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Department of Family Medicine, Center for Primary Care and Prevention, Brown Medical School, Memorial Hospital of Rhode Island, Pawtucket, RI 02860;
*
Department of Family Medicine and the Department of Medicine-Cardiology, University of Wisconsin Medical School, Madison, WI 53715-1849 and
Department of Community Health, Institute for Community Health Promotion, Brown University, Providence, RI 02903
3To whom correspondence should be addressed. E-mail: charles_eaton{at}mhri.org
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ABSTRACT |
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 TOP ABSTRACT Office-based systemsNutrition counseling toolsLITERATURE CITED |
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KEY WORDS: • primary care • nutrition education • office system • prevention • nutrition counseling
Nutrition-related diseases such as coronary heart disease, stroke, hypertension, diabetes mellitus and certain cancers are the leading causes of morbidity and mortality in the United States and most developed western societies. It has been estimated that between 300,000 to 800,000 deaths per year could be prevented in the United States, if Americans followed national dietary recommendations (1
). Most Americans have a primary care physician whom they see on average at least once every 2 y. Office visits to primary care physicians’ offices could be an effective method to provide nutrition assessment and counseling and impact on the morbidity and mortality of these leading causes of death. Noting this fact, the Healthy People 2010 Health Objectives and the U.S. Preventive Services Task Force have enumerated specific nutrition counseling recommendations for primary care physicians (2
,3
). In addition, specific clinical guidelines regarding hypertension, hypercholesterolemia and diabetes mellitus contain specific nutrition counseling recommendations (4
–7
).
Primary care physicians are receptive to this idea, with 72% considering it their responsibility to perform nutrition counseling (8
). However, the frequency and time spent in nutrition counseling by primary care physicians suggest that this responsibility turns into effective action much less commonly. Nonacute visits to primary care include nutrition counseling only 30–42% of the time and primary care physicians perform nutrition counseling at visits for cardiovascular disease, hypertension and diabetes mellitus only 25–45% of the time (2
,9
). The time spent in nutrition counseling in primary care is usually less than 5 min per patient, with the average time being 1 min (9
,10
). This counseling needs to be understood in the context of an average office visit lasting 10–16 min (11
).
Thus nutrition counseling in the primary care office setting needs to be performed more frequently, although it is unlikely that it will be done unless it can be accomplished in a short period of time.
Several investigators have enumerated the barriers to effective preventive counseling by primary care physicians (12
,13
). Applied to nutrition counseling, these include the following:
The effectiveness of nutrition counseling in changing dietary habits in primary care settings is well documented in numerous clinical trials (14
–20
). Most studies did not use primary care physicians as the sole source of the nutrition counseling but rather used a combination of health educators, nurses or dieticians and self-help materials and an office-based organized approach to nutrition counseling (21
). Physicians can gain the skills necessary to perform effective nutrition counseling. By use of a 5A’s behavioral approach—Address the agenda, Assess, Advise, Assist, Arrange Follow-up—primary care physicians have demonstrated that they can be trained and can effectively help patients lower blood cholesterol through dietary counseling and an office-based systems approach (14
,22
,23
). The purpose of this paper is to discuss how to develop an effective office-based system regarding nutrition counseling in a primary care setting and to share some effective tools used in office-based nutrition counseling projects.
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Office-based systems |
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TOPABSTRACTOffice-based systemsNutrition counseling toolsLITERATURE CITED |
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,24
).
The Health Education and Research Trial (HEART) Project was a multicenter randomized trial that tested methods to improve primary care practice systems for heart disease prevention in 45 primary care practices in the Midwest (24
). The investigators found that certain practices were able to adopt an office systems approach more effectively than others. Using cross-case analysis, they identified eight factors that influenced which practices were able to develop effective office-based systems (25
). These factors included effective leadership; priority setting for preventive services; joint planning by physicians, staff, and office administration; cooperation and teamwork; acquisition of resources for preventive services; increased support and ownership for the planning and implementation process; accomplishment of office systems improvements; and personal changes of physicians or staff (e.g., changing diet, losing weight).
Major influences that hindered office system improvements included patient load, turmoil related to reorganization, lack of widespread office routines, hospital-affiliated practice, poor communication and fragmentation within a clinic.
From this and other prevention projects, the Agency for Healthcare Research and Quality (AHQR) developed a workbook on organizing an office system for delivering preventive services, Putting Prevention into Practice (PPIP), which is available at http://www.ahrq.gov/ppip/manual (26
).
Applying these principles of organizing an office system to nutrition, the following eight-step approach can be utilized.
Step 1.
Develop a written policy for nutrition counseling, targeting patients with specific diagnoses or types of office visits—diabetes mellitus, obesity, hyperlipidemia, hypertension, prenatal care, health maintenance exams.
Step 2.
Perform chart audits to determine baseline rates of nutrition counseling for selected conditions.
Step 3.
Develop a written plan outlining each person’s role and responsibility in the office system to implement nutrition counseling effectively.
Step 4.
Find a champion. Choose a well-respected and influential office staff member who will be the coordinator of nutrition counseling within the office.
Step 5.
Develop or adapt tools to implement nutrition counseling—a screening tool to assess eating habits; algorithms or guidelines outlining nutrition guidelines for specific diagnoses; patient education materials.
Step 6.
Set a start date.
Step 7.
Meet frequently to assess how things are going and modify the plan as necessary.
Step 8.
Resurvey charts and reassess periodically. Revise goals and plans as necessary.
Once a system that identifies patients in need of nutrition counseling is in place, physicians and staff need to have skills training and tools to effectively counsel patients. A physician-delivered nutrition counseling algorithm has been shown to be effective in primary care settings (14
). This approach includes five steps:
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Nutrition counseling tools |
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TOPABSTRACTOffice-based systemsNutrition counseling toolsLITERATURE CITED |
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Chronic disease vital sign stamp.
Investigators have demonstrated that using a vital sign stamp that includes smoking status has increased smoking cessation counseling and increased smoking cessation rates (27
). It has been suggested that a vital sign stamp including height, weight, waist circumference, body mass index, blood pressure, physical activity and smoking status might improve the identification of patients at risk for nutrition-related diseases and foster more frequent nutrition counseling.
Rate Your Plate.
This semiquantitative food frequency questionnaire directs a patient to record his/her eating patterns, and provides an assessment of the nutritional quality of the food choices. This tool has been validated and shown to be an effective part of a program to lower patient’s cholesterol in primary care practice, worksites and other community settings (28
). Several different versions are available by contacting Dr. Gans or in the appendixes of the reference cited (28
). A password-protected interactive version of Rate Your Plate is also available at the Brown University Nutrition Academic Award website http://biomed.brown.edu/courses/nutrition/login.html. To increase efficiency, patients can fill out the questionnaire before the office visit, in the waiting or in the examining room. Providers can be trained to interpret the questionnaire, praise the patient for positive food choices, help the patient determine which nutrition issues are most problematic (Column A) and determine whether the patient would like to change these eating habits. The Let’s Eat kit contains a companion set of recommendations for each Rate Your Plate food category, which was developed to encourage brief nutritional counseling (29
). Figure 1
and Figure 2
are examples of the dietary recommendations for the Meats category. Mutually acceptable goal setting is performed and a nutrition prescription is given.
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Rapid Eating and Activity Assessment for Patients (REAP).
This is a similar tool, developed by the Nutrition Academic Awardees to evaluate and counsel for healthy eating. It is described in a companion paper in this supplement (30
).
Heart Disease Prevention (HDP) system.
A series of heart disease prevention tools for primary care practices is available from the HEART trial (24
) at http://www.fammed.wisc.edu/research/heart/.
For nutrition counseling, several of the tools found under the Patient Education heading are applicable. Low Fat, Low Cholesterol Eating Guidelines (Fig. 3A, B
) is an example of the two-page format used for patient handouts on this website. These patient education materials were designed to be simple enough that they could be used by practice staff with minimal nutrition training, could be easily copied when supplies ran low and could be reviewed with the patient in the short time frame of the office visit. Additional nutrition topics are also available, including eating out, weight loss and exercise.
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). As part of this initiative, health insurers need to reimburse primary care physicians for providing nutrition counseling at the same level as office visits for acute medical problems.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Supported in part by National Institutes of Health grant HL03948 (Linking Resources for Brown Medical Nutrition Education).
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LITERATURE CITED |
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TOPABSTRACTOffice-based systemsNutrition counseling toolsLITERATURE CITED |
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1. McGinnis, J. M. & Foege, W. H. (1993) The actual causes of death in the United States. J. Am. Med. Assoc. 270:2207-2212.
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3. U.S. Preventive Services Task Force (1998) Clinician’s Handbook for Preventive Services 2nd ed. 1998:400-412 U.S. Public Health Service/International Medical Publishing Washington, DC.
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20. Milkereit, J. & Graves, J. S. (1992) Follow-up dietary counseling benefits attainment of intake goals for total fat, saturated fat, and fiber. J. Am. Diet. Assoc. 92:603-605.[Medline]
21. Thompson, R. L., Summerbell, C. D., Hooper, L., Higgins, J.P.T., Little, P. S., Talbot, D. & Ebrahim, S. (2002) Dietary advice given by a dietitian versus other health professional or self-help resources to reduce blood cholesterol (Cochrane Review). The Cochrane Library, Issue 2 2002 Update Software Oxford, UK.
22. Whitlock, E., Orleans, T., Pender, N. & Allan, J. (2002) Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach. Am. J. Prev. Med. 22:267-284.[Medline]
23. Sciamana, C., Gans, K. M. & Goldstein, M. G. (2000) Physician-delivered nutrition counseling: why and how?. Med. Health R. I. 83:351-355.[Medline]
24. McBride, P. E., Underbakke, G., Plane, M. B., Massoth, K., Brown, R. L., Solberg, L. I., Ellis, L., Schrott, H. G., Smith, K., Swanson, T., Spencer, E., Pfeifer, G. & Knox, A. (2000) Improving prevention systems in primary care practices: the Health Education and Research Trial (HEART). J. Fam. Pract. 49:115-125.[Medline]
25. Knox, A. B., Underbaake, G., McBride, P. E. & Mejicano, G. C. (2001) Organization development strategies for continuing medical education. J. Contin. Educ. Health Prof. 221:15-23.
26. Agency for Healthcare Research and Quality (AHRQ) (2001) Putting Prevention into Practice. A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach. AHRQ Pub. no. APPIP01-0001, October 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/ppip/manual.
27. Fiore, M. C., Jorenby, D. E., Schensky, A. E., Smith, S. S., Bauer, R. R. & Baker, T. B. (1995) Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clinic Proc. 70:303-304.[Medline]
28. Gans, K., Hixson, M. L., Eaton, C. B. & Lasater, T. M. (2000) Rate Your Plate: a dietary assessment and educational tool for blood cholesterol control. Nutr. Clin. Care 3:163-169.
29. Gans, K. M., Lovell, H. J., Lasater, T. M., McPhillips, J. B., Raden, M. & Carleton, R. A. (1996) Evolution of the Let’s Eat Kit: using quantitative and qualitative data to evaluate and refine a self-help nutrition kit for lowering fat intake. J. Nutr. Educ. 28:157-163.
30. Gans, K. M., Eaton, C. B., Ross, E., Barner, C., Wylie-Rosett, J. & McMurray, J. (2003) REAP and WAVE: new tools to rapidly access/discuss nutrition with patients. J. Nutr. 133(suppl.):556S-562S.
31. Fuchs, V. (2002) What’s ahead for health insurance in the United States?. N. Engl. J. Med. 346:1822-1824.
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