Direct observation of exercise counseling in community family practice

BACKGROUND: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood. METHODS: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis. RESULTS: In 4,215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor. CONCLUSIONS: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.     

Improving firearm storage habits: impact of brief office counseling by family physicians

BACKGROUND: Firearm injury is the leading cause of injury-related death among youth and second leading cause of injury-related death overall in the United States. Our objective is to determine the impact of brief office counseling by family physicians on patients' firearm storage habits. METHODS: Of the 1,233 patients who completed the enrollment questionnaire, 156 (13%) reported they had guns in their household and agreed to participate in the study. Postintervention survey instruments were completed by 127 (81%) of participants. Participants received either no counseling, verbal counseling alone, or counseling and a gun safety brochure from their physician. Firearm storage habits were measured at baseline and 60 to 90 days after intervention. RESULTS: At the postintervention interview, 64% of the group receiving verbal counseling and 58% of the group receiving verbal counseling plus written information made a safe change in gun storage compared with 33% of participants in the no-intervention group (P =. 02). A logistic regression model controlling for demographics and gun ownership showed that compared with the no-intervention group, intervention participants were three times more likely to make safe changes. CONCLUSIONS: Family physicians' brief counseling efforts made a significant positive impact in the firearm storage habits of their patients. With a verbal or written recommendation, a significant improvement was observed in firearm storage.     

Characterizing patient requests and physician responses in office practice

OBJECTIVE: To assess the reliability, applicability, and validity of a refined system (taxonomy of requests by patients [TORP]) for characterizing patient requests and physician responses in office practice. STUDY SETTINGS: Data were obtained from visits to six general internists practicing in North-Central California in 1994 and eight cardiologists practicing in the same region in 1998. STUDY DESIGN: This was an observational study of patient requests and physician responses in two practice settings. Patients were surveyed before and after the visit. Physicians were surveyed immediately after the visit, and all visits were audio recorded for future study. DATA COLLECTION/EXTRACTION METHODS: TORP was refined using input from a multidisciplinary panel. Audiotape recordings of 131 visits (71 in internal medicine and 60 in cardiology) were rated independently by two coders. Estimates of classifying reliability (intercoder agreement on the sorting of requests into categories) and unitizing reliability (intercoder agreement on the labeling of elements of discourse as "requests" and subsequent classification into categories) were calculated. Validity was assessed by testing three specific hypotheses concerning the antecedents and consequences of patient requests and request fulfillment. PRINCIPAL FINDINGS: The overall unitizing kappa for identifying patients' requests was 0.64, and the classification kappa was 0.73, indicating substantial agreement beyond chance. The average patient made 4.19 requests for information and 0.88 requests for physician action; there were few differences in the spectrum of requests between internal medicine and cardiology. Approximately 15 percent of visits included a direct request for completion of paperwork. Patients who were very or extremely worried about their health made more requests than those who were not (6.06 vs. 3.89, p < 0.05). Visits involving more patient requests took longer (p < 0.05) and were perceived as more demanding by the treating physician (p = 0.025). The vast majority of requests were fulfilled. CONCLUSIONS: The refined TORP shows evidence of both unitizing and classification reliability and should be a useful tool for understanding the clinical negotiation. In addition, the system appears applicable to both generalist and specialist practices. More experience with the system is necessary to appraise TORP's ability to predict important clinical outcomes.     

Nurse and physician patient counseling about tobacco smoking in Jordan

The objective of this study was to identify whether nurses are as likely as physicians to feel prepared to assist patients to quit smoking, to have smoked in front of patients, or to have received training on counseling patients about smoking cessation. The sample consisted of 262 nurses and 251 physicians, ages 18 years and older, from public and private hospitals in Jordan. It was found that nurses were more likely than physicians to receive training on counseling patients about smoking cessation (41% vs. 18%); more likely to currently smoke (30% vs. 19%); and less likely to feel prepared to assist patients to quit smoking (78% vs. 95%). Smoking status and training were associated with counseling patients about smoking. Approximately 19% of nurses and 81% of physicians who currently or formerly smoked had previously smoked in front of patients. Nurses compared with physicians have lower agreement with statements involving smoking-related responsibilities and views on smoking policy, but higher agreement that second-hand smoke is related to selected diseases. Physicians felt more strongly than nurses that they should serve as role models for the public, routinely advise their smoking patients to quit, and speak to lay groups about smoking. In conclusion, a greater level of smoking cessation training among physicians and nurses in Jordan is warranted.     

饮食、运动习惯对学龄前儿童超重和肥胖的影响

目的:了解武汉市学龄前儿童超重和肥胖的流行情况,探讨其影响因素。方法:随机整群抽取武汉市江汉区5所幼儿园共1 120名儿童,按照标准方法测量其身高、体重,并以WHO儿童BMI标准作为超重和肥胖评价标准;采用自拟问卷对儿童及其家庭基本情况、饮食和运动习惯进行调查。结果:1 120名儿童中,超重和肥胖发生率分别为13.2%和11.9%,男童发生率均显著高于女童(P<0.001);多因素非条件Logistic回归分析结果显示,出生为巨大儿(OR=1.662,95%CI:1.066～2.590)、进食量多(OR=4.640,95%CI:3.319～6.486)、进食速度快(OR=2.121,95%CI:1.452～3.098)、喜欢吃洋快餐(OR=1.907,95%CI:1.363～2.668)、喜欢吃蛋类(OR=1.518,95%CI:1.115～2.086)等5个因素是学龄前儿童超重和肥胖的危险因素;经常吃蔬菜、水果(OR=0.659,95%CI:0.477～0.911)、周末平均户外活动时间≥2 h(OR=0.635,95%CI:0.469～0.858)则是超重和肥胖的保护因素。结论:武汉市学龄前儿童超重和肥胖流行率高于全国平均水平,改善不良饮食和运动习惯可有效地预防超重和肥胖的发生。     

A comparison on health-related lifestyle,dietary habits,and depression by exercise frequency of college students

BACKGROUND/OBJECTIVESThe study was performed to investigate health-related lifestyle, dietary habits, and depression according to exercise frequency to understand complex factors that affect effective health management. Thus, exercise frequency, health-related lifestyle, dietary habits, and depression were evaluated in college students in Seoul and Gyeonggi-do areas.SUBJECTS/METHODSA survey was conducted on college students, aged 19–29, in Seoul and Gyeonggi-do areas from May 13 to May 31, 2020. A total of 594 questionnaires were collected and 566 (269 from males, 297 from females) were statistically analyzed, except 28 with incomplete responses. Collected data were analyzed using SPSS WIN 21.0 program.RESULTSThe sex distribution of the 3 groups according to exercise frequency was significantly different; the ratio of males in over 3 times/week group was significantly higher than those in 1–2 times/week group and no-exercise group (P < 0.001). The height (P < 0.001), weight (P < 0.001), and body mass index (P < 0.05) were significantly higher in over 3 times/week group compared to no-exercise group. The ratio of subjects who answered ‘good’ or ‘very good’ for subjective health condition was significantly high in the order of ‘over 3 times/week’ group (59.1%), ‘1–2 times/week’ group (34.5%), and ‘no-exercise’ group (25.0%) (P < 0.001). The ratio for meal regularity was high as 56.6% in ‘over 3 times/week’ group and the ratio for irregular meals was significantly higher in ‘no-exercise’ group (67.2%) and ‘1–2 times/week’ group (54.9%) (P < 0.001). Among questions on dietary habits, ‘Eat meat, fish, egg or beans’ (P < 0.01) and ‘Eat fruit’ (P < 0.01) were significantly higher in ‘over 3 times/week’ group compared to ‘no-exercise’ group. ‘Drink more than 2 liters of water’ (P < 0.001) was 0.70 in ‘over 3 times/week’ group, which was significantly higher than 0.54 in ‘1–2 times/week’ group and 0.38 in ‘no-exercise’ group. Moderate depression and severe depression that need treatments were significantly lower in ‘over 3 times/week’ group (18.7%) compared to ‘1–2 times/week’ group (26.0%) and ‘no-exercise’ group (29.7%) (P < 0.05).CONCLUSIONSIt is considered that combined intervention for exercise habits, proper dietary habits, and depression management is needed for effective health management.     

Direct observation of nutrition counseling in community family practice

BACKGROUND: Despite the large potential of dietary changes to reduce morbidity and mortality, the frequency, time spent, and factors associated with nutrition counseling in primary care are not well studied. METHODS: In a cross-sectional study of 84 family physician practices in northeast Ohio, nutrition counseling was measured by direct observation on 2 days for all consecutive ambulatory visits. The frequency, time spent, and patient and visit characteristics associated with nutrition counseling were determined. RESULTS: Among 138 family physicians, only 6% included nutrition counseling in the majority (>50%) of patient encounters. Among 3475 consecutive outpatient visits in adults, nutrition counseling occurred in 24% of all patient visits, 17% of visits for acute illnesses, 30% of chronic illness visits, and 41% of well-care visits. The average time spent on nutrition counseling was 55 seconds, ranging from <20 seconds to >6 minutes. Nutrition counseling occurred in 45% of visits for diabetes, 25% of visits for cardiovascular disease, 31% of visits for hypertension, 26% of prenatal visits, and 33% of visits by obese patients (body mass index >30). Nutrition counseling was more likely to occur during visits by patients who were older or had diabetes mellitus, during visits for well care or chronic illness, and during longer visits. CONCLUSION: Despite considerable variability from physician to physician, nutrition counseling occurs in approximately one fourth of all office visits to family physicians. The observed efforts by family physicians to focus nutrition counseling on high-risk patients may increase its impact.     

Factors associated with colon cancer screening: the role of patient factors and physician counseling

BACKGROUND: The prevalence of colon cancer screening is nationally low. The relative contribution of patient factors and physician counseling patterns to the low prevalence of screening is unclear. METHODS: We used multivariable analysis to examine the prevalence of colon cancer screening nationally and the reasons for this low prevalence using data from the 2000 National Health Interview Survey, a nationally generalizable survey of US households. RESULTS: Among 11,427 respondents to the Cancer Control Supplement, 16% reported annual fecal occult blood testing (FOBT) and 29% reported having undergone a sigmoidoscopy in the last 5 years or a colonoscopy in the last 10 years. After adjusting for age, sex, body mass index (BMI), healthcare access, and region of the country, Hispanics were less likely to undergo FOBT [OR 0.7 (95% CI 0.6-0.9)] and sigmoidoscopy or colonoscopy [OR 0.8 (95% CI 0.7-0.9)] compared to Whites. Respondents with lower education levels were also less likely to undergo screening. These factors were not associated with being less adherent to physician recommendations for screening. Nevertheless, non-Whites and those less educated were less likely to receive counseling from their health provider about colon cancer screening. Among respondents who did not undergo FOBT, 64% were unaware they needed the test; only 2% cited pain and discomfort as a deterrent, but 94% were not counseled by their physician about the test. Among those who did not undergo sigmoidoscopy or colonoscopy, 72% were unaware that they needed the test and only 1% was deterred by pain and discomfort; 92% were not counseled by their physician. CONCLUSION: The low prevalence of screening for colorectal cancer appears to be due to lack of awareness and inadequate provider counseling rather than poor patient acceptance for screening. Systematic counseling about colorectal cancer screening will likely improve screening rates and reduce disparities by race/ethnicity and education.     

Direct observation and patient recall of health behavior advice

BACKGROUND: Patient recall of health behavior change discussions with physicians is an important intermediate outcome to adherence with recommendations and subsequent behavior change. This study reports patient recall of health behavior discussions during outpatient visits and tests patient and visit characteristics associated with recall. METHODS: In a cross-sectional study of 2670 adult outpatients visiting 138 family physicians in 84 practices, provision of health behavior advice was measured by direct observation. Patient recall of discussion of each health behavior topic was assessed by patient survey. RESULTS: Patient recall rates ranged from 11% for substance use assessment to 75% of smokers recalling smoking cessation advice. Patient demographics were not associated with recall. In multivariable models, the strongest predictor of patient recall of diet and exercise advice was the duration of the advice. Advice provided during well care visits was more likely to be recalled by patients than during illness visits, but presence of a health behavior-relevant diagnosis during an illness visit was associated with a 2-fold increase in patient recall. CONCLUSIONS: Patient recall of health behavior advice is enhanced by longer duration of advice and by linking advice to visit contexts that represent teachable moments.     

Acculturation and dietary habits of Korean Americans

This is the first study to investigate how food and nutrient intakes vary with the levels of acculturation of Korean Americans using a dietary assessment tool tested for validity and reliability. The respondents were Korean Americans (n 486) resident in the Greater New York metropolitan area, USA. They were divided into two groups according to the total score of acculturation: low- and high-acculturated groups. Using a food-frequency questionnaire and a modified Suinn-Lew Asian self-identity acculturation scale, differences in the frequencies of food items, food groups and nutrient intakes consumed were analysed by level of acculturation. The low-acculturated group tended to consume significantly more rice, mixed rice, soyabean paste chigae (pot stew), saengsun (fish) chigae, kimchi chigae, other fish broiled or baked, eggs, kimchi, spinach, persimmons, and white or brown sugar in coffee or tea. The high-acculturated group demonstrated a statistically greater tendency to consume bread, cereal, spaghetti, ham, green salad, sweetcorn, chocolate, candies and diet soft drinks. The more acculturated an individual, the more significant was the tendency to consume sweets. The more acculturated group had significantly (P<0.05) higher intakes of % energy from total fat, thiamin, vitamin E and folate, while the low-acculturated group consumed greater amounts of Na, niacin and dietary fibre. The information from the present study can be used to describe dietary habits according to various aspects of acculturation, and allows a better understanding of the dynamics of acculturation and dietary habits.     

The dietary habits of doctors and teachers

A questionnaire was completed by 408 general practitioners and 385 secondary school teachers about their own dietary intake with response rates of 48% and 45% respectively. Over half of each group were of ideal weight and only 3% of the total were obese.
The group of general practitioners, reported that they ate significantly less fats and salt and significantly more fibre and polyunsaturated fats in their diet than the teachers. Teachers were significantly more likely to avoid food additives in their diet, 70% made an effort to avoid them compared to 47% of doctors.     

Designing and using measures of quality based on physician office records

This article presents our principles for developing performance measures to assess the quality of ambulatory care. The measures were developed as part of a project for developing and evaluating methods to promote ambulatory care quality (DEMPAQ). We describe our design for the performance measures, present examples of the DEMPAQ review criteria, and show the formats we used to feed back information to physicians. We conclude by presenting the results of our appraisal of the performance measures showing how evaluation can aid in the interpretation of measurement findings.     

Assessing and counseling the obese patient: Improving resident obesity counseling competence

ObjectiveTo evaluate obesity counseling competence among residents in a primary care training programMethodsWe delivered a 3 h obesity curriculum to 28 Primary Care residents and administered a pre-curriculum and post curriculum survey looking specifically at self-assessed obesity counseling competence.ResultsNineteen residents completed both the pre curriculum survey and the post curriculum survey. The curriculum had a positive impact on residents’ ability to ascertain patient’s stage of change, use different methods to obtain diet history (including 24 h recall, food record or food frequency questionnaire), respond to patient’s questions regarding treatment options, assist patients in setting realistic goals for weight loss based on making permanent lifestyle changes, and use of motivational interviewing to change behavior. When looking at the 5As domains, there was a significant improvement in the domains of Assess, Advise, and Assist. The proportion of residents with a lower level of self-assessed obesity counseling competence reduced from 75% before the curriculum to 37.5% (p = 0.04) after the curriculum.ConclusionOur curriculum addressing weight loss counseling using the 5As model increased obesity counseling competence among residents in a primary care internal medicine residency program.     

Effects of dietary, drinking, and smoking habits on the prognosis of gastric cancer

Although it has been clarified that dietary, drinking, and smoking habits contribute to the onset of gastric cancer, little is known about their impact on prognosis of gastric cancer. To examine this question, a prognostic analysis was conducted using data from Aichi Cancer Center Research Institute and Hospital. From January 1988 to December 1994, information on 877 gastric cancer patients (578 men and 299 women) regarding habitual smoking and drinking, food consumption, histological grade, and clinical stage of tumor as well as follow-up results were collected. Survival status of all patients was followed up until December 1998, and the survival function was estimated by the Kaplan-Meier method. Proportional hazard analysis was used to test the effect of each lifestyle item on gastric cancer death. After controlling for age, gender, histological grade, and stage of disease, hazard ratios (HR) were calculated. Values for consumption of raw vegetables [HR = 0.74, 95% confidence interval (CI) = 0.56-0.98], tofu (HR = 0.65, 95% CI = 0.42-0.99), and chicken meat (HR = 0.61, 95% CI = 0.39-0.95) more than three times per week demonstrated significantly decreased risk. However, the risk ratio was 2.53 (95% CI = 1.22-5.29) for habitual smokers, and an inverse dose-response relationship was also found between ever smoking and gastric cancer patient survival. Therefore, this study suggested that frequent intake of raw vegetables and tofu is favorable, whereas habitual smoking is an adverse prognostic factor for gastric cancer. Our study implies that an improvement of survival of Japanese gastric cancer might be achieved by lifestyle improvement.     

Therapeutic homework: the use of behavioral assignments in office counseling

Office counseling provides an intensive, short-term opportunity for patients to learn new response patterns and coping skills. Progress is enhanced to the extent that patients experiment with and practice new approaches in real-life situations outside the physician's office. Particularly in a family medicine context, with its associated time constraints, it is important for patients' between-session experience to be orchestrated carefully to solidify or act upon learning from brief counseling sessions. Behavioral assignments and other therapeutic homework are essential tools for the family physician to take advantage of between-session opportunities for patients to learn and change. Examples of therapeutic homework include self-monitoring, lists, narrative accounts, questionnaires, action assignments, and published patient education material. This paper provides theoretical background about therapeutic homework and presents guidelines that should increase the likelihood that behavioral assignments will be understood and carried out in an effective way.     

饮食行为及饮食习惯对学龄前期儿童超重肥胖的影响

目的 了解苏州市工业园区学龄前期儿童超重肥胖的现状,探讨其中饮食相关因素,提供预防方法。方法 采用随机抽样的方法,在苏州工业园区斜塘街道所属于幼儿园随机抽取5所3～6岁儿童2 034名作为本次研究的调查现场,进行问卷调查和相关体格测量。结果 超重肥胖检出率为16.8%,进食膨化食品次数多(χ2=9.200,P<0.05)、喜欢看食品广告(χ2=13.069,P<0.05),尤其膨化食品和甜饮料广告(P<0.05)、临睡前进食主食和零食、食欲好、吃饭时间短、边看电视边吃零食(P均<0.05)为学龄前儿童超重肥胖的危险因素。结论 为儿童营造健康的饮食环境,培养儿童良好的饮食行为,可有效预防儿童超重肥胖的发生。     

家庭喂养方式与饮食习惯对儿童肥胖的影响

了解家庭喂养方式与儿童饮食习惯对儿童肥胖的影响,为开展儿童肥胖干预提供科学依据.方法 采取分层整群抽样方法,按经济水平好、中、差抽取重庆市渝中区、荣昌县和开县的2970名一~六年级在校学生进行身高、体重、腰围等体格检查,并对其家长或监护人进行家庭喂养方式与儿童饮食习惯问卷调查.结果 受访家长或监护人中,38.0%会强迫孩子吃某种食物,56.6%会觉得孩子吃得不够而想尽办法要求孩子“多吃一点”.41.4%的儿童喜食咸的食物,87.0%的儿童喜欢吃水果,11.9%的儿童吃饭速度快,28.8%的儿童吃饭速度慢.强迫孩子吃某种食物、想尽办法要求孩子“多吃一点”、孩子是否爱吃水果及孩子吃饭速度等为儿童肥胖的影响因素(P值均<0.05).结论 不恰当的家庭喂养方式及儿童不良饮食习惯均可引起儿童肥胖.