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Institute for Community Health Promotion, Brown University Medical School, Providence, RI 02903;
*
Tufts University Medical School, HNRC/New England Medical Center Hospital, Boston, MA 02111;
Department of Clinical Nutrition, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-8877;
**
Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY 10461 and
Center for Primary Care and Prevention, Brown Medical School, Memorial Hospital of Rhode Island, Pawtucket, RI 02860
3To whom correspondence should be addressed. E-mail: kim_gans{at}brown.edu
 |
ABSTRACT |
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 TOP ABSTRACT Nutrition Academic AwardDescription of WAVERapid Eating and Activity...Implications and conclusionsLITERATURE CITED |
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KEY WORDS: • dietary assessment • nutrition counseling • patient education • physician training
Diet plays an important role in many diseases, including the most common health problems: heart disease, certain cancers, obesity, stroke, hypertension and type 2 diabetes mellitus (1
–7
). Nutritional problems are very prevalent in the United States. Over three quarters of U.S. adults consume fewer than five servings of fruits and vegetables daily (8
). Only one third consume 
30% calories from fat (9
) and only 36% consume <10% of calories from saturated fat (9
). Only 46% meet dietary recommendations for calcium, with only 19% of girls aged 9–19 meeting these recommendations (9
). Only 21% consume the recommended amount of sodium daily (9
). The prevalence of obesity has also increased sharply (10
,11
), with over 60% of the population overweight or obese (12
). Only 15% of adults do the recommended amount of physical activity, and 40% of adults engage in no leisure-time physical activity (9
).
Dietary changes can be helpful in preventing or treating health problems such as obesity, hypertension and high blood cholesterol, and dietary counseling has been shown to reduce medication costs (13
–22
). The effectiveness of nutritional counseling in changing dietary habits has been found in a number of studies (23
–25
). Many national agencies stress the importance of physician involvement in lifestyle counseling (6
,23
,26
–28
). Dietary intervention studies in medical settings have shown that physicians can be helpful in helping patients make positive dietary changes (29
–34
). Primary care physicians are also able to incorporate physical activity counseling into a regular office visit (35
–42
), and can be effective at weight loss counseling (43
–48
) as well.
Despite this evidence, many physicians do little nutrition counseling themselves nor do they refer patients to dietitians (49
–54
). Visits to primary care providers include nutrition counseling only 25–45% of the time (9
,55
,56
), and the time spent averages only 1 min (56
). Physicians often do not counsel overweight and obese patients to lose weight (57
,58
), and physicians do not regularly counsel patients on physical activity and, when they do, it is often when the patient is already overweight or ill (59
,60
).
Several barriers to conducting nutrition counseling in the physician’s office have been identified. These barriers include not enough time, inadequate nutrition training in medical schools and residency, perceived lack of adequate counseling skills, failure to believe that diet change will be helpful, poor reimbursement and lack of an office structure and tools to facilitate nutritional counseling (51
,52
,61
–65
). Although most primary care physicians are interested in learning more about nutrition and feel that lifestyle counseling is an important responsibility for them, they lack confidence in their ability to change patient behavior (49
,61
,63
,66
–68
). Many physicians also believe that patients do not want to and will not change dietary behaviors (69
), a conclusion that is not evidence-based.
In 1999 there were an estimated 756.7 million physician office visits in the United States, 2.8 visits per person (70
). About half of these were to primary care practitioners (70
). Most adults view physicians as their single most credible source of health information. Patients consistently report preventive services as a high priority for their health care and want physicians to provide nutrition counseling (71
). Data from the four-state Health Education and Research Trial revealed that 72% of patients would like their physician to talk to them about diet, and 66% of patients would like their physician to talk to them about weight loss (72
,73
). In addition, 95% agreed that they would change their diet and 93% agreed that they would lose weight if told to do so by their physician (72
,73
). Such data show that patients want their physicians to be involved in nutrition counseling, and they are willing to try to make changes. Patients, rather than being alienated by physician inquiry about lifestyle, expect and may even welcome it (71
). Patients also cite physicians’ failure to give such information as reasons not to request preventive services. Diet counseling of patients can strengthen the patient-physician relationship, enhance the quality of care received and enhance the patient’s satisfaction with treatment (74
). Thus, the lack of nutritional counseling by physicians is problematic (75
).
When dietary counseling does occur, advice given may not be optimally effective in bringing about behavioral change. For example, the commonly offered advice, "Eat less saturated fat," may not be useful if patients do not know which of the foods they eat are high in saturated fat and what lower saturated fat alternatives might be. Similarly, the advice routinely given to diabetics, "Go on a 1200 calorie per day diet," may be too vague to allow successful implementation. In addition, such a diet is too extreme and difficult to achieve as an initial goal if a patient is consuming >1800 calories a day at baseline. In all of these instances, more effective advice could be given if the physician were able to provide more specific counseling based on the patient’s baseline diet.
Unfortunately for physicians who lack formal training in nutrition, an inability to gather baseline dietary information from patients may represent a significant barrier to delivering effective counseling. For these physicians, tools enabling them to rapidly and accurately assess patients’ diets and exercise habits could be instrumental in allowing them to more effectively counsel patients. Furthermore, the utility of such tools could be increased if they were to provide information aiding the physician in discussing the patient’s answers and counseling them appropriately. The purpose of this paper is to discuss two new tools that have been developed by the Nutrition Academic Award (NAA)4 Program to help physicians and other health care providers conduct nutrition assessment and counseling with their patients in a practical and effective manner.
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Nutrition Academic Award |
|---|
|
TOPABSTRACTNutrition Academic AwardDescription of WAVERapid Eating and Activity...Implications and conclusionsLITERATURE CITED |
|---|
). (The NAA is discussed in detail in the overview paper of this symposium series.) One goal of the NAA is to identify and/or develop practical nutrition assessment and education materials that could be disseminated nationally for use by physician practices and for patient education. One of the first needs that the NAA investigators identified was for tools to help incorporate nutrition assessment into the medical interview. Tools that use brief acronyms have been used to help physicians identify alcoholism (77
–81
) and sleep disorders (82
,83
) in their patients. NAA wanted to develop a similar type of tool for nutrition. |
Description of WAVE |
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|
TOPABSTRACTNutrition Academic AwardDescription of WAVERapid Eating and Activity...Implications and conclusionsLITERATURE CITED |
|---|
). Briefly, the objectives of WAVE are to 1) provide a quick tool for primary care providers to discuss weight, physical activity and eating habits with their adult patients; 2) present a four-letter acronym that is easy to remember and use in provider-patient interactions; 3) identify weight, nutrition and physical activity issues that need to be addressed during the office visit or by referral to a dietitian; and 4) reinforce the importance of nutrition and physical activity in health promotion and disease prevention (84
).
The WAVE Pocket Card is formatted as a one-page (front/back), two-column, two-row table, with each quadrant dedicated to a letter of the acronym. The front side addresses the assessment component (Fig. 1
), whereas the reverse side provides recommendations for educating patients (Fig. 2
). Within each letter grid, key questions and resources guide the primary care provider in assessment and education.
|
|
) in the abbreviated BMI table displayed in the "W" quadrant. The Weight quadrant on the "Recommendations" side of the pocket card provides the clinician with suggested approaches to assist patients in initiating weight control. To quickly determine the patient’s activity level, the provider next introduces the questions listed on the "A" quadrant of the "Assessment" side of the WAVE card. Examples of moderate amounts of physical activity are listed in the "Recommendations" Activity section.
Diet (defined on WAVE as Variety and Excess) may be evaluated by several methods. If there is sufficient time, the provider can conduct a very brief (3–5 min) 1-d recall of the patient’s food-intake habits. Based on the foods reported, the provider can determine whether the patient appears to be eating appropriate numbers of servings from the Food Guide Pyramid (Variety) as well as whether he or she is eating too much fat, salt, sugar and calories (Excess) recommended in the Dietary Guidelines for Americans (86
). An alternative to assessing diet via a 1-day recall would be the use of a self-administered food habits questionnaire, which patients could complete in the waiting room or at home. REAP, a new tool for measuring diet (variety and excess) is described below. The Variety and Excess boxes on the assessment side of the WAVE card include the number of servings recommended for each tier of the Food Guide Pyramid (87
) as well as questions to determine whether the patient is eating excess amounts of certain nutrients. On the recommendations side of the WAVE card, Food Guide Pyramid food choices and servings sizes are given as well as food choices that provide excess amounts of certain nutrients. The card also lists counseling tips to aid the practitioner in setting dietary goals with the patient.
The WAVE can be incorporated in the patient interview by the addition of about 5–10 min. A formative evaluation of the WAVE tool was obtained in conjunction with clinical training of medical students at two medical schools. In general the tool was found to be helpful in addressing patients’ lifestyle and nutrition issues related to weight, activity and diet (84
). The WAVE card and resources to facilitate incorporating the WAVE in patient interviews can be downloaded from the following web addresses: http://biomed.brown.edu/courses/nutrition/naa/resources.html and http://www.utsouthwestern.edu/naa/wave.htm. The template for the WAVE Pocket Card can be downloaded for reproduction as a 5'' x 7'' card to carry conveniently in a lab-coat pocket or in an 8
'' x 11'' format. A Palm Pilot version of WAVE is also available at the Mercer University School of Medicine website: http://med2.mercer.edu/ncvd/default.htm.
|
Rapid Eating and Activity Assessment for Patients (REAP) |
|---|
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TOPABSTRACTNutrition Academic AwardDescription of WAVERapid Eating and Activity...Implications and conclusionsLITERATURE CITED |
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–93
), although they all address nutrition issues for a specific health problem only (e.g., high blood cholesterol) and/or do not address major nutritional issues in a brief, user-friendly format. A dietary assessment tool for use in a health care practice environment should meet certain criteria. It should be easy to administer by health care providers or office staff; be easy for patients to complete—ideally without assistance; provide feedback that is immediate and compatible with in-office evaluation; have low associated costs; and address dietary issues that are national nutrition priorities for adults (92
). To meet these needs, the NAA developed the Rapid Eating and Activity Assessment for Patients (REAP) tool. REAP has been described further elsewhere (94
).
Briefly, REAP has been designed to assess diet related to the Food Guide Pyramid (87
) and the 2000 U.S. Dietary Guidelines (86
). REAP includes questions to assess intake of whole grains, calcium-rich foods, fruits and vegetables, fat, saturated fat and cholesterol, sugary beverages and foods, sodium, alcoholic beverages and physical activity (see excerpt in Fig. 3
). REAP also includes questions regarding whether the patient shops and prepares his/her own food; ever has trouble being able to shop or cook; follows a special diet; eats or limits certain foods for health or other reasons; and how willing the patient is to make changes to eat healthier.
|
An accompanying Physician Key aids the provider in discussing the patient’s answers and counseling them appropriately. The REAP Physician Key includes sections on patients at risk, further evaluation and treatment as well as counseling points/further information for each major dietary area (see example in Fig. 4
). For example, if a patient answers on REAP that he or she usually/often eats or drinks <2–3 servings of milk, yogurt or cheese a day, the Physician Key advises the provider that patients at risk are 18- to 50-y-olds consuming less than two servings of dairy products per day or those aged 14–18 or 51+ years who consume less than three servings. The Key then advises the provider to inquire into reasons for low intake, including lactose intolerance, and if the patient is unable to consume dairy, to suggest lactose-reduced/free dairy products, nondairy high calcium foods or consider supplementation. The key also discusses that dairy products are a good source of calcium and vitamin D, and that adequate calcium and vitamin D intakes are important in the prevention and treatment of osteoporosis (e.g., 95
–97
); high calcium intakes may help to prevent colon cancer (e.g., 98
,99
); and adequate calcium and dairy food intakes are important in the treatment of hypertension (e.g., 100
–102
).
|
). Pilot testing of REAP with physicians and medical students revealed high rankings on such parameters as usefulness, ease and practicality, and the validation studies with medical students and consumers indicated that REAP has excellent reliability scores, correlates well with the Healthy Eating Index scores (103
) and reflects intake of most food groups and nutrients related to the Dietary Guidelines (94
). Current versions of REAP and its accompanying Physician Key may be used with permission and are available online at www.biomed.brown.edu/courses/nutrition. |
Implications and conclusions |
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TOPABSTRACTNutrition Academic AwardDescription of WAVERapid Eating and Activity...Implications and conclusionsLITERATURE CITED |
|---|
.
|
–106
). Some patients, especially those with multiple dietary and/or medical problems, should also be referred to a dietitian for further dietary assessment and counseling and may require medical nutrition therapy. REAP and WAVE can be helpful tools to facilitate nutrition assessment and counseling in the provider’s office. These tools could be used by physician assistants, nurses and other health care providers in addition to physicians. Future activities planned for REAP and WAVE include developing case-based training materials for using the tools; developing a version of WAVE for pediatric patients; computerizing the tools; developing accompanying patient education materials; and disseminating the tools through various channels.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Supported in part by National Institutes of Health grant HL 03948 (Linking Resources for Brown Medical Nutrition Education).
4 Abbreviations used: BMI, body mass index; NAA, National Academic Award; NHLBI, National Heart, Lung and Blood Institute; REAP, Rapid Eating and Activity Assessment for Patients; WAVE, Weight, Activity, Variety and Excess.
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LITERATURE CITED |
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TOPABSTRACTNutrition Academic AwardDescription of WAVERapid Eating and Activity...Implications and conclusionsLITERATURE CITED |
|---|
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