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INTRODUCTION

INTRODUCTION. Thank you for taking the time to participate in this activity. As you will see from this presentation, effective nutrition counselling by GPs plays an important role in public health.

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INTRODUCTION

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  1. INTRODUCTION Thank you for taking the time to participate in this activity. As you will see from this presentation, effective nutrition counselling by GPs plays an important role in public health. This presentation contains 47 slides on nutrition counselling and education, and should take 1 hour to complete. During the presentation, you will be asked some questions. Please print the ‘answer sheet’ pdf(to open using hyperlink, place cursor over hyperlinked words, right click mouse and select ‘open hyperlink’) and record your answers on it. This activity is an RACGP-accredited Category 2 activity. To receive 2 Category 2 points, please print and complete the evaluation form. Please fax this and the completed answer sheet to Discovery Sydney (02 9925 3748). At the conclusion of this activity, there will be a short presentation (9 slides) on the role of chicken in a healthy diet. We hope the information will be of assistance to you when advising your patients about a healthy diet.

  2. NUTRITION COUNSELLING AND EDUCATION: WHY,WHO & HOW? Proudly sponsored by the Australian Chicken Meat Federation Inc

  3. LEARNING OBJECTIVES • Understand the importance of the GP’s role in providing nutrition counselling • Learn how to optimise patient nutrition counselling sessions • Consider system changes to improve the effectiveness of nutrition counselling in your practice

  4. PRESENTATION OUTLINE • Why is nutrition education important? • Who should deliver nutrition education? • What do GPs think and do about nutrition counselling? • How should nutrition counselling be delivered? • What are the obstacles to nutrition counselling?

  5. WHY IS NUTRITION EDUCATION IMPORTANT? • Established knowledge: nutrition plays an important role in the aetiology and management of many diseases affecting Australians1 • In 2003, a significant proportion of the burden of disease in Australia was directly attributable to nutrition2: Reference: 1. National Public Health Partnership. Eat Well Australia. Canberra: Strategic Inter-Governmental Nutrition Alliance (SIGNAL). 2001; 2. Begg S, et al. The burden of disease and injury in Australia 2003. PHE 82. Canberra: AIHW. 2007

  6. PRESENTATION OUTLINE • Why is nutrition education important? • Who should deliver nutrition education? • What do GPs think and do about nutrition counselling? • How should nutrition counselling be delivered? • What are the obstacles to nutrition counselling?

  7. WHO SHOULD DELIVER NUTRITION EDUCATION? • GPs have the potential to decrease morbidity and mortality for many chronic diseases if they provide effective nutrition counselling1 • Reasons include: • GPs are public health agents who see 80% of the population each year2 • 54.7% of GP/adult encounters involve overweight or obese people3 • GPs are often long-term advisers who gain access to the daily lives and living conditions of all strata of the population4 • GPs are highly regarded as a reliable source of nutrition information5 Reference: 1. Eaton CB et al. J Nutr. 2003 Feb;133:563S-6S; 2. Commonwealth Department of Health and Family Services (CDH & FS): General practice. Changing the future partnerships. Report of the General Practice Strategy Review Group. Canberra: Pine Printers, 1998; 3. Britt H, et al. General practice activity in Australia 2002–2003. AIHW Cat No GEP 14. Canberra: AGPS, 2003. 4. Watt GCM. BMJ. 1996;312:1026-9; 5. Worsley A. Eur J Clin Nutr. 1999;53 Suppl 2:S101-7

  8. GP AS IMPORTANT AS DIETICIANS IN NUTRITION COUNSELLING (1) • An Australian randomised control trial compared clinical outcomes in patients (N=273) with one or more chronic conditions (overweight, hypertension, Type 2 diabetes) • Interventions: • Dietician counselled: 6 sessions over 12 months • GP+dietician counselled: 6 sessions with dietician and GP reviewed progress in 2 of the 6 sessions, over 12 months • Control: no dietician counselling, usual care by GP Reference: 1. Pritchard DA, et al. J Epidemiol Community Health. 1999;53:311-6

  9. GP AS IMPORTANT AS DIETICIANS IN NUTRITION COUNSELLING (2) Results: • Both intervention groups reduced weight and blood pressure compared with controls • Compared with patients counselled by dietician alone, patients counselled by GP+dietician were: • More likely to complete the intervention programme • Lost more weight (6.7kg vs 5.6kg) Reference: 1. Pritchard DA, et al. J Epidemiol Community Health. 1999;53(5):311-6

  10. PRESENTATION OUTLINE • Why is nutrition education important? • Who should deliver nutrition education? • What do GPs think and do about nutrition counselling? • How should nutrition counselling be delivered? • What are the obstacles to nutrition counselling?

  11. WHAT DO GPS THINK AND DO ABOUT NUTRITION COUNSELLING? (1) • A survey of GPs showed 72% thought it was their responsibility to perform nutrition counselling1 • On average, in 10-15 min consultations, the time spent on nutrition counselling was found to be 1 min2,3 • In Australia, nutrition counselling is below a desirable level and/or national targets4 Reference: 1. Kushner RF. Prev Med 1995;24: 546–50 ; 2. Eaton CB, et al. Am J Prev Med. 2002; 23: 174–9; 3. Glanz K, et al. J Gen Intern Med. 1995;10:89–92; 4. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  12. WHAT DO GPS THINK AND DO ABOUT NUTRITION COUNSELLING? (2) • A survey of GPs in NSW showed nutrition counselling was provided mostly for diabetes, lipid disorders and obesity1: Reference: 1. Nicholas L, et al. Eur J Clin Nutr. 2005;59 Suppl 1:S140-5

  13. QUESTION 1 • The Australian study by Pritchard et al. showed that patients counselled by GP+dietician were equally likely to complete the intervention programme, compared with patients counselled by dietician alone • True • False

  14. PRESENTATION OUTLINE • Why is nutrition education important? • Who should deliver nutrition education? • What do GPs think and do about nutrition counselling? • How should nutrition counselling be delivered? • What are the obstacles to nutrition counselling?

  15. HOW SHOULD NUTRITION COUNSELLING BE DELIVERED? To maximise patient motivation and adherence: • Consider factors that increase the effectiveness of patient education • Take a patient-centred approach • Assess patient’s readiness to change: ‘stages of change’ model • Use motivational interviewing (These topics are covered in the following few slides)

  16. FACTORS THAT INCREASE THE EFFECTIVENESS OF PATIENT EDUCATION (1) • A patient’s sense of trust in their GP1 • Face-to-face delivery2 • Patient involvement in the decision-making3,4 • See “A patient-centred approach” • Highlighting the benefits and costs5,6 • See “Motivational interviewing” Reference: 1. Trachtenberg F, et al. J Fam Pract. 2005;54:344–52; 2. Ellis S. Pat Educ Couns. 2004;52:97–105; 3.Mead N, et al. Patient Educ Counsel. 2002;48(1):51–61; 4. Rao J, et al. Arch Fam Med. 2000;9:1148–55; 5. Littel J, et al. Behav Modif. 2002;26:223–73; 6. Schauffler H, et al. J Fam Pract. 1996;42:62–8

  17. FACTORS THAT INCREASE THE EFFECTIVENESS OF PATIENT EDUCATION (2) • Strategies to assist patients remembering what they have been told1 e.g. patient leaflet, summarise goals at the end of the consultation • Tailoring information to the patient’s interest in change2 • Strategies that address the difficulty in adherence3,4 Reference: 1. Ley P. Patients’ understanding and recall in clinical communication failure. In: Pendleton D, Hasler J, editors. Doctor-patient communication. London: Academic Press, 1983; 2. Steptoe A, et al. Am J Public Health. 2001;91:265–9; 3. Rao J, et al. Arch Fam Med. 2000;9:1148–55 ; 4. Branch L, et al. Med Care. 2000;38:70–7

  18. A PATIENT-CENTRED APPROACH (1) A patient-centred approach involves1: • Actively involving the patient in the consultation • Respecting the patient’s autonomy • Encouraging the patient’s role in decision making • Embracing a more holistic approach that includes health promotion and disease prevention Reference: 1. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  19. A PATIENT-CENTRED APPROACH (2) Encouraging more active patient involvement and inclusion in the consultation has a number of benefits: • Clarification of what is expected of you by the patient1 • Stronger patient autonomy, patient responsibility and patient self management2,3 • Increased patient and doctor satisfaction1 • Enhances the quality of communication4,5 • Better adherence to the recommended prevention activities5,6 Reference: 1. Grol R. Improving practice. A systematic approach to implementation of change in patient care. Oxford: Elsevier Science, 2004; 2. Shortell S, et al. Milbank Q. 1998;76:1–37; 3. Gold M, et al. J Fam Prac. 1990;30:639–44; 4. Tan S. The collaborative method: ensuring diffusion of quality improvement in health care: Report on the Collaborative Workshop, June 2003; 5. King L. Review of literature on dissemination and research on health promotion and illness/injury prevention activities. In: Sydney National Centre for Health Promotion, Department Public Health and Community Medicine, University of Sydney, 1995; 6. Ferrence R. Can J Public Health. 1996;87:S24–7

  20. PATIENT’S READINESS TO CHANGE: ‘STAGES OF CHANGE’ MODEL (1) “The ‘stages of change’ model1 identifies 5 basic stages of change that are viewed as a cyclical, ongoing process during which the person has differing levels of motivation and readiness to change and the ability to relapse or repeat a stage. Each time the stage is repeated, the person learns from the experience and gains skills to help them move onto the next stage.”2 Reference: 1. Tenove S. Can J Nurs Res. 1999;31:95–9; 2. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  21. PATIENT’S READINESS TO CHANGE: ‘STAGES OF CHANGE’ MODEL (2) Stages of change1: • Precontemplation: the person does not consider the need to change • Contemplation: the person considers changing a specific behaviour • Determination: the person makes a serious commitment to change • Action: change begins (large or small) • Maintenance: change is sustained over a period of time Adapted from RACGP ‘Green Book’2 Reference: 1. RACGP ‘Red Book’ Taskforce. Guidelines for preventive activities in general practice. 6th edn. South Melbourne: RACGP. 2005; 2. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  22. QUESTION 2 • Which stage of change is reflected in these comments?

  23. MOTIVATIONAL INTERVIEWING (1) • Definition: ‘a directive, patient centred counselling style for eliciting behaviour change by helping patients to explore and resolve ambivalence’1 • Motivational interviewing1: • Has been shown to be effective in a number of areas in the primary care setting, including nutrition and diet • Is a useful approach when patients show a degree of ambivalence Reference: 1. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  24. MOTIVATIONAL INTERVIEWING (2) Systematically directing the patient toward motivation to change Offering advice and feedback when appropriate Selectively using empathetic reflection to reinforce certain processes Seeking to elicit and amplify the patient’s discrepancies about their health related behaviour to enhance motivation to change Motivational Interviewing Reference: 1. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  25. MOTIVATIONAL INTERVIEWING STRATEGIES (1) • Regard the person’s behaviour as their personal choice • Ambivalence is normal • Let the patient decide how much of a problem they have • Explore both the benefits and costs associated with the problem as perceived by the patient • Encourage the patient to rate their motivation to change out of 10 and explore how to increase this score Reference: 1. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  26. MOTIVATIONAL INTERVIEWING STRATEGIES (2) • Avoid arguments and confrontation • Confrontation, making judgments or moving ahead of the patient generates resistance and tends to entrench attitudes and behaviour • Encourage discrepancy • Change is likely when a person’s behaviour conflicts with their values and what they want • The aim of motivational interviewing is to encourage this confrontation to occur within the patient, not between the doctor and patient • Highlighting any discrepancy encourages a sense of internal discomfort (cognitive dissonance) and helps to shift the patient’s motivation • When highlighting the discrepancy, in the first instance, let the patient make the connection Reference: 1. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  27. QUESTION 3 What are the four components of motivational interviewing? (Insert the correct words in the spaces below. Record your answers on your answer sheet.) WORDS: motivation, elicit, advice, discrepancies, feedback, empathetic, amplify, processes, change, systematically. • ________directing the patient toward _______to change. • Seeking to ______and ______the patient’s __________about their health related behaviour to enhance motivation to ______. • Selectively using _______reflection to reinforce certain _________. • Offering ______ and _______when appropriate.

  28. THE 5-STEP MODEL An effective way to incorporate the elements of nutrition counselling presented in the last few slides is to use the 5As1,2: • Ask (or address) • Assess • Advise • Assist • Arrange Reference: 1. Ockene I, et al. Arch Intern Med 159:725-31; 2. RACGP National Standing Committee. SNAP: A population health guide to behavioural risk factors in general practice. South Melbourne: RACGP. 2004

  29. CASE SCENARIO: USING THE 5As 1. Address the agenda: “Your blood test results show your cholesterol levels have increased substantially since your last test. I think we should review your eating habits and try to make some improvements.” Reference: 1. Ockene I, et al. Arch Intern Med. 1999;159:725-31

  30. 2. Assess patient’s readiness to change and relevant diet experience: “How do you feel about making some changes to your diet?” “Can you think of some recent changes in your eating habits that may have contributed to the rise in cholesterol?”

  31. 3. Advise: “To help you understand how important this is for your heart, I’ll tell you about a study that was done in America a few years back. The study looked at about 45,000 men over an 8-year period. They found that those who were most likely to develop heart disease ate more red meat, processed meat, refined grains, sweets, French fries, and high-fat dairy products. In comparison, the group that had the lowest risk of heart disease ate more vegetables, fruit, legumes, whole grains, fish, and poultry.1” “Based on your health risks and current diet, let’s focus on lowering your fat intake and adding a few more vegies to your diet.” Reference: 1. Hu FB, et al. Am J Clin Nutr2000; 72: 912-921

  32. EATING FOR A HEALTHY HEART For many years, the traditional Australian diet has been too high in meat and animal fat and lacking in vegetables, fruits and grains. This has made us very vulnerable to heart and blood vessel disease, not to mention a whole range of other diseases. You can make a huge difference to your heart and to your general health just by making a few simple changes in your way of eating. Start gradually, and see how many of these changes you can incorporate into your daily diet. Make vegetables a major part of at least one meal each day and eat fruit frequently. Choose wholegrain breads instead of white varieties more often. Eat more cereals (rice, pasta and other grains) and legumes (dried peas and beans). Try flavouring these with small amounts of lean meat, rather than basing the whole meal around meat. Use only very small amounts of very lean meats, and eat poultry without skin. Choose low-fat dairy products (milk, yoghurt and cheese). Eat fish (fresh or canned and not fried) at least twice a week. Make high-fat and/or high-sugar bakery products, fast foods, desserts, soft drinks and confectionery occasional treats rather than everyday food. Use monounsaturated or polyunsaturated oils (e.g. olive, canola, sunflower and safflower) for cooking. Use small amounts of margarine spreads or olive oil instead of butter. Grill, boil, steam, bake or microwave rather than fry. Reduce your salt intake. Look for the Heart Foundation Tick for healthy food choices. Drink plenty of water. Rediscover the joy of cooking wholesome meals at home, and teach your kids! “Here are some information sheets to get you started. On the back, there are suggestions about how you can reduce your fat intake and other healthy eating habits.” Reference: 1. National Heart Foundation of Australia. Dietary fats and heart disease. 2004. Available at: http://www.heartfoundation.org.au/document/NHF/nrcr_diet_fats_mar04.pdf; 2. myDr.com.au. Eating for a healthy heart. Available at:: http://www.mydr.com.au/default.asp?article=3105

  33. “I’m going to give you some fill out at home…This is something that I get my patients to fill out when they have to change their behaviour. It’s called a decision balance. Think about what you would like and dislike about not making any changes to your diet and then do the same for making changes. It helps you to weigh up the pros and cons. We can talk about your answers when you bring it back at your next visit.” Click here to open and print a blank Decision Balance form, which you can give to your patients Reference: 1. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006

  34. 4. Assist: “How about we try to start with two or three of these Heart Foundation recommendations.1” “Which of these do you feel you are most likely to stick to?” “What do you think will be the main difficulties in changing your diet?” Reference: 1. National Heart Foundation of Australia. Dietary fats and heart disease. 2004

  35. 5. Arrange follow-up: “If you feel you need more help, I can refer you to a dietician.” “Otherwise, I’d like to see how you’re going in about a month’s time.”

  36. PRESENTATION OUTLINE • Why is nutrition education important? • Who should deliver nutrition education? • What do GPs think and do about nutrition counselling? • How should nutrition counselling be delivered? • What are the obstacles to nutrition counselling?

  37. WHAT ARE THE OBSTACLES TO NUTRITION COUNSELLING? Common obstacles identified by GPs Lack of time Lack of confidence Lack of knowledge Patients’ attitudes Financial obstacles Reference: 1. Nicholas L. Aus Family Phys 2004;33:957-9; 2. Judd H, et al. Management of obesity in general practice: Report from the nutrition fellowship 1987. Sydney, Australia: RACGP, 1988.

  38. OVERCOME OBSTACLES THROUGH PRACTICE ORGANISATION (1) The above obstacles can be overcome to some extent by the development of a preventive program that includes1: • Setting practice priorities • Listing what roles each practice member currently undertakes and how nutrition counselling can be integrated into existing roles and responsibilities Reference: 1. RACGP National Standing Committee. SNAP: A population health guide to behavioural risk factors in general practice. South Melbourne: RACGP. 2004

  39. OVERCOME OBSTACLES THROUGH PRACTICE ORGANISATION (2) • Reviewing the way in which appointments and follow up are arranged • Establishing information systems to support nutrition counselling (e.g. updating and managing tools and patient education materials) • Conducting ongoing quality improvement programs (e.g. audits) • Developing links with local services (e.g. dieticians) Reference: 1. RACGP National Standing Committee. SNAP: A population health guide to behavioural risk factors in general practice. South Melbourne: RACGP. 2004

  40. FINANCIAL INCENTIVES (1) Interventions for behavioural risk factors, such as nutrition, can be part of a successful business model for GPs. It can be an attractive component of practice programs to encourage patients to attend the practice.1 Reference: 1. RACGP National Standing Committee. SNAP: A population health guide to behavioural risk factors in general practice. South Melbourne: RACGP. 2004

  41. FINANCIAL INCENTIVES (2) There are a number of commonwealth programs that may help provide financial support. These include: • Practice Incentive Program (PIP) incentives to incentives for establishment of chronic disease register and recall systems (www.hic.gov.au/providers/incentives_allowances/pip/new_incentives.htm) • The program to help fund practice nurses in rural practices (www.hic.gov.au/providers/incentives_allowances/pip/new_incentives/nurse_incentive.htm) • Under Medicare, EPC care planning services attract a Medicare rebate. An EPC multidisciplinary care plan may only be provided to patients with at least one chronic or terminal medical condition AND complex care needs requiring multidisciplinary care from a team of health care providers including the patient’s GP (www.health.gov.au/epc/careplan.htm)

  42. QUESTION 4 • How often do you assess diet in patient’s with health risks? • How often do you provide verbal nutrition advice to these patients? • How often do you offer referral for nutrition counselling? Answers to be indicated on answer sheet as:  Very frequently  Frequently  Sometimes  Rarely  Don’t know

  43. QUESTION 5 What types of patient education materials does your practice have concerning nutrition? (Tick all applicable) • Pamphlet/booklet • Computerised leaflet (e.g. pdf files) • Posters • Videos • Other

  44. QUESTION 6 What proportion of your patients from culturally and linguistically diverse backgrounds are able to read and/or understand the patient nutrition information materials? Answers to be indicated on answer sheet as:  All  Most  Some  Few  Don’t know

  45. QUESTION 7 Think of two changes that you can make to your practice systems to better support or improve the effectiveness of nutrition counselling sessions. Write these down in the space provided.

  46. SUMMARY • Nutrition plays an important role in the aetiology and management of many diseases affecting Australians1 • GPs, along with dieticians, are at the forefront of providing nutrition management in Australia2 • In Australia, nutrition counselling is below a desirable level and/or national targets3 • When counselling about nutrition, use strategies and tools that maximise patient motivation and adherence4 • Some obstacles to effective nutrition counselling can be overcome through practice organisation4 • There are financial incentives for the management of behavioural risk factors4 1. National Public Health Partnership. Eat Well Australia. Canberra: Strategic Inter-Governmental Nutrition Alliance (SIGNAL). 2001; 2. Nicholas L. Aus Family Phys 2004;33:957-9; 3. RACGP ‘Green Book’ Project Advisory Committee. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 2nd edn. South Melbourne: RACGP. 2006 ; 4. RACGP National Standing Committee. SNAP: A population health guide to behavioural risk factors in general practice. South Melbourne: RACGP. 2004

  47. THANK YOU FOR COMPLETING THIS ACTIVITY! The next few slides will highlight the role of chicken in a healthy diet. We hope this update is useful when advising your patients. Printable PDFs of patient education materials are available at the end of this presentation.

  48. THE ROLE OF CHICKEN IN HEALTHY DIETS

  49. CHICKEN DELIVERS IMPORTANT NUTRIENTS Delivers essential vitamins and minerals Lean chicken meat: An excellent source of protein Over 55% of the total fat content is unsaturated fat Reference: 1. Food, Health and Nutrition: Where Does Chicken Fit? www.chicken.org.au

  50. HOW DOES LEAN CHICKEN COMPARE WITH OTHER LEAN MEATS? Stir-fried lean chicken breast has the lowest total fat content compared to other meat sources Stir-fried lean chicken breast contains more than 55% unsaturated fatty acids Stir-fried lean chicken breast provides higher amounts of niacin equivalents than other lean stir-fry cuts of meat Reference: 1. Food, Health and Nutrition: Where Does Chicken Fit? www.chicken.org.au

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