1. health and fitness
2. disease
3. cholesterol

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.
QUIZ
Question 1
Which of the following statements regarding fruit and
vegetable intake is CORRECT?
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.
Question 2
Which of the following statements regarding obesity
is CORRECT?
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.
Question 3
Poor nutrition results in a range of disease processes.
Which of the following statements is CORRECT?
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.
Question 4
Changes in nutritional intake can affect the risk
of future illness.
Which of the following statements is CORRECT?
A. Low GI diets decrease the body’s 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
This involves 5 steps:
• Ask
• Assess
• Advise
• Assist
• Arrange.
Question 5 – Ask
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 Merri’s case?
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?
Question 6 – Assess
Merri’s 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?
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. Merri’s 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
Merri’s 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 Sam’s current nutrition?
A.
B.
C.
D.
Are you taking any nutritional supplements such as multivitamins?
Have you noticed any decrease in your appetite recently?
Have you been eating more ‘take away’ meals than you used to?
Have you been drinking at least 8 cups of fluid per day?
Question 8 – Advise
Sam asks your advice regarding a healthy intake
of fruit and vegetables.
Which of the following statements is CORRECT?
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.
Question 9 – Advise
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:
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.
Question 10 – Advise
Sam also asks about fluid intake as he wonders if
he should be drinking more water.
Which is the MOST appropriate advice for Sam’s
fluid intake?
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.
Question 11 – Advise
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?
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.
Question 12 – Advise
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?
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’.
Question 13 – Advise
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?
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.
Question 14 – Advise
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?
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.
Question 15 – Advise
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?
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.
Question 16 – Advise
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?
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.
Question 17 – Advise
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?
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.
Question 18 – Advise
In taking further history you discover that Merri’s
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?
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.
Question 19 – Assist
Some patients, particularly those with chronic disease
and the elderly, may suffer from malnutrition. How can
you assist this group of patients?
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.
Question 20 – Arrange
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?
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.
Question 21 – Arrange
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?
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.
Question 22
Antioxidant and vitamin supplements are highly
promoted as being beneficial to health.
Which of the following statements is CORRECT?
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.
Question 23
John’s 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?
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.
Question 24
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?
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.
Question 25
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?
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 child’s overall diet
C. Parents have a large influence in establishing their child’s 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
foods
• Eat plenty of vegetables, legumes and fruits
• Choose wholemeal or wholegrain cereals, including breads, rice,
pasta, noodles
• Include lean meat, fish, poultry and/or alternatives
• Include 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 intake
Choose food low in salt
Limit your alcohol intake if you choose to drink
Consume only moderate amounts of sugars and foods containing
added sugars.
Talk to patients about hydration and physical
activity
• Drink plenty of water
• Prevent weight gain by being physically active and eating
according to your energy needs
• Care for your food by preparing and storing it safely
• Encourage 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
Ask
• How 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 day
• experience unintentional weight gain of >4 kg in 12 months, or
• experience 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 change
• Contemplation – the patient is considering making a change, but
still unsure
• Ready – the patient is ready to make a change and take action
• Maintenance – the patient has made a change and needs
encouragement to sustain the change.
Advise
• Give feedback on the patient’s current diet. ADVISE them to follow
the current Australian dietary recommendations
• You may like to give them a more individualised ‘Lifescripts
prescription’.
Assist
Assist the patient to:
• understand the benefits of healthy nutrition
• formulate, negotiate and implement achievable goals to improve
their nutrition.
Arrange
• Arrange to follow up the patient yourself
• Arrange 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
melon
• ½ cup of fruit juice
• four dried apricots or 1½ tablespoons of sultanas, or
• 1 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 potato
• 1 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 requirements
• Cereals 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 serves
• Protein 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 milk
• 40 g (2 slices) of cheese
• 200 g carton of yoghurt, or
• 250 mL custard.
Eating for health using the 5As: case
studies
Case study 1: Eating for two
Ask
• Chloe, aged 27 years, has a long routine visit for her first
antenatal
appointment
• Lifestyle 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 instructor
• There has been no weight change yet, or over the past year
• Chloe 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 day
• eats 4 serves of fruit per day
• eats 4–6 serves of cereals per day
• supplements folate with 500 µg per day until 3 months and
consumes folate rich foods
• eats 1.5–2 serves iron rich food per day
• eats some iodine rich foods such as seafood (or iodine supplement)
• eats 2–3 serves of calcium rich foods
• avoids fish containing high mercury levels
• avoids 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 serve
• how to follow the Dietary guidelines for Australian adults
• increasing 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 defects
• the required intake of iron rich foods, adequate calcium and
recommended fluid and caffeine intake
• the risk of listeria infection during pregnancy, and risk of abortion,
still birth, septicaemia and meningitis
• the risk of contracting the parasite toxoplasmosis
• avoid 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 chemist
• providing her with Food Standards Australia information on avoiding
listerosis
• writing a Lifescript for increasing fruit and vegetable intake and for
pregnancy, and a nutrition in pregnancy evidence card
• discussing goals such as adding extra serves of fruit and vegetables
to her diet.
Case study 1: Eating for two
Arrange
• Arrange 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 intake
• her pregnancy is progressing well (apart from mild nausea) and all
tests are normal
• she is using the Australian dietary guidelines and Pregnancy
Lifescript.
What other nutritional issues would you discuss before Chloe’s baby
is born?
Case study 1: Eating for two
• Current breastfeeding recommendations recommend exclusive
breastfeeding for at least the first 6 months
• Daily dietary recommendations during breastfeeding include
7 serves vegetables/legumes, 5 serves fruit, 5–7 serves cereal,
2 serves milk/yogurt/cheese
• Parental eating habits have a significant effect on the nutritional risk
of their children.
Case study 2: It’s 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/m2
• She has no past history of CVD, is taking no medication, is a
nonsmoker, and drinks two glasses of wine 2–3 nights per week
• Family 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: It’s in the genes
Ask
You take this opportunity to discuss nutrition with Meg.
What initial questions would you ask Meg?
Case study 2: It’s 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: It’s in the genes
Assess
• Meg’s vegetable intake is inadequate for healthy nutrition.
What other factors in Meg’s diet or life would you want to assess,
considering her elevated BP and family history?
Case study 2: It’s in the genes
Assess Meg’s:
• diet using Lifescripts questionnaire or ‘1 day food recall’
• salt intake
• saturated and total fat intake as abnormal lipid levels is an added
risk factor for end organ disease
• alcohol intake (if you have not asked this previously).
Meg’s level of physical activity would also be an important
consideration in assessing her overall risk.
Case study 2: It’s in the genes
Assess
On assessing Meg’s 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: It’s in the genes
Advise
• You acknowledge to Meg that she is unwilling to make any changes
now
• You do provide feedback on her current diet, specifically alcohol and
salt intake (and also physical activity levels) that may be affecting
her BP
• You reinforce the importance of maintaining a healthy body weight
• You also advise that her fruit and vegetable intake is not ideal, and
improving these would benefit her long term health.
Case study 2: It’s 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: It’s 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 patient
• looking to the future
• getting the patient to rate their motivation and confidence on a
scale of 1–10
• identifying 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: It’s in the genes
Assist
• If Meg is willing, discuss the benefits of improving eating habits
• Allow Meg to explain the difficulties she would face in trying to
change her diet
• As Meg is in the precontemplation stage, this is probably all that it is
appropriate at this consultation.
Case study 2: It’s in the genes
Assist
Other health messages for Meg could include:
• decreasing salt intake may enable her BP to be managed without
needing medication
• improving 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 medication
• increased fruit and vegetable intake will have general beneficial
health effects.
Case study 2: It’s in the genes
Arrange
• Meg 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 mmHg
• Blood test results are normal apart from a mildly elevated total and
LDL cholesterol and a low HDL cholesterol.
Case study 2: It’s 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.
B.
C.
D.
Precontemplation
Contemplation
Ready
Maintenance.
Case study 2: It’s 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 changes
Not making changes
Pros
Cons
Pros
Better long term
health
Effort of thinking up
new meals
Current dietary habits Risk of future
easier to follow
illness
Possibly avoiding Possible increased
medication
cost of healthier meals
Change in shopping
habits
Cons
Cost of
medications
Case study 2: It’s in the genes
Advise
In view of Meg’s persisting elevated BP and mildly abnormal lipids,
you could suggest goals including:
• reducing salt intake/increasing potassium intake
• decreasing saturated and trans fat intake
• changing to mono- and poly-unsaturated fats and oils
• increasing fruit and vegetable intake
• decreasing alcohol and increasing physical activity (if applicable).
Case study 2: It’s 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 cholesterol
• Useful websites include Lifescripts Nutrition online, Heart
Foundation and the Australian dietary recommendations for general
diet information.
Case study 2: It’s in the genes
Assist
Negotiate ‘SMARTS’ goals with Meg to improve her nutrition (eg. salt intake).
Specific
I will no longer add salt to my meals at the table
Measurable
I will not have the salt shaker on the table
Agreed
I am willing to make this change to my habits and have agreed
to this with my doctor and my husband
Realistic
I will not cook with salt, but use herbs and spices instead
Time
I am returning for a BP check with the practice nurse in 4 weeks
Support
I know my husband will be very supportive, because he has
always wanted me to stop using salt at the table
Case study 2: It’s 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 week
• replacing full fat milk with skim milk or reduced/low fat milk
• using low fat cheese instead of full fat cheese
• changing to a mono or poly-unsaturated spread instead of a high
saturated fat dairy spread
• choosing lean meats and trimming fat/removing skin before cooking
• choosing less fatty ‘cold meat’; avoid salami, sausages.
Case study 2: It’s in the genes
Arrange
• In 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 goals
• In 2–3 months time you follow up on Meg’s nutritional changes.
Case study 3: It’s in my glands, doctor
• Rex Baron, aged 56 years, attended your practice for removal of a
fish hook from his finger 6 weeks ago
• He has no significant past medical history, but his BMI is 28 kg/m2,
waist circumference is 100 cm and BP 140/90 mmHg. He is a
nonsmoker
• He 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 Rex’s waist circumference?
Case study 3: It’s in my glands, doctor
• Increased waist circumference is an indicator of central obesity, a
risk factor for type 2 diabetes and CVD
• Measuring waist circumference is simpler and more important than
insulin resistance for diagnosing and predicting risk for metabolic
syndrome and type 2 diabetes
• In men this is >94 cm (or >90 cm in men of Asian, south or central
American descent) and in women >80 cm
• Be 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: It’s in my glands, doctor
Metabolic syndrome is defined as central obesity in concurrence with
any two of the following factors:
• raised triglycerides
• reduced HDL cholesterol
• raised blood pressure
• raised fasting plasma glucose.
In patients with metabolic syndrome, the risk of developing heart
disease or diabetes is increased 2–4 fold.
Case study 3: It’s 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 change
• Rex is willing to have further tests including HbA1c and an eye
assessment
• He is keen to improve his situation and discusses lifestyle measures
such as increasing activity and altering diet.
Case study 3: It’s 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: It’s 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: It’s 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’.
Breakfast
2 eggs, 2 sausages, buttered toast, 1 cup of white coffee with 2 sugars
Morning snack 1 cup white coffee 2 sugars, 2 chocolate Tim Tams, piece of fruit cake
Lunch
2 meat pies with tomato sauce, 1 doughnut, 1 banana, 1 can of coke
Afternoon tea
2 honey sandwiches, 1 Mars bar, 1 can of coke
Late afternoon 2 stubbies of beer (normal strength), few handfuls of salted nuts
Tea
Fish and chips with tomato sauce, bowl of ice cream with chocolate topping
Evening
1 cup of white coffee 2 sugars, 3 butter shortbread biscuits
What do you think about Rex’s diet?
Case study 3: It’s in my glands, doctor
Advise
• You support Rex in the efforts that he is already making to change
his lifestyle and discuss that additional changes over time would
be beneficial
• Your nutritional assessment reveals that he has quite a high intake
of high GI carbohydrate foods and high saturated fat foods
• You advise Rex that it is worthwhile negotiating goals to change
the type of carbohydrate foods he is eating and alter his fat
intake
• SMARTS goals could be considered for fat intake reduction and
carbohydrate intake modification.
Case study 3: It’s in my glands, doctor
Assist
• Rex is willing to change his diet to try to improve his long term
health, as his mother has had many complications from her
diabetes
• Both the amount and type of carbohydrate eaten will affect blood
glucose level
• To make dietary changes, Rex needs to understand GI and
glycaemic load (GL).
Case study 3: It’s 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: It’s in my glands, doctor
• Consuming a diet where high GI foods are replaced by low GI
foods improves glycaemic control
• Low GI diets increase the body’s 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 longer
• It can also help manage the symptoms of polycystic ovary
disease.
Case study 3: It’s 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 consumed
• High GI foods increase the GL more than low GI foods if the same
quantity of food is eaten
• Quantity is also important, as eating large amounts of low GI foods
can still provide a significant GL.
Case study 3: It’s 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 GL
• replacing high GI foods with lower GI foods
• breakfast cereals based on oats, barley and/or bran
• lower GI potato options (eg. new potatoes or sweet potato)
• enjoying all other types of fruit and vegetables, including salad
• pasta, noodles and/or quinoa, and using Basmati or Doongara rice
• avoid refined carbohydrates (eg. soft drinks, cakes &
confectionary) or use artificial sweetener alternatives
• regular meals and snacks to spread the load throughout the day.
Case study 3: It’s 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 loss
• Increasing physical activity may help increase HDL and decrease
weight
• Rex’s 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 cholesterol
• Rex’s dietary changes may be complex, and optimal management
would involve referral to a dietician and/or a diabetes educator.
Case study 3: It’s in my glands, doctor
Arrange
• As 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: It’s 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 results
• previous attempts to make dietary changes.
The dietician will assess the patient’s dietary history.
To find a dietician, consult the Dietitians Association of Australia.
Case study 3: It’s in my glands, doctor
Arrange
You may also need some strategies to increase Rex’s chances he will
attend the dietician. These could include:
• explaining the benefits
• discussing any factors which may prevent him attending
• outlining the expected cost
• telephoning the dietician (with Rex’s consent and in his presence)
to discuss his situation; this may need to be repeated at future visits
• meeting 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 cancer
• He visits you today for a repeat prescription of eye drops for chronic
glaucoma
• Bert 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 therapy
• Today 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 smaller
• eats no fruit and 2–3 serves of vegetables some evenings
• usually 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 Bert’s answers, you consider him to be nutritionally at risk.
What else could you ask to further assess Bert’s nutrition?
Case study 4: Look doctor … I have my youthful
figure back!
Ask
The following questions are useful in further assessing Bert’s 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!
Ask
• Bert 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 tea
• Bert 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/m2)
• Bert is not depressed or likely to be suffering from a physical problem
• He 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 Bert’s 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!
Advise
• Bert is also not eating enough serves of dairy food to obtain the
requisite amount of calcium
• Due to his osteoporosis, Bert would need to be consuming at least
2–3 serves per day and preferably more.
Outline some strategies for increasing Bert’s 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 fruit
• yoghurt as a side dish with curries, or yoghurt based dips
• add low fat cheese to pancakes, omelettes, pasta and vegetable
dishes
• add low fat milk or skim milk powder to casseroles, soups and sauces
• using 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 calcium
• fish 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 Bert’s 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!
Advise
• It is important that Bert choose low fat dairy products
• In light of Bert’s 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 avocado
• If 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 Bert’s
eating plan (monitor to ensure that they do not replace regular food
intake and seek a dietician’s 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 changes
• examining barriers for him in trying to improve his nutrition and
considering ways to work around each one
• assessing 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:
Specific
I’ll buy enough fruit when I shop me to eat two pieces every day
Measurable
If fruit is left over at the end of the week I haven’t eaten enough
Agreed
My daughter visits once per week and I’ve agreed with both her and my doctor that
I’ll eat two pieces of fruit each day
Realistic
Now I’ll make a note of it on my shopping list each week
Time
My daughter will check each week that I’m getting enough fruit and I’ll visit the
doctor again in 4 weeks and he will check how I am going
Support
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 vegetables
• eat more serves of dairy (or appropriate source of calcium)
• drink more fluids, especially water
• eat more energy rich foods to maintain his weight in the healthy range
and prevent further weight loss (with a BMI of 20 kg/m2, 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
Bert’s diet?
• Consume healthy high kilojoule foods
• Eat small frequent meals and high energy snacks
• Enrich 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 Bert’s fluid intake.
Case study 4: Look doctor … I have my youthful
figure back!
Assist
Bert should aim for:
• one glass of fluid with each meal
• one to two glasses between meals
• fluid intake with medications
• increased fluid intake on warm days and with physical activity.
Case study 4: Look doctor … I have my youthful
figure back!
Assist
• Bert 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 cancer
• He 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!
Assist
• A diet high in fruit and vegetables is associated with a reduced
incidence of bowel cancer
• A diet high in antioxidants is beneficial for optimal health
• There 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 bladder
• It 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!
Arrange
• Bert is ready to begin making some nutritional changes
• Arrange to follow up Bert to ensure he maintains the changes he is
making, and negotiate any further changes
• Monitor Bert’s weight and appetite
• A 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 content
• Bert 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
12
10
8
6
4
2
0
9.6
7.8
6.6
7.7
6.4
4.9
2.7
2.7
si
s
gs
O
st
eo
p
or
o
dr
u
Illi
ci
t
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it
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ica
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h
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ity
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ol
e
ig
h
H
ba
c
To
b
BM
BP
0.1
o
% total disease burden
Total burden attributable to risk factors for
men (2003)
Lifestyle choices accounted for 32% of the disease burden.
Beggs et al 2007
10
7.3
8
7.3
6.8
5.8
6
5.8
4
1.5
2
0.7
1.2
0.3
s
l
O
st
eo
p
or
o
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ho
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dr
ug
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it
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o
ba
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ch
ol
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er
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ig
h
H
Ph
ys
ica
H
l in
ac
ig
h
BM
ity
I
0
BP
% total disease burden
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)
Males
Females
87.6
100
83.7
80
60
61.9
52.4
45
39.9
40
20
13.5 14.4
9.3 8.5
Hypertension
High
cholesterol
0
Inadequate fruit
intake
AIHW 2006
Inadequate
vegetable
intake
excess weight
Opportunity and practice gap
Opportunity
• Over one-half of all patients presenting in general practice are
overweight/obese; many with poor diets.
Current practice
• Nutrition and weight raised in 3.6% of consultations.
Britt et al 2007
Brief interventional model – 5 As
•
•
•
•
•
Ask
Assess
Advise
Assist
Arrange.
ASK – Who?
• Recommend asking all patients about nutrition, diet, and important
risk factors independent of weight
• Raise nutrition as part of general health assessment/health check
• Link 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
Assess
Advise
Assist
Arrange.
ASSESS – What?
•
•
•
•
•
Ask about recent weight gain or loss
Weight, height, BMI
Waist circumference
Fruit and vegetable consumption
Record information in patients medical
record
• More detailed dietary assessment in at
risk patients.
RACGP 2004
Dietary assessment
• Lack of validated brief dietary assessment tools for primary care
• Lifescripts assessment and prescription for nutrition and weight
management
• 24 hour recall
• Food diary: type, amounts, time, location, thoughts and feelings.
DoHA Lifescript resources available online
Brief interventional model – 5As
•
•
•
•
•
Ask
Assess
Advise
Assist
Arrange.
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 requirements
• 4–9 serves for women, 6–12 serves for men.
One serve includes:
• two slices of bread
• one medium bread roll
• 1 cup cooked rice, pasta, noodles
• 1 cup porridge
• 1 1/3 cup breakfast cereal
• 1/2 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
What’s 1 serve?
Fruit
• one medium size piece of fruit
• two to three small pieces of fruit (apricot,
plums)
• 1/2 cup fruit juice (125 mL)
• 1 cup canned fruit.
Vegetables
• 1/2 cup cooked vegetables/legumes (75 g)
• one medium potato
• 1 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
dishes
• Add fruit to breakfast cereal and yoghurt
• Try vegetables at breakfast (baked beans, tomatoes, mushrooms
on toast)
• Fruit as a snack (try smoothies, dried fruit).
The Australian guide to healthy eating
Enjoy a range of foods every day
NHMRC 2003
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 intake
• Include red meat up to three to four times per week
• Try to eat two to three fish meals per week
• Legumes should be included in at least two meals per week
• For those with elevated LDL, limit cholesterol
rich foods such as egg yolks and offal
• Limit 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 calcium
• Choose low or reduced fat options
• Limit 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 day
• Dehydration often confused with hunger
• Fresh 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 moderation
• Alcohol – 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 pressure
• Weight management and increased physical activity key to
management
• Limit intake of saturated and trans fat
• Regular meals, spread evenly throughout the day
• Based on high fibre, low GI carbohydrate foods, including
wholegrain breads, cereals, legumes, vegetables and fruit
• Follow a low GL eating pattern.
Glycaemic index
• Both the amount and type of carbohydrate foods consumed will
affect blood glucose levels
• The 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 acting
• Low GI foods have been shown to improve blood glucose control.
Glycaemic index
Low GI
High 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 consumed
• Low 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
management
• Lower alcohol intake
• Adopt a high potassium and reduced salt eating pattern
• Reduce salt to less than 4 g per day (1550 mg sodium),
<1 teaspoon salt
• Reduce processed foods, choose foods with less than 120 mg
sodium per 100 g
• Avoid adding salt during cooking and at the table
• Dosages of antihypertensive medications may need to be reduced
in those adopting low salt diet.
Elevated LDL cholesterol
• Reduction in excess body weight
• Reduction in LDL levels when saturated fat is replaced by monoor poly-unsaturated fats (olive, canola, sunflower, soybean,
peanut oils)
• Limit ‘take away’ and high fat snack foods to once per week
• Choose low or reduced fat dairy products; limit cheese to twice
per week
• Limit cholesterol rich foods such as egg yolks and offal
• Increase 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 yoghurt
• Plant sterol/stanol enriched foods have an additive effect in
lowering LDL when combined with statins
• No adverse effects reported of daily consumption, although long
term safety information not available.
Brief interventional model – 5As
•
•
•
•
•
Ask
Assess
Advise
Assist
Arrange.
Facilitating lifestyle change
The best thing you could do is give up fatty foods, lose weight, and
eat more fruit and vegetables.
What’s the next best thing?
Stages of readiness to change
Initiation
of risk
behaviour
RELAPSE
Not ready to
change
Making
changes
Thinking
about
change
Ready to
change
Maintenance
of behaviour
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
Reasons
• Do not acknowledge the need to change
• Not seen as important to change at this time
• Lack confidence in ability to change.
Strategies
• Discuss benefits of change, relate to personal situation
• Acknowledge difficulties discuss competing priorities
• Discuss perceived difficulties, emphasis small gradual change
• Door 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 patient’s 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 change
Costs of remaining the same
Costs of change
Benefits of remaining the same.
Costs of change
Benefits of remaining the same
Benefits of change
Costs of remaining
the same
Glycaemic index
Benefits of Improving eating habits
Benefits 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 habits
Cons 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 chunks
• Goals can be moved progressively toward the ideal situation,
need
to start where the person is at
• Let 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
Specific
I will try to limit the amount of cheese I eat to one
match box size piece, twice per week
Measurable/Agreed 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
Realistic
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
Time 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
• Frequency
• Amount
• Type.
Questions to ask
•
•
•
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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
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Ask
Assess
Advise
Assist
Arrange.
Arrange
Consider referral to a dietician for:
• specific dietary conditions (eg. coeliac, diabetes)
• nutrition counselling, behaviour change
• detailed dietary assessment and prescription.
Provide information on medical history and medications in referral to
dietician. To find a dietician visit www.daa.asn.au.
Arrange
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Eating disorders unit for extreme eating behaviours
Heart Foundation Heart Health Information Service: 1300 36 27 87
Nutrition Australia
Patients should be reviewed 2–3 monthly to promote sustain
lifestyle changes.