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Nutrition Counseling

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Title: PowerPoint Presentation Author: Patricia M. Vannatta Last modified by: mahdiyeh Created Date: 2/10/2003 5:25:12 PM Document presentation format – PowerPoint PPT presentation

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Title: Nutrition Counseling


1
Nutrition Counseling
  • Dr. A.Nadjarzadeh PhD , Nutritionist

2
Objective
  • Learn how to counsel a patient to improve diet
    and physical activity in a manner that is
    effective, minimizes frustration, shows respect
    for the patient and maintains good communication

3
Case study
  • Ms X is a 51 year old nurse who came in 3 weeks
    ago and saw a doctor for her sinus infection.
    That doctor was not her PCP and referred her to
    her PCP, Dr. D for a health maintenance visit and
    follow-up of her sinus infection. He also had
    her come in last week for a fasting lipid profile
    and blood glucose.

4
  • Lab
  • Total Cholesterol 270
  • LDL 175
  • HDL 30
  • Fasting Glucose 125
  • Todays vital signs
  • Weight 195
  • Height 54
  • Blood Pressure 150/95
  • BMI 33.54

5
And now Dr. D will demonstrate how to counsel
Ms. X to improve her lifestyle and reduce her
reduce CHD risk!
6
  • Is Dr. Ds advice likely to help Ms. X?

7
By the end of the counseling session, Dr. D
should have
  • known Ms. Xs diet and habits
  • known whether she is interested in changing any
    aspect of her lifestyle
  • known whether she is ready to implement a weight
    loss plan in the next month
  • appropriately counseled her regarding her risks,
    diet, and lifestyle

8
A Quick Guide to Lifestyle Counseling The 5A
Technique
9
The 5-A Technique
  • ASK
  • ADVISE
  • ASSESS
  • ASSIST
  • ARRANGE

10
ASK
  • Would the patient would benefit from changes in
    nutrition or physical activity?

11
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12
ASK
  • Would the patient would benefit from changes in
    nutrition or physical activity?
  • If yes, perform diet, habit, and nutrition
    assessments

13
Diet and Habit Assessment
A F F E C T S
14
The 5-A Technique
  • ASK
  • ADVISE
  • ASSESS
  • ASSIST
  • ARRANGE

15
ADVISE
  • Advise patient to change the behavior
  • Make it personally relevant
  • Make it brief
  • Id advise you to change this
  • behavior because. . .
  • the risks of behavior
  • benefits of changing behavior

16
Advice Example Physical Activity
you should get 30 minutes of physical activity
most days because you have several risks for
CHD and physical activity can lower all of these
risks (Obesity, High LDL Cholesterol, Low HDL
Cholesterol, Diabetes, Hypertension, risk of MI)
17
Possible Dietary Advice
  • Calories to maintain ideal body weight
  • Less than 30 of calories from fat
  • Low saturated and trans fat (as low as possible
    below 10 of calories)
  • 20-35 grams of fiber/day
  • At least 5 fruits and vegetables/day
  • lt 2.5 grams sodium (6 grams salt)/day
  • 0.4 mg of folate and 1200 mg of calcium/day
  • Less than 2 alcohol drinks/d (1 for women)

18
The 5-A Technique
  • ASK
  • ADVISE
  • ASSESS
  • ASSIST
  • ARRANGE

19
Assess
  • Patients Readiness to Change
  • Pre-contemplation (not interested)
  • Contemplation (within 6 months)
  • Preparation (within a month)
  • Action (working on it)
  • Maintenance

20
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21
The 5-A Technique
  • ASK
  • ADVISE
  • ASSESS
  • ASSIST
  • ARRANGE

22
Assist
  • How to assist depends upon readiness to change
    and barriers to change

23
Pre-contemplation (not interested)
  • ASSISTANCE
  • Offer educational material
  • Invite future inquires

24
Contemplation, Preparation, Action, Maintenance
  • ASSISTANCE
  • 1. Identify barriers to change
  • 2. Address barriers
  • Provide educational materials
  • Inform of programs available in the community
  • Offer referral as needed for intensive
    counseling

25
Barriers to Change
  • Typical barriers might include
  • Hunger or withdrawal symptoms
  • Fear of failure
  • Lack of support (family, friends, co-workers)
  • Depression
  • Unrealistic goals
  • Environmental barriers
  • Financial concerns

26
Barriers to Change
  • Solutions might include
  • Problem solving
  • Support groups
  • Psychotherapy
  • Medication

27
Educational Materials
28
Support Programs
29
Referral
  • Psychotherapist
  • Personal trainer
  • Group program
  • Health educator
  • Dietician

30
Counseling Services that can be Provided by
Dieticians
  • Detailed diet assessment, including readiness to
    change and barriers to change
  • In depth dietary counseling (counting calories,
    choosing healthier foods, shopping, motivational
    tools, food models, etc.)
  • Frequent follow-up

31
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32
The 5-A Technique
  • ASK
  • ADVISE
  • ASSESS
  • ASSIST
  • ARRANGE

33
ARRANGE FOLLOW-UP
  • During current visit
  • schedule follow up (generally within 2 weeks)
  • At the follow-up visit
  • find out how patient is doing
  • recycle patients who have restarted unhealthy
    behavior or are having problems

34
Counseling to modify lifestyle The 5As
  • Ask assess risks
  • Advise give brief advice to change (all
    patients!)
  • Assess determine stage of readiness to change
  • Assist
  • provide materials
  • identify and address barriers and/or make
    referrals if ready
  • Arrange follow-up to improve compliance

35
And now Dr. P will demonstrate how to counsel
Ms. X to improve her lifestyle
36
What are this patients diet and lifestyle
habits?
37
Diet and Habit Assessment
38
What is Ms. Xs stage of readiness to change her
diet?
  • 1. Pre-contemplation
  • 2. Contemplation
  • 3. Preparation
  • 4. Action
  • 5. Maintenance

39
What is Ms. Xs stage of readiness to increase
physical activity?
  • 1. Pre-contemplation
  • 2. Contemplation
  • 3. Preparation
  • 4. Action
  • 5. Maintenance

40
What is Ms. Xs stage of readiness to quit
smoking?
  • 1. Pre-contemplation
  • 2. Contemplation
  • 3. Preparation
  • 4. Action
  • 5. Maintenance

41
Is Dr. Ps advice likely to help Ms. X lose
weight?
42
Treating Obesity Without Frustration
  • Define success generously
  • Use a systematic approach 5As
  • Assess readiness to change
  • Assess barriers to change
  • Use appropriate tools to assess motivation
  • Address obstacles creatively
  • Determine whether referral is appropriate and to
    whom patient should be referred
  • Frequent follow-up for patients in preparation,
    action, or maintenance

43
Counseling Overweight Children
  • Step 1 Calculate BMI
  • Step 2 Determine BMI Percentile
  • Step 3 Interpret the Risk
  • Step 4 Choose a course of action

ARKANSAS CLINICIANS GUIDE TO WEIGHT PROBLEMS IN
CHILDREN AND ADOLESCENTS
44
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45
http//www.bcm.tmc.edu/cnrc/bodycomp/bmiz2.html
46
  • At Risk of Overweight
  • Patients with a personal or family history of
    co-morbidities need full evaluation for
    overweight
  • If no history of co-morbidities, encourage
    healthy lifestyle and follow up in 1 year to
    recheck BMI

47
  • Overweight
  • Needs full evaluation and treatment for overweight

48
Assess Overweight
  • Age first noted
  • Perceived causes by child and parent
  • Prior weight loss attempts
  • Time in sedentary activities (TV, video games,
    computer)
  • Time in physical activity (sports, walking,
    outdoor play)
  • Body image, family stress and any depressive
    symptoms

49
Assess Co-Morbidities
  • Family History obesity, diabetes,
    hyperlipidemia, HTN, MI, stroke
  • PMH chronic diseases
  • ROS sleep apnea, worsening asthma, exercise
    intolerance, reflux, limb pain, emotional
    difficulties, menstrual irregularities

50
Assess Diet
  • Milk/dairy (should be 3-5 servings a day of skim
    or 1)
  • Fruits and vegetables (should be 5-9 servings a
    day)
  • Intake of soft drinks and fruit and sugar drinks
  • Fast food consumption
  • Food behavior (large portions, skipping meals,
    eating while watching TV, high calorie snacking,
    binge eating)

51
  • Physical Examination
  • Body habitus, BP (age appropriate), chest,
    extremities, acanthosis nigricans, thyromegaly,
    striae
  • Labs
  • Cholesterol panel
  • Consider fasting glucose if FHx of type 2
    diabetes or signs of insulin resistance
  • Other lab based on individual findings

52
Clinical Pearls
  • First goal is no further weight gain. Children
    may "grow into" their weight as their height
    increases.
  • Increase fruits and vegetables, use skim or 1
    milk. Decrease sugared drinks, candy, junk and
    fast foods.
  • Turn off the TV while eating. Remove unhealthy
    snacks from view. Put out fruits and vegetables.
    Regular meal times including breakfast. Childs
    fist-size portions only. Limit snacking to
    healthy foods.

53
  • Encourage anything that increases breathing and
    heart rate (brisk walking, bicycling, dancing,
    other sports). Work up to one hour a day.
  • Set limits on TV, video, and computer time (2
    hrs/day total).
  • Self-monitoring is one of the most helpful tools.
    Have them record physical activity and diet,
    weigh every 2-4 weeks. Review records when
    patient comes back and give praise and/or problem
    solve.

54
  • Parents should act as role models, play with
    children, and eat meals together at the table at
    home.
  • If child continues to have inappropriate weight
    gain, reassess for compliance or the presence of
    emotional problems.
  • Consider referral for problems beyond your scope
    of management such as co-morbidities, possible
    abuse or severe psychopathology

55
Counseling Practice Session
  • Objectives
  • Determine the patients stage of readiness to
    change
  • Provide brief, personalized advice explaining the
    behavior that should be changed and why
  • Assist the patient in a manner that is
    appropriate for the stage of readiness to change

56
Counseling Practice Session
  • Logistics
  • 4 cases
  • For each case, one student role plays patient
    (script available)
  • Two students role play physician (may tag team
    and or use time in-time out)
  • Educational handouts will be available on
    physical activity, diet, and smoking
  • Clinicians guide is available for content on the
    pediatric case

57
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58
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