Physician-Delivered Pt-Centered Nutrition Counseling

Physician-delivered interventions need to be brief, occupying a small part of the outpatient encounter. (56, 57) The physician-delivered nutrition counseling intervention is designed to take the physician 7-10 minutes to imple­ment, and uses the pt-centered counseling model emphasiz­ing the use of questioning, provision of in­formation, and eliciting of feelings related to six con­tent areas: 1) desire and motivation to change dietary behavior; 2) experience with dietary change; 3) factors inhibiting dietary change (barriers); 4) re­sources for change (strengths); 5) plan for change; and 6) meth­ods for deal­ing with factors that may interfere with the plan. The physician is also taught to provide information regarding the relationship of elevated lipids to CHD and of diet to elevated lipids; to paraphrase and feed back the information obtained from the pt to help him or her develop a plan for dietary change and for sub­se­quent GNI visits if indicated; the importance of providing educational materials to pts; and the im­portance of follow-up for behavioral change. Thus, the intervention combines the use of questioning with the pro­vision and feedback of relevant in­formation and follow-up to as­sist the pt to make dietary changes necessary to reach the LDL-C goals. A pt-centered nutrition intervention counseling algorithm (and follow-up algorithm) was developed in WATCH (See Section C.1.1.) and is part of the packet affixed to each study pt’s chart each time he/she is seen by the physician (see Section D.8.3.2.) (see appendix F for algorithms).

Training of physicians to do patient-centered counseling. 

All study physicians will be trained to perform pt-centered nutritional counseling and to use the DRA and dietary goal sheets with pts.  Introducing the study and building adequate skills will take 3 hours, including a 2.5 hour group session (5-10 MDs), followed by a half-hour individual session conducted in their offices with a simulated pt (see Section C.1.1.) During the individual session physicians are provided with immediate feed-back regarding their counsel­ing skills, and have an opportunity to correct problems. The P.I., co-investigators, and project coordi­nator will conduct the training. These training sessions were well accepted in WATCH.

The 2.5 hour group educational session will cover four subject areas:

1. Nutritional intervention for cholesterol lowering (including the NCEP guidelines).

2. Pt-centered counseling skills training.

3. Integrating RD (GNI) intervention into physician-delivered dietary intervention.

4. Use of pt nutrition education aids (i.e., DRA and dietary goal sheets) and other program materials.

The training package includes slides, videotape, role play exercises, handouts, and instruction for the use of the various materials (See appendix N for a single copy of a package of this type from the PDSIP project).

The half-hour individual training session will be completed in the physician’s office within 2 weeks after the group session, with the physician delivering the nutrition counseling intervention to a simulated pt (a trained health educator/evaluator). The physician is given immediate feedback regarding his/her counsel­ing skills. If the physician’s level of skill is not adequate to do di­etary counseling, the health educator/evaluator will request another individual session (This was available but did not occur in WATCH). In the unlikely event that a physician remains at an unsatisfactory level, we will nonetheless allow that physician to remain in the study.

NCEP Follow-up Guidelines.

During the training sessions the physicians will be introduced to the NCEP guidelines and their study-specific modifications. As in WATCH, we have chosen to have two intervention paths based on the pt’s LDL-C level. For pts with LDL-C measurements in the upper decile, the guidelines will suggest initial physician intervention and immediate referral to the GNI. We believe that these pts have LDL-C levels that are unlikely to fall into the goal range (see NCEP guidelines, appendix E) with physician intervention only, and that a coor­dinated initial approach is appropri­ate. For pts in the 75th to 90th per­centile, we will suggest initial physician intervention only as a cost-effective approach. The guidelines suggest that these pts be referred to the GNI at 3 months if they do not reach the goal LDL-C.

The NCEP guidelines may, in some pts, set a goal LDL-C that represents less than a 10% decrease (e.g., a pt with an LDL-C of 165 mg/dl and no other risk factors, for whom the goal is an LDL-C <160 mg/dl. As this study has a 5% difference in serum LDL-C between conditions I & II as one of its primary end­points, the guidelines will sug­gest that a 10% reduction in LDL-C  should be a minimum goal for all study pts.

Office Support Program. 

Group Nutrition Intervention Program (GNI)

The RD-implemented GNI will be similar to the 4-session program utilized in WATCH, and will include an initial individual session, followed by 3 group sessions. (see appendix G for outline of group sessions)

The primary nutritional and behavioral objectives of the GNI are to:

• 1. Increase the pt’s awareness of the dietary risk factors associated with CHD;
• 2. Increase the pt’s knowledge of nutrition in the context of a diet designed to lower serum cholesterol (Step One or Step Two with the addition of individual goals as indicated);
• 3. Negotiate and tailor realistic goals for each pt;
• 4. Enhance the pt’s skills for adherence to a cholesterol lowering eating pattern; and
• 5. Increase the pt’s confidence in his/her ability to make dietary changes

Spouses will be encouraged to attend the group sessions because support by family members, especially spouses, is important in achieving and main­taining be­hav­ioral change.  (107) Groups will meet in the demonstration kitchen/classroom at the UMMC Prevention Center (see Facilities and Environment). This allows for the experience of working with foods (many may be new to study pts) and for the crucial element of group support. Pt and spouse attendance records will be kept and evaluated as possible out­come predictor variables.

The protocol for each pt is as follows:

Step 1. Referral to the GNI program by a physician or by the DLMC.

The GNI program will be available to pts in Conditions I and II.  However, pts in Condition I must be referred by their physicians, while in Condition II they will be referred by their physician or by the Dietitian Lipid Management Counselor (DLMC) who coordinates the Systems-Based Lipid Management Program for pts in condition II (See Section D.8.4.1.) Study pts in both conditions will be tracked by the site coordinators, and when re­ferred by their physicians to dietitian services for assistance with cholesterol lowering all study pts (conditions I & II) will be placed in the GNI program.

Step 2. Individual Counseling Session with the RD

On referral to the GNI, the pt will be scheduled for an individual counseling session within two weeks.  The purpose of the individual session is to provide a thorough assessment of nutritional status; including measurements of height, weight, and basal energy expenditure (based on the Harris-Benedict Equation), and an evaluation of any medical history with nutritional implications.  The RD will review the pt’s typical eating pattern,  targeting specific areas of concern. An assessment of pt barriers to dietary change will be made, and customized goals according to pt needs and abilities will be developed. The pt will be given a 7DDR (see section C.1.7.) to complete. The 7DDR will be used both to educate the pt about diet and as a basis for setting individual dietary goals. The referring physician will be sent a note indicating that the pt has started the GNI program and giving information about the pt’s dietary behavior and goals. This note will also be placed in the Lotus Notes data base, for use by the DLMC. Because the RD is blinded to pt assignment, such electronic notes for condition I pts will be sent but not utilized (but they are identical to the written note sent to the physician).

Step 3. Participation in Group Sessions

The pt will attend the first group session within 2 weeks of the individual session, and can choose a day or evening class. Three GNI sessions will be held 2 weeks apart over a period of 6 weeks (appendix G). Each RD-led group session will last 2 hours and will be activity-oriented. The decision to run three 2-hour sessions is based on the need for approximately 6 hours for adequate teaching, learning, and skill de­velopment (e.g. food preparation and cooking demonstrations and practice) and the desire to not reduce adherence by requiring the pts to return to the clinical center too many times. The number of sessions also represents a compromise between the very potent effect seen with expensive, intensive multisession programs (16) and what is realistic in a real-world primary care setting. We have found this number of sessions to be efficacious (see section C.1.4.) If a pt misses a GNI session he/she will have the option of attending an equivalent session of another group. Pts will be given simple assignments to complete at home. After the last group session a summary note will be sent to the referring physician, describing the pt's progress and suggesting areas for physician support.

Training of Registered Dietitians

At the beginning of Phase II of the project, the 2 participating RDs will be trained to implement the GNI. The training program will consist of two four-hour joint sessions and one half-hour individual session.

Joint Training Sessions

The objectives of the first training session will be to:

1. Acquaint RDs with the scope and aim of the project, including the rationale underlying the interventions.

2. Review the NCEP guidelines for identifying and treating high-risk pts, including discussion of the major risk factors for CHD and how the approach adopted by this project complements the guidelines.

3. Acquaint the RDs with the components of the GNI program.

4. Provide an overview of group process theory and adult learning theory.

5. Present the theoretical and practical basis for whole-food dietary change, and the transition to a more healthful and interesting way of eating.

The objectives of the second session will be to:

1. Provide detailed instruction on the components of the intervention: objectives of the 1 individual and 3 group sessions; use of the pt instruction materials: use of the diet assessment and pt evaluation forms; procedures to be followed for monitoring pts' progress through the program.

2. Provide training to improve the RDs’ counseling skills in a manner similar to that given the physicians.

3. Provide an overview of cognitive and behavioral techniques.

4. Identify pt and RD barriers to implementing the intervention and ways to overcome them.

Individual Training Session