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1 From the Preventive Cardiology Program, University of Wisconsin Hospital and Clinics, Madison, and the University of Wisconsin Medical School-Madison (GU and PEM), and the Department of Family Medicine, University of Wisconsin Medical School-Eau Claire (ES)
2 Presented at the symposium "An Evidence-Based Approach to Medical Nutrition Education," held at Experimental Biology 2005 in San Diego, CA, 2 April 2005. 3 Supported by grant no. HL003965-05 from the National Institutes of Health. 4 Address reprint requests to PE McBride, Cardiovascular Medicine Room 2150 HSLC, 750 Highland Avenue, Madison WI 53705-2221. E-mail: pem{at}medicine.wisc.edu.
ABSTRACT
The World Wide Web is a valuable source of nutrition and health information, but the time and effort required to take advantage of this resource may stand in the way of routine use in medical education and practice. The Nutrition Academic Award (NAA) has produced numerous examples of Web-based nutrition resources, including nutrition assessment tools, patient education materials, and presentations and curricula for professional education. The University of Wisconsin Medical Nutrition Handbook provides evidence-based nutrition care guides for common clinical problems, including obesity, diabetes, hypertension, lipid disorders, and the metabolic syndrome. Incorporation of these resources into medical practice may increase the provision of effective nutrition care.
Key Words: Nutrition resources • Internet • Nutrition Academic Award • nutrition handbook • clinical practice • nutrition assessment • nutrition counseling
INTRODUCTION
The World Wide Web is an important source of health-related information available to anyone who has a computer and Internet access. The Pew Internet and American Life Project reports that as of August 2003, 63% of Americans go online, and that 8 of 10 Internet users have looked for health information (1, 2). Within the category of health information, more than one-half of Internet users report going online in the past 2 y to research diet and nutrition (2).
Physicians and other health care providers also use the Internet as a source of information. Recent surveys report that three-quarters of primary care physicians have Internet access at work and that nearly all of them (98%) access it at least once per week (3, 4). According to the Canadian Medical Association, 66% of Canadian physicians use the Internet as a tool to support treatment or in direct patient care, including searching medical databases (57%) and referring to clinical practice guidelines (5). Truswell et al (6) suggest that nutrition guidance by physicians would be improved if computers could be used to print out reliable nutrition information for a particular diagnosis and emphasize the need for access to relatively brief, evidence-based, up-to-date and practical dietary guidelines.
Although the Internet can be a valuable resource for patients and practitioners, the vast amount of nutrition information available makes finding scientifically sound, pertinent sites time consuming and frustrating. About 60% of physicians surveyed agree that "searching the Internet takes too much effort" (3). A recent Google (Google Inc, Mountain View, CA) search for the term nutrition yielded 89 500 000 sites, without any guarantee of reliability. Many government agencies and professional organizations have developed accurate, easy-to-use materials on a variety of nutrition topics, but navigation of these sites can be difficult unless a directory of frequently used sites is created.
NUTRITION ACADEMIC AWARD WEB-BASED RESOURCES
The National Heart, Lung, and Blood Institute Nutrition Academic Award (NAA) offers a wide variety of resources to facilitate nutritional education, and many of these resources are available on the national NAA website (Internet: http://www.nhlbi.nih.gov/funding/training/naa/) (7). The "NAA Products" link contains the NAA Nutrition Curriculum Guide for medical schools, instructional materials, nutrition education publications, practice tools, and links to other materials including slide sets and more (Figure 1). By clicking the link for "NAA Members," you can access the individual NAA sites and a wide variety of resources. These resources include, for example, the WAVE (weight, activity, variety, excess) and REAP (rapid eating assessment for patients) nutritional assessment tools from Brown University, which provide a mnemonic for medical providers to use when asking about nutrition in clinical encounters. This has proven to be very useful in both clinical practice and in teaching clinical nutritional assessment. In addition, the University of Arkansas has specific programs aimed at addressing obesity in youth and adults. The sites at the University at Texas Southwestern Medical Center, the University of Pennsylvania School of Medicine, and others provide excellent training materials for students and providers in nutrition (Table 1)
FIGURE 1.. National Nutrition Academic Award home page (Internet: http://www.nhlbi.nih.gov/funding/training/naa/).
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TABLE 1. Web-based Nutrition Academic Award (NAA) resources
WEB-BASED MEDICAL NUTRITION HANDBOOK
One of the goals of the NAA at the University of Wisconsin was the development of a nutrition handbook for use by medical professionals. The handbook was intended as a quick reference to evidence-based guidelines, dietary modifications for common medical problems, practical patient recommendations, and pertinent references. Although the initial intent was to develop a paper handbook, the growing use and potential of the Internet led the authors to develop a Web-based Medical Nutrition Handbook (Internet: http://naa.medicine.wisc.edu). The advantages of a Web-based tool include access from any computer; the ability to link to clinical practice guidelines, patient education materials, and tools already developed; and the option of updating handbook contents without reprinting paper copies.
The introduction and philosophy of the University of Wisconsin NAA Medical Nutrition Handbook is based on the extensive review of current evidence conducted by the US Preventive Services Task Force (USPSTF). This review found that counseling interventions could produce changes in the core components of a healthy diet (including saturated fat, fiber, fruit, and vegetables) among adult patients at increased risk of diet-related chronic disease. As a result, the USPSTF recommends intensive behavioral diet counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. This counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians (8).
On the basis of comments and input from clinicians in academic and private practice, the Handbook was formatted by using a problem-based approach to encourage its use during clinical patient care. The most common nutrition-related clinical problems, including obesity, diabetes, lipid disorders, hypertension, and metabolic syndrome, were selected as the first 5 topics to be developed.
Each clinical problem is presented in the Handbook in a process-oriented format that uses the "5 A's" structure recommended by the USPSTF. The 5 A's model is an algorithm for behavior change counseling designed to facilitate evidence-based, effective patient intervention in a short period of time (9). The repetition of the 5 A's format in each of the clinical topics is intended to reinforce the process of counseling for behavior change, thus encouraging more effective counseling with more patients in clinical practice. Because this model is recommended for use with any type of counseling for patient behavior change, patient counseling in other areas (smoking cessation, exercise, etc) may also improve. The 5 A's are as follows:
Each clinical topic in the Handbook includes the following sections:
The "Brief Nutrition Counseling Tools" include suggestions for conducting nutrition counseling in either 5 or 15 min. These tools were developed in response to comments from medical school faculty, researchers, and clinicians who reviewed the Handbook and felt that even though it was a valuable resource, busy practitioners would not use it unless a streamlined option was available (Table 2). Comments from clinicians who are currently using the Handbook indicate that the "Brief Nutrition Counseling Tools" are the most frequently used and the most helpful sections of the Handbook.
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TABLE 2. Brief nutrition counseling for obesity—5-min version
Physicians report that time is a significant barrier to providing nutrition counseling in the practice setting. In primary care, the reason for most patient visits relates to acute care issues (sore throat, injury, etc; 10). If nutrition is to be incorporated into this type of visit, the interaction must be short and to the point because the bulk of the visit will be consumed by the acute care issue. A health maintenance or chronic illness visit offers more time for discussion of lifestyle, but practitioners are often not confident in their ability to focus the nutrition discussion, take a history, and provide counseling in a reasonable amount of time.
The 5- and 15-min tools attempt to address these concerns by streamlining the process and providing guidelines for focused history and counseling. These tools maintain the 5 A's structure, but include only the most critical elements of the process, acknowledging that the shortened approach will not allow for much patient input and will require a more directive behavior change approach.
The "Goal" and "Rationale" for each topic are evidence-based and supported by recent journal articles and clinical guidelines. As an example, the goal for the hypertension topic states, "Help patients lower blood pressure with lifestyle modification, ie, lose weight if indicated, adopt the DASH-sodium diet, increase physical activity, and limit alcohol intake," and the rationale includes information on prevalence, associated cardiovascular risk, and lifestyle modification from the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure" (11).
The "Evaluation" section outlines guidelines for obtaining and assessing anthropometric data, related laboratory values, diet history, physical activity history, and an assessment of patient readiness to change behavior. The discussion of anthropometric data includes guidelines for use of body mass index and for the measurement of waist circumference, both of which are critical elements in the assessment of overall risk. Diet history recommendations include links to tools developed to facilitate the use of diet recall or food-frequency assessments as well as tools that help to estimate portion sizes. The Rapid Eating Assessment for Patients is a tool developed by the NAA program at Brown University (http://bms.brown.edu/nutrition/). It provides a patient questionnaire and an answer key for health professionals. The answer key identifies eating habits that put a patient at risk and provides additional questions or testing for these habits, as well as suggested counseling messages for each habit.
The "Evaluation" section also presents Prochaska and DiClementi's Stages of Change model to help identify the patient's stage of readiness to change (12). Typical patient characteristics and the most effective interventions at each stage are identified, which help health professionals make the best use of the counseling time that they spend with patients.
The "Management" section begins with guidelines for the Advise step of the 5 A's, which includes an overview of diet and activity recommendations for each clinical problem, as well as examples of the physician message for the patient. See the sample fiber recommendations for lipid disorders in Table 3. Under the Agree step, recommendations for weight loss, diet, and exercise goals are reviewed. The Assist section includes links to provide more detail on calorie content, grocery shopping, food preparation, increasing fruit and vegetables, portion control, and restaurant eating, as well as increasing physical activity. See the sample details on carbohydrate counting in Tables 4 and 5. The Arrange step in the process discusses referral to registered dietitians and other diet or activity resources. Web resources for patients and professionals are included at the end of each section, as are books or other written resources.
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TABLE 3. Increasing fiber in your diet
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TABLE 4. Sample detail on carbohydrate counting
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TABLE 5. Comparison of carbohydrate choices in 2 lunch menus
SUMMARY
Computers can be an important resource for reliable nutrition information and nutrition counseling in medical care, but accessing helpful, accurate information on the Internet is time consuming. The national NAA website, as well as websites from the individual NAA schools, offer a variety of products. The University of Wisconsin NAA Medical Nutrition Handbook provides readily available guidance and resources on evidence-based clinical guidelines, nutrition assessment and counseling, and patient education for physicians-in-training or in practice.
GU and PEM were responsible for the concept of the Medical Nutrition Handbook. ES compiled the resources for the Handbook, wrote the content, and collaborated with the website designer. GU and PEM reviewed the content of the Handbook for accuracy and style. GU wrote the manuscript for this article and ES and PEM reviewed it. None of the authors had any conflicts of interest.
ACKNOWLEDGMENTS
We thank the Department of Medicine at the University of Wisconsin Medical School for assistance in constructing and supporting the website for the Medical Nutrition Handbook.
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