Welcome to Good nutrition an interactive workshop designed to assist general practitioners GPs and t

1
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.
2
Which of the following statements regarding fruit
and vegetable intake is CORRECT?
QUIZQuestion 1
A. Most Australians consume sufficient quantities
of fruit and vegetables in their normal
dietsB. Osteoporosis contributes more to the
disease burden in Australia than lack of dietary
fruit and vegetablesC. 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.
3
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 obeseC. 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.
4
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 diabetesB. High
total carbohydrate intake is an established risk
factor for CVDC. Diets high in soluble fibre are
associated with lower plasma HDL cholesterol
levelsD. Consumption of predominantly low
glycaemic index (GI) foods is a risk factor in
the development of type 2 diabetes.
5
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 insulinB. Weight loss of 10 kg or more is
required to significantly decrease risk of
diabetes in those with impaired glucose
toleranceC. A 10 weight loss is associated with
at least a 40 reduction in obesity related
cancer deathsD. An extra serve per day of
fruit/vegetables per adult would have a minimal
effect on cancer incidence.
6
The 5As approach can be used in dealing with
nutrition
This involves 5 steps
Ask Assess Advise Assist Arrange.
7
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?
8
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 monthsB. Merri does
not need investigations at this stage her CV
risk is lowC. Merris 6 cup fluid intake
(including 2 cups of water) per day is
adequateD. Merri should be started on a diet
and exercise program to help her achieve her
ideal weight.
9
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?
Question 7 Assess
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?
10
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
dayC. Fruits and vegetables are a good source of
protein an essential nutrientD. Frozen or
canned vegetables are an acceptable source of
daily vegetable intake.
11
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/nutsB. Butte
r in preference to margarinesC. 3 serves of
bread, cereals, rice, noodlesD. 4 serves of
dairy, including milk/yoghurt/cheese.
12
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
providesB. Any beverage or drink is counted as
fluid, but water is the best choiceC. Artificial
ly sweetened cordials are acceptable but may have
a diuretic effectD. Fruit juice should be
limited to four glasses per day.
13
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 plumB. One slice of bread or 1 cup of
cerealC. 1 cup of fruit juiceD. Half a cup of
cooked vegetables.
14
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 intakeB. Only a small amount of daily
salt intake comes directly from food, most is
added at the table or while cookingC. Use
commercial sauces such as tomato sauce or soy
sauce to add flavour to food, rather than adding
saltD. Choose packaged foods which are labelled
low salt or no added salt.
15
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
cholesterolB. 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
fatsD. Cholesterol is present in many foods
including nuts, avocado, eggs, fatty meats and
dairy products.
16
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 choiceB. 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 foodsD. Foods which contain vegetable
oil are a healthier alternative to foods that
contain butter.
17
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
weekB. Barbecued chicken with gravy and a tasty
stuffing is a healthy choiceC. Doner
kebab/souvlaki with tabouli in pita or Lebanese
bread are good optionsD. Asian take away
choices are almost all low fat so are worth
considering.
18
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
madeB. Eating 400 kj more than energy needs per
day will result in approximately 4 kg weight
gain over 1 yearC. A chocolate biscuit and a
scoop of ice cream each contain about 100
kjD. Making dietary changes without increasing
physical activity levels will not have any long
term effect on weight.
19
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 cholesterolB. Plant sterol
margarines can be used in place of cholesterol
lowering medicationsC. 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.
20
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 foodsB. Choosing foods with a
high GI improves glycaemic control in those with
diabetesC. High GI foods reduce hunger and keep
you feeling fuller for longerD. The GI alone
is insufficient to use as a basis for a healthy
diet.
21
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 45
cups of tea and/or coffee each dayB. Encourage
snacking on a range of vegetables, either raw or
cooked throughout the dayC. Prescribe patients
to eat small frequent meals and high energy
snacks that are individualised to their
needsD. Suggest eating high fat foods with each
meal and snack.
22
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 changeB. Practice information systems
should generate reminders or lists of patients
overdue for follow upC. Patients should be
reviewed yearly for 2 years after desired changes
are achievedD. Emphasis at follow up is on
measurable outcomes such as weight loss or gain.
23
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 counsellingB. A
patient who needs dietary management help for
chronic diseaseC. A patient who has recent
significant weight loss and is waking at night
with back painD. Patient with complex dietary
needs due to a combination of diseases such as
hyperlipidaemia and osteoporosis.
24
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 healthB. The consumption of
antioxidant supplements such as beta carotene
is recommended, especially in patients with
heart diseaseC. Eating plenty of plant based
foods is the best way to ensure adequate
antioxidant levelsD. Food based sources of
folate supply adequate levels of folate in
pregnancy, negating the need for supplements.
25
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 cellsB. Vitamin E is
recommended for anyone who has heart disease or
is at risk of developing itC. Antioxidants
include Vitamin A, Vitamin E, beta carotene
and flavinoidsD. Antioxidants are present in
green leaf tea and green leafy vegetables but
not in black leaf tea.
26
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 cancerB. There is a
direct link between high dietary fat consumption
and cancer at several sitesC. There is good
evidence that high intake of fruit and vegetables
reduces the risk of cancer of the oesophagus
and rectumD. There is evidence of a link between
high dietary processed red meat intake and
cancer at several sites.
27
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
themB. The food provided at childcare centres is
only a small and, therefore, insignificant part
of a childs overall dietC. Parents have a large
influence in establishing their childs eating
habitsD. Children should be given dietary
supplements such as fish oil capsules to ensure
good long term health.
28
SLIDE PRESENTATION
Nutrition, diet and the 5As
29
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).
30
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.
31
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.
32
Evaluating nutrition
How would you approach the subject of nutrition
with a patient with whom you have previously not
addressed dietary issues?
33
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?
34
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.
35
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 Contemplat
ion 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.
36
Advise Give feedback on the patients current
diet. ADVISE them to follow the current
Australian dietary recommendations You may
like to give them a more individualised
Lifescripts prescription.AssistAssist the
patient to understand the benefits of healthy
nutrition formulate, negotiate and implement
achievable goals to improve their nutrition.
37
Arrange Arrange to follow up the patient
yourself Arrange referral, if necessary.
38
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.
39
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.
40
What is a serve of cereals?
Daily intake women 49 serves, men 612
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 12 serves Protein includes meat
(lean), fish (preferably oily), poultry
(skinless), eggs, nuts and soy alternatives
(eg. textured vegetable protein and tofu).
41
What is a serve of dairy?
Daily intake 23 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.
42
Eating for health using the 5As case studies
43
Case study 1 Eating for two
Ask Chloe, aged 27 years, has a long routine
visit for her first antenatal appointment Lifes
tyle 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.
44
Case study 1 Eating for two
AssessDuring pregnancy, why do nutrition
assessments need to be more comprehensive?
45
Case study 1 Eating for two
During pregnancy, assessment should determine
whether the patient eats 56 serves of
vegetables per day eats 4 serves of fruit per
day eats 46 serves of cereals per
day supplements folate with 500 µg per day
until 3 months and consumes folate rich
foods eats 1.52 serves iron rich food per
day eats some iodine rich foods such as seafood
(or iodine supplement) eats 23 serves of
calcium rich foods avoids fish containing high
mercury levels avoids foods at risk of
transmitting listerosis and toxoplasmosis.
46
Case study 1 Eating for two
Chloe is eating 1 piece of fruit (recommended
amount is 4 serves) eating 23 vegetables
(recommended amount is 56 serves) not taking
any folate supplementation and has not been
avoiding food borne infections.Chloe is
nutritionally at risk.
47
Case study 1 Eating for two
Ask and AssessChloe 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.
PrecontemplationB. ContemplationC. ReadyD.
Maintenance
48
Case study 1 Eating for two
AdviseWhat general advice can you give Chloe
regarding nutrition?
49
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 56 serves of vegetables per day.
50
Case study 1 Eating for two
What extra advice will you give Chloe because she
is pregnant?
51
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.
52
Case study 1 Eating for two
Assist What can you do to help Chloe with these
dietary recommendations?
53
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.
54
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 Chloes baby is
born?
55
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, 57 serves
cereal, 2 serves milk/yogurt/cheese Parental
eating habits have a significant effect on the
nutritional risk of their children.
56
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/m2 She has no past
history of CVD, is taking no medication, is a
nonsmoker, and drinks two glasses of wine 23
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.
57
Case study 2 Its in the genes
Ask You take this opportunity to discuss
nutrition with Meg. What initial questions
would you ask Meg?
58
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.
59
Case study 2 Its in the genes
Assess Megs 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?
60
Case study 2 Its in the genes
Assess Megs 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).Megs level of
physical activity would also be an important
consideration in assessing her overall risk.
61
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. ReadyD. Maintenance.
62
Case study 2 Its 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.
63
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 cancerB. Employ motivational
interviewing techniquesC. Refer her to a
dietician to reinforce what you have told
herD. Use cognitive behavioural therapy to help
her change her incorrect beliefs about her diet.
64
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
patient looking to the future getting the
patient to rate their motivation and confidence
on a scale of 110 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?
65
Case study 2 Its 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.
66
Case study 2 Its in the genes
AssistOther 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 increas
ed fruit and vegetable intake will have general
beneficial health effects.
67
Case study 2 Its 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.
68
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. PrecontemplationB. ContemplationC. Ready
D. Maintenance.
69
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.
70
Case study 2 Its in the genes
AdviseIn view of Megs 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).
71
Case study 2 Its in the genes
AssistMeg 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.
72
Case study 2 Its in the genes
AssistNegotiate SMARTS goals with Meg to
improve her nutrition (eg. salt intake).
73
Case study 2 Its in the genes
AssistNegotiate 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.
74
Case study 2 Its 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 23
months time you follow up on Megs nutritional
changes.
75
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 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 Rexs
waist circumference?
76
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 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.
77
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 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 24 fold.
78
Case study 3 Its in my glands, doctor
AskRex 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.
79
Case study 3 Its in my glands, doctor
AssessToday 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. 80
Case study 3 Its in my glands, doctor
AssessRex 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. PrecontemplationB. ContemplationC. Rea
dyD. Maintenance.
81
Case study 3 Its in my glands, doctor
AssessRex has begun to make changes and you need
to support him in maintaining these. You ask Rex
to do a 1 day food recall.
What do you think about Rexs diet?
82
Case study 3 Its 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.
83
Case study 3 Its 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).
84
Case study 3 Its in my glands, doctor
Glycaemic index is a way of rankingA. The
carbohydrate content of the particular
foodB. The effect that the food has on
BGLsC. The glucose content of the food being
assessedD. The amount of insulin that a food
stimulates the body to release.
85
Case study 3 Its 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 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
longer It can also help manage the symptoms of
polycystic ovary disease.
86
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 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.
87
Case study 3 Its in my glands, doctor
AssistTo 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.
88
Case study 3 Its in my glands, doctor
AssistOther 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 Rexs 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 Rexs dietary
changes may be complex, and optimal management
would involve referral to a dietician and/or a
diabetes educator.
89
Case study 3 Its 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?
90
Case study 3 Its in my glands, doctor
ArrangeYour 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 patients dietary history. To find a
dietician, consult the Dietitians Association of
Australia.
91
Case study 3 Its in my glands, doctor
ArrangeYou may also need some strategies to
increase Rexs 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 Rexs
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.
92
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.
93
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 23 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 23 nights per week.
94
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?
95
Case study 4 Look doctor I have my youthful
figure back!
AskThe 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?

96
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.
97
Case study 4 Look doctor I have my youthful
figure back!
What do you think is Berts current stage of
change?A. PrecontemplationB. ContemplationC. Re
adyD. Maintenance.
98
Case study 4 Look doctor I have my youthful
figure back!
Advise Bert is not drinking enough fluid. What
is the recommended dailyliquid intake for an
adult?A. Eight glasses of any fluidB. Eight
glasses of waterC. Six glasses of any
fluidD. Six glasses of water.
99
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 23 serves per
day and preferably more.Outline some strategies
for increasing Berts serves of dairy.
100
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.
101
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?
102
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 Berts
degree of osteoporosis, he may need medication to
preserve/improve bone density.
103
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.
104
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?
105
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 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 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 Berts
eating plan (monitor to ensure that they do not
replace regular food intake and seek a
dieticians advice if unsure).
106
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.
107
Case study 4 Look doctor I have my youthful
figure back!
Assist When Bert is ready to make changes,
SMARTS goals could include
108
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).
109
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 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.
110
Case study 4 Look doctor I have my youthful
figure back!
Assist Outline strategies for increasing Berts
fluid intake.
111
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.
112
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?
113
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.
114
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.
115
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
Berts 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.
116
Ingredients for change in general practice
117
Why bother with nutrition?
Burden of disease and opportunities in general
practice.How can I address nutrition in general
practice?Ask/Assess Who and howAdvise General
nutrition recommendations and for those with
existing nutrition related conditionsAssist Be
haviour change techniquesArrange Referral and
follow up
118
Total burden attributable to risk factors for
men (2003)
Lifestyle choices accounted for 32 of the
disease burden.
Beggs et al 2007
119
Total burden attributable to risk factors for
women (2003)
Lifestyle choices accounted for 32 of the
disease burden.
Beggs et al 2007
120
Prevalence of risk factors (20032005)
AIHW 2006
121
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
122
Brief interventional model 5 As
Ask Assess Advise Assist Arrange.
123
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
124
Brief interventional model 5As
Ask Assess Advise Assist Arrange.
125
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
126
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
127
Brief interventional model 5As
Ask Assess Advise Assist Arrange.
128
The Australian guide to healthy eating
Enjoy a variety of foods every day
NHMRC 2003
129
Breads and cereals
How much of these foods should we eat?
Amount depends on energy requirements 49
serves for women, 612 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
130
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
131
The Australian guide to healthy eating
Enjoy a range of foods every day
NHMRC 2003
132
Whats 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.
133
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).
134
The Australian guide to healthy eating
Enjoy a range of foods every day
NHMRC 2003
135
Meat and meat alternatives
How much meat/meat alternatives should we eat?
12 serves per day. One serve includes
65100 g cooked meat or chicken (¼ of the plate
with your main meal or palm size) 80120 g
cooked fish fillet two small eggs ½ cup
cooked legumes 1/3 cup peanuts or almonds
¼ cup sunflower seeds or sesame seeds.
136
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.
137
The Australian guide to healthy eating
Enjoy a range of foods every day
138
Dairy foods how much?
23 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.
139
The Australian guide to healthy eating
Enjoy a range of foods every day
140
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).
141
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.
142
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 (GI foods have been shown to improve blood glucose
control.
143
Glycaemic index
144
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.
145
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), 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.
146
Elevated LDL cholesterol
Reduction in excess body weight Reduction 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
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.
147
Phytosterol/stanol enriched foods
23 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.
148
Brief interventional model 5As
Ask Assess Advise Assist Arrange.
149
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?
150
Stages of readiness to change
Maintenance of behaviour change
Initiation of risk behaviour
RELAPSE
Not ready to change
Making changes
Thinking about change
Ready to change
151
Ingredients for change
Importance (why should I change)
Readiness
Confidence (How will I do it self efficacy)
Rollnick et al 1999
152
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 Discus
s perceived difficulties, emphasis small gradual
change Door open policy, review at future
visits.
153
Helping ambivalent patients
I would like to improve my eating habits
BUTWhat about patients who are uncertain about
change? How can I help motivate them?
154
Questions to ask
Ask about the patients pros and cons of
changeWhat 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?
155
Explore the cost-benefit balance
Benefits of change Costs of remaining the
same Costs of change Benefits of remaining
the same.
156
Glycaemic index
157
Helping patients who are ready for goal setting
158
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