Nutrition Counseling Dr. A.Nadjarzadeh PhD , Nutritionist
Jan 03, 2016
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!
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
ASK
Would the patient would benefit from changes in nutrition or physical activity?
If yes, perform diet, habit, and nutrition assessments
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)
Assess
Patient’s Readiness to Change:Pre-contemplation (not interested)Contemplation (within 6 months)Preparation (within a month)Action (working on it)Maintenance
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
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
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
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
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
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
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