Family Practice

This Article Abstract FREE Full Text (PDF) E-letters: Submit a response Alert me when this article is cited Alert me when E-letters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Search for citing articles in: ISI Web of Science (7) Request Permissions Google Scholar Articles by Moore, H. Articles by Waine, C. Search for Related Content PubMed PubMed Citation Articles by Moore, H. Articles by Waine, C. Social Bookmarking          What's this?

Family Practice Vol. 17, No. 2, 197-202
© Oxford University Press 2000

Nutrition and the health care agenda: a primary care perspective

Helen Moore, Ashley J Adamson^a, Timothy Gill^b and Colin Waine^c

Centre for Research in Primary Care, Nuffield Institute for Health, University of Leeds, 71–75 Clarendon Road, Leeds LS2 9PL,
^a Human Nutrition Research Centre, University of Newcastle upon Tyne,
^b Rowett Research Institute, Aberdeen and
^c Sunderland Health Authority, Sunderland, UK.

Moore H, Adamson AJ, Gill T and Waine C. Nutrition and the health care agenda: a primary care perspective. Family Practice 2000; 17: 197–202.

Received 27 April 1999; Revised 15 October 1999; Accepted 26 October 1999.

	Abstract

Top Abstract Introduction Dietary advice: a public... Dietary advice in primary... Nutrition education for primary... The challenge References

 
The current climate of prioritizing in the NHS brings into focus the debate surrounding efficient and effective management of conditions associated with the modern lifestyle. In any such debate, nutrition should be considered a primary issue as there is now international consensus regarding the optimum diet for the prevention of both coronary heart disease and cancer. Over recent years, government has stated that primary care is in an ideal setting to provide nutrition education to the public. However, we present the case that there currently is a mismatch between the attitude of the public, who appear willing to accept dietary advice from primary care professionals, and the reluctance on behalf of these professionals to fulfil this role. Dissatisfaction with the quality of nutrition education received by those working in primary care is often cited as a barrier to providing dietary advice to patients. With that in mind, we go on to discuss educational strategies that may motivate primary care staff to increase their involvement in providing dietary advice for their patients. The challenge to those involved in the delivery of nutrition training to primary care professionals is to convince them that dietary intervention is worthwhile and that they can make a positive contribution to dietary change within the current organization of primary care. Increasing motivation is an essential outcome of such training, along with providing the skills and knowledge to fulfil this role. The contribution which diet could make is significant and, in this time of questioning priorities, the role of nutrition needs to be put firmly on the health care agenda.

Keywords. Diet, dietary intervention, nutrition education, primary care.

	Introduction

Top Abstract Introduction Dietary advice: a public... Dietary advice in primary... Nutrition education for primary... The challenge References

 
The current climate of prioritizing in the NHS brings into focus the debate surrounding the efficient and effective management of conditions closely associated with our modern lifestyle. In such a debate, nutrition should be considered a primary issue, as diet, in combination with other lifestyle factors, is implicated in the development of a large proportion of the most prevalent chronic conditions in the UK, including coronary heart disease (CHD), diabetes, obesity and cancer. The management of these conditions consumes a substantial percentage of the resources of the NHS. The estimated cost of drug treatment of all those at risk of CHD already exceeds NHS resources,¹ and the cost of weight loss using new drugs for obesity has been estimated at £344.80 per kilogram lost.² Nutritional research over 30 years has resulted in international consensus regarding the optimum diet for the prevention of CHD.^3,4 Evidence suggests that at population level, small reductions in blood cholesterol, achieved by a change in diet, can contribute a significant reduction in the level of morbidity and mortality from CHD.⁵ In UK primary care, the OXCHECK⁶ and British Family Heart⁷ studies demonstrated that a nurse-led, lifestyle modification programme for the reduction of cardiovascular risk can result in modest risk reduction; which if more widely applied would bring about meaningful improvements in the health of the population.^8,9 Changes to the intake of fats, salt and fibre as well as fruit and vegetable and fish consumption have produced beneficial effects and improved the management of hypertension, hyperlipidaemia and diabetes.^4,10–12 In the overweight, even relatively small amounts of weight loss can lead to meaningful improvements in blood pressure, blood lipids, glucose control and insulin levels.^14–17

Despite this, the UK medical profession remains ambivalent about the role of nutrition in disease prevention.^18,19 In a 1990 report regarding CHD prevention in the medical curriculum, Tunstall-Pedoe stated that there was "a large body of academic and professional medical opinion that recommends no action or teaching on the subject (of nutrition)".²⁰ This is despite the Royal College of General Practitioners²¹ and the Royal College of Physicians²² having endorsed the role of the GP in CHD prevention.

Government nutritional recommendations for the prevention of cardiovascular disease have existed since the 1970s.²³ Despite reiteration of the recommendations,⁴ change to the population's diet is slow.²⁴ The Nutrition Task Force, established by the government in an attempt to accelerate progress towards attaining Health of the Nation CHD targets, recommended a co-ordinated approach, involving food producers and manufacturers, public health measures and education.²⁵ However, they also stated that primary care is an ideal setting to deliver opportunistic, dietary advice to the public.²⁵

Here we argue that there is a need to rethink the provision of dietary advice for CHD prevention in primary care. To make this point, we firstly present the evidence that there is currently a mismatch between the needs and expectations of patients regarding health promotion and dietary advice and an apparent reluctance on behalf of GPs to fulfil this role. Whilst primary care nurses appear more committed to this role,²⁶ their involvement is curtailed by a perceived lack of preparedness and nutritional knowledge. We go on to discuss the part that nutrition education for health professionals could play in addressing these problems. Nutrition education for primary health care teams (PHCTs) could promote a model of dietary intervention that is applicable within the current organization of primary care.

	Dietary advice: a public perspective

Top Abstract Introduction Dietary advice: a public... Dietary advice in primary... Nutrition education for primary... The challenge References

 
Barriers that prevent people changing what they eat are well documented and include the cost of healthier food, lack of access to healthier food, increased preparation time and dietary conservatism.^27–30 Surveys point to significant public confusion regarding healthy eating.^29,31 In a survey of 1700 members of the public, people rated lack of nutritional knowledge to be the greatest barrier to changing their diet.²⁹ This survey also investigated actual knowledge levels of the public regarding nutritional terminology and the nutritional value of food. Both were found to be poor, indicating a need for an accessible source of dietary information.

It is well reported that the public see primary care staff as credible and acceptable sources of lifestyle advice, including dietary advice.^29,32–34 A study conducted in The Netherlands found that although GPs were perceived as having slightly less expertise than both dietitians and the government food agency, they were more likely to be consulted and by more segments of the population.³⁴ Our own study of the views of patients in Sunderland found that 70% thought that their GP or nurse "knew a great deal about nutrition" (H Moore, AJ Adamson, T Gill and C Waine, unpublished).

Similarly, there appears to be no lack of enthusiasm for dietary advice among patients in primary care. A South Tyneside study found that patients believed that GPs and nurses should be more involved in assessing and offering advice on lifestyle change.³⁵ A large Medical Research Council survey of primary care reported that patients wanted more advice than they received.³⁶ Similar findings have been reported in Australian work.^37,38

	Dietary advice in primary care: the perspective of health professionals

Top Abstract Introduction Dietary advice: a public... Dietary advice in primary... Nutrition education for primary... The challenge References

 
The literature regarding the attitude of primary care staff towards dietary interventions is less conclusive. Although some surveys report a positive attitude towards such interventions, others report the existence of significant barriers that limit their involvement. In an evaluation of changes to health promotion in primary care initiated following the introduction of the new contract for general practice,³⁹ LeTouze and Calman found that both doctors and nurses had a positive attitude towards health promotion activities for the prevention of CHD.⁴⁰ Likewise, in a study of weight management in UK general practice, 98% of responding GPs believed that it was part of their role to counsel patients about weight problems.⁴¹ Work in the USA has found that both doctors and nurses have favourable attitudes to giving dietary advice.^42–44 Nurses firmly believed that dietary counselling for cholesterol reduction should be part of their role, but felt that they were not prepared to provide this service.⁴⁴ They also perceived that they were unlikely to be successful in helping people achieve dietary change.⁴⁴ Cant et al.²⁶ reported similar obstacles in the UK and, in addition, the issues of space in the practice and lack of support from the GP were described.

Other work suggests that GPs in particular lack the inclination to provide dietary advice. Commonly cited barriers include lack of time, lack of nutritional knowledge and lack of confidence, poor patient compliance and lack of teaching materials.^45,46 An Australian review of nutrition counselling⁴⁷ reported that while 15–17% of GPs declare a special interest in nutrition, the extent of their involvement in nutrition counselling does not reflect this. McPherson⁴⁸ suggested that medical practitioners are trained in the treatment of disease and therefore do not adapt easily or skilfully to the role of health promoter. Johnston⁴⁹ suggested that many GPs are not convinced that modification of behavioural risk factors will result in the required improvement in health. It has been reported that GPs are most likely to engage in interventions to reduce smoking⁵⁰ and blood pressure^50,51 in preference to other risk factor modification. Heywood et al.⁵¹ suggested that this is because measuring blood pressure takes little time, gives immediate, quantifiable feedback and calls for less behavioural effort than other lifestyle interventions. They also suggested that the strength of the evidence regarding the effectiveness of the intervention may be a factor in the uptake of preventive activities.⁴⁷ In this respect, nutrition interventions may fare more poorly than other lifestyle interventions, such as smoking cessation, where the medical evidence may be perceived as more robust.

There is also evidence that health professionals believe that the public are simply unwilling to make dietary change.^29,44 A survey of 150 GPs and 50 practice nurses²⁹ found that 73% of GPs and 36% of practice nurses believed apathy to be the greatest barrier to dietary change amongst the public. However, concurrently, members of the public were asked whether they were concerned about food and its relationship to health. Only 19% stated they ate what they liked and did not worry.²⁹

UK surveys reveal that there are important gaps in the nutritional knowledge of both doctors and nurses.^29,44,52,53 These studies reported that knowledge of nutritional concepts was sound, but translation of these into practical dietary advice is more difficult.

A UK GP recently stated that although he accepted the role of nutrition as a major determinant of health, he was unlikely to attempt any nutritional intervention in his everyday work.⁵⁴ The evidence presented paints a picture of a lack of conviction of the role of nutrition in prevention activities, inconsistent knowledge levels and levels of involvement in prevention activities that are less than ideal.^36,51,55 It is likely that a significant change in these factors is necessary if the potential of nutrition to contribute to disease prevention is to be realized.

	Nutrition education for primary care staff

Top Abstract Introduction Dietary advice: a public... Dietary advice in primary... Nutrition education for primary... The challenge References

 
One reason why nutrition may be afforded low status by some GPs could be that nutrition traditionally has been of low priority in the medical school curriculum. A survey of American medical students⁵⁶ examined how important they felt nutrition to be at the start and end of their training. Whilst 74% of entrants believed nutrition was of importance to their medical career, on completion of their training, none of the new graduates remained convinced.⁵⁶ Indeed, dissatisfaction with the quality of nutrition training they have received has been reported amongst GPs and nurses.^29,45,46,57

Efforts to raise the profile of nutrition amongst health professionals culminated in the Nutrition Core Curriculum document, published in 1994 by the Nutrition Task Force.⁵⁸ It described the basic nutritional science concepts and applications to equip health professionals with sufficient knowledge to fulfil the role of nutrition educators of the public. Special reference was made to the needs of those working in primary care. In response to this document, the English Nursing Board (ENB) published its Nutrition for Life⁵⁹ document which provided a framework for education establishments regarding relevant nutrition education for pre- and post-registration nurses. The ENB did not, however, set specific standards for nutrition input. Early responses to the document on behalf of some institutions have endorsed its usefulness but suggest that nutrition teaching is not being provided in sufficient depth.⁶⁰

Whilst the above documents provide guidance on the content of nutrition education programmes, effective methods of delivery remain less clear and there is little published work that specifically examines this. The evaluation that is available has demonstrated that nutrition education delivered to practice nurses can improve nutritional knowledge⁶¹ and that training regarding the use of dietary counselling techniques for GPs can increase their use of such techniques.⁶² However, there is a lack of robust evidence and, in the absence of more specific guidance, those planning nutrition education programmes for primary care staff need to incorporate elements shown to contribute to the effectiveness of more general continuing medical education (CME).^63–65 This includes programmes based on the theory of adult learning, in which learners are involved in identifying their own learning needs and which include active learner participation.

Analysis of the impact of nutrition education programmes aimed at the public can also provide clues to improving nutrition training of health professionals. An American review of such nutrition education interventions⁶⁶ suggested that the apparent inability of much nutrition education to change behaviour is due to the misapplication of the knowledge–attitude–behaviour educational model. The knowledge commonly supplied is of a ‘how to’ nature and would therefore only be put into practice by those already motivated to change their behaviour. The review recommended that motivational messages need to be included more consciously in all nutrition education.⁶⁶

This focus on increasing motivation to give dietary advice, rather than purely increasing knowledge, has been acknowledged as a prerequisite for nutrition training of medical students,⁶⁷ student nurses and nurse educators.⁶⁰ Weinsier⁶⁷ stated that "the primary goal is to sensitize medical students to the relevance of nutrition in the prevention and treatment of disease. Imparting nutritional knowledge should be secondary to that goal". Weinsier believed that the critical motivating factor for medical staff is to ensure that the content of the nutrition education package is seen as clinically applicable. As time is such an important factor in primary care and lack of time is cited as a reason for non-attendance at nutrition training sessions,⁶¹ it should be noted that Weinsier believes that it is unnecessary to provide hours of teaching to fulfil the aims of communicating the key principles and raising awareness.⁶⁷ The aim is not to produce a nutritional expert but rather to equip practitioners with a level of knowledge and skills useful in a primary care setting.

Finding the right mode of delivery of nutrition training to professionals working in primary care will help to overcome the commonly acknowledged barriers to participation. Most of the discussion on this issue has focused on improving undergraduate and formal post-graduate training,^56,67,68 but perhaps the greatest scope for improving nutrition attitudes and skills lies with continuing education. ‘Educational outreach’ has been shown to be an effective training technique capable of changing practitioner behaviour in a randomized trial.⁶⁹ The technique involves providing a series of short interactions and discussions on a topical issue, and reinforcing these messages with credible scientific literature and concise, graphical educational material. A similar approach has already been utilized with some demonstrated benefit in the nutrition training of practice nurses.⁷⁰

The current interest in self-directed learning and the use of personal learning plans in both CME and nursing education⁷¹ present an opportunity to focus on the real nutrition training needs of primary health care professionals and how these can be achieved within the limitations of the existing training environment. The option on practice-based learning plans has been raised by the Chief Medical Officer's review of CME.⁷² Such an approach would allow the involvement of other health professionals, such as dietitians, in the training network.

	The challenge

Top Abstract Introduction Dietary advice: a public... Dietary advice in primary... Nutrition education for primary... The challenge References

 
This article presents evidence that few people are apathetic about what they eat and indeed many appear to want more lifestyle advice than they currently get. However, this is not always matched by a similar degree of enthusiasm amongst primary care staff to work with patients on dietary change. Nutrition-related diseases such as CHD, stroke, diabetes, obesity and certain cancers provide the greatest burden on NHS resources. Most of these conditions are managed in general practice, and the PHCT are well placed to provide a key role in effective prevention efforts. However, changes to current general practice to include a greater focus on diet and lifestyle will have to be achieved if these conditions are to be managed effectively and efficiently.

Within the current organization of primary care, it could be argued that there is limited time to give detailed dietary advice. As described by van Weel, the model of intervention in primary care aims to "achieve as much effect as possible by an individualised intervention which is as limited as possible".⁷³ To be effective, acceptable and useful, it is likely that dietary interventions need to fit into this model. However, the arrangement in which patients are seen frequently and on an ongoing basis has been shown to enhance the effectiveness of lifestyle interventions,^16,17,74 and this seems to fit very well with the model of UK primary care.

Given the amount of trust and credibility invested in GPs by the public, the dietary advice they do give is potentially extremely important. Inconsistent dietary messages, leading to the opinion that "the experts keep changing their minds" are known to undermine peoples' attempts to change what they eat.²⁹ It is therefore imperative that all primary care staff have a basic level of nutritional knowledge that is accurate and up to date.

The model of dietary intervention suited to primary care may not necessarily involve a great increase in time spent by the GP. Mant suggests that the most effective role a GP can play in nutrition education for their patients is the "legitimisation and reinforcement of public health information by brief advice".⁵⁴ Similarly, Buttriss stated that GPs need to give the importance of nutrition "their endorsement", leaving more detailed dietary counselling to other members of the primary care team such as nurses and dietitians.²⁹ For this endorsement to occur on a widespread basis, a change in prevailing attitude and increase in motivation among GPs must occur.

It is a challenge to nutrition educators to convince these influential practitioners that they can be effective in promoting lifestyle change and provide them with the motivation, skills and knowledge that can be used to maximum effect within the organization of primary care. There is a major need to develop nutrition education programmes that are perceived as relevant, are based upon adult learning theory and where time has been taken to identify the specific motivators for the health professionals. A well-motivated, informed and skilled PHCT could play a major part in facilitating dietary change in their patients, translating nutritional guidelines into meaningful and practical terms, reflecting the social and cultural mix of the local population. Primary care groups and local commissioning could help to address specific local issues, increasing the relevance to the population. In this time of changing health care priorities, there are great opportunities to maximize the health gain possible with diet. The potential contribution that diet could make to the nation's health is significant and it therefore needs to be put firmly on the health care agenda.

	Acknowledgments

 
We thank the members of the Centre for Research in Primary Care, University of Leeds.

	References

Top Abstract Introduction Dietary advice: a public... Dietary advice in primary... Nutrition education for primary... The challenge References

 
¹ Wald NJ. Cholesterol and coronary heart disease: to screen or not to screen. In Marmot M, Elliot (eds). Cornary Heart Disease Epidemiology, From Aetiology To Public Health. Oxford Medical Publications, 1995: 358–368.

² Muir J. RCP reports on the role of drugs for obesity. (Editorial) Guidelines in Practice 1999; 2: 3.

³ Wood D. European and American recommendations for coronary heart disease prevention. Eur Heart J 1998; 19 (Suppl A): A12– A19.

⁴ Department of Health. Committee on Medical Aspects of Food Policy. Nutritional Aspects of Cardiovascular Disease. Report on Health and Social Subjects No. 46. London: HMSO, 1994.

⁵ Law MR, Wald NJ, Thompson SG. By how much and how quickly does serum cholesterol concentration lower risk of ischaemic heart disease? Br Med J 1994; 308: 367–373.[Abstract/Free Full Text]

⁶ Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results from the OXCHECK Study. Br Med J 1995; 310: 1099–1104.[Abstract/Free Full Text]

⁷ Wood DA, Kinmonth AL, Pyke SDM on behalf of the Family Heart Study Group. A randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principle results of the British Family Heart Study. Br Med J 1994; 308: 313–320.[Abstract/Free Full Text]

⁸ Fowler G. The OXCHECK study. In Sharp I (ed.). Coronary Heart Disease Prevention in Primary Care: The Way Forward. Report of an expert meeting. National Heart Forum. London: HMSO, 1995: 13–17.

⁹ Wood D. The British Family Heart Study. In Sharp I (ed.). Coronary Heart Disease Prevention in Primary Care: The Way Forward. Report of an expert meeting. National Heart Forum. London: HMSO, 1995: 18–21.

¹⁰ British Diabetic Association. Dietary recommendations for people with diabetes: an update for the 1990s. Nutrition sub-committee of the BDA's Professional Advisory Committee. Diabetic Med 1992; 9: 189–202.[Web of Science][Medline]

¹¹ Ness AR, Powles JW. Fruit and vegetables, and cardiovascular disease. A review. Int J Epidemiol 1997; 26: 1–13.[Abstract/Free Full Text]

¹² Cappuccio FP, Markandu ND et al. Double-blind randomised trial of modest salt restriction in older people. Lancet 1997; 350: 850–854.[Web of Science][Medline]

¹³ Whelton PK, Lawrence JA et al. Sodium reduction and weight loss in the treatment of hypertension in older persons. a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). J Am Med Assoc 1998; 279: 839–846.[Abstract/Free Full Text]

¹⁴ Scottish Inter Collegiate Guidelines Network. Obesity in Scotland. Integrating Prevention with Weight Management. SIGN (pub) No. 8. Edinburgh, 1996.

¹⁵ Meisler JG, St Jeor S. American Health Foundation roundtable on healthy weight. Am J Clin Nutr 1996; 63 (Suppl): 409s–411s.

¹⁶ National Heart, Lung and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. National Heart, Lung and Blood Institute June, 1998.

¹⁷ Centre for Reviews and Dissemination. The prevention and treatment of obesity. Effect Health Care 1997; 3: 2.

¹⁸ Ramsay LE, Yeo WW, Jackson PR. Dietary reduction of serum cholesterol: time to think again. Br Med J 1991; 303: 953–957.

¹⁹ Editorial. Don't bother with diet, says professor. Pract Nurs 1994; 5: 4.

²⁰ Tunstall-Pedoe H. What is the effect of change in blood lipids and diet on the risk of coronary heart disease? In Sharp I (ed.). Coronary Heart Disease Prevention in Undergraduate Medical Education. A report of a meeting held by the National Forum for Coronary Heart Disease Prevention in association with the British Heart Foundation. London: National Forum for Coronary Heart Disease Prevention, 1992: 27–33.

²¹ Waine C. A preventive service in primary care. In Waine C (ed.). Coronary Heart Disease. Prevention, Management and Rehabilitation. London: Royal College of General Practitioners, 1996: 11–28.

²² Royal College of Physicians of London. Prevention of Coronary Heart Disease. Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society. London, 1976.

²³ Department of Health and Social Security. Diet and Coronary Heart Disease. Report of the Advisory Panel of the Committee on Medical Aspects of Food Policy (Nutrition) on diet in relation to cardiovascular disease and cerebrovascular disease. London: HMSO, 1974.

²⁴ Ministry of Agriculture Fisheries and Food. The National Food Survey 1995. London: The Stationery Office, 1996.

²⁵ Department of Health. Eat Well. An action plan from the nutrition task force to achieve the Health of the Nation targets on diet and nutrition. London: Department of Health, 1994.

²⁶ Cant S, Killoran A, Calnan, M. Preventing Heart Disease. The Role of the Community Nurse. London: Health Education Authority, 1993.

²⁷ Dobson B, Beardsworth A et al. Diet, Choice and Poverty: Social and Nutritional Aspects of Food Consumption Among Low Income Families. Centre for Research in Social Policy: Loughborough University of Technology, 1994.

²⁸ Department of Health. Low Income, Food, Nutrition and Health: Strategies for Improvement. A report by the Low Income Project Team for the Nutrition Task Force. Health of the Nation Report. London: HMSO, 1996.

²⁹ Buttriss JL. Food and nutrition: attitudes, beliefs, and knowledge in the United Kingdom. Am J Clin Nutr 1997; 65 (Suppl): 1985s– 1995s.

³⁰ Thompson RL, Margetts BM et al. The Health Education Authority's health and lifestyle survey 1993: who are the low fruit and vegetables consumers? J Epidemiol Community Health 1998; 53: 294–299.[Abstract]

³¹ Mela DJ. Consumer estimates of the percentage energy from fat in common foods. Eur J Clin Nutr 1993; 47: 735–740.[Web of Science][Medline]

³² McCron R, Budd J. Mass communication and health education. In Sutherland I (ed.). Health Education Perspectives and Choices. George Allen and Unwin, 1979: 199–216.

³³ Stott NC, Pill RM. ‘Advise yes, dictate no’. Patients views on health promotion in the consultation. Fam Pract 1990; 7: 125–131.[Abstract/Free Full Text]

³⁴ Hiddink GJ, Hautvast JGAJ et al. Consumers' expectations about nutrition guidance: the importance of primary care physicians. Am J Clin Nutr 1997; 65 (Suppl): 1974s–1979s.

³⁵ Gallagher M. Patients' views. Pract Nurs 1994; 15: 8–12.

³⁶ Wallace PG, Brennan PJ et al. Are general practitioners doing enough to promote healthy lifestyle? Findings of the Medical Research Council's general practice research framework study on lifestyle and health. Br Med J Clin Res Edn 1987; 194: 940–942.

³⁷ Richmond R, Kehoe L et al. General practitioners' promotion of healthy lifestyles: what patients think. Aust NZ J Publ Health 1996; 20: 195–200.

³⁸ Slama KJ, Redman S et al. Community views about the role of general practitioners in disease prevention. Fam Pract 1989; 6: 203–209.[Abstract/Free Full Text]

³⁹ Department of Health and Welsh Office. General Practice in the National Health Service: A New Contract. London: Department of Health, 1989.

⁴⁰ LeTouze S, Calman M. The banding scheme for health promotion in general practice. Health Trends 1996; 28: 3.

⁴¹ Cade J, O'Connell S. Management of weight problems and obesity: knowledge, attitudes and current practice of general practitioners. Br J Gen Pract 1991; 41: 147–150.[Web of Science][Medline]

⁴² Wilt PH, Hubbard RNC et al. Knowledge, attitudes, treatment practices, and health behaviors of nurses regarding blood cholesterol and cardiovascular disease. Prev Med 1990; 19: 466–475.[Web of Science][Medline]

⁴³ Levine BS. A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of nutrition in medical practice. Am J Clin Nutr 1993; 57: 115–119.[Abstract/Free Full Text]

⁴⁴ Ienatsch, G. Knowledge, attitudes, treatment practices, and health behaviors of nurses regarding blood cholesterol. J Continuing Educ Nurs 1999; 30: 13–19.[Medline]

⁴⁵ Kushner RF. Barriers to providing nutrition counselling by physicians: a survey of primary care practitioners. Prev Med 1995; 24: 546–552.[Web of Science][Medline]

⁴⁶ Hiddink GJ, Hautvast JG et al. Nutrition guidance by primary care physicians: perceived barriers and low involvement. Eur J Clin Nutr 1995; 49: 842–851.[Web of Science][Medline]

⁴⁷ Helman A. Nutrition and general practice: an Australian perspective. Am J Clin Nutr 1997; 65 (6 Suppl): 1939s–1942s.

⁴⁸ McPherson K. A population approach to interventions in primary care: assessing the evidence. In Sharp I. (ed.). Coronary Heart Disease Prevention in Primary Care: The Way Forward. Report of an expert meeting. National Heart Forum. London: HMSO, 1995: 27–36

⁴⁹ Johnston A. Health related-behaviour change. In Sharp I (ed.). Coronary Heart Disease Prevention in Primary Care: The Way Forward. Report of an expert meeting. National Heart Forum. London: HMSO, 1995: 36–47

⁵⁰ Calnan M, Williams S. Coronary heart disease prevention: the role of the general practitioner. Final Report to the Department of Health. University of Kent. 1992. In Cant S et al. (eds). Preventing Heart Disease. The Role of the Community Nurse. London: Health Education Authority, 1993: 5.

⁵¹ Heywood A, Ring I. Screening for cardiovascular disease and risk reduction counselling behaviours of general practitioners. Prev Med 1994; 23: 292–301.[Web of Science][Medline]

⁵² Francis J, Roche M et al. Would primary health care workers give appropriate dietary advice after cholesterol screening? Br Med J 1989; 298: 1620–1622.

⁵³ Murray S, Narayan V et al. Study of dietetic knowledge among members of the primary health care team. Br J Gen Pract 1993; 43: 229–231.[Web of Science][Medline]

⁵⁴ Mant D. Effectiveness of dietary intervention in general practice. Am J Clin Nutr 1997; 65 (Suppl): 1933s–1938s.

⁵⁵ Silagy C, Muir J et al. Lifestyle in general practice: rates recalled by patients. Br Med J 1992; 305: 871–874.

⁵⁶ Parker D, Emmett PM et al. Final year medical students' knowledge of practical nutrition. J R Soc Med 1991; 85: 338.[Abstract]

⁵⁷ George M. Missing the target. Nurs Standard 1995; 9: 18–19.

⁵⁸ Department of Health. Nutrition Core Curriculum for Nutrition in the Education of Health Professionals. London: Department of Health, 1995.

⁵⁹ English National Board. Nutrition for Life: Issues for Debate in the Development of Education Programmes. London: English Nursing Board, 1995.

⁶⁰ Senior, A. Nutrition for life. Nurs Standard 1998; 12: 26–28.

⁶¹ Cadman L, Wiles R. Nutrition advice in primary care: evaluation of practice nurse nutrition training programmes. J Hum Nutr Dietet 1996; 9: 147–156.

⁶² Ockene JK, Ockene IS et al. Physician training for patient centered nutrition counseling in a lipid intervention trial. Prev Med 1995; 24: 563–570.[Web of Science][Medline]

⁶³ Davis DA, Thomson MA et al. Changing physician performance. A systematic review of the effect of continuing medical education strategies. J Am Med Assoc 1995; 274: 700–705.[Abstract/Free Full Text]

⁶⁴ Oxman AD, Thomson MA et al. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J 1995; 153: 1423–1431.[Abstract]

⁶⁵ Wensing M, Grol R. Single and combined strategies for implementing changes in primary care: a literature review. Int J Qual Health Care 1994; 6: 115–132.[Abstract/Free Full Text]

⁶⁶ Society for Nutrition Education. Nutrition education and implications. In service preparation in nutrition education for professionals and paraprofessionals. J Nutr Educ 1995; 27: 347–353.

⁶⁷ Weinsier RL. Medical-nutrition education—factors important for developing a successful program. National Dairy Council Award for Excellence in Medical/Dental Nutrition Education Lecture, 1995. Am J Clin Nutr 1995; 62: 837–840.[Abstract/Free Full Text]

⁶⁸ Kushner RF, Thorp FK et al. Implementing nutrition into the medical curriculum: a user's guide. Am J Clin Nutr 1990; 52: 401–403.[Abstract/Free Full Text]

⁶⁹ Baker R, Khunti K. Educational outreach: a practical method for changing clinical practice. Audit Trends 1996; 4: 22–23.

⁷⁰ Cadman L. Bite-sized training. Pract Nurs 1996; 17: 607–609.

⁷¹ Spencer-Jones R. Self-directed learning- where now? Educ Gen Pract 1998; 9: 498–501.

⁷² Elwyn GJ. Professional and practice development plans for primary care teams. Br Med J 1998; 316: 1619–1620.[Free Full Text]

⁷³ van Weel C. Morbidity in family medicine: the potential for individual nutritional counselling, an analysis from the Nijmegen Continuous Morbidity Registration. Am J Clin Nutr 1997; 65 (Suppl): 1928s–1932s.

⁷⁴ Raw M, McNeil A, West R. Smoking cessation: evidence based recommendations for the healthcare system. Br Med J 1999; 318: 182–185.[Free Full Text]

CiteULike    Connotea    Del.icio.us    What's this?

This article has been cited by other articles:

				L. R. Simkin-Silverman, M. B. Conroy, and W. C. King Treatment of Overweight and Obesity in Primary Care Practice: Current Evidence and Future Directions American Journal of Lifestyle Medicine, July 1, 2008; 2(4): 296 - 304. [Abstract] [PDF]

				J. J van Binsbergen and A. J. Drenthen Patient information letters on nutrition: development and implementation Am. J. Clinical Nutrition, April 1, 2003; 77(4): 1035S - 1038. [Abstract] [Full Text] [PDF]

This Article Abstract FREE Full Text (PDF) E-letters: Submit a response Alert me when this article is cited Alert me when E-letters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Search for citing articles in: ISI Web of Science (7) Request Permissions Google Scholar Articles by Moore, H. Articles by Waine, C. Search for Related Content PubMed PubMed Citation Articles by Moore, H. Articles by Waine, C. Social Bookmarking          What's this?

Online ISSN 1460-2229 - Print ISSN 0263-2136

Copyright © 2009 Oxford University Press

Oxford Journals Oxford University Press

• Site Map
• Privacy Policy
• Frequently Asked Questions

Other Oxford University Press sites: Oxford University Press Oxford Journals China Oxford Journals Japan American National Biography Booksellers' Information Service Children's Fiction and Poetry Children's Reference Corporate & Special Sales Dictionaries Dictionary of National Biography Digital Reference English Language Teaching Higher Education Textbooks Humanities International Education Unit Law Medicine Music Online Products Oxford English Dictionary Reference Rights and Permissions Science School Books Social Sciences Very Short Introductions World's Classics