health behavior change: case discussions in nutrition€¦ · •harvard school of public health...
TRANSCRIPT
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A M Y L O C K E , M D , F A A F P , A B I H M
HEALTH BEHAVIOR CHANGE: CASE DISCUSSIONS IN NUTRITION
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RECOMMENDED PRACTICE CHANGES
1. Adequately assess patients’ current dietary habits
2. Assess patient specific barriers to optimal nutrition
3. Use motivational interviewing to move patients towards
healthier options
• Use SMART goals
4. Work as a part of a team to provide practice-based
counseling and community-based resources to help
patients achieve and maintain a healthy lifestyle
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BARRIERS TO PROVIDING ADVICE
• Time
• Priorities for the visit
• Expertise/Feelings of inadequacy
• Perception of efficacy
• Lack of referral options
• Stigma/negative physician attitudes
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DEVELOPING A CUSTOMIZED PLAN
Detailed History
Review the
options
Realistic short-and long-term goals
Engage team
Reassess
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FINDING MOTIVATION
• What motivates?
• What are goals?• Lose weight?
• Lower blood pressure? Cholesterol? Sugar?
• Fall less?
• Be stronger?
• Feel better?
• Live longer?
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MOTIVATION: WHAT DOESN’T WORK
• Brief one-time educational intervention
• Unrealistic goals
• Guilt
• Recommend against exercise due to chronic
disease
• Focus on dramatic weight loss
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WHERE TO BEGIN?
• Change takes time
• Think of a goal you accomplished
• Set small concrete goals
• Write them down and commit to someone else
• Get someone to check in on progress
• Can be office, friend, family, etc.
• Track success
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SOLUTIONS
• Meet patients where they are
• Simple messages
• Focus on positives
• (what to do more of)
• Lead by example
• SMART Goals
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MOTIVATING INDIVIDUALS WITH CLEAR GOALS
• Health and wellness over weight loss• Feel better, have more energy
• Short term
• Positive
• Tailored: start with one step
• Play: What is fun?
• Self Monitoring: tracking
• Each day is a new day
• Close follow-up
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SMART GOALS
• Specific
• Measurable
• Achievable
• Realistic
• Time-bound
Make a list of meals for the week with a shopping list each
Sunday so that I have food in the house to make dinner each
night without going to the store
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CASE: CHIEF COMPLAINT
• Wants to loose weight
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HISTORY OF PRESENT ILLNESS
• 45 yo woman with with a recent diagnosis of pre-
diabetes presents with BMI of 30 and a desire to loose
weight. She is here today to discuss. She has tried
dieting in the past and after initial weight loss, she
regains more.
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HISTORY
• PMH: Seasonal allergies
• Meds/OTC: Flonase, Vitamin D
• Allergies: Penicillin
• Family History:
• Father: HTN
• Mother: breast cancer at 70
• Sister: depression
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SOCIAL HISTORY
• Lives with her husband and three kids ages 7, 10 and
15.
• Minimal alcohol
• No tobacco or other drugs
• College degree, works as a middle school teacher
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REVIEW OF SYSTEMS
• Some fatigue, tired when wakes up
• Occasional headaches
• Congested in Spring
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PHYSICAL EXAMINATION
• Obese woman in no apparent distress
• Exam is otherwise unremarkable
• BP 125/79
• BMI 32
• A1C 5.8
• Lipids: Total Cholesterol 195, TG 160, HDL 45, LDL 98
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LIFESTYLE HISTORY
• Nutrition: eats some fruits and veggies; cooks at home 3
nights a week
• Physical Activity: on feet at work; plays with kids on
weekends; walks dog
• Sleep: 6 hrs per night
• Stress: work balance; child care
• Social Connection: well connected with family and
friends
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ASSESSMENT
• Obese woman with pre-diabetes interested in weight
loss. Some fatigue and headaches. Diet quality is
unclear. Minimal physical activity and insufficient
sleep. Significant stressors. Good social support.
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PLAN
• What would you like to do?
• Who do you want on your team?
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ASSESSING DIETARY HABITSWHAT I S THE PAT IENT EAT ING?
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LIFESTYLE HISTORY
• Nutrition:
• Physical Activity:
• Sleep:
• Stress:
• Social Connection:
• Screen time:
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ASSESSING DIETARY HABITS
• Free form discussion
• 24 hour recall
• 24-72 hr diet diary
• Specific questions:
• Frequency cooking, eating out, assess barriers
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QUICK NUTRITION HISTORY
• Fruits and veggies
• Eating out
• Beverages
• Snacks
• 24 hr food recall
• Happy with food eaten?
• Cooking skills
• Time and money constraints
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TAILORING THE MESSAGE
• Fruits and veggies
• Healthy fats
• Cut back on fast food
• Limit sweet beverages
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FOOD RECALL EXERCISE
• In the next few minutes:
• pair up
• take a 24 hour food recall with your partner
• Don’t forget snacks and beverages
• switch
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DEBRIEF
• Issues that came up?
• How do you interpret the results?
• What do you do next?
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ASSESSING BARRIERSWHAT ARE THE ROADBLOCKS?
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• Food knowledge
• Cooking skill
• Food prep interest
• Taste preference
• Family expectations
• Recognition of satiety
• Mindless eating
BARRIERS: INDIVIDUAL
• Ability to read food labels
• Financial/food availability
• Time management• Hours worked
• Child care
• Other activities (i.e. TV)
• Emotional eating
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BARRIERS: SOCIETAL
• Industry/lobby
• Advertising
• Subsidies
• Normalcy
• Bad food everywhere
• Obesity commonplace
• Food availability
• Food deserts
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ASSESSING BARRIERS ROLE PLAY
• In pairs, one person is the patient and the other the
physician
• Stay in your role as you discuss roadblocks
• Have the “patient” rate their likelihood of being
able to make the change (1-10)
• Ask what makes them choose the number they
chose rather than a lower number
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DEBRIEF ROLE PLAY EXERCISE
• Share what worked and what didn’t work
• As the patient, how did you feel?
• As the physician, what could you have done
differently?
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MOTIVATING CHANGEHOW DO WE DO SOMETHING DIFFERENT?
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MOTIVATING CHANGE EXERCISE
• In pairs, one person is the patient and the other the
physician (switch from last exercise)
• Stay in your role as you discuss setting a SMART goal
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SMART GOALS
• Specific
• Measurable
• Achievable
• Realistic
• Time-bound
Bike 30 minutes three times a week at the park near my house with my neighbor after dinner
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DEBRIEF ROLE PLAY EXERCISE
• Share what worked and what didn’t work
• As the patient, how did you feel?
• As the physician, what could you have done
differently?
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USING RESOURCESWHO CAN HELP?
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BUILDING THE TEAM
• The office
• The health system
• The community
• The country
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• Physician
• APRN/PA
• Nurse
• Medical Assistants
THE OFFICE TEAM
• Pharmacist
• Dietician
• Social Work
• Psychology
• Health Coach
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NEW PROGRAMS
• Shared medical visits
• Nurse/dietician visits with T/G codes
• Comprehensive Lifestyle Programs
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HEALTH SYSTEM PARTNERS
• Specialties: cards, endocrine, ortho, etc.
• Disciplines: PT, health coaching, dieticians, public
health, pharmacy, psychology
• Human Resources
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COMMUNITY PARTNERS
• Community foundations
• Grocery stores
• Culinary schools
• Recreation centers (i.e. YMCA)
• Community gardens
• City urban planners
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• My Fitness Pal
• Spark People
• Fitbit
• MyNetDiary
• My Plate
APPS
• Sage Project
• ShopWell
• Nutrients (Foodle)
• HealthyOut
• Lose It
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RESOURCES FOR PATIENTS
• Harvard School of Public Health
• www.nutritionsource.org
• Ending the Food Fight, David Ludwig
• www.endingthefoodfight.com
• Mindless Eating: Why We Eat More Than We Think, Brian Wansink
• www.mindlesseating.org
• Many apps and websites
• ABE’s for Everyone
• My Fitness Pal, Sparkpeople, etc.
• The Hunger Within, Marilyn Migliore
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WHAT CAN YOU DO?
• Feed yourself and those
you love with healthy
food
• Focus on food over
nutrients
• Learn to cook
• Move for fun
• Lobby for change
• Nationally
• Locally
• Patients
• Meet people where they are
• Talk about lifestyle with patients
• Set large and small goals