Nutrition Counseling

Dr. A.Nadjarzadeh PhD , Nutritionist

Objective

Learn 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 study

Ms 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

Today’s vital signs:Weight 195#Height 5’4”Blood 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. D’s advice likely to help Ms. X?

By the end of the counseling session, Dr. D should have

known Ms. X’s 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

The 5-A Technique

ASKADVISEASSESSASSISTARRANGE

ASK

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

ASK

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

If yes, perform diet, habit, and nutrition assessments

Diet and Habit Assessment

A

F

F

ECTS

The 5-A Technique

ASKADVISEASSESSASSISTARRANGE

ADVISE

Advise patient to change the behavior Make it personally relevantMake it brief

“I’d 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)

The 5-A Technique

ASKADVISEASSESSASSISTARRANGE

Assess

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

The 5-A Technique

ASKADVISEASSESSASSISTARRANGE

Assist

How 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) Depression Unrealistic goals Environmental barriers Financial concerns

Barriers to Change

Solutions might include: Problem solving Support groups Psychotherapy Medication

Educational Materials

Support Programs

Referral

PsychotherapistPersonal trainerGroup programHealth educatorDietician

Counseling Services that can be Provided by

Dieticians

Detailed 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

The 5-A Technique

ASKADVISEASSESSASSISTARRANGE

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 5A’s

Ask: 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 ready

Arrange: follow-up to improve compliance

And now Dr. P will demonstrate how to

counsel Ms. X to improve her lifestyle

What are this patient’s diet and lifestyle

habits?

Diet and Habit Assessment

What is Ms. X’s stage of readiness to change

her diet?

1. Pre-contemplation2. Contemplation3. Preparation4. Action5. Maintenance

What is Ms. X’s stage of readiness to

increase physical activity?

1. Pre-contemplation2. Contemplation3. Preparation4. Action5. Maintenance

What is Ms. X’s stage of readiness to quit

smoking?

1. Pre-contemplation2. Contemplation3. Preparation4. Action5. Maintenance

Is Dr. P’s advice likely to help Ms. X lose

weight?

Treating Obesity Without Frustration

Define “success” generously Use a systematic approach: 5A’sAssess 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 Children

Step 1: Calculate BMIStep 2: Determine BMI PercentileStep 3: Interpret the RiskStep 4: Choose a course of action

ARKANSAS CLINICIAN’S GUIDE TO WEIGHT PROBLEMS IN CHILDREN AND ADOLESCENTS

http://www.bcm.tmc.edu/cnrc/bodycomp/bmiz2.html

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-Morbidities

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

Assess Diet

Milk/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. Child’s 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 Session

ObjectivesDetermine the patient’s 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 smokingClinician’s guide is available for content on the pediatric case