Nutrition counseling in private practice: attitudes and activities of family physicians

A community approach to cardiovascular disease control is advocated for the United States because of the high disease incidence and prevalence relative to other countries. The goal of this approach is to change nutrition behavior of all members of the community. As part of a program to identify barriers to physician participation, a survey of a random sample of family practice clinical faculty in a midwestern state was made to determine (a) if physicians agree that it is appropriate to give nutritional advice to a patient who came to the clinic for another reason, (b) the proportion of patients given nutritional advice, and (c) the barriers to giving nutritional advice. Most physicians report that giving nutritional advice to patients visiting them for other reasons is considered appropriate, but almost half the physicians give advice about dietary fat, dietary sodium, or dietary fiber to fewer than 20% of their patients. Only about 10% of physicians give advice to more than 80% of their patients. Absence of elevated risk factor levels or nutritional disease is the most common reason for not giving advice. Perceived lack of patient interest and expectation of patient nonadherence are also barriers. Unpalatability of the diet is occasionally a barrier. Cost of the diet is not a consideration. From these data it is concluded that family physicians consider it appropriate to give nutritional advice to patients who are not necessarily seeking it, but the perception that patients do not need or want, and would not follow, the advice inhibits physicians from delivering nutrition messages in private practice.     

Children's bone health, calcium and vitamin D--how much do nurses and health visitors know?

Two focus groups of health visitors, practice nurses and community nursery nurses were held to find out how much health visitors and nurses know about children's bone nutrition, and whether they are able to identify dietary sources of these nutrients. Results showed that these professionals spend a significant part of their time giving nutritional advice about children and young people and answering questions on a range of dietary matters. They were well informed about the importance for bone health of calcium, vitamin D, exercise and a healthy, balanced diet. The biggest misconception was that dairy products in the UK contain vitamin D. Most of the professionals knew that bone strength develops quickly during childhood, and some that it does so in adolescence but few were aware that 90% of the full genetic potential for bone strength is achieved before adulthood. The groups reported confusion over the Government's initiatives for vitamin D supplements, and lack of guidance from Primary Care Trusts on making Healthy Start vitamins available at clinics for mothers and babies. Overall, health visitors and nurses have a good knowledge of bone health but there are gaps and more educational resources are needed, including on dietary sources of vitamin D. The Government needs to give clear guidelines about its initiatives for vitamin D supplements for mothers and children aged under five years. It is disappointing that the Dairy Council's 3-a-Day message on meeting essential calcium needs through three daily servings of dairy foods has not got through.     

Alternatives for macronutrient intake and chronic disease: a comparison of the OmniHeart diets with popular diets and with dietary recommendations

BACKGROUND: Enhancements to current dietary advice to prevent chronic disease are of great clinical and public health importance. The OmniHeart Trial compared 3 diets designed to reduce cardiovascular disease (CVD) risk-one high in carbohydrate and 2 that replaced carbohydrate with either unsaturated fat or protein. The lower carbohydrate diets improved the CVD risk factors. Several popular diets claiming health benefits emphasize carbohydrate, fat, or protein or various combined approaches. OBJECTIVE: The objective of this study was to compare the macronutrient contents of the OmniHeart trial diets to those of several popular diets and to evaluate each diet for consistency with national health guidelines. DESIGN: The macronutrient contents of 7-d menu plans from the OmniHeart Study, Dietary Approaches to Stop Hypertension (DASH), Zone, Atkins, Mediterranean, South Beach, and Ornish diets were evaluated for consistency with the US Food and Nutrition Board's Acceptable Macronutrient Distribution Ranges (AMDRs) and with the dietary recommendations of several health organizations. RESULTS: The OmniHeart diets fulfilled the major AMDRs, but, of the popular diets, only the Zone diet did. The OmniHeart diets were generally consistent with national guidelines to prevent cancer, diabetes, and heart disease, whereas most popular diets had limitations for fulfilling one or more guidelines. CONCLUSIONS: Although the OmniHeart protein and unsaturated fat diets were superior to the carbohydrate diet in improving CVD risk, all 3 study diets were consistent with national guidelines to reduce chronic disease risk, which suggests that the guidelines might now be fine-tuned to optimize disease prevention. Popular diets vary in their nutritional adequacy and consistency with guidelines for risk reduction.     

Are dietary recommendations for dietary fat reduction achievable?

Despite several sets of dietary guidelines aimed at reducing fat intakes in the UK populations the actual fat intake in the UK has remained remarkably constant over the last decade. It is therefore of utmost importance to understand why the advice of the 1980s was not taken on board by the nation, to enable the achievement of current nutritional targets for dietary fat set for 2005. The nature of the diets of those individuals in the UK who have low fat intakes in line with the dietary goals are considered here, with the aim to increase our understanding of how the goals can be achieved in the free-living population. This paper postulates that a low fat diet will be easier to achieve, more palatable and hence more acceptable to the consumer if the dietary fat is replaced with a mixture of energy from sugar and starch. Further research is required to gain a greater understanding of what type of dietary composition will enable the free-living population to achieve a reduction in their dietary fat intake. This in turn will allow the dissemination of appropriate nutritional advice in the future and inform product development initiatives in the food industry.     

Navigating dietary advice for multiple sclerosis

BackgroundMultiple sclerosis (MS) is an inflammatory demyelinating disease with no known cure. Numerous diets are promoted to reduce symptoms or even cure MS, despite insufficient evidence for any therapeutic diet. There are few qualitative studies exploring the experiences of people with MS in relation to diet, and no use of theory to explain the findings.PurposeTo explore the experiences of adults with MS when navigating dietary advice, their attitudes when making dietary decisions, and their needs regarding dietary resources and education.MethodsIn this qualitative study, we conducted six focus groups with people with MS (n = 33 plus one spouse without MS). Groups were audio‐recorded and transcribed verbatim. Primary analysis used a general inductive approach with thematic analysis. Secondary analysis aligned themes with the constructs of the self‐determination theory.ResultsSix themes emerged: (a) confusion about where to seek dietary advice; (b) scepticism towards national dietary guidelines; (c) personalized approaches to dietary change; (d) barriers to dietary changes; (e) judging if dietary changes work; and (f) wanting dietary guidelines for MS.ConclusionPeople with MS are highly motivated to make dietary changes and improve their health. The self‐determination theory explained why people with MS make dietary modifications, and the varying levels of motivation. MS‐specific dietary resources and nutrition education need to incorporate ways to increase autonomous forms of motivation. Future dietary intervention studies could use the self‐determination theory as a framework to improve long‐term adherence to healthier diets.     

The relationship between beliefs about nutrition and dietary practices of the elderly

Data were collected from home interviews of 424 noninstitutionalized individuals, 58 to 100 years old, in the Houston metropolitan area, to assess the relationships between dietary intake, socioeconomic variables, beliefs about nutrition, and use of nutritional supplements. Two-thirds of the subjects took nutritional supplements. The most common forms were vitamin C, calcium, and multivitamins. With the exception of vitamin B-6, magnesium, and dietary fiber, which were higher in diets of users of nutritional supplements than in diets of nonusers, nutrient density (amount of nutrient per 1,000 kcal) did not differ between the two groups. Attitudes toward the use of nutritional supplements, health foods, and/or nutritional quality of conventional foods differed with sex, age, income, and educational level. Nutrient intake of those with more positive feelings about nutritional supplements was higher, perhaps as a result of increased awareness of diet and health. Nutrition education that is targeted to issues of interest to people in this age group is needed; topics such as the role of nutrients in disease prevention and appropriate nutritional supplementation might be explored. This survey indicates that, although the practice of supplementation may be beneficial to augment nutritional quality of the diet for elderly people, use of nutritional supplements is not restricted to those whose dietary intake is of lower nutrient density than that of nonusers.     

What price a healthy diet?

The majority of attempts to determine the cost of a healthy diet have indicated that eating ‘healthily’ does not need to be more expensive. Adapting the UK diet to nutritional recommendations does however require significant changes to present consumption patterns and even greater changes are required if cost is an additional constraint. The poorest people in the population have the greatest difficulty in meeting dietary guidelines. Not only would they probably have to increase their proportional expenditure on food, but a lack of resources, limited access to value-for-money food and insufficient nutritional knowledge will compound their problems. This issue presents a real challenge to nutritionists and the food industry.     

Traditional Indian beliefs about the dietary management of diabetes—an exploratory study of the implications for the management of Gujarati diabetics in Britain

The aim of this small study was to explore the extent to which traditional beliefs about diet, health and diabetes, as described in the classics of Ayurvedic medicine, are held by Indian (Gujarati) diabetics in Britain. This was undertaken to give insight into the patients' perspective on appropriate management of their condition and to identify and possible areas of conflict between traditional remedies and western treatment of diabetes. In addition, eating habits were examined in order to assess the extent to which the dietary modifications advocated by either medical system were being followed.
Patients satisfaction with the advice given by doctors and dietitians and its appropriateness to their eating habits was also investigated.
The results indicated that the traditional belief in the value of bitter foods and bitter herbs in the management of diabetes was common amongst Gujarati patients attending the diabetes clinics at two London Hospitals. The majority ate karela, guar, tindora or methi leaves once a fortnight or more frequently as part of a meal. But only a small minority (18%) used bitter foods or bitter herbs therapeutically, giving rise to little conflict between traditional and western medicine.
Findings also indicate that despite their generally poor understanding of English, patients were aware of the principles of the diabetic diet advocated by doctors and dietitians. These were not however always put into practice. This might be due in part to a lack of specificity in advice, possibly arising from a lack of detailed knowledge concerning the foods, eating habits and beliefs of these patients.     

Recent national French food and nutrient intake data

In France, the first national dietary survey, called ASPCC, was done in 1993-1994. According to this survey, the mean fat intake in France is rather high, both for men (37.7%) and women (40%). Saturated fat intake is above 15% of energy. The intake of fruit and vegetables is particularly low for younger people and manual workers. Fruit intake is also lower for people from the north of the country. These data show the necessity of a targeted nutritional policy in France. Therefore, public health authorities are determining new dietary guidelines. The fact that people with unsatisfactory nutritional status are often not concerned with nutrition proves the importance of simple understandable food-based dietary guidelines.     

Dietary management of food allergy in children

Currently, the only treatment for any food hypersensitivity (including food allergy) is the dietary avoidance of the causative allergen, using an elimination diet. In addition to being used for the management of food hypersensitivity, an elimination diet may also be used in the diagnosis of food allergy. Dietary exclusion should be managed by a dietitian or other health professional with nutritional expertise to ensure that the exclusion does not lead to a nutritionally-deficient diet. There are three main types of elimination diets: single-food exclusion; multiple-food exclusion; the 'few-food' diet, which requires the avoidance of a large number of allergens and therefore concentrates on the foods that can be included rather than the foods that need to be avoided. Any sort of elimination diet is hard to manage. Thus, as well as ensuring that the diet is nutritionally adequate, it is essential that families are given advice and support relevant to their circumstances to aid them in the day-to-day management of the diet, so that it remains varied and enjoyable for food-allergy sufferers. This approach involves advice about which alternative foods are available, provision of 'free-from' recipes and guidance on which nutritional supplements are needed to meet their nutritional needs.     

Use of qualitative methods to study diet, acculturation, and health in Chinese-American women

Improving the health status of minority populations in the United States is a major public health challenge. This report describes an anthropological approach to obtaining information needed for designing and evaluating a culturally appropriate dietary intervention for Chinese-Americans. Ninety-minute qualitative interviews were conducted with 30 less-acculturated Chinese-American women in their native language (Cantonese or Mandarin), soliciting information from participants regarding usual food consumption; knowledge, attitude, and beliefs about diet and disease; and factors that influence food choices. Interviews were recorded, translated, transcribed, and coded for themes. Two focus groups with 6 participants each were conducted to cross-validate the interview findings. Among our participants, breakfast was usually the first meal to be "Westernized," largely for reasons of convenience. Food quality, cost, and availability were some of the most important predictors of dietary change after immigration to the United States. Respondents said that there was a strong connection between diet and disease. However, they were not familiar with US dietary guidelines, food labels, or other sources of dietary information, but reported that friends and Chinese newspapers were their primary source of nutrition information. We used these findings to develop quantitative dietary survey instruments adapted for Chinese-Americans. This type of qualitative groundwork is an important precursor to the design, implementation, and evaluation of dietary interventions for minorities.     

A comparison of the nutritional beliefs of human immunodeficiency virus (HIV) seropositive and seronegative homosexual men

One-hundred and eighty-eight HIV-seropositive (index cases) and 45 HIV-seronegative (controls) homosexual men completed a questionnaire to assess their nutritional beliefs and practices, their psychosocial characteristics and information sources. Most individuals, irrespective of their HIV serological status, perceived the need to change their diet. Dietary changes were those which would be perceived as healthy by the general population, for example, a low-fat, high-fibre diet. Most HIV-seropositive individuals believed that vitamin and mineral supplements were especially important for their health and this was mirrored in their relative increased use of these substances compared to controls. Dietetic advice was not effective in terms of reported changes in dietary practice.
This work shows that although dietetic advice could be important in the management of HIV infection, in terms of altering dietary intake to promote weight gain, current practice needs to be reviewed in an attempt to improve efficacy. These results highlight the need to consider psychological characteristics when monitoring dietary compliance.     

云南某高校高护女生膳食结构调查

目的了解学院医学部高护女大学生的营养状况，指导学生合理膳食。方法采用24h膳食记录法和称重法连续3d分别调查医学院大二、三年级高护女生膳食中每餐所吃食物（包括零食、水果）的品种、数量。结果学生蛋白、Fe、视黄醇、VitB2、VitC摄入充足，蛋白质拳源较合理。热理及Ca严重不足；三大产能营养素分布及一日三餐热量分布均不合理，脂肪来源不舍理。结论建议学生调整膳食结构，多注意平衡膳食、食物多样化，适当增加热能、植物性脂肪的供给及矿物质钙、铁摄入，合理地分配三餐膳食营养素等。     

Adoption and maintenance of a Mediterranean diet in patients with coronary heart disease from a Northern European population: a pilot randomised trial of different methods of delivering Mediterranean diet advice

Background:  A Mediterranean diet has been shown to protect against coronary heart disease (CHD). Adherence to a Mediterranean diet can be assessed using a Mediterranean diet score. The primary aim of this pilot study was to examine whether CHD patients in a Northern European population would adopt and maintain a Mediterranean diet, with a secondary aim of comparing the effectiveness of different methodologies aimed at improving compliance.
Methods:  Sixty-one patients with a diagnosis of CHD were randomised to one of three groups: either to receive conventional dietetic advice for CHD or advice to implement a Mediterranean-style diet using either behavioural counselling or nutritional counselling. Patients received a follow-up assessment at 6 months (adoption) and a subset of patients was followed up at 12 months (maintenance). The primary outcome measure was the between-group difference in the mean change in Mediterranean diet score (MDS).
Results:  The change in MDS was not significantly different between groups. However, all three groups reported a significant within-group increase in MDS ( P  < 0.01) at 6 and 12 months follow-up.
Conclusions:  All three groups made dietary changes towards a Mediterranean diet, but behavioural counselling did not have significant additional benefit over nutritional counselling in initiating and maintaining dietary change, and neither method offering specific Mediterranean diet advice had any significant benefit in terms of improvement in MDS over conventional dietetic practice.     

Nutritional Information Provision to Cancer Patients and Their Relatives Can Promote Dietary Behavior Changes Independent of Nutritional Information Needs

We investigated whether obtaining nutritional information influences reported changes in dietary behavior in cancer survivors and their relatives and whether nutritional information needs influence this association. We included 239 cancer survivors and their relatives, recruited from an online panel of cancer survivors and relatives. This panel completed a survey about their experiences with nutritional information provision by healthcare professionals and the media in the period after diagnosis, their information needs regarding nutrition and cancer, and whether they changed their dietary behavior since diagnosis. The survey showed that 56% of respondents obtained nutritional information, mostly during treatment. Respondents who obtained nutritional information more often reported to have altered their dietary behavior after diagnosis. This association was not altered by having information needs. The reported changes in dietary behavior were coherent with the recommendations of the World Cancer Research Fund: respondents reported to choose less products that promote weight gain, increased intake of plant foods, and decreased meat and alcohol use. Respondents who obtained nutritional information more often changed their dietary behavior, regardless whether they had nutritional information needs. This might be an indication that healthcare professionals should provide nutritional information not only to those expressing a need for nutritional information.     

Should foods or nutrients be the focus of guidelines to promote healthful eating?

A variety of different dietary patterns can achieve the nutrient goals for a given population and therefore be considered as healthful. This means that guidelines for a healthy diet can be tailored to suit different cultures and food preferences. Although food‐based dietary guidelines are used worldwide, there is also authoritative dietary advice in relation to single nutrients, especially those of public health relevance. This includes recommendations to eat less salt, free sugars and ‘saturates’ as well as more fibre. However, it can be difficult for consumers to make simultaneous reductions in salt, sugars and saturated fatty acids as well as increases in dietary fibre, given that food choices are made according to a variety of considerations, including taste preferences, culture, convenience and cost, as well as health. In addition, media coverage of new scientific findings, especially those that challenge current dietary guidelines, can confuse consumers and hamper efforts to eat healthfully. Both food‐based dietary guidelines and recommended nutrient intakes can help consumers eat healthfully, providing they are supported by sound nutrition science, communicated well and delivered in a way that promotes beneficial changes in behaviour.     

Behind the scenes of doctors' nutritional advice: the infrastructure of nutrition information that is used in practice

Though this sixth Heelsum meeting has concentrated on over- and under-nutrition, GPs in their work look after patients with a wide range of diseases that may be helped by different dietary managements (van Weel C. Morbidity in family medicine: the potential for individual nutritional counselling, an analysis from the Nijmegen Continuous Morbidity Registration. Am J Clin Nutr 1997; 65 (suppl 6): 1928s-32s). Much attention is paid to evidence from randomized controlled trials (RCTs). However, most of the nutrition advice by physicians has to be based on accumulated evidence from different sources other than Cochrane reviews and RCTs (Truswell AS. Levels and kinds of evidence for public-health nutrition. Lancet 2001; 357: 1061-2; Truswell AS. Some problems with Cochrane reviews of diet and chronic disease. Eur J Clin Nutr 2005; 59 (suppl 1): s150-4). This paper will briefly review the informational infrastructure of human nutrition, being regularly updated, that is in the background of doctors' advice on diets to their patients. The main parts of this nutrition information include: (i) recommended nutrient intakes/dietary reference intakes, (ii) dietary goals and guidelines, (iii) textbooks of human nutrition, (iv) chapters on nutrition in medical textbooks, (v) ABC of Nutrition, written for GPs and (vi) lastly, a new book about the research on diet and coronary heart disease (CHD) in the 20th century contains the main pieces of evidence that underlie today's nutrition guidance both to people at risk of CHD and for the general community.     

Helping communities control tuberculosis

Community health workers (CHWs) can help prevent the spread of tuberculosis (TB) in various ways. They can educate community members about TB symptoms and how TB is transmitted. They can encourage people with active TB to seek and complete treatment. They can check household contacts of infectious patients to identify and manage young children at special risk. Many people believe that TB cannot be cured, that God, magic, or witchcraft causes TB, or that only cursed or bad people acquire TB. These beliefs explain why many people seek treatment from traditional healers rather from medical personnel. CHWs need to be aware of these beliefs and to consider them when developing appropriate advice and relevant community health education. Some important public health advice to prevent the spread of TB includes covering the mouth and nose when coughing or sneezing, disposing of sputum carefully, and prohibiting children from sleeping in the same room as an infectious adult. CHWs should screen the whole family for TB, especially the young children, and evaluate the nutritional status of the children, if someone in the household has TB. Malnourished children are especially at risk of TB. CHWs need to ask the parents about and examine the child for the presence or absence of TB symptoms in their child. They need to perform a tuberculin test. They should immediately refer children with symptoms (vomiting, fever, persistent cough, weight loss) to a physician.     

Practitioner and lay perspectives of the service provision of nutrition information leaflets in primary care

Background: In primary care, leaflets are often used to communicate health information. Increasingly, primary healthcare practitioners need to provide dietary advice. There is limited research exploring how nutrition information leaflets are used in primary care. The present study explored practitioner and lay experiences with respect to providing and receiving nutrition information in primary care, focusing in particular on the use of leaflets for nutrition information. Methods: A qualitative design was used incorporating focus groups with 57 practitioners based at seven general practitioner practices and a purposive sample of 30 lay participants attending six Consumer Health Organisations within one primary care trust. Focus groups were taped and transcribed verbatim and data were analysed thematically, assisted by computer software n6 ® (QSR International Pty Ltd, Melbourne, Australia). Results: Practitioners discussed barriers to giving nutritional advice, access to leaflets, lay receptiveness to advice and their perceptions about the value of leaflets to lay people. Food was not considered in terms of its nutritional components by lay participants and the need for nutritional information was not perceived to be relevant until they had received a medical diagnosis. Lay participants discussed the importance of receiving nutritional advice relating to their medical diagnosis and the altered status of written information that was delivered personally. Practitioner and lay groups suggested improvements to ensure that nutritional advice be supported by relevant and appropriate written information. Conclusions: This research has underlined the continuing importance of nutrition information leaflets and concludes that there is particular value in involving lay participants in the development of nutrition information leaflets.     

Evaluation of the effectiveness of a nutritional health education leaflet in changing public knowledge and attitudes about eating and health

A nutritional health education leaflet EAT WELL, BE WELL was written and produced by a Wessex working party on diet and health. The leaflet's effectiveness in changing people's knowledge about, and attitudes towards, healthy eating was evaluated by means of a postal survey. Half of a random sample of electors were sent the nutritional leaflet. A few weeks later, the whole sample were sent a short 'Eating and Health' questionnaire. There was a 62 per cent response rate, with no significant difference between the group who had previously received the leaflet and the group who had not.
The mean scores on the factual questions did not differ significantly between the two groups, providing little evidence that the nutritional leaflet increased public knowledge. The evaluation suggests that the mass distribution of this leaflet is not an effective method of health education.
The survey did indicate that previous nutrition education has successfully put across the message to eat less sugar, fat and salt, and more fibre. It also showed, however, that there is still confusion about some aspects of healthy eating, including the place of starchy foods in the diet.