A colleague just sent this my way and it might be appropriate for some
considering obesity work. Robert C. Bowman, M.D.   :

                              ARBOR CLINICAL NUTRITION UPDATES ©
This week is a little different since, in addition to the regular issue
that was distributed some days ago, we are also sending out a special (and
colourful) supplement. It is on the topic of nutrition in medical family
practice, and is based on the proceedings of a workshop conducted in
Holland recently by what is known as the "Heelsum Collaboration".  Please
feel free to share this issue with health professional colleagues and
students.

Background
The Heelsum Collaboration is a group of doctors and scientists in the
fields of nutrition, health promotion, nutrition education and
communication, general practice, epidemiology and methodology, Over the
last decade they have collaborated in research and discussion to help
family doctors use nutrition in a more appropriate way.

We confess to a particular interest in this topic, since the
Editor-in-chief (who is a family physician as well as a nutritionist) is a
participant in the Collaboration and gave a paper at the workshop.  If any
of our health professional readers would like to participate in the Heelsum
collaboration themselves, they are welcome to contact Prof.Gert Jan Hiddink
<[log in to unmask]>.

We hope you will find this summary interesting.
           ____________________________________________________
                                 SPONSORS SECTION

Both the fourth International Heelsum Collaboration workshop itself and
this special supplement issue were supported by sponsorship from the Dutch
Dairy Foundation.
         ____________________________________________________
                                CONFERENCE REVIEW

This supplement provides some highlights of the Fourth Heelsum
International Workshop on nutrition in general practice.

The full papers (and summarised discussions) from this workshop were
published as a supplement to the European Journal of Clinical Nutrition
(ref.1). Additional highlights can be viewed on the web at:
www.nutritionmagazine.nl.

Obesity can be treated in general practice
---------------------------------------------------------------
Previous Heelsum workshops have seen much discussion on management of
obesity as a gloomy problem that doctors tended to avoid, because it seems
much easier to write a drug prescription than to persuade someone to eat
less food and stick with it.

The consensus has been that the GP alone cannot eliminate obesity any more
than they can eliminate smoking. Society has to support the doctor’s
efforts. This is clearly already happening with smoking and it is starting
to happen with overweight and obesity.

Doctors should recognise and draw attention to increasing adiposity. But if
they have done so and the patient does not take the appropriate action the
doctor should not regard this as a personal failure.

By the time of the most recent Heelsum workshop, the prospects for success
in treating obesity in general practice had become brighter. In the social
and political environment obesity has become widely discussed as a general
concern. A GP who raises the subject with the patient and suggests
lifestyle changes now has society on his side.

An exciting paper was presented by one of the research team for an
innovative UK project called Counterweight (see next paragraph), the aim of
which was to empower general practices to tackle obesity (ref.2). It found
that obesity can be well treated in general practice, although it requires
a team effort. The study’s interim outcomes are both encouraging and
feasible for GPs to apply.

Counterweight project
---------------------------------
Subjects and method: 80 general practices in England and Scotland. After an
initial practice audit phase, general practices were trained in a team
approach in which the GP’s main role was to identify overweight patients
and provide them with initial motivation for a referral to the practice
nurse. The nurse was trained to conduct 6 individual and 6 group
counselling sessions. 1,549 patients with mean BMI=36.9 were recruited into
the study.

Results Interim data (as of 2004) showed just under a half the patients had
fully completed all elements of the intervention. An encouraging proportion
of patients achieved significant weight loss - see Graph in Acrobat
version.

Ref: McQuigg M. et al. Empowering primary care to tackle the obesity
epidemic: the Counterweight Programme. Eur J Clin Nutr. 2005 Aug;59 Suppl
1:S93-100; discussion S101.

How GPs communicate about nutrition
---------------------------------------------------------
Dr.Sonja van Dillen reported on her research into family doctors’ nutrition
communication styles (ref.3).

Subjects and method: 267 Dutch family doctors completed a questionnaire on
their nutrition communication style and other variables.

Results: Five main styles were demonstrated. Most GPs had one predominant
style, although they might vary this from time to time depending on
practice and patient factors (e.g. clinical diagnosis).

Examples of these styles using the GP’s own words:
• Motivational: “You should not diet frenetically but simply follow a
healthy diet and have more physical exercise.”
• Confrontional: “I warn patients with cardiovascular disease several
times, but many are headstrong.”
• Reference: “You should make an appointment with a dietitian to get
specific diet advice”
• Informational: “It is important to eat less saturated fat, but the final
decision is up to you.”
• Holistic: “I note how a patient is living so that I can come back to the
subjects during a next visit.”

Table: Frequency of use of various style by family physicians

  Style         % of GPs        Patient factor

--------------------------------------------------------------------------
  Motivational          42%     Hypertension
  Confrontational       24%     CHD
  Reference             24%
  Informational         9%      New patient
  Holistic              2%      Chronic illness


Ref: van Dillen SM. et al. Nutrition communication styles of family
doctors: results of quantitative research. Eur J Clin Nutr. 2005 Aug;59
Suppl 1:S47-55; discussion S56.

Can the Internet help?
----------------------------------
Several papers dealt with the role of the Internet in facilitating
nutrition for health professionals (refs.4-6).

Some key potential applications include:
• Patient reminders and support via email, integrated with GP desktop
clinical management software. That software can prompt GPs to measure BMI,
ask about diet etc.
• Web sites that provide a means for patients to record, store and display
their progress (e.g. weight monitoring).
• Web sites offering dietary assessment of food intake, and tailored advice
on management options, based on patients inputting their individual
clinical and other data.
• Social support for lifestyle change through common interest groups (e.g.
Internet chat, blogs).
• Providing reliable information from credible sources, to counter the
`avalanche’ of unevaluated web sites on nutrition currently on the
Internet.

The Internet also has a key function in keeping doctors updated on the
latest clinical nutrition research. Your editor was proud to present a
paper on the role of the Arbor Clinical Nutrition Updates in meeting this
need (ref.6).

The power of communication
--------------------------------------------
Communications expert Ted Baartmans gave a paper highlighting four
activities that can greatly contribute to the communication between GPs and
their patients regarding diet and other lifestyle change (ref.7):

1. Asking non-judgemental questions that help to understand the patients’
perspective on their medical condition, its causes and possible treatments.

2. Listening carefully to the patients’ replies and trying to pick up clues
to the patient’s understanding as well as their ability to adhere to a
recommended treatment.

3. Working with patients and family members to set realistic and achievable
goals for behavioural change.

4. Involving their patients in active problem solving.

Ref: Koster FR. et al. The power of communication. Modifying behaviour:
effectively influencing nutrition patterns of patients. Eur J Clin Nutr.
2005 Aug;59 Suppl 1:S17-21; discussion S22-3


A Cochrane “Diet and nutrition” subfield?
------------------------------------------------------------
Although GPs prefer to give evidence-based advice, much nutrition teaching
is based more on animal experiments and human epidemiological data than on
the randomised controlled trials that form the basis of the Cochrane
Collaboration.

There are a number of systematic reviews on nutrition-related subjects in
the Cochrane Library. But there is currently no specific `field’ for `Diet
and Nutrition’ in relation to general practice, and this may tend to work
against systematic review of the evidence-base for nutrition
recommendations in primary care.

A major session of the workshop discussed the feasibility of setting up
such a sub-field within the existing Cochrane Primary Health Care Field.
This should help ensure that nutritionists are not left behind in the move
towards the evidence-based approach.


About the workshop
-------------------------------
Healthy nutrition is essential in health promotion The fact that the
proverbial apple keeps the doctor away is an attractive proposition to both
patients and policy makers who have to watch their budgets.

This dual benefit of nutrition’s key role in general practice for both the
individual wellbeing and health economics was the focus of the 2004 Fourth
International Heelsum Workshop: ‘Empowering Family Doctors and Patients in
Nutrition Communication’ .

The workshop was attended by 28 expert speakers from Australia, Canada,
Croatia, Italy, the Netherlands, Spain, UK, and the USA.

It covered three elements of nutrition in family practice: disease-based
evidence, individual strategies for change and the population interface of
primary care.

The workshop was based on results of research, as well as participants’
direct experience in providing nutrition interventions. These had taken
place as individual counselling (e.g. GP consultations or brochures) or at
the community level (information for groups and communities). The internet
is increasingly used to reach people to encourage dietary change.

The focus of the workshop was on:
• creating a supportive and reinforcing environment for GPs and their
patients
• individually tailored nutrition communication strategies;
• dietary and lifestyle interventions aimed at communities;
• current and future nutrition communication via the internet.
References:
1. Anon. Empowering Family Doctors and Patients in Nutrition Communication.
Eur J Clin Nutr. 2005 Aug;59 Suppl 1:S1-196.
2. McQuigg M. et al. Empowering primary care to tackle the obesity
epidemic: the Counterweight Programme. Eur J Clin Nutr. 2005 Aug;59 Suppl
1:S93-100; discussion S101.
3. van Dillen SM. et al. Nutrition communication styles of family doctors:
results of quantitative research. Eur J Clin Nutr. 2005 Aug;59 Suppl
1:S47-55; discussion S56.
4. Bouwman LI. et al. Personalized nutrition communication through ICT
application: how to overcome the gap between potential effectiveness and
reality. Eur J Clin Nutr. 2005 Aug;59 Suppl 1:S108-15; discussion S116.
5. Brug J. et al. The internet and nutrition education: challenges and
opportunities. Eur J Clin Nutr. 2005 Aug;59 Suppl 1:S130-7; discussion
S138-9.
 6. Helman AD. Arbor Clinical Nutrition Updates: evidence-based clinical
nutrition education using the Internet. Eur J Clin Nutr. 2005 Aug;59 Suppl
1:S117-20; discussion S121.
7. Koster FR. et al. The power of communication. Modifying behaviour:
effectively influencing nutrition patterns of patients. Eur J Clin Nutr.
2005 Aug;59 Suppl 1:S17-21; discussion S22-3.
8. Anon. International workshop on nutritional attitudes and practices of
primary care physicians. Heelsum, Netherlands, December 11-13, 1995. Am J
Clin Nutr. 1997 Jun;65(6 Suppl):1927S-2022S.
9. Anon. Nutrition guidance of family doctors towards best practice.
Proceedings of the Third Heelsum International Workshop. Heelsum, The
Netherlands. December 10-12, 2001. Am J Clin Nutr. 2003 Apr;77(4
Suppl):999S-1092S.
10. Anon. Family doctors and patients: is effective nutrition interaction
possible? Proceedings of the Second International Workshop. Heelsum, the
Netherlands, December 14-16, 1998. Eur J Clin Nutr. 1999 May;53 Suppl
2:S1-114.
       ____________________________________________________

BECOMING A SUBSCRIBER
Non subscribers who would like like to receive the Clinical Nutrition
Updates should subscribe from our website at:
        www.nutritionupdates.org/sub/sub01.php?item=2

This is a FREE service to health professionals and students.

Alternatively you can send us a request email to <[log in to unmask]>.
Include details of: your name, email address, the country where you live,
the institution you are associated with (if relevant) and your professional
background. The Updates are available in English, Spanish, Portuguese,
Italian, French, Turkish, Russian, Korean and Japanese.

IF YOU WANT TO CHANGE YOUR SUBSCRIPTION DETAILS:
We now use an automated system for making changes (such as new email
address, unsubscribing or requesting an additional language edition) which
you can access on our website at:
        www.nutritionupdates.org/sub/change.html

Please note that we no longer accept email requests for such changes.