Nutrition and Physical Activity Counseling

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Nutrition and Physical Activity Counseling

• ICM2
• November 23, 2004
• Gary Wheeler, M.D.
  Arlo Kahn, M.D.
• Pediatrics
  Family and Preventive Medicine

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UAMS Nutrition Curriculum

• Freshman year
• Supermarket Tour (ICM1)
• Paired Nutrition Assessment
• Introduction to Preventive Nutrition (ICM1)
• Preventive Nutrition Clinical Correlations
• Hyperlipidemia, Diabetes, Folate (Biochem)

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UAMS Nutrition Curriculum

• Sophomore year
• The Obesity Epidemic (ICM 2)
• Introduction to Counseling (ICM 2)

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UAMS Nutrition Curriculum

• Junior year
• Cardiovascular Disease and Nutrition (Family
  Practice Clerkship)
• Pediatric Nutrition Skills (Pediatric Clerkship)

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UAMS Nutrition Curriculum

• Senior year
• Nutrition and prevention updates (Block 10)

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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

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Virginia Winston

• Ms Winston 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. DeMentaux 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.

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• Lab
• Total Cholesterol 270
• LDL 175
• HDL 30
• Fasting Glucose 125
• Todays vital signs
• Weight 195
• Height 54
• Blood Pressure 150/95
• BMI 33.54

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And now Dr. DeMentaux will demonstrate how to
counsel Ms. Winston to improve her lifestyle and
reduce her reduce CHD risk!
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• Is Dr. DeMentauxs advice likely to help Ms.
  Winston?

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

• known Ms. Winstons diet and habits
• known whether she is interested in changing any
  aspect of her lifestyle
• known whether she is ready to implement a weight
  loss plan in the next month
• appropriately counseled her regarding her risks,
  diet, and lifestyle

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A Quick Guide to Lifestyle CounselingThe 5A
Technique
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The 5-A Technique

• ASK
• ADVISE
• ASSESS
• ASSIST
• ARRANGE

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ASK

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

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ASK

• Would the patient would benefit from changes in
  nutrition or physical activity?
• If yes, perform diet, habit, and nutrition
  assessments

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Diet and Habit Assessment
A F F E C T S
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The 5-A Technique

• ASK
• ADVISE
• ASSESS
• ASSIST
• ARRANGE

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ADVISE

• Advise patient to change the behavior
• Make it personally relevant
• Make it brief
• Id advise you to change this
• behavior because. . .
• the risks of behavior
• benefits of changing behavior

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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)
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Possible Dietary Advice

• Calories to maintain ideal body weight
• Less than 30 of calories from fat
• Low saturated and trans fat (as low as possible
  below 10 of calories)
• 20-35 grams of fiber/day
• At least 5 fruits and vegetables/day
• lt 2.5 grams sodium (6 grams salt)/day
• 0.4 mg of folate and 1200 mg of calcium/day
• Less than 2 alcohol drinks/d (1 for women)

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The 5-A Technique

• ASK
• ADVISE
• ASSESS
• ASSIST
• ARRANGE

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Assess

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

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The 5-A Technique

• ASK
• ADVISE
• ASSESS
• ASSIST
• ARRANGE

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Assist

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

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Pre-contemplation (not interested)

• ASSISTANCE
• Offer educational material
• Invite future inquires

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Contemplation, Preparation, Action, Maintenance

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

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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

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Barriers to Change

• Solutions might include
• Problem solving
• Support groups
• Psychotherapy
• Medication

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Educational Materials
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Support Programs
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Referral

• Psychotherapist
• Personal trainer
• Group program
• Health educator
• Dietician

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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

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The 5-A Technique

• ASK
• ADVISE
• ASSESS
• ASSIST
• ARRANGE

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ARRANGE FOLLOW-UP

• During current visit
• schedule follow up (generally within 2 weeks)
• At the follow-up visit
• find out how patient is doing
• recycle patients who have restarted unhealthy
  behavior or are having problems

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Counseling to modify lifestyleThe 5As

• 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

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And now Dr. PreVentaux will demonstrate how to
counsel Ms. Winston to improve her lifestyle
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What are this patients diet and lifestyle
habits?
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Diet and Habit Assessment
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What is Ms. Winstons stage of readiness to
change her diet?

• 1. Pre-contemplation
• 2. Contemplation
• 3. Preparation
• 4. Action
• 5. Maintenance

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What is Ms. Winstons stage of readiness to
increase physical activity?

• 1. Pre-contemplation
• 2. Contemplation
• 3. Preparation
• 4. Action
• 5. Maintenance

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What is Ms. Winstons stage of readiness to quit
smoking?

• 1. Pre-contemplation
• 2. Contemplation
• 3. Preparation
• 4. Action
• 5. Maintenance

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Is Dr. PreVentauxs advice likely to help Ms.
Winston lose weight?
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Treating Obesity Without Frustration

• Define success generously
• Use a systematic approach 5As
• Assess readiness to change
• Assess barriers to change
• Use appropriate tools to assess motivation
• Address obstacles creatively
• Determine whether referral is appropriate and to
  whom patient should be referred
• Frequent follow-up for patients in preparation,
  action, or maintenance

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Counseling Overweight Children

• Step 1 Calculate BMI
• Step 2 Determine BMI Percentile
• Step 3 Interpret the Risk
• Step 4 Choose a course of action

ARKANSAS CLINICIANS GUIDE TO WEIGHT PROBLEMS IN
CHILDREN AND ADOLESCENTS
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http//www.bcm.tmc.edu/cnrc/bodycomp/bmiz2.html
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• 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

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• Overweight
• Needs full evaluation and treatment for overweight

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Assess Overweight

• Age first noted
• Perceived causes by child and parent
• Prior weight loss attempts
• Time in sedentary activities (TV, video games,
  computer)
• Time in physical activity (sports, walking,
  outdoor play)
• Body image, family stress and any depressive
  symptoms

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Assess Co-Morbidities

• Family History obesity, diabetes,
  hyperlipidemia, HTN, MI, stroke
• PMH chronic diseases
• ROS sleep apnea, worsening asthma, exercise
  intolerance, reflux, limb pain, emotional
  difficulties, menstrual irregularities

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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 drinks
• Fast food consumption
• Food behavior (large portions, skipping meals,
  eating while watching TV, high calorie snacking,
  binge eating)

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• 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

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Clinical Pearls

• First 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.

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• 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.

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• 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

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Counseling Practice Session

• Objectives
• Determine the patients stage of readiness to
  change
• Provide brief, personalized advice explaining the
  behavior that should be changed and why
• Assist the patient in a manner that is
  appropriate for the stage of readiness to change

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Counseling Practice Session

• Logistics
• 4 cases
• For 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 smoking
• Clinicians guide is available for content on the
  pediatric case

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