for dinner tonight" may initiate a useful dialog and create the opportunity for counseling. Perhaps the biggest barrier is the actual cost of food and the perception that healthier equates to costlier. Are healthier choices more expensive? The answer is generally yes, but not for all food groups. The biggest price differences occur in meat and dairy. It has been estimated that overall, there is $1.50 per day increase in cost of a healthy diet (Rao, Afshin, Singh, & Mozaffarian, 2013). This equates to approximately $550 per year that may be substantial for a struggling family. But the clinician can provide some tips to keep cost down. Prices vary substantially among markets; the clinician needs an appreciation of which stores have the best values in which neighborhoods. Store brands will usually save the consumer money. Unit prices rather than item price allow for comparison shopping. What about organic products? Diets of organic food alleviate consumption of harmful pesticides and antibiotics contained in the food. Pesticide ingestion from produce varies with type of produce with some fruits containing very high levels and some very little. This is an important consideration because foods labeled organic are more expensive. Foods labeled as organic generally will cost the consumer about 30% more but that too varies. The USDA (2017) estimates that organic spinach and carrots cost about 7% more, but organic eggs are about 82% more expensive. Clinicians can help patients decide which foods are worth the extra expense.

Ensure patients have access to all available nutritional benefits. Clinicians have a responsibility to know eligibility for government programs and community resources and refer appropriately. Discussing nutritional access, constraints of time, and resources with the patient will help decrease barriers to a healthy diet.

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