This lesson on nutrition has been developed by the Healthy Primary Care team at Griffith University, lead by Associate Professor Lauren Ball. The lesson is designed for medical students on their general practice rotation.
You can connect with us and your peers by posting an interesting piece of nutrition information on Twitter and:
Please watch the video to the right before you begin:
Before you start, please provide your name so your participation can be recorded:
- Assess and reflect on your own self-perceived competence in providing nutrition care.
- Understand common nutrition assessment and screening procedures and how to select the most appropriate tool during consultations.
- Understand the development, strengths and limitations of the Australian Dietary Guidelines and the Australian Guide to Healthy Eating.
- Identify and access evidence guidelines for General Practitioners regarding nutrition.
Part 1 should take less than 30 minutes to complete. It will provide you with an overview of nutrition care by GPs. To get the most out of the session, please complete the questionnaire that assesses your current confidence in nutrition.
Should GPs provide nutrition care?
Nutrition is a ‘noisy’ space. This is because nutrition information is shared by many sources on a range of platforms, including celebrity chefs, bloggers, friends and family, health professionals, and even the National Health and Medical Research Council (NHMRC).
The Australian Government states that primary care is the ideal setting to promote healthy eating (1). Australians highly value discussions about nutrition during consultations with GPs (2); they want to be asked questions about their diet, and appreciate referrals to nutrition-specialists such as dietitians (2).
General Practitioners are very important in supporting patients to improve their dietary behaviours to align with national dietary recommendations which are informed by peer-reviewed evidence (3). Nutrition science is evolving and the evidence about diet and health is updated over time. As a future GP, it is essential that you stay up-to-date with high-quality evidence in nutrition and practice guidelines so that you can deliver effective nutrition care, and safely support people to eat well.
But, do GPs have the right skills in nutrition?
Our research has shown that GPs can effectively enable patients to improve their eating through brief, routine consultations (3). You may like to check out our recent systematic review (see infographic to the right). Dietary improvements include increasing vegetable intake and reducing intakes of discretionary foods, resulting in positive health and weight management outcomes (3-6). Promoting healthy eating should therefore be a priority for GPs.
Unfortunately, many GPs feel they have insufficient nutrition knowledge and report low self-efficacy in nutrition (7, 8). These barriers commonly prevent GPs from raising the topic of nutrition with patients. Given that GPs can be effective, the real challenge is helping medical students and GPs feel confident in their existing nutrition skills. You may not realise that you are already trained! After all, you have been eating your whole life and each day you engage with nutrition concepts through your food preparation, cooking, consumption and your own health.
Who, me? How competent am I?
The Healthy Primary Care NUTCOMP tool is a systematically validated tool that is designed to measure the self-perceived competence of health professionals to provide nutrition care (9). Self-perceived competence encompasses the knowledge, skills and attitudes that facilitate safe and effective health care practices. Specifically, the tool focuses on four areas:
- Confidence in knowledge about nutrition and chronic disease,
- Confidence in nutrition skills,
- Confidence in communication and counselling about nutrition, and
- Attitudes towards nutrition care.
ACTIVITY: NUTCOMP Self-Assessment
- Open the NUTCOMP questionnaire below and save it to your computer.
- There are four sections to complete.
- Answer each question in each section and tally up your points.
- Convert your score out of 175 to a percentage and keep a record of your score.
How did you go?
Please watch this short video to see how certain health professionals scored in NUTCOMP (9, 10, 11).
Congratulations, you have finished Part 1!
Before starting Part 2, you will need a list of all the food you eat in a day.
This section will show you how to start a conversation about nutrition with a patient and assess their diet. To get the most out of the activity, you will be asked to recall your own diet over the previous 24-hours or start a record for the next 24 hours. Once the food record is complete, this section will take approximately 30 minutes.
How do I work out what my patient eats?
Nutrition assessment is multifaceted, it involves anthropometry, biochemistry, clinical findings, diet and nutrition focused physical findings (13). Clinicians often use validated assessment tools, such as the Subjective Global Assessment (14) and Patient-Generated Subjective Global Assessment (15). The diet is only one component of nutrition assessment and clearly, comprehensive nutrition assessment takes time (16).
Dietitians commonly use a diet history to collect diet data in clinical practice. A diet history is a systematic method used to collect retrospective dietary data that indicates one’s usual food intake over the course of a week (17). It takes about 20 minutes for a trained dietitian to perform one in practice. Dietitians use tools and visual aids to determine accurate portion sizes of food and beverages (17).
ACTIVITY: Nutrition Assessment
Do you know what you eat and drink in a day?
1. Open up a new document and write down as much information as possible about the food and drinks you consumed in the past 24 hours.
2. Alternatively, start keeping a diary now and come back to this lesson tomorrow when you have finished.
Recording your own diet can help you reflect on the complexity involved in dietary assessment.
Have a look at the poor diet history (left) and thorough diet history (right) examples. How do these compare with your own diet history? What important information is missing in your food record? Did you remember supplements, alcohol, condiments and discretionary items?
Now let's think about how to assess diet in a consultation. Please watch the following short video:
Tools to use with patients
These tools are fast (<2 minutes) and require little to no training to undertake. High scores as a result of performing screening warrant further investigation and in most circumstances, a referral to an accredited practising dietitian (APD). General practitioners should regularly complete nutrition screening with their patients and seek to coordinate their care when needed.
- Nutricare Desk Cards
- Malnutrition Universal Screening Tool (MUST) (18)
- Malnutrition Screening Tool (MST) (19)
What can I do with this information?
After hearing what their patient eats, most GPs indicate that it’s pretty clear whether or not their patient has an opportunity to improve their diet. Given that fewer than 5% of Australian adults consume the recommended intake of vegetables (20), you will probably find that nearly all patients could improve their diet.
Referring patients to a dietitian is the recommended practice if you don’t have the time or confidence to provide advice during a consultation. You can search for an Accredited Practising Dietitian on the Dietitians Australia website.
Congratulations, you have finished Part 2!
Part 3 will cover the national dietary guidelines and what you can recommend to patients.
Part 3 talks in more detail about the Australian Dietary Guidelines and describes key nutrition information you can give patients to support them to eat well. This section also contains tools and evidence guidelines you can use to help structure the way you deliver nutrition care. There are further readings available to learn more about nutrition for your future practice.
What should Australians be eating?
The Australian Dietary Guidelines (ADGs) were made in 2013 after a synthesis of over 55,000 journal articles, comprising the best available scientific evidence to provide information on types and amounts of foods, food groups and dietary patterns aiming to:
- promote health and wellbeing,
- reduce the risk of diet-related conditions, and
- reduce the risk of chronic disease (21).
The ADGs apply to all healthy Australians, as well as those with common diet-related risk factors such as being overweight (21). This means that the guidelines do not apply to people who need special dietary advice for a medical condition, or to the frail elderly (21). For these patients, you should refer to an Accredited Practising Dietitian.
For further explanation of the guidelines and continuing education you can read the longer ADGs report at: https://www.eatforhealth.gov.au/guidelines.
The eatforhealth site also contains links to companion documents for the ADGs. You may want to explore the Nutrient References Values for Australia and New Zealand and Infant Feeding Guidelines. The Nutrient Reference Values document details recommended amounts of macronutrients and micronutrients required to avoid deficiency, toxicity and chronic disease for different ages and genders.
What advice do I give to my patients?
The Australian Guide to Healthy Eating (AGHE) is a tool within the Australian Dietary Guidelines which guides Australians on the amounts and types of food to be consumed each day. The guide promotes drinking plenty of water, and the consumption of plant-based oils. It suggests limiting discretionary foods, such as processed foods, sugar-sweetened beverages and alcohol. The AGHE reiterates the Australian Dietary Guidelines by using visual messaging. GPs are well-positioned to provide patients with the AGHE or have a poster in their consultation room.
The five food groups – fruit, vegetables, grains, milk, yoghurt and cheese products and lean meats (or alternatives) each contain a different profile of macronutrients and micronutrients. Grains typically contain carbohydrate, fibre, and low levels of protein in addition to B vitamins (thiamin, riboflavin, niacin and folate), iron and magnesium. Fruit and vegetables contain similar levels of macronutrients and fibre, but also contain vitamin A, vitamin C, potassium, magnesium, folate and iron. Meat/alternatives are high in protein, B vitamins (thiamin, niacin and B12), iron, magnesium, potassium, zinc and selenium. Dairy/alternatives are high in protein and contain B vitamins (B12) protein, calcium.
The AGHE illustrates a diet that contains a variety of whole, predominantly plant-based foods. Thus far, we have discussed nutritional value in terms of food groups, macronutrients and micronutrients. There is increasing evidence of the role that whole foods play in promoting health and wellbeing, and of the role of food components other than nutrients in disease prevention. These non-nutrient components include phytochemicals, carotenoids, flavonoids, isoflavonoids, polyphenols and non-digestible oligosaccharides. Most but not all food components and the interactions between each other are not well researched. Nutrition science is constantly evolving and it is important to keep up to date with the recent research in nutrition.
It is noteworthy that sections containing meat and dairy also include plant-based alternatives, which means that the guide is suitable to support plant-based or vegan diets. The food groups are referred to as lean meats/alternatives and milk, yoghurt and cheese products/alternatives.
This lesson focuses on the Australian Guide to Healthy Eating for Adults. You should also be aware of the Indigenous Guide to Healthy Eating, Healthy Eating During Your Pregnancy, Giving Your Baby Your Best Start and Healthy Eating for Children. These can be found at: https://www.eatforhealth.gov.au/guidelines.
There is also a brochure.
What about alcohol?
The latest NHMRC guidelines to reduce health risks from drinking alcohol were published in 2009. The NHMRC are currently updating these guidelines as a result of a working committee and expert review. The latest advice for healthy men and women are to drink no more than 10 standard drinks per week and no more than 4 standard drinks on any one day (22). Please refer to the reading for more information for children and young people, pregnancy and breastfeeding (22). Finalised alcohol guidelines are estimated to be published in the fourth quarter of 2020.
Are there guidelines for specific health conditions?
The Royal Australian College of General Practitioners publication has been developed to assist GPs and practice staff to support patients with risky behaviours related to smoking, nutrition, alcohol and physical activity (SNAP). The guide is designed to be applied to adults in general practice, rather than children and adolescents (23). The SNAP guide details how to assess whether a patient is ready to make lifestyle change, a five-step model (ask, assess, advise, assist, arrange) for detection, assessment and management of smoking, alcohol, nutrition and physical activity (23). The publication also discusses practical business strategies and includes resources, tools and referral services (23).
The RACGP HANDI website contains a series of ‘entries’ that guide GPs on how to treat patients without pharmaceutical intervention. In order to develop an entry, there needs to be sufficient high-quality peer reviewed evidence that demonstrates efficacy and practicality for general practice (24). There several nutrition-related entries which continue to grow over time. The committee is led by Professor Paul Glasziou and the Healthy Primary Care team lead, A/Prof Lauren Ball, is also on this committee.
Topics include dietary advice to help with weight management, type 2 diabetes, irritable bowel syndrome, eczema, diarrhoea plus more.
Congratulations, you have finished Part 3!
Part 4 will help you continue your nutrition learning.
What next for nutrition care?
Where can I continue my nutrition education?
Tertiary Education – Universities also offer short courses e.g. Monash University has an online course for nutrition for Polycystic Ovarian Syndrome.
Education in Nutrition: https://educationinnutrition.com.au/
Dietitian Connection: https://dietitianconnection.com/category/webinars/
Before you go, please fill in an anonymous feedback form. We are continuously improving this lesson and cannot do this without your feedback.
Dietitians Australia: https://dietitiansaustralia.org.au/
Sports Dietitians Australia: https://www.sportsdietitians.com.au/
PEN: Practice-based evidence in nutrition https://www.pennutrition.com/index.aspx
Baker Institute: https://baker.edu.au/
Nutrition Education Materials Online (NEMO): https://www.health.qld.gov.au/nutrition
Heart Foundation: https://www.heartfoundation.org.au/
National Drug and Alcohol Research Centre: https://ndarc.med.unsw.edu.au/
- Australian Government. National Primary Health Care Strategic Framework. Canberra: Commonwealth of Australia; 2013.
- Ball L, Desbrow B, Leveritt M. An exploration of individuals’ preferences for nutrition care from Australian primary care health professionals. Australian Journal of Primary Health. 2014;20(1):113-20.
- Ball L, Johnson C, Desbrow B, Leveritt M. General practitioners can offer effective nutrition care to patients with lifestyle-related chronic disease. Journal of Primary Health Care. 2013;5(1):59-69.
- Christian JG, Bessesen DH, Byers TE, Christian KK, Goldstein MG, Bock BC. Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Archives of Internal Medicine. 2008;168(2):141-6.
- Martin PD, Dutton GR, Rhode PC, Horswell RL, Ryan DH, Brantley PJ. Weight loss maintenance following a primary care intervention for low‐income minority women. Obesity. 2008;16(11):2462-7.
- Sacerdote C, Fiorini L, Rosato R, Audenino M, Valpreda M, Vineis P. Randomized controlled trial: effect of nutritional counselling in general practice. International journal of epidemiology. 2006;35(2):409-15.
- Harris MF, Fanaian M, Jayasinghe UW, Passey M, Lyle D, McKenzie S, et al. What predicts patient-reported GP management of smoking, nutrition, alcohol, physical activity and weight? Australian Journal of Primary Health. 2012;18(2):123-8.
- Ball L, Hughes R, Leveritt M. Health professionals’ views of the effectiveness of nutrition care in general practice setting. Nutrition & Dietetics. 2013;70(1):35-41.
- Ball LE, Leveritt MD. Development of a validated questionnaire to measure the self-perceived competence of primary health professionals in providing nutrition care to patients with chronic disease. Family Practice. 2015;32(6):706-10.
- Keaver L, O’Meara C, Mukhtar M, McHugh C. Providing nutrition care to patients with chronic disease: an Irish teaching hospital healthcare professional study. Journal of Biomedical Education. 2018;2018.
- Al-gassimi O, Shah HBU, Sendi R, Ezmeirlly HA, Ball L, Bakarman MA. Nutrition competence of primary care physicians in Saudi Arabia: a cross-sectional study. BMJ Open. 2020;10(1):e033443.
- Nabeeh K, Moukhtar A, El-Etreby A, Ibraim A. Exploration of nutritional concepts among patients of chronic liver diseases and their health care providers. Int J of Clinical Nutrition. 2017;5:1-7.
- Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition Care Process and Model update: Toward realizing people-centered care and outcomes management. Journal of the Academy of Nutrition and Dietetics. 2017;117(12):2003-14.
- Dietitians/Nutritionists from the Nutrition Education Materials Online “NEMO" Team. Subjective Global Assessment 2009.
- Dietitians/Nutritionists from the Nutrition Education Materials Online “NEMO" Team. Validated Nutrition Assessment Tools: Comparison Guide 2009.
- Academy of Nutrition and Dietetics. NCP Step 1: Nutrition Assessment 2018.
- Medical Research Council. Diet Histories 2020.
- Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’(‘MUST’) for adults. British Journal of Nutrition. 2004;92(5):799-808.
- Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-64.
- Australian Institute of Health and Welfare (AIHW). Australia’s health 2018: in brief. Canberra; 2018.
- Australian Government Department of Health. About the Australian Dietary Guidelines 2105.
- National Health and Medical Research Council. Australian Guidelines to Reduce Health Risks from Drinking Alcohol 2020.
- The Royal Australian College of General Practitioners (RACGP). Smoking, nutrition, alcohol, physical acitvity (SNAP): A population health guide to behavioural risk factors in general practice (2nd edition). Melbourne; 2015.
- The Royal Australian College of General Practitioners (RACGP). Handbook of Non-Drug Interventions (HANDI). 2020.
This lesson was designed by the Healthy Primary Care team, led by A/Prof Lauren Ball.
Lauren is an Advanced Accredited Practising Dietitian and Principal Research Fellow at Griffith University.
If you have any questions, or would like to get in touch with Lauren, please use any of the following links: