Welcome to Good nutrition – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address the nutritional

Welcome to Good nutrition – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address the nutritional and dietary requirements of their patients to improve their health and prevent disease.

Which of the following statements regarding fruit and vegetable intake is CORRECT?

QUIZ

Question 1

A. Most Australians consume sufficient quantities of fruit and vegetables in their normal diets

B. Osteoporosis contributes more to the disease burden in Australia than lack of dietary fruit and vegetables

C. Men are higher consumers of fruit and vegetables than women in Australia

D. Alcohol consumption and dietary levels of fruit and vegetables have similar impact on overall health in Australia.

Which of the following statements regarding obesity is CORRECT?

Question 2

A. The majority of Australian children are outside of the healthy weight range

B. Among patients presenting to GPs, more men than women are overweight or 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.

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) andtype 2 diabetes

B. 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.

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 body’s 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.

The 5As approach can be used in dealing with nutrition

• Ask• Assess• Advise• Assist • Arrange.

This involves 5 steps:

Merri, aged 26 years, is overweight and presents for the first time at your practice for a routine Pap test and check up. As you assess her weight and general health, you decide to ask her about nutritional issues.Which is the MOST helpful initial screening question about nutrition in Merri’s 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?

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?

Question 6 – Assess

A. Merri is at risk nutritionally because she has gained 5 kg in the past 12 months

B. Merri does not need investigations at this stage – her CV risk is lowC.Merri’s 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.

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. Are you taking any nutritional supplements such as multivitamins?B. Have you noticed any decrease in your appetite recently?C. Have you been eating more ‘take away’ meals than you used to?D. Have you been drinking at least 8 cups of fluid per day?

Sam asks your advice regarding a healthy intake of fruit and vegetables. Which of the following statements is CORRECT?

Question 8 – Advise

A. Rice is considered a vegetable and may be included in the daily requirements

B. 5 serves of fruit and vegetables should be consumed each 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.

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/nutsB. Butter in preference to margarinesC.3 serves of bread, cereals, rice, noodlesD.4 serves of dairy, including milk/yoghurt/cheese.

Sam also asks about fluid intake as he wonders if he should be drinking more water.Which is the MOST appropriate advice for 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 bestchoice

C.Artificially sweetened cordials are acceptable but may have a diuretic effect

D.Fruit juice should be limited to four glasses per day.

You have explained to Sam the number of serves for each of the main food groups he should eat daily. He asks for more information about how much is ‘a serve’. Which of the following is equivalent to 1 serve or portion?


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.

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’.

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 fatsD.Cholesterol is present in many foods including nuts, avocado, eggs,

fatty meats and dairy products.

Most food is prepackaged and must be labelled with ingredients and some nutrients. Merri asks what she should look for when reading food labels. Which of the following is CORRECT?


A. Checking the ingredient list is adequate for deciding on which of two alternative products is the healthier choice

B. Aim for foods that are low in saturated fat, low in sodium (salt) and low in fibre

C.Foods with the Heart Foundation Tick are lower in both saturated and trans fat, sodium (salt) and kilojoules when compared to similar foods

D.Foods which contain vegetable oil are a healthier alternative to foods that contain butter.

Merri wants to start eating a healthier diet, but also likes to have a break from cooking. She asks your advice about choosing healthy ‘take away/fast food’.Which of the following is CORRECT?


A. Try to limit pies, pizza, hamburgers and creamy pasta dishes to twice per week

B. Barbecued chicken with gravy and a tasty stuffing is a healthy choice

C.Doner kebab/souvlaki with tabouli in pita or Lebanese bread are good options

D.Asian ‘take away’ choices are almost all low fat so are worth considering.

Although willing to consider a diet that will improve her overall health, Merri wonders whether what she eats really has any affect on her weight.Which of the following statements is CORRECT?


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.

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.

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 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.

Some patients, particularly those with chronic disease and the elderly, may suffer from malnutrition. How can you assist this group of patients?

Question 19 – Assist

A. Recommend adequate hydration by consuming 4–5 cups of tea and/or coffee each day

B. Encourage snacking on a range of vegetables, either raw or cooked throughout the day

C.Prescribe patients to eat small frequent meals and high energy snacks that are individualised to their needsD.Suggest eating high fat foods with each meal and snack.

Once strategies/goals for improved nutrition have been negotiated with patients, follow up is important. Which of the following statements regarding follow up is CORRECT?

Question 20 – Arrange

A. Patients should be reviewed at 2 weeks to help increase the chance of sustaining long term dietary change

B. Practice information systems should generate reminders or lists of patients overdue for follow up

C.Patients should be reviewed yearly for 2 years after desired changes are achieved

D.Emphasis at follow up is on measurable outcomes such as weight loss or gain.

Effective management of some patients’ nutritional requirements may need referral to a dietician. In which of the following situations would referral to a dietician NOT be an appropriate next step?

Question 21 – Arrange

A. A morbidly obese patient who needs a specific dietary prescription and counselling

B. A patient who needs dietary management help for chronic 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.

Antioxidant and vitamin supplements are highly promoted as being beneficial to health. Which of the following statements is CORRECT?

Question 22

A. The use of vitamin supplementation in asymptomatic individuals is now established as beneficial to health

B. The consumption of antioxidant supplements such as beta carotene is recommended, especially in patients with heart disease

C.Eating plenty of plant based foods is the best way to ensure adequate antioxidant levels

D.Food based sources of folate supply adequate levels of folate in pregnancy, negating the need for supplements.

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?

Question 23

A. Antioxidants may act by preventing molecules known as ‘free radicals’ from attacking and damaging healthy cells

B. Vitamin E is recommended for anyone who has heart disease or is at risk of developing it

C.Antioxidants include Vitamin A, Vitamin E, beta carotene andflavinoids

D.Antioxidants are present in green leaf tea and green leafy vegetables but not in black leaf tea.

Toby has a strong family history of cancer. He has read contradictory information on the internet about how diet can prevent cancer and would like your advice. Which of the following statements is CORRECT?

Question 24

A. Recent evidence has established that high intake of omega 3 fatty acids/fish reduces the risk of breast and prostate cancer

B. There is a direct link between high dietary fat consumption andcancer at several sites

C.There is good evidence that high intake of fruit and vegetables reduces the risk of cancer of the oesophagus and rectum

D.There is evidence of a link between high dietary processed red meat intake and cancer at several sites.

Nutrition is not only an important consideration for adults, it is also important for healthy development in children.Which of the following statements is CORRECT?

Question 25

A. If a child dislikes a particular food there is no point in continuing to offer it to them

B. The food provided at childcare centres is only a small and, therefore, insignificant part of a child’s overall diet

C.Parents have a large influence in establishing their child’s eating habitsD.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’.

AssistAssist 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.


AssessDuring pregnancy, why do nutrition assessments need to be more comprehensive?


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.


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.


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


AdviseWhat general advice can you give Chloe regarding nutrition?


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.


What extra advice will you give Chloe because she is pregnant?


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.


Assist What can you do to help Chloe with these dietary recommendations?


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.


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?


• 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.


Ask You take this opportunity to discuss nutrition with Meg. What initial questions would you ask Meg?


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.


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?


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.


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. PrecontemplationB. Contemplation C. ReadyD. Maintenance.


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.


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 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.


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?


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.


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• increased fruit and vegetable intake will have general beneficial

health effects.


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.


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. ReadyD. Maintenance.


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 Cons

Better long term health

Effort of thinking up new meals

Current dietary habits easier to follow

Risk of future illness

Possibly avoiding medication

Possible increased cost of healthier meals

Cost of medications

Change in shopping habits


AdviseIn 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).


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.


AssistNegotiate ‘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


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.


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?


• 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.


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.


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.


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. <9.0%B. <8.0%C. <7.0%D. <6.0%.


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. ReadyD. Maintenance.


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’.

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?


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.


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).


Glycaemic index is a way of ranking:A. 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.


• 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.


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.


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.


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 • 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.


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?


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 patient’s dietary history. To find a dietician, consult the Dietitians Association of Australia.


ArrangeYou 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.


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.


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?


AskThe 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?


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.


What do you think is Bert’s current stage of change?A. PrecontemplationB. ContemplationC. ReadyD. Maintenance.


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.


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.


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.


Advise Bert mentions that he does not like plain milk or yogurt.

What alternative nondairy sources of calcium would you suggest?


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.


Advise Summarise the advice that you would give Bert at this point of the consultation.


Advise If Bert also had an abnormal lipid profile with raised total and LDL cholesterol and low HDL, how may this affect your advice?


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).


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.


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


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).


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.


Assist Outline strategies for increasing Bert’s fluid intake.


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.


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?


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.


• 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.


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 howAdvise: General nutrition recommendations and for those with

existing nutrition related conditionsAssist: Behaviour change techniquesArrange: Referral and follow up

Total burden attributable to risk factors for men (2003)

Lifestyle choices accounted for 32% of the disease burden.

9.6

4.9

2.7

0.1

7.77.8 6.46.6

2.7

02

468

1012

% to

tal d

isea

se b

urde

n

Beggs et al 2007

Total burden attributable to risk factors for women (2003)

Lifestyle choices accounted for 32% of the disease burden.

Beggs et al 2007

7.3 7.35.8 5.8

1.5 1.2

6.8

0.7 0.3

0

2

4

6

8

10

% to

tal d

isea

se b

urde

n

Prevalence of risk factors (2003–2005)

61.9

13.5

39.9

83.7

4552.4

87.6

9.314.4 8.5

0

20

40

60

80

100

Inadequate fruitintake

Inadequatevegetable

intake

excess weight Hypertension Highcholesterol

Males Females

AIHW 2006

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


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



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


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).

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.



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.



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 breadsPorridgePasta, noodlesAll beansSweet potatoAll dairy foodsApple, pear, orangesChocolate

White breadCornflakesBrown riceJasmine ricePotatoesWatermelon

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 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.

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.



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

Maintenance of behaviour changeRELAPSERELAPSE

Not ready to Not ready to changechange

Making Making changeschanges

Thinking Thinking aboutabout

changechangeReady to Ready to changechange

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 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?

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 indexBenefits of Improving eating habits Benefits of continuing to eat the same

Better diabetes control Lose weight (possibly)More energyBetter for family too

Less effortNo disruption to family eating habitsI 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 foodNeed to learn how to cook differentlyNeed to cook differently for myself or change family mealsMay affect social situations

Long term health consequences (possibly)Continue to feel tiredRecurring 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

• 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?



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

• 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.

Documents

Welcome to Good nutrition – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address the nutritional