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- Paula M. Brauer PhD, RD,
- Lee Anne Sergeant BASc, RD,
- Bridget Davidson MHSc, RD,
- Rick Goy MSc, and
- Linda Dietrich MEd, RD
Purpose: Patients’ perceptions of preventive lifestyle in primary care practice were examined. Methods: Practice was assessed with a modified version of the Primary Care Assessment Survey (PCAS). This was mailed to random samples of patients twice, using practice mailing lists from three Ontario Family Health Networks (FHNs). Family Health Networks are physician-based group practices, with additional nurse-led telephone advisory services to provide care 24 hours a day, seven days a week. The PCAS questionnaire consisted of nine scales (ranging from 0 to 100). For preventive counselling, additional questions on diet and exercise counselling were included to determine how the physician delivered the intervention. Results: Of the 2184 survey questionnaires mailed to patients, 22% were undeliverable. The response rate was 62% at valid addresses (49% of all mailed questionnaires). Of the nine scales, scores (± standard deviation) for preventive counselling were lowest at 33 ± 25. In particular, rates of diet (37%) and exercise (24%) counselling were low in the FHNs. For most other aspects of primary care services, patients generally rated FHNs highly. The majority of patients advised about diet and exercise were given verbal advice or pamphlets. Conclusions: In these primary health care organizations, considerable room exists for increased preventive counselling, especially about diet and exercise.- Purpose: South Asian immigrants to Canada are at high risk for developing diabetes, and culturally relevant diet counselling tools are needed. We examined perceived needs and preferences for diet counselling resources based on the newly revised Canadian Diabetes Association meal planning guide. Methods: Five focus groups of individuals fromdifferent regions of South Asia (n=53) discussed portion size estimating methods, cultural values and holidays, food group classifications, and common South Asian foods. A focus panel with dietitians (n=8) provided insight on current diabetes educationmethods and resources for teaching South Asian clients. Results: The dietitian panelmembers reported a need for resources targeted at differing client skill levels. They also noted preferences for individual counselling, and common barriers to education including finances, access, South Asian diets, and cultural views on health. Community focus groups reported larger portions but fewer dailymeals in Canada. Ingredients and portions were notmeasured. Fasting was an important value, and sweets were a crucial component of holidays. Resources in South Asian languages, inclusion of pictures, and separate legumes, sweets, and snacks food groups were preferred. Conclusions: Findings can be used when developing new counselling tools for the South Asian community.
- Purpose: The Resident Assessment Instrument–Home Care (RAI-HC) is widely used to assess needs of home care clients and includes five items used to screen for malnutrition. This study involved defining malnutrition risk and identifying other items within the RAI-HC that might improve malnutrition screening among adults aged 65 or older receiving home care. Methods: A literature review, three focus groups of community care access centre case managers (n=29), and five key informant interviews with registered dietitians were used to identify malnutrition risk factors and indicators. A nominal group (n=5) was used to rank RAI-HC malnutrition risk items. Data were charted and integrated to create the final list of potential risk factors. Results: Seven malnutrition indicators (dietary intake, appetite, dysphagia, nutrition support, end-stage disease, weight status, and fluid intake) and seven risk factors (health status, functional ability, self-reported poor health, mood status, social function, cognitive performance, and trade-offs) were considered important concepts in the construct of malnutrition for older home care clients. Conclusions: These items identified through divergent methods form the basis for developing a screening-formalnutrition-risk tool for home care.
- Paula M. Brauer PhD, RD,
- Rhona M. Hanning PhD, RD,
- Jose F. Arocha PhD,
- Dawna Royall MSc, RD,
- Andrew Grant MB, ChB, MRCP, FRCPC, FACMI, DPhil,
- Linda Dietrich MEd, RD, and
- Roselle Martino MHSc, RD
Purpose: Care maps or clinical pathways for nutrition therapy of dyslipidemia could add to current practice guidelines, by providing templates for feasible and recommended diet counselling processes. A care map was therefore developed by engaging expert and generalist dietitians and external experts from across Canada in a multi-stage consensus process. Methods: First, a qualitative study was undertaken with a convenience sample of 12 practitioners to identify possible diet care options, using hypothetical client scenarios and cognitive analysis. Second, these care options were rated for five case scenarios considered typical (overweight clients, with or without clinical cardiovascular disease and other comorbidities, potentially motivated to change, consuming high-fat diets, and facing various major barriers to eating behaviour change). The rating was conducted through a survey of participants. Highly appropriate, recommended, and feasible options for counselling were ranked through a two-round modified Delphi process, with teleconference discussions between rounds. Results: Forty-nine professionals started the consensus process; 39 (80%) completed all aspects. Numerous care processes were appropriate for all clients, with additional focus on barriers for low-income clients, sodium intake for clients with hypertension, and smoking cessation in smokers. Conclusions: The resulting care map, “Dietitians’ Quick Reference Guide for Clinical Nutrition Therapy for Overweight Clients with Dyslipidemia,” provides a basis for current practice and new effectiveness studies.- Diet interventions for dyslipidemia can produce clinically relevant changes in lipoprotein levels. To determine whether current nutrition counselling practices are consistent with such interventions, we studied aspects of Canadian dietitians’ practice. Respondents to a self-administered mail survey (n=350) described practice for three groups of clients: those without and those with cardiovascular disease counselled through ambulatory care, and those with cardiovascular disease who were hospitalized. The process-of-care factors assessed were time spent in initial and follow-up sessions, diet, anthropometry, blood lipids, physical activity, and social and genetic factors. Organization factors assessed included availability of medical history and laboratory data, and perceived support for counselling services. Initial individual interview times averaged one hour, with 49% to 57% of respondents offering scheduled follow-up services versus passive or no followup services. Overall, counselling practices were consistent with efficacious interventions, but there was wide variation. This was particularly evident in ambulatory care, where higher percentages of clients received follow-up care when respondents reported multidisciplinary group practice; better access to the medical history, and more frequent assessment of measured body weight, client social support, and laboratory data during follow-up care (all p<0.01). Health care effectiveness may be improved through changes in the process and organization of services.
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Practice Guidelines: Pedantic Pontification or Pragmatic Progress? 2003 Ryley-Jeffs Memorial Lecture
Development and use of practice guidelines is one strategy to assist health professionals in translating research into practice. There has been a significant growth in the number of practice guidelines developed, with the increased focus on justifying health care costs and demonstrating outcomes. Quality and influence on established practice, however, has sometimes been lacking. Recognizing both the importance of practice guidelines and some of the controversies surrounding their quality and use, Dietitians of Canada convened a task group to make recommendations on future development. They reviewed the practice guideline programs of others and identified the key elements needed to ensure any dietetics-produced guidelines would be credible, feasible and applicable to clinical counselling, administration and community health promotion. In this memorial lecture, the chair of that task group briefly reviews the history of dietetic practice guidelines, new innovations in systematic review and consensus development methods, and specifically the Delphi process used to develop a new Dietetic Practice Guidelines Framework. The 34 elements of the framework direct overall management of the guideline development process, including topic nomination, systematic literature review, group judgment, and pilot testing.
