nutrition counseling dr. a.nadjarzadeh phd, nutritionist

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  • Nutrition Counseling

    Dr. A.Nadjarzadeh PhD , Nutritionist

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

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

  • Lab: Total Cholesterol 270LDL 175HDL 30Fasting Glucose 125

    Todays vital signs:Weight 195#Height 54Blood Pressure 150/95BMI 33.54

  • And now Dr. D will demonstrate how to counsel Ms. X to improve her lifestyle and reduce her reduce CHD risk!

  • Is Dr. Ds advice likely to help Ms. X?

  • By the end of the counseling session, Dr. D should haveknown Ms. Xs diet and habitsknown whether she is interested in changing any aspect of her lifestyleknown whether she is ready to implement a weight loss plan in the next monthappropriately counseled her regarding her risks, diet, and lifestyle

  • A Quick Guide to Lifestyle Counseling:The 5A Technique


  • ASKWould the patient would benefit from changes in nutrition or physical activity?

  • ASKWould the patient would benefit from changes in nutrition or physical activity?

    If yes, perform diet, habit, and nutrition assessments

  • Diet and Habit AssessmentAF



  • ADVISEAdvise patient to change the behavior Make it personally relevantMake it brief

    Id advise you to change this behavior because. . .the risks of behaviorbenefits of changing behavior

  • Advice Example: Physical Activity you should get 30 minutes of physical activity most days

    because you have several risks for CHD

    and physical activity can lower all of these risks (Obesity, High LDL Cholesterol, Low HDL Cholesterol, Diabetes, Hypertension, risk of MI)

  • Possible Dietary Advice Calories to maintain ideal body weight Less than 30% of calories from fatLow saturated and trans fat (as low as possible below 10% of calories)20-35 grams of fiber/dayAt least 5 fruits and vegetables/day< 2.5 grams sodium (6 grams salt)/day0.4 mg of folate and 1200 mg of calcium/dayLess than 2 alcohol drinks/d (1 for women)


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


  • AssistHow to assist depends upon readiness to change and barriers to change

  • Pre-contemplation (not interested)

    ASSISTANCE:Offer educational materialInvite future inquires

  • Contemplation, Preparation, Action, Maintenance

    ASSISTANCE:1. Identify barriers to change 2. Address barriers: Provide educational materials Inform of programs available in the communityOffer referral as needed for intensive counseling

  • Barriers to Change Typical barriers might include: Hunger or withdrawal symptoms Fear of failure Lack of support (family, friends, co-workers)DepressionUnrealistic goalsEnvironmental barriersFinancial concerns

  • Barriers to ChangeSolutions might include: Problem solvingSupport groupsPsychotherapy Medication

  • Educational Materials

  • Support Programs

  • Referral

    PsychotherapistPersonal trainerGroup programHealth educatorDietician

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


  • ARRANGE FOLLOW-UP During current visit:schedule follow up (generally within 2 weeks)

    At the follow-up visit:find out how patient is doingrecycle patients who have restarted unhealthy behavior or are having problems

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

  • And now Dr. P will demonstrate how to counsel Ms. X to improve her lifestyle

  • What are this patients diet and lifestyle habits?

  • Diet and Habit Assessment

  • What is Ms. Xs stage of readiness to change her diet?1. Pre-contemplation2. Contemplation3. Preparation4. Action5. Maintenance

  • What is Ms. Xs stage of readiness to increase physical activity?1. Pre-contemplation2. Contemplation3. Preparation4. Action5. Maintenance

  • What is Ms. Xs stage of readiness to quit smoking?1. Pre-contemplation2. Contemplation3. Preparation4. Action5. Maintenance

  • Is Dr. Ps advice likely to help Ms. X lose weight?

  • Treating Obesity Without FrustrationDefine success generously Use a systematic approach: 5AsAssess readiness to changeAssess barriers to changeUse appropriate tools to assess motivationAddress obstacles creativelyDetermine whether referral is appropriate and to whom patient should be referredFrequent follow-up for patients in preparation, action, or maintenance

  • Counseling Overweight ChildrenStep 1: Calculate BMIStep 2: Determine BMI PercentileStep 3: Interpret the RiskStep 4: Choose a course of actionARKANSAS CLINICIANS GUIDE TO WEIGHT PROBLEMS IN CHILDREN AND ADOLESCENTS


  • At Risk of Overweight:

    Patients with a personal or family history of co-morbidities need full evaluation for overweight

    If no history of co-morbidities, encourage healthy lifestyle and follow up in 1 year to recheck BMI

  • Overweight:

    Needs full evaluation and treatment for overweight

  • Assess Overweight

    Age first notedPerceived causes by child and parentPrior weight loss attemptsTime in sedentary activities (TV, video games, computer)Time in physical activity (sports, walking, outdoor play)Body image, family stress and any depressive symptoms

  • Assess Co-MorbiditiesFamily History: obesity, diabetes, hyperlipidemia, HTN, MI, strokePMH: chronic diseasesROS: sleep apnea, worsening asthma, exercise intolerance, reflux, limb pain, emotional difficulties, menstrual irregularities

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

  • Physical Examination Body habitus, BP (age appropriate), chest, extremities, acanthosis nigricans, thyromegaly, striae

    Labs Cholesterol panel Consider fasting glucose if FHx of type 2 diabetes or signs of insulin resistance Other lab based on individual findings

  • Clinical PearlsFirst goal is no further weight gain. Children may "grow into" their weight as their height increases.

    Increase fruits and vegetables, use skim or 1% milk. Decrease sugared drinks, candy, junk and fast foods.

    Turn off the TV while eating. Remove unhealthy snacks from view. Put out fruits and vegetables. Regular meal times including breakfast. Childs fist-size portions only. Limit snacking to healthy foods.

  • Encourage anything that increases breathing and heart rate (brisk walking, bicycling, dancing, other sports). Work up to one hour a day.

    Set limits on TV, video, and computer time (2 hrs/day total).

    Self-monitoring is one of the most helpful tools. Have them record physical activity and diet, weigh every 2-4 weeks. Review records when patient comes back and give praise and/or problem solve.

  • Parents should act as role models, play with children, and eat meals together at the table at home.

    If child continues to have inappropriate weight gain, reassess for compliance or the presence of emotional problems.

    Consider referral for problems beyond your scope of management such as co-morbidities, possible abuse or severe psychopathology

  • Counseling Practice SessionObjectivesDetermine the patients stage of readiness to changeProvide brief, personalized advice explaining the behavior that should be changed and whyAssist the patient in a manner that is appropriate for the stage of readiness to change

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

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