Presentation on theme: "Welcome to Good nutrition – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address the nutritional."— Presentation transcript:
Welcome to Good nutrition – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address the nutritional and dietary requirements of their patients to improve their health and prevent disease.
Which of the following statements regarding fruit and vegetable intake is CORRECT? QUIZ Question 1 A.Most Australians consume sufficient quantities of fruit and vegetables in their normal diets B.Osteoporosis contributes more to the disease burden in Australia than lack of dietary fruit and vegetables C.Men are higher consumers of fruit and vegetables than women in Australia D.Alcohol consumption and dietary levels of fruit and vegetables have similar impact on overall health in Australia.
Which of the following statements regarding obesity is CORRECT? Question 2 A.The majority of Australian children are outside of the healthy weight range B.Among patients presenting to GPs, more men than women are overweight or obese C.Less than one-half of adults presenting to the GP are considered overweight or obese D.Raised body mass index (BMI) is the biggest risk factor for disease in Australia.
Poor nutrition results in a range of disease processes. Which of the following statements is CORRECT? Question 3 A.Obesity is a major risk factor for cancer, cardiovascular (CVD) and type 2 diabetes B.High total carbohydrate intake is an established risk factor for CVD C.Diets high in soluble fibre are associated with lower plasma HDL cholesterol levels D.Consumption of predominantly low glycaemic index (GI) foods is a risk factor in the development of type 2 diabetes.
Changes in nutritional intake can affect the risk of future illness. Which of the following statements is CORRECT? Question 4 A.Low GI diets decrease the bodys sensitivity to insulin B.Weight loss of 10 kg or more is required to significantly decrease risk of diabetes in those with impaired glucose tolerance C.A 10% weight loss is associated with at least a 40% reduction in obesity related cancer deaths D.An extra serve per day of fruit/vegetables per adult would have a minimal effect on cancer incidence.
The 5As approach can be used in dealing with nutrition AskAssessAdviseAssistArrange. This involves 5 steps:
Merri, aged 26 years, is overweight and presents for the first time at your practice for a routine Pap test and check up. As you assess her weight and general health, you decide to ask her about nutritional issues. Which is the MOST helpful initial screening question about nutrition in Merris case? Question 5 – Ask A.Were you overweight as a child or in your teenage years? B.How much alcohol do you drink on average per week? C.Have you made any attempts in the past to change your weight? D.How many serves of fruit and vegetables do you eat in a day?
Merris BMI is 28 (5 kg gained last 12 months); BP is normal. She: is a nonsmoker with no past or family CVD history; eats 1 piece of fruit and two vegetables & drinks 4 cups of coffee and 2 glasses of water most days. Which initial assessment is CORRECT? Question 6 – Assess A.Merri is at risk nutritionally because she has gained 5 kg in the past 12 months B.Merri does not need investigations at this stage – her CV risk is low C.Merris 6 cup fluid intake (including 2 cups of water) per day is adequate D.Merri should be started on a diet and exercise program to help her achieve her ideal weight.
Question 7 – Assess Merris father, Sam, aged 69 years, lives alone since his wife died 3 years ago. He: presents with a vague unwell feeling; is treated for mild hypertension and chronic glaucoma; appears to have lost weight. Which is the MOST helpful screening question for assessing Sams current nutrition? A.Are you taking any nutritional supplements such as multivitamins? B.Have you noticed any decrease in your appetite recently? C.Have you been eating more take away meals than you used to? D.Have you been drinking at least 8 cups of fluid per day?
Sam asks your advice regarding a healthy intake of fruit and vegetables. Which of the following statements is CORRECT? Question 8 – Advise A.Rice is considered a vegetable and may be included in the daily requirements B.5 serves of fruit and vegetables should be consumed each day C.Fruits and vegetables are a good source of protein – an essential nutrient D.Frozen or canned vegetables are an acceptable source of daily vegetable intake.
Sam asks what other advice you can give him regarding his daily intake of nutrients in order to optimise his health. You advise him to consume each day: Question 9 – Advise A.1 serve of meat/fish/poultry/eggs/nuts B.Butter in preference to margarines C.3 serves of bread, cereals, rice, noodles D.4 serves of dairy, including milk/yoghurt/cheese.
Sam also asks about fluid intake as he wonders if he should be drinking more water. Which is the MOST appropriate advice for Sams fluid intake? Question 10 – Advise A.Three to four glasses of alcohol may be consumed each day for the health benefits it provides B.Any beverage or drink is counted as fluid, but water is the best choice C.Artificially sweetened cordials are acceptable but may have a diuretic effect D.Fruit juice should be limited to four glasses per day.
You have explained to Sam the number of serves for each of the main food groups he should eat daily. He asks for more information about how much is a serve. Which of the following is equivalent to 1 serve or portion? Question 11 – Advise A.One small piece of fruit such as an apricot or a plum B.One slice of bread or 1 cup of cereal C.1 cup of fruit juice D.Half a cup of cooked vegetables.
Returning to Merri, if on examination she was found to have mild hypertension, what further lifestyle advice regarding decreasing salt intake would help her to manage this? Question 12 – Advise A.Garlic salt and onion salt are good alternatives to table salt if you wish to lower your salt intake B.Only a small amount of daily salt intake comes directly from food, most is added at the table or while cooking C.Use commercial sauces such as tomato sauce or soy sauce to add flavour to food, rather than adding salt D.Choose packaged foods which are labelled low salt or no added salt.
If Merri had an abnormal lipid profile (eg. high LDL and low HDL cholesterol), advice about fat and cholesterol would be beneficial. Which of the following statements about dietary fats is CORRECT? Question 13 – Advise A.Saturated fats raise blood cholesterol while polyunsaturated fats may lower blood cholesterol B.Saturated fat is found in butter and olive oil, as well as many commercially baked products such as biscuits C.Monounsaturated fats are healthier than saturated fats – no need for Merri to limit consumption of foods that contain these fats D.Cholesterol is present in many foods including nuts, avocado, eggs, fatty meats and dairy products.
Most food is prepackaged and must be labelled with ingredients and some nutrients. Merri asks what she should look for when reading food labels. Which of the following is CORRECT? Question 14 – Advise A.Checking the ingredient list is adequate for deciding on which of two alternative products is the healthier choice B.Aim for foods that are low in saturated fat, low in sodium (salt) and low in fibre C.Foods with the Heart Foundation Tick are lower in both saturated and trans fat, sodium (salt) and kilojoules when compared to similar foods D.Foods which contain vegetable oil are a healthier alternative to foods that contain butter.
Merri wants to start eating a healthier diet, but also likes to have a break from cooking. She asks your advice about choosing healthy take away/fast food. Which of the following is CORRECT? Question 15 – Advise A.Try to limit pies, pizza, hamburgers and creamy pasta dishes to twice per week B.Barbecued chicken with gravy and a tasty stuffing is a healthy choice C.Doner kebab/souvlaki with tabouli in pita or Lebanese bread are good options D.Asian take away choices are almost all low fat so are worth considering.
Although willing to consider a diet that will improve her overall health, Merri wonders whether what she eats really has any affect on her weight. Which of the following statements is CORRECT? Question 16 – Advise A.Changing from full fat to low fat dairy products will not have any significant effect on weight loss if it is the only change made B.Eating 400 kj more than energy needs per day will result in approximately 4 kg weight gain over 1 year C.A chocolate biscuit and a scoop of ice cream each contain about 100 kj D.Making dietary changes without increasing physical activity levels will not have any long term effect on weight.
Merri has heard information in the media about plant sterols and omega 3 oils being good for overall health. Which of the following statements about these products is CORRECT? Question 17 – Advise A.Plant sterols lower cholesterol by blocking the absorption of cholesterol B.Plant sterol margarines can be used in place of cholesterol lowering medications C.Omega 3 fats are a polyunsaturated fat found naturally only in marine foods (eg. fish) D.The Heart Foundation recommends eating fresh fish once per week.
In taking further history you discover that Merris mother had diabetes. Merri asks if her diet could help in lowering her risk of diabetes. You explain the concept of GI. Which of the following statements is CORRECT? Question 18 – Advise A.Glycaemic index is a measure of the glucose content of various foods B.Choosing foods with a high GI improves glycaemic control in those with diabetes C.High GI foods reduce hunger and keep you feeling fuller for longer D.The GI alone is insufficient to use as a basis for a healthy diet.
Some patients, particularly those with chronic disease and the elderly, may suffer from malnutrition. How can you assist this group of patients? Question 19 – Assist A.Recommend adequate hydration by consuming 4–5 cups of tea and/or coffee each day B.Encourage snacking on a range of vegetables, either raw or cooked throughout the day C.Prescribe patients to eat small frequent meals and high energy snacks that are individualised to their needs D.Suggest eating high fat foods with each meal and snack.
Once strategies/goals for improved nutrition have been negotiated with patients, follow up is important. Which of the following statements regarding follow up is CORRECT? Question 20 – Arrange A.Patients should be reviewed at 2 weeks to help increase the chance of sustaining long term dietary change B.Practice information systems should generate reminders or lists of patients overdue for follow up C.Patients should be reviewed yearly for 2 years after desired changes are achieved D.Emphasis at follow up is on measurable outcomes such as weight loss or gain.
Effective management of some patients nutritional requirements may need referral to a dietician. In which of the following situations would referral to a dietician NOT be an appropriate next step? Question 21 – Arrange A.A morbidly obese patient who needs a specific dietary prescription and counselling B.A patient who needs dietary management help for chronic disease C.A patient who has recent significant weight loss and is waking at night with back pain D.Patient with complex dietary needs due to a combination of diseases such as hyperlipidaemia and osteoporosis.
Antioxidant and vitamin supplements are highly promoted as being beneficial to health. Which of the following statements is CORRECT? Question 22 A.The use of vitamin supplementation in asymptomatic individuals is now established as beneficial to health B.The consumption of antioxidant supplements such as beta carotene is recommended, especially in patients with heart disease C.Eating plenty of plant based foods is the best way to ensure adequate antioxidant levels D.Food based sources of folate supply adequate levels of folate in pregnancy, negating the need for supplements.
Johns father recently suffered a myocardial infarction. John has read that antioxidants are good for preventing heart disease and asks your opinion. Which of the following statements is CORRECT? Question 23 A.Antioxidants may act by preventing molecules known as free radicals from attacking and damaging healthy cells B.Vitamin E is recommended for anyone who has heart disease or is at risk of developing it C.Antioxidants include Vitamin A, Vitamin E, beta carotene and flavinoids D.Antioxidants are present in green leaf tea and green leafy vegetables but not in black leaf tea.
Toby has a strong family history of cancer. He has read contradictory information on the internet about how diet can prevent cancer and would like your advice. Which of the following statements is CORRECT? Question 24 A.Recent evidence has established that high intake of omega 3 fatty acids/fish reduces the risk of breast and prostate cancer B.There is a direct link between high dietary fat consumption and cancer at several sites C.There is good evidence that high intake of fruit and vegetables reduces the risk of cancer of the oesophagus and rectum D.There is evidence of a link between high dietary processed red meat intake and cancer at several sites.
Nutrition is not only an important consideration for adults, it is also important for healthy development in children. Which of the following statements is CORRECT? Question 25 A.If a child dislikes a particular food there is no point in continuing to offer it to them B.The food provided at childcare centres is only a small and, therefore, insignificant part of a childs overall diet C.Parents have a large influence in establishing their childs eating habits D.Children should be given dietary supplements such as fish oil capsules to ensure good long term health.
SLIDE PRESENTATION Nutrition, diet and the 5As
Talk to patients about enjoying a range of nutritious foodsEat plenty of vegetables, legumes and fruitsChoose wholemeal or wholegrain cereals, including breads, rice, pasta, noodlesInclude lean meat, fish, poultry and/or alternativesInclude milk, yoghurt, cheeses and/or alternatives (low or reduced fat varieties should be chosen where possible).
Talk to patients about limiting certain foods Limit saturated fat and trans fat and moderate total fat intakeChoose food low in saltLimit your alcohol intake if you choose to drinkConsume only moderate amounts of sugars and foods containing added sugars.
Talk to patients about hydration and physical activity Drink plenty of waterPrevent weight gain by being physically active and eating according to your energy needsCare for your food by preparing and storing it safelyEncourage and support breastfeeding.
Evaluating nutrition How would you approach the subject of nutrition with a patient with whom you have previously not addressed dietary issues?
Like other lifestyle risk factors, diet can be dealt with using the 5As AskHow many serves of fruit and vegetables do you eat in a day?Have you experienced any unintentional recent weight gain or loss over the past year?Have you had any change in appetite?
Assess A normal adult is considered nutritionally at risk if they:eat less than 5 serves of vegetables and 2 serves of fruit per dayexperience unintentional weight gain of >4 kg in 12 months, orexperience significant weight loss and poor appetite.
Consider stage of change To assess how ready a patient is to change their lifestyle, ask: How interested are you in improving your eating habits?Precontemplation – the patient is not ready to changeContemplation – the patient is considering making a change, but still unsureReady – the patient is ready to make a change and take actionMaintenance – the patient has made a change and needs encouragement to sustain the change.
AdviseGive feedback on the patients current diet. ADVISE them to follow the current Australian dietary recommendationsYou may like to give them a more individualised Lifescripts prescription. Assist Assist the patient to:understand the benefits of healthy nutritionformulate, negotiate and implement achievable goals to improve their nutrition.
ArrangeArrange to follow up the patient yourselfArrange referral, if necessary.
What is a serve of fruit? Two serves of fruit a day is the minimum daily recommended amount. A serve of fruit includes:one medium size apple, banana, orange, one-quarter of a rock melon½ cup of fruit juicefour dried apricots or 1½ tablespoons of sultanas, or1 cup of canned or fresh fruit salad.
What is a serve of vegetables? An average adult should consume at least 5 serves of vegetables per day. One cup of cooked vegetables constitutes 2 serves. A serve of vegetables includes:½ cup cooked vegetables (75 g)one medium potato1 cup of salad vegetables, or ½ cup of cooked dried legumes (eg. lentils). Note: Rice and pasta do not count as a vegetable.
What is a serve of cereals? Daily intake: women 4–9 serves, men 6–12 serves, depending on energy requirementsCereals include oats, rye, bread, breakfast cereals, rice, pasta, noodles, cous cous. Wholegrain or wholemeal varieties should be chosen. What is a serve of protein?Daily intake: 1–2 servesProtein includes meat (lean), fish (preferably oily), poultry (skinless), eggs, nuts and soy alternatives (eg. textured vegetable protein and tofu).
What is a serve of dairy? Daily intake: 2–3 serves. A serve of dairy food includes:250 mL of low fat milk40 g (2 slices) of cheese200 g carton of yoghurt, or250 mL custard.
Eating for health using the 5As: case studies
Case study 1: Eating for two AskChloe, aged 27 years, has a long routine visit for her first antenatal appointmentLifestyle history reveals that Chloe is a nonsmoker; has now stopped drinking; and gets plenty of physical activity as she works part time as an aerobics instructorThere has been no weight change yet, or over the past yearChloe is happy for you to perform a brief nutritional assessment.
Case study 1: Eating for two Assess During pregnancy, why do nutrition assessments need to be more comprehensive?
Case study 1: Eating for two During pregnancy, assessment should determine whether the patient:eats 5–6 serves of vegetables per dayeats 4 serves of fruit per dayeats 4–6 serves of cereals per daysupplements folate with 500 µg per day until 3 months and consumes folate rich foodseats 1.5–2 serves iron rich food per dayeats some iodine rich foods such as seafood (or iodine supplement)eats 2–3 serves of calcium rich foodsavoids fish containing high mercury levelsavoids foods at risk of transmitting listerosis and toxoplasmosis.
Case study 1: Eating for two Chloe is:eating 1 piece of fruit (recommended amount is 4 serves)eating 2–3 vegetables (recommended amount is 5–6 serves)not taking any folate supplementation and has not been avoiding food borne infections. Chloe is nutritionally at risk.
Case study 1: Eating for two Ask and Assess Chloe is willing to make some nutritional changes to benefit her own health and possibly the health of her baby. She is keen to do whatever is best, now that she is finally pregnant. What stage of change is Chloe in? A. Precontemplation B. Contemplation C. Ready D. Maintenance
Case study 1: Eating for two Advise What general advice can you give Chloe regarding nutrition?
Case study 1: Eating for two General advice could include:the size of a servehow to follow the Dietary guidelines for Australian adultsincreasing to 4 serves of fruit and 5–6 serves of vegetables per day.
Case study 1: Eating for two What extra advice will you give Chloe because she is pregnant?
Case study 1: Eating for two Advise Chloe on:folate supplementation to decrease the risk of neural tube defectsthe required intake of iron rich foods, adequate calcium and recommended fluid and caffeine intakethe risk of listeria infection during pregnancy, and risk of abortion, still birth, septicaemia and meningitisthe risk of contracting the parasite toxoplasmosisavoid alcohol throughout pregnancy to avoid fetal alcohol syndrome.
Case study 1: Eating for two Assist What can you do to help Chloe with these dietary recommendations?
Case study 1: Eating for two Assist Chloe by:writing a recommendation for folate to take to the chemistproviding her with Food Standards Australia information on avoiding listerosiswriting a Lifescript for increasing fruit and vegetable intake and for pregnancy, and a nutrition in pregnancy evidence carddiscussing goals such as adding extra serves of fruit and vegetables to her diet.
Case study 1: Eating for two ArrangeArrange a follow up appointment for Chloe. Her nutrition can be reviewed at the next antenatal visit. At the next antenatal visit Chloe:has increased her fruit and vegetable intakeher pregnancy is progressing well (apart from mild nausea) and all tests are normalshe is using the Australian dietary guidelines and Pregnancy Lifescript. What other nutritional issues would you discuss before Chloes baby is born?
Case study 1: Eating for two Current breastfeeding recommendations recommend exclusive breastfeeding for at least the first 6 monthsDaily dietary recommendations during breastfeeding include 7 serves vegetables/legumes, 5 serves fruit, 5–7 serves cereal, 2 serves milk/yogurt/cheeseParental eating habits have a significant effect on the nutritional risk of their children.
Case study 2: Its in the genes Meg, aged 43 years, is well and has returned to the practice for her Pap test results, have a breast check and a BP check (it was elevated at her last visit)Her Pap test is normal, BP is 150/90 mmHg, BMI is 21 kg/m 2She has no past history of CVD, is taking no medication, is a nonsmoker, and drinks two glasses of wine 2–3 nights per weekFamily history: her father died aged 58 years following a myocardial infarction; an uncle is being treated for angina; and her mother is taking medication for high cholesterol.
Case study 2: Its in the genes Ask You take this opportunity to discuss nutrition with Meg. What initial questions would you ask Meg?
Case study 2: Its in the genes Ask Meg:How much fruit and vegetables do you eat in a day?Have you had any recent unintentional weight change? Meg tells you she eats 2 serves of fruit and 2 serves of vegetables on most days, and has had no recent weight change.
Case study 2: Its in the genes AssessMegs vegetable intake is inadequate for healthy nutrition. What other factors in Megs diet or life would you want to assess, considering her elevated BP and family history?
Case study 2: Its in the genes Assess Megs:diet using Lifescripts questionnaire or 1 day food recallsalt intakesaturated and total fat intake as abnormal lipid levels is an added risk factor for end organ diseasealcohol intake (if you have not asked this previously). Megs level of physical activity would also be an important consideration in assessing her overall risk.
Case study 2: Its in the genes Assess On assessing Megs willingness to change her diet and physical activity levels, she tells you that she considers herself fit and healthy and not overweight. She is not concerned about her blood pressure being a bit up. What stage of change is Meg currently in? A.Precontemplation B.Contemplation C.Ready D.Maintenance.
Case study 2: Its in the genes AdviseYou acknowledge to Meg that she is unwilling to make any changes nowYou do provide feedback on her current diet, specifically alcohol and salt intake (and also physical activity levels) that may be affecting her BPYou reinforce the importance of maintaining a healthy body weightYou also advise that her fruit and vegetable intake is not ideal, and improving these would benefit her long term health.
Case study 2: Its in the genes What technique could you use to assist Meg to understand the desirability of changing her nutritional habits? A.Inform her that she is likely to develop diseases such as stroke, heart attack and cancer B.Employ motivational interviewing techniques C.Refer her to a dietician to reinforce what you have told her D.Use cognitive behavioural therapy to help her change her incorrect beliefs about her diet.
Case study 2: Its in the genes A systematic approach to motivational interviewing involves:examining the good things about improving lifestyle (eg. nutrition or physical activity)asking about the less good things, and how and why it concerns the patientlooking to the futuregetting the patient to rate their motivation and confidence on a scale of 1–10identifying strengths and barriers to lifestyle change and self management. As Meg is at the precontemplation stage, how could you use this technique in your consultation with her?
Case study 2: Its in the genes AssistIf Meg is willing, discuss the benefits of improving eating habitsAllow Meg to explain the difficulties she would face in trying to change her dietAs Meg is in the precontemplation stage, this is probably all that it is appropriate at this consultation.
Case study 2: Its in the genes Assist Other health messages for Meg could include:decreasing salt intake may enable her BP to be managed without needing medicationimproving her diet may help prevent the potential long term effects of high BP such as stroke and heart attack if Meg has elevated lipids, then dietary changes may be enough to manage these without needing medicationincreased fruit and vegetable intake will have general beneficial health effects.
Case study 2: Its in the genes ArrangeMeg wants to stay healthy and in view of her persisting mild hypertension and family history of hyperlipidaemia and CVD, you arrange to check her blood lipids. You also check fasting blood glucose level, electrolytes, urea and creatinine. Meg returns 2 weeks later.Her BP today is 145/90 mmHgBlood test results are normal apart from a mildly elevated total and LDL cholesterol and a low HDL cholesterol.
Case study 2: Its in the genes Meg now has her test results and has thought about the nutritional issues you discussed, but is still unsure about making changes to her diet. What stage of change is Meg now in? A.Precontemplation B.Contemplation C.Ready D.Maintenance.
Case study 2: Its in the genes Motivational interviewing techniques you could use at this consultation include, discussing the pros and cons of both making changes and not making changes. Making changesNot making changes ProsConsProsCons Better long term health Effort of thinking up new meals Current dietary habits easier to follow Risk of future illness Possibly avoiding medication Possible increased cost of healthier meals Cost of medications Change in shopping habits
Case study 2: Its in the genes Advise In view of Megs persisting elevated BP and mildly abnormal lipids, you could suggest goals including:reducing salt intake/increasing potassium intakedecreasing saturated and trans fat intakechanging to mono- and poly-unsaturated fats and oilsincreasing fruit and vegetable intakedecreasing alcohol and increasing physical activity (if applicable).
Case study 2: Its in the genes Assist Meg has moved into the ready stage of change.You now provide Meg with one to two suitable take home patient information brochures from the Heart Foundation on healthy eating, salt, fats and cholesterolUseful websites include Lifescripts Nutrition online, Heart Foundation and the Australian dietary recommendations for general diet information.
Case study 2: Its in the genes Assist Negotiate SMARTS goals with Meg to improve her nutrition (eg. salt intake). SpecificI will no longer add salt to my meals at the table MeasurableI will not have the salt shaker on the table AgreedI am willing to make this change to my habits and have agreed to this with my doctor and my husband RealisticI will not cook with salt, but use herbs and spices instead TimeI am returning for a BP check with the practice nurse in 4 weeks SupportI know my husband will be very supportive, because he has always wanted me to stop using salt at the table
Case study 2: Its in the genes Assist Negotiate SMARTS goals with Meg at a later visit to cut down saturated and trans fat, and replace with mono and poly-unsaturated fats. Possibilities could include:limiting take away meals to once per weekreplacing full fat milk with skim milk or reduced/low fat milkusing low fat cheese instead of full fat cheesechanging to a mono or poly-unsaturated spread instead of a high saturated fat dairy spreadchoosing lean meats and trimming fat/removing skin before cookingchoosing less fatty cold meat; avoid salami, sausages.
Case study 2: Its in the genes ArrangeIn 4 weeks time you arrange for Meg to visit the practice nurse for a BP check and to discuss how she is going with her goalsIn 2–3 months time you follow up on Megs nutritional changes.
Case study 3: Its in my glands, doctor Rex Baron, aged 56 years, attended your practice for removal of a fish hook from his finger 6 weeks agoHe has no significant past medical history, but his BMI is 28 kg/m 2, waist circumference is 100 cm and BP 140/90 mmHg. He is a nonsmokerHe was asked to have his fasting blood glucose level (BGL), cholesterol and triglycerides measured and advised to return for more thorough assessment with the results of these tests. What is the significance of Rexs waist circumference?
Case study 3: Its in my glands, doctor Increased waist circumference is an indicator of central obesity, a risk factor for type 2 diabetes and CVDMeasuring waist circumference is simpler and more important than insulin resistance for diagnosing and predicting risk for metabolic syndrome and type 2 diabetesIn men this is >94 cm (or >90 cm in men of Asian, south or central American descent) and in women >80 cmBe alert for lean men with pot bellies who are at risk of metabolic syndrome even when not overweight. You suspect Rex has metabolic syndrome.
Case study 3: Its in my glands, doctor Metabolic syndrome is defined as central obesity in concurrence with any two of the following factors:raised triglyceridesreduced HDL cholesterolraised blood pressureraised fasting plasma glucose. In patients with metabolic syndrome, the risk of developing heart disease or diabetes is increased 2–4 fold.
Case study 3: Its in my glands, doctor Ask Rex returns for his follow up visit. His test results showed fasting blood glucose of 12 mmol/L, normal triglycerides and HDL are 0.8 mmol/L (total and LDL cholesterol mildly elevated). A random BGL was 15 mmol/L. Rex has metabolic syndrome and type 2 diabetes.You discuss the implications with Rex and ask him about his current diet, appetite and weight changeRex is willing to have further tests including HbA1c and an eye assessmentHe is keen to improve his situation and discusses lifestyle measures such as increasing activity and altering diet.
Case study 3: Its in my glands, doctor Assess Today you have a long appointment with Rex to advise him of his test results and to negotiate goals for managing his metabolic syndrome and type 2 diabetes.Today his waist circumference is 99.5 cm, BP 140/85 mmHg, and HbA1c 9.3%. What HbA1c level would you aim for? A. <9.0% B. <8.0% C. <7.0% D. <6.0%.
Case study 3: Its in my glands, doctor Assess Rex has begun to walk for 15 minutes each day and is trying to increase this. He has attempted to improve his diet, but is confused about what he should eat and what foods he should avoid. What stage of change do you consider Rex is in? A.Precontemplation B.Contemplation C.Ready D.Maintenance.
Case study 3: Its in my glands, doctor Assess Rex has begun to make changes and you need to support him in maintaining these. You ask Rex to do a 1 day food recall. Breakfast2 eggs, 2 sausages, buttered toast, 1 cup of white coffee with 2 sugars Morning snack1 cup white coffee 2 sugars, 2 chocolate Tim Tams, piece of fruit cake Lunch2 meat pies with tomato sauce, 1 doughnut, 1 banana, 1 can of coke Afternoon tea2 honey sandwiches, 1 Mars bar, 1 can of coke Late afternoon2 stubbies of beer (normal strength), few handfuls of salted nuts TeaFish and chips with tomato sauce, bowl of ice cream with chocolate topping Evening1 cup of white coffee 2 sugars, 3 butter shortbread biscuits What do you think about Rexs diet?
Case study 3: Its in my glands, doctor AdviseYou support Rex in the efforts that he is already making to change his lifestyle and discuss that additional changes over time would be beneficialYour nutritional assessment reveals that he has quite a high intake of high GI carbohydrate foods and high saturated fat foodsYou advise Rex that it is worthwhile negotiating goals to change the type of carbohydrate foods he is eating and alter his fat intakeSMARTS goals could be considered for fat intake reduction and carbohydrate intake modification.
Case study 3: Its in my glands, doctor AssistRex is willing to change his diet to try to improve his long term health, as his mother has had many complications from her diabetesBoth the amount and type of carbohydrate eaten will affect blood glucose levelTo make dietary changes, Rex needs to understand GI and glycaemic load (GL).
Case study 3: Its in my glands, doctor Glycaemic index is a way of ranking: A.The carbohydrate content of the particular food B.The effect that the food has on BGLs C.The glucose content of the food being assessed D.The amount of insulin that a food stimulates the body to release.
Case study 3: Its in my glands, doctor Consuming a diet where high GI foods are replaced by low GI foods improves glycaemic controlLow GI diets increase the bodys sensitivity to insulin, reduces the risk of heart disease, reduces blood cholesterol levels, helps people lose and control weight, reduces hunger and maintains a feeling of fullness for longerIt can also help manage the symptoms of polycystic ovary disease.
Case study 3: Its in my glands, doctor What is GL?Glycaemic load is determined by both the GI of the food and the total amount of that food consumedHigh GI foods increase the GL more than low GI foods if the same quantity of food is eatenQuantity is also important, as eating large amounts of low GI foods can still provide a significant GL.
Case study 3: Its in my glands, doctor Assist To assist Rex achieve a diet with a lower GL, discuss:watching serving sizes of carbohydrate foods – the most significant influence on GLreplacing high GI foods with lower GI foodsbreakfast cereals based on oats, barley and/or branlower GI potato options (eg. new potatoes or sweet potato)enjoying all other types of fruit and vegetables, including saladpasta, noodles and/or quinoa, and using Basmati or Doongara riceavoid refined carbohydrates (eg. soft drinks, cakes & confectionary) or use artificial sweetener alternativesregular meals and snacks to spread the load throughout the day.
Case study 3: Its in my glands, doctor Assist Other factors that need to be considered include:Rex has a raised BMI and central obesity – he needs to reduce his total energy/kilojoule consumption to enable weight lossIncreasing physical activity may help increase HDL and decrease weightRexs HDL is low while total cholesterol and LDL are mildly elevated. Choosing low fat dairy products and lean meats, and replacing saturated fats with mono- and poly-unsaturated fats, will help decrease total cholesterolRexs dietary changes may be complex, and optimal management would involve referral to a dietician and/or a diabetes educator.
Case study 3: Its in my glands, doctor ArrangeAs Rex has diabetes (a chronic condition), you could consider developing a GP Management Plan and introducing a team care approach incorporating yourself, a diabetes educator, a dietician and possibly an exercise physiologist. What would you include in your referral to the dietician and how would you access a dietician?
Case study 3: Its in my glands, doctor Arrange Your referral to a dietician should include information on:medical conditions related to diet (eg. metabolic syndrome, diabetes control, abnormal lipids)medications and blood test resultsprevious attempts to make dietary changes. The dietician will assess the patients dietary history. To find a dietician, consult the Dietitians Association of Australia.
Case study 3: Its in my glands, doctor Arrange You may also need some strategies to increase Rexs chances he will attend the dietician. These could include:explaining the benefitsdiscussing any factors which may prevent him attendingoutlining the expected costtelephoning the dietician (with Rexs consent and in his presence) to discuss his situation; this may need to be repeated at future visitsmeeting with Rex, the dietician and the diabetes educator to create a care plan. It is also important that you arrange for Rex to have regular follow up appointments with you.
Case study 4: Look doctor … I have my youthful figure back! Bert, aged 67 years, has been living alone since his wife died 12 months ago from bowel cancerHe visits you today for a repeat prescription of eye drops for chronic glaucomaBert has a history of mild osteoporosis, possibly related to corticosteroid use for asthma when he was younger. His respiratory symptoms are now well controlled with occasional inhaled bronchodilator therapyToday Bert appears to have lost weight and you begin a nutritional assessment.
Case study 4: Look doctor … I have my youthful figure back! You ask Bert:Have you had any unintentional weight change – loss or gain?Have you noticed any change in appetite?How much fruit and vegetables do you eat each day?What is your fluid intake? Bert tells you he:knows his clothes have become loose – belt is two notches smallereats no fruit and 2–3 serves of vegetables some eveningsusually drinks 2 cups of black coffee and 2 cups of black tea per day and has one can of beer 2–3 nights per week.
Case study 4: Look doctor … I have my youthful figure back! In light of Berts answers, you consider him to be nutritionally at risk. What else could you ask to further assess Berts nutrition?
Case study 4: Look doctor … I have my youthful figure back! Ask The following questions are useful in further assessing Berts situation: Are you eating less than three-quarters of your normal amount of food? Are you drinking less fluid than you used to? How much dairy (eg. milk, cheese, yoghurt) do you eat each day? Are you taking any vitamin, mineral or other supplements?
Case study 4: Look doctor … I have my youthful figure back! AskBert is eating and drinking considerably less than he used to, his wife used to buy and prepare all meals, give him a glass of water with meals and make more cups of teaBert tries to eat cheese each day but does not like plain milk or yoghurt. He struggles to prepare meals for himself and today his BMI is 20 kg/m 2 )Bert is not depressed or likely to be suffering from a physical problemHe is unaware of healthy eating habits and has trouble preparing meals, but is aware he is losing weight and accepts he needs to change his diet.
Case study 4: Look doctor … I have my youthful figure back! What do you think is Berts current stage of change? A.Precontemplation B.Contemplation C.Ready D.Maintenance.
Case study 4: Look doctor … I have my youthful figure back! Advise Bert is not drinking enough fluid. What is the recommended daily liquid intake for an adult? A.Eight glasses of any fluid B.Eight glasses of water C.Six glasses of any fluid D.Six glasses of water.
Case study 4: Look doctor … I have my youthful figure back! AdviseBert is also not eating enough serves of dairy food to obtain the requisite amount of calciumDue to his osteoporosis, Bert would need to be consuming at least 2–3 serves per day and preferably more. Outline some strategies for increasing Berts serves of dairy.
Case study 4: Look doctor … I have my youthful figure back! Advise Strategies for increasing dairy intake include:yoghurt or cheese and biscuits for a snack, cereal and milk for breakfast, or as a snack, low fat custard over fresh or tinned fruityoghurt as a side dish with curries, or yoghurt based dipsadd low fat cheese to pancakes, omelettes, pasta and vegetable dishesadd low fat milk or skim milk powder to casseroles, soups and saucesusing flavouring such as cocoa or banana and low fat ice cream/yoghurt for a smoothie.
Case study 4: Look doctor … I have my youthful figure back! Advise Bert mentions that he does not like plain milk or yogurt. What alternative nondairy sources of calcium would you suggest?
Case study 4: Look doctor … I have my youthful figure back! Advise Alternatives to dairy products include:soy milk with added calciumfish with edible bones (salmon, sardines)that some calcium is also found in green leafy vegetables, almonds and sesame seeds. If Bert is unable to obtain adequate calcium from his diet, he may need a calcium supplement. Depending on Berts degree of osteoporosis, he may need medication to preserve/improve bone density.
Case study 4: Look doctor … I have my youthful figure back! Advise Summarise the advice that you would give Bert at this point of the consultation.
Case study 4: Look doctor … I have my youthful figure back! Advise If Bert also had an abnormal lipid profile with raised total and LDL cholesterol and low HDL, how may this affect your advice?
Case study 4: Look doctor … I have my youthful figure back! AdviseIt is important that Bert choose low fat dairy productsIn light of Berts weight loss and inadequate energy intake, encourage him to eat healthy fats such as mono- or poly-unsaturated margarine/oils including olive and canola oil, nuts and avocadoIf triglycerides are normal, encourage Bert to increase carbohydrate intake by having frequent snacks (eg. low fat dairy desserts and tinned fruit in natural juice) and by drinking fruit juice. Consider adding nutritional supplements (powdered or liquid) to Berts eating plan (monitor to ensure that they do not replace regular food intake and seek a dieticians advice if unsure).
Case study 4: Look doctor … I have my youthful figure back! Assist Motivational interviewing to help Bert improve his nutritional intake could include:discussing the pros and cons of making changesexamining barriers for him in trying to improve his nutrition and considering ways to work around each oneassessing his confidence in being able to make changes to his dietary habits and examining ways to improve this.
Case study 4: Look doctor … I have my youthful figure back! Assist When Bert is ready to make changes, SMARTS goals could include: S pecific Ill buy enough fruit when I shop me to eat two pieces every day M easurable If fruit is left over at the end of the week I havent eaten enough A greed My daughter visits once per week and Ive agreed with both her and my doctor that Ill eat two pieces of fruit each day R ealistic Now Ill make a note of it on my shopping list each week T ime My daughter will check each week that Im getting enough fruit and Ill visit the doctor again in 4 weeks and he will check how I am going S upport My daughter and grandchildren will be very supportive of me trying to eat more fruit
Case study 4: Look doctor … I have my youthful figure back! Assist Other areas of nutrition to negotiate goals with Bert about are:eat more vegetableseat more serves of dairy (or appropriate source of calcium)drink more fluids, especially watereat more energy rich foods to maintain his weight in the healthy range and prevent further weight loss (with a BMI of 20 kg/m 2, Bert is currently in the healthy weight range).
Case study 4: Look doctor … I have my youthful figure back! Assist What are some strategies for increasing the kilojoule content in Berts diet?Consume healthy high kilojoule foodsEat small frequent meals and high energy snacksEnrich foods (eg. adding grated low fat cheese to vegetables)Include a protein food with each meal (eg. a boiled egg for breakfast)Avoid too much tea and coffee; drink low fat milk or fruit juice instead.
Case study 4: Look doctor … I have my youthful figure back! Assist Outline strategies for increasing Berts fluid intake.
Case study 4: Look doctor … I have my youthful figure back! Assist Bert should aim for:one glass of fluid with each mealone to two glasses between mealsfluid intake with medicationsincreased fluid intake on warm days and with physical activity.
Case study 4: Look doctor … I have my youthful figure back! AssistBert expresses concern that his wife died of bowel cancer and wonders if there is anything he can do to decrease his own risk of bowel cancerHe vaguely remembers something being said about diet or vitamins that can prevent cancer at the time that she was first diagnosed. How would you respond to this question?
Case study 4: Look doctor … I have my youthful figure back! AssistA diet high in fruit and vegetables is associated with a reduced incidence of bowel cancerA diet high in antioxidants is beneficial for optimal healthThere is insufficient evidence that antioxidant or vitamin supplements have the same beneficial effects.
Case study 4: Look doctor … I have my youthful figure back! There is good evidence that a diet high in fruit and vegetables reduces the risk of cancer of the: mouth pharynx, oesophagus, stomach, colon, rectum and lung, and probably reduces the risk of cancer of the larynx, pancreas, breast and bladderIt also possibly reduces risk of cancer of the ovaries, cervix, endometrium, thyroid, liver, prostate and kidney.
Case study 4: Look doctor … I have my youthful figure back! ArrangeBert is ready to begin making some nutritional changesArrange to follow up Bert to ensure he maintains the changes he is making, and negotiate any further changesMonitor Berts weight and appetiteA dietician would be able to help Bert work out a low saturated, high mono- or poly-unsaturated fat diet, which also contains a high calcium contentBert may be willing for you to arrange Meals on Wheels for him to reduce the workload of preparing meals.
Ingredients for change in general practice
Why bother with nutrition? Burden of disease and opportunities in general practice. How can I address nutrition in general practice? Ask/Assess:Who and how Advise:General nutrition recommendations and for those with existing nutrition related conditions Assist:Behaviour change techniques Arrange:Referral and follow up
Total burden attributable to risk factors for men (2003) Lifestyle choices accounted for 32% of the disease burden. Beggs et al 2007
Total burden attributable to risk factors for women (2003) Lifestyle choices accounted for 32% of the disease burden. Beggs et al 2007
Prevalence of risk factors (2003–2005) AIHW 2006
Opportunity and practice gap OpportunityOver one-half of all patients presenting in general practice are overweight/obese; many with poor diets. Current practiceNutrition and weight raised in 3.6% of consultations. Britt et al 2007
Brief interventional model – 5 As AskAssessAdviseAssistArrange.
ASK – Who? Recommend asking all patients about nutrition, diet, and important risk factors independent of weightRaise nutrition as part of general health assessment/health checkLink nutrition to presenting issues: – management of existing chronic disease – blood pressure, elevated lipids and glucose – weight gain or loss – fatigue – wound management, reoccurring infections – children's health. RACGP 2004
Brief interventional model – 5As Ask AssessAdviseAssistArrange.
ASSESS – What? Ask about recent weight gain or lossWeight, height, BMIWaist circumferenceFruit and vegetable consumptionRecord information in patients medical recordMore detailed dietary assessment in at risk patients. RACGP 2004
Dietary assessment Lack of validated brief dietary assessment tools for primary careLifescripts assessment and prescription for nutrition and weight management24 hour recallFood diary: type, amounts, time, location, thoughts and feelings. DoHA Lifescript resources available online
Brief interventional model – 5As AskAssess AdviseAssistArrange.
The Australian guide to healthy eating Enjoy a variety of foods every day NHMRC 2003
Breads and cereals How much of these foods should we eat?Amount depends on energy requirements4–9 serves for women, 6–12 serves for men. One serve includes:two slices of breadone medium bread roll1 cup cooked rice, pasta, noodles1 cup porridge1 1/3 cup breakfast cereal1/2 cup muesli. NHMRC 2003
Breads and cereals What about type – are all breads and cereals equal?Wholegrain varieties are preferable: – wholegrain/wholemeal bread, crispbread – high fibre breakfast cereal (>6 g fibre/100 g) – rolled oats/porridge – brown rice, wholemeal pasta.At least 6 g wholegrain fibre per day equals 2 serves of breads and cereals. What about GI/GL? National Heart Foundation 2006
The Australian guide to healthy eating Enjoy a range of foods every day NHMRC 2003
Whats 1 serve? Fruitone medium size piece of fruittwo to three small pieces of fruit (apricot, plums)1/2 cup fruit juice (125 mL)1 cup canned fruit. Vegetables1/2 cup cooked vegetables/legumes (75 g)one medium potato1 cup salad vegetables. Frozen or canned vegetables in natural juice can be as nutritious as fresh.
Fruit and vegetable intake – practical strategies Aim for ½ plate mixed vegetables/salad with main meal (no limit on vegetables, excluding potatoes)Add extra veggies/legumes to stews, casseroles, stir fry and pasta dishesAdd fruit to breakfast cereal and yoghurtTry vegetables at breakfast (baked beans, tomatoes, mushrooms on toast)Fruit as a snack (try smoothies, dried fruit).
NHMRC 2003 The Australian guide to healthy eating Enjoy a range of foods every day
Meat and meat alternatives How much meat/meat alternatives should we eat?1–2 serves per day. One serve includes: – 65–100 g cooked meat or chicken (¼ of the plate with your main meal or palm size) – 80–120 g cooked fish fillet – two small eggs – ½ cup cooked legumes – 1 / 3 cup peanuts or almonds – ¼ cup sunflower seeds or sesame seeds.
Meat and meat alternatives What types should we eat?Protein sources must be lean to limit saturated fat intakeInclude red meat up to three to four times per weekTry to eat two to three fish meals per weekLegumes should be included in at least two meals per weekFor those with elevated LDL, limit cholesterol rich foods such as egg yolks and offalLimit consumption of processed meats.
The Australian guide to healthy eating Enjoy a range of foods every day
Dairy foods – how much? 2–3 servings per day for adequate intake of calciumChoose low or reduced fat optionsLimit cheese to twice per week for those with elevated lipids.
The Australian guide to healthy eating Enjoy a range of foods every day
Drinks Drink plenty of water – aim for 8 glasses per dayDehydration often confused with hungerFresh or unsweetened fruit juices (maximum one small glass, 150 mL daily)Skimmed/semiskimmed milks (counted as part of dairy food)Artificially sweetened drinks are safe in moderationAlcohol – 2 standard drinks/day or less for both men and women (new recommendations).
Diabetes/impaired glucose tolerance (IGT) Individuals with diabetes/IGT often have elevated triglycerides, low HDL levels and high blood pressureWeight management and increased physical activity key to managementLimit intake of saturated and trans fatRegular meals, spread evenly throughout the dayBased on high fibre, low GI carbohydrate foods, including wholegrain breads, cereals, legumes, vegetables and fruitFollow a low GL eating pattern.
Glycaemic index Both the amount and type of carbohydrate foods consumed will affect blood glucose levelsThe GI is a ranking of carbohydrate containing food according to the impact on blood glucose levels: –high GI foods (>70) – fast acting –low GI foods (<55) – slow actingLow GI foods have been shown to improve blood glucose control.
Glycaemic index Low GIHigh GI Multigrain breads Porridge Pasta, noodles All beans Sweet potato All dairy foods Apple, pear, oranges Chocolate White bread Cornflakes Brown rice Jasmine rice Potatoes Watermelon
Glycaemic load GI cannot be used in isolation to decide food choices.Glycaemic load takes into account the type of carbohydrate (GI) as well as the amount consumedLow GL eating pattern: –choose nonrefined carbohydrate rich in dietary fibre –limit the amount of carbohydrates from refined sources such as fruit juices, soft drinks, cakes, biscuits, confectionary –watch portion sizes and spread out carbohydrate foods throughout the day.
Hypertension Weight management and increased physical activity key to managementLower alcohol intakeAdopt a high potassium and reduced salt eating patternReduce salt to less than 4 g per day (1550 mg sodium), <1 teaspoon saltReduce processed foods, choose foods with less than 120 mg sodium per 100 gAvoid adding salt during cooking and at the tableDosages of antihypertensive medications may need to be reduced in those adopting low salt diet.
Elevated LDL cholesterol Reduction in excess body weightReduction in LDL levels when saturated fat is replaced by mono- or poly-unsaturated fats (olive, canola, sunflower, soybean, peanut oils)Limit take away and high fat snack foods to once per weekChoose low or reduced fat dairy products; limit cheese to twice per weekLimit cholesterol rich foods such as egg yolks and offalIncrease foods high in soluble fibre (eg. fruit, oats, legumes)Include foods enriched with plant sterols.
Phytosterol/stanol enriched foods 2–3 serves of plant sterol/stanol enriched foods per day has been shown to reduce LDL by 10%1 serve plant sterol enriched foods equals 2 teaspoons margarine, 1 cup breakfast cereal, 1 cup milk or 1 small tub yoghurtPlant sterol/stanol enriched foods have an additive effect in lowering LDL when combined with statinsNo adverse effects reported of daily consumption, although long term safety information not available.
Brief interventional model – 5As AskAssessAdvise AssistArrange.
Facilitating lifestyle change The best thing you could do is give up fatty foods, lose weight, and eat more fruit and vegetables. Whats the next best thing?
Stages of readiness to change Initiation of risk behaviour Maintenance of behaviour change RELAPSE Not ready to change Makingchanges Thinkingabout change change Ready to change
Ingredients for change Importance (why should I change) Readiness Confidence (How will I do it – self efficacy) Rollnick et al 1999
Not ready to change ReasonsDo not acknowledge the need to changeNot seen as important to change at this timeLack confidence in ability to change. StrategiesDiscuss benefits of change, relate to personal situationAcknowledge difficulties discuss competing prioritiesDiscuss perceived difficulties, emphasis small gradual changeDoor open policy, review at future visits.
Helping ambivalent patients I would like to improve my eating habits BUT… What about patients who are uncertain about change? How can I help motivate them?
Questions to ask Ask about the patients pros and cons of change What do you see as the benefit of improving your eating habits/losing weight? What makes it difficult for you to improve your eating habits/lose weight?Summarise pros and cons. Given the pros and cons, is this something you would like help with now?
Explore the cost-benefit balance Benefits of changeCosts of remaining the sameCosts of changeBenefits of remaining the same.
Glycaemic index Benefits of Improving eating habitsBenefits of continuing to eat the same Better diabetes control Lose weight (possibly) More energy Better for family too Less effort No disruption to family eating habits I like the taste of food I eat Cons of improving eating habitsCons of continuing to eat the same Takes time and effort to shop for new types of food Need to learn how to cook differently Need to cook differently for myself or change family meals May affect social situations Long term health consequences (possibly) Continue to feel tired Recurring infections
Helping patients who are ready for goal setting
Goal setting – patients ready to change Breaking down behaviour change into small manageable chunksGoals can be moved progressively toward the ideal situation, need to start where the person is atLet patients devise or select their own goals and identify high risk situations to be avoided.
Goal setting I will avoid eating all chocolate and sweets starting tomorrow. I will eat more vegetables. I will aim to limit chocolate to one bar once per week. I will try to include salad with my lunch at least three times per week.
SMART goal setting S pecific I will try to limit the amount of cheese I eat to one match box size piece, twice per week M easurable/ A greed My wife has agreed not to use cheese in cooking, and to buy a much smaller amount. We are going to keep it out of sight in the refrigerator, so I am less likely to snack on it R ealistic This is realistic for me because I hate the taste of low fat cheese and will be happy if I can eat the real stuff occasionally T ime specific I will see the nurse in 2 weeks for a blood pressure check and we can review how I have been going with my goals
Negotiation of dietary change F requency A mount T ype.
Questions to ask What do you think is possible for you to do?What could you do to make a small change in that direction?Is that realistic for you, could you keep that up long term?What do you need to do to make that happen?
Brief interventional model – 5As AskAssessAdviseAssist Arrange.
Arrange Consider referral to a dietician for:specific dietary conditions (eg. coeliac, diabetes)nutrition counselling, behaviour changedetailed dietary assessment and prescription. Provide information on medical history and medications in referral to dietician. To find a dietician visit
Arrange Eating disorders unit for extreme eating behavioursHeart Foundation Heart Health Information Service: Nutrition AustraliaPatients should be reviewed 2–3 monthly to promote sustain lifestyle changes.