Dietary advice in British General Practice - Nature

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Dietary advice in British General Practice. D Pereira Gray1*. 1Professor of General Practice, University of Exeter, Barrack Road, Exeter, Devon, UK. Diet is a ...
European Journal of Clinical Nutrition (1999) 53, Suppl 2, S3±S8 ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00 http://www.stockton-press.co.uk/ejcn

Dietary advice in British General Practice D Pereira Gray1* 1

Professor of General Practice, University of Exeter, Barrack Road, Exeter, Devon, UK

Diet is a major determinant of health. It is now clear that at least as far as reducing the content of fat and sugar and increasing the content of fruit and vegetables is concerned, considerable gains can reasonably be expected if populations can be persuaded to alter their life style. In Western societies family medicine=general practice forms the front line of the Health Service and in the United Kingdom the contact rate between the population and primary care doctors now averages ®ve encounters a year and relationships last an average of eleven years. This gives primary care, particularly in the form of multiprofessional teams of doctors and nurses, a substantial opportunity to explain the principles of healthy eating. Primary care worldwide is increasingly taking on responsibility for advising on life style, for example with smoking, immunisation, family planning etc. The provision of dietary advice in primary care is already common in the management of many chronic diseases, like hypertension and hyperlipidaemia, where over 90% of patients are exclusively managed in family medicine. It is probable that the provision of dietary advice will in future extend beyond diseased patients and will play a much higher role in relation to healthy patients. Descriptors: diet; general practice; primary care

Introduction There is an old Chinese aphorism that `We are what we eat'. On the whole this was relatively ignored until the last 25 y, but nowadays it is increasingly recognised in the rest of the world that there lies within these ®ve simple words a profound truth. The awareness that human behaviour affected health was relatively slow in coming because in the second half of the nineteenth and the ®rst half of the twentieth century infectious disease dominated the medical agenda. Small pox was a worldwide scourge, and my father, working as a family doctor in Exeter, in the South West of England, saw diphtheria as a major problem. I have talked with older women patients in our general practice, who tell me of diphtheria causing three deaths in a single family in a single epidemic. Even in my lifetime, tuberculosis and poliomyelitis were big medical problems. Behaviour Two big steps occurred in medical thinking within a year of each other. First Lalonde (1975), a Minister of Health in Canada, published the Lalonde report. In summary, this showed that by then the evidence was that human behaviour in general was a major determinant of illness and death. Of course this was behaviour in general and not just dietary behaviour, but the point was made in a report that had worldwide impact. The very next year McKeown (1976) writing from the UK, published The Role of Medicine ± Dream Mirage or Nemesis. This put the issue another way round and emphasised the in¯uence of the environment on health and disease. *Correspondence to: D Pereira Gray, Professor of General Practice, University of Exeter, Barrack Road, Exeter, EX2 5DW, Devon, UK

These two key publications combined had the effect of focusing attention on non-infectious causes of disease. Recent ideas such as from Dickerson (1998) suggest that `There now seems to be suf®cient evidence to justify serious attention being given to a relationship between food, nutrition, and truancy, expulsion from school and anti-social or violent behaviour'. Diet In a whole variety of ways, the incidence and prevalence of disease is now being linked to the way people eat. Moreover this relationship holds for many of the most important diseases of our time, namely those from which the greatest number of people die. In particular, dietary habits have been linked with the incidence and prevalence of diseases and death rates for ischaemic heart disease and cancer, the two principal causes of death in the Western world (Austoker, 1994). De®nitions Food is such a big issue and includes such a wide variety of substances, that it is necessary within the con®nes of a single lecture to draw some boundaries. First, although controversial, I will not include alcohol. Secondly, I am including dental caries, although the condition is managed mainly by dentists not doctors, because of the link with eating sugar. Thirdly, I will brie¯y include breast feeding, which is usually considered separately, but by de®nition is an important form of human feeding. Finally, I will not touch on beef consumption, which seems to be a special case and has political rami®cations. UK approach My approach will be to follow as best I can the brief that you have given me, namely to describe and comment on nutrition and health from a British point of view. Where the multicultural nature of British society seems particularly

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relevant, then I will comment brie¯y on ethnic issues. I apologise that I cannot read Dutch and I never cease to admire the way colleagues in the Netherlands often are ¯uent in at least four European languages. I am dealing primarily with policies and publications in the United Kingdom, as this is what I have been asked to do. In doing so, I have drawn heavily on a Committee of the British Government called the Committee On Medical Aspects of Food and Nutrition Policy. This is usually abbreviated to COMA. It is traditionally chaired by the Chief Medical Of®cer for England and attended by the Chief Medical Of®cers for Scotland, Wales and Northern Ireland. It has one general practitioner member, Professor Godfrey Fowler, OBE, Emeritus Professor of General Practice at the University of Oxford (COMA, 1989; 1991a,b; 1992; 1993; 1994a,b; 1995, 1996, 1997, 1998a,b). Breast feeding It is obvious that breast feeding is the natural source of nourishment for babies, but substantial cultural and organisational factors inhibit breast feeding for many mothers all round the world. Commercial issues are so great that the World Health Organisation has found it necessary to intervene to try to restrain the aggressive marketing of arti®cial milk, especially in developing countries. Our health promotion slogan is `Breast is best'. This is because of the balance of the composition of human milk and the transfer of protective substances thought to be mainly antibodies. Breast-fed children are measurably healthier, develop fewer infections, and are less likely to become obese. In fact in the UK, we have sharp differences in breast feeding rates both by geographical area, by ethnic group, and by social classes. Geographical areas In 1995, initial breast feeding rates were 68% in England and Wales, 55% in Scotland, and signi®cantly lower, being only 45%, in Northern Ireland. The likelihood of breast feeding correlates positively with the mother having received a higher education and being a higher social class. By 6 weeks after the baby's birth, breast feeding was continuing in 65 ± 66% in England, Scotland and Wales but was less in Northern Ireland (COMA, 1995). Ethnic factors Ethnic factors are important (Qureshi, 1989). COMA (1997) reported that 10% of Bangladeshi babies, 18% of Indian, 24% of Pakistani, and 38% of white babies were only ever bottle fed. Trends The most important ®gure is the trend in the proportion of mothers breast feeding. This fortunately shows a slow but progressive increase in the proportion of babies being breast fed (Martin, 1978; Martin & Monk, 1982; Martin & White, 1988; Martin et al, 1992). Folate intake in pregnancy In 1995, 75% of mothers knew that their intake of folic acid in early pregnancy `could be good for them and their baby' (COMA, 1997).

Anaemia in children I will argue later that overnutrition is becoming a bigger problem in the Western World. However, whilst thinking about children I must mention the work of a general practitioner in the South West of England (James et al, 1995) who has written three articles over a few years in the British Medical Journal all showing that anaemia in children is a signi®cant problem in his general practice in Bristol, that it is commoner in certain ethnic groups, and that it can be diagnosed and treated in general practice. Caries The opinion for several years in the UK is that dietary sugar consumed by children is associated with an increased risk of later development of dental caries (COMA, 1989). In the UK this has been challenged by the food industry, for example by the Sugar Bureau (1998) Food Safety Information Bulletin: The Sugar Bureau Submission Bulletin 94. This has not affected government policy, which remains as originally stated and children's medicines are being altered to reduce the sugar content. Obesity Obesity has been a growing problem for many years. By 1993, 13% of men and 15% of women (OPCS, 1993) were obese and over half of the British population was overweight. By 1996, the Health Survey of England showed 16% of men and 17% of women were obese (PrescottClarke & Primatesta, 1996). At least in the UK, obesity is getting worse. Since more than half of the population is now overweight, it appears that the commonest problem of nutrition in population terms in the UK is now over-nutrition rather than undernutrition. Nevertheless, recent surveys show serious pockets of undernutrition especially in association with the presence of poverty and hospital admission for example. Nutritional advice in general practice and primary care Primary care has emerged as the dominant issue in healthcare world-wide. It has long been established as the leading form of ®rst contact care here in the Netherlands and in the UK. However, developments like the health maintenance organisations in the USA and now new changes in France, all con®rm that governments increasingly realise the central importance of the primary health component of national health systems. To answer the main question given to me by the organisers of this conference, namely whether primary care can be expected to deliver dietary advice it is necessary to seek out the key facts. Three subsidiary questions arise: does primary care have the opportunity (both in terms of contacts and in time), do primary care staff have the motivation, and do they have the ability to provide appropriate care about eating? I propose to tackle each of those in turn. I apologise, since I cannot read Dutch, and your Journal Huisarts en Wetenschap, I have to rely on British statistics. Nevertheless, there is a wealth of material con®rming the close alliance both in philosophy and in practice between Dutch

Dietary advice in British General Practice D Pereira Gray

and British general practitoners, so I hope the conclusion will be of interest and relevant to colleagues here in the Netherlands. First we need to de®ne who in the UK we include as primary care staff. For the purpose of this lecture, I include district nurses, general medical practitioners, health visitors (public health nurses working from general practices) and practice nurses. All these normally work together in the primary health care teams. In addition, working in primary care, but outside these teams are dentists and pharmacists. The key advice Before we can study role or effectiveness, it is necessary to determine if there is any consistency or consolidation in terms of the research evidence about eating and health. It would be easy to give a lecture about this one part of the topic and I refrain from doing so in order to tackle the topic you have given me, namely the relationship and the role of primary care. Suf®ce it to say that research in a whole range of major diseases, notably ischaemic heart disease, diabetes, and cancer is all leading in the same direction and fortunately actually agreeing. It follows that some golden principles have emerged: People should eat less fat and preferably not more than 30% of their energy requirement. Vegetables and fruit are under-eaten and have substantial health promoting properties. Our diets should include more ®bre; ®sh can be eaten with bene®t; alcohol if taken in moderation is not harmful. Without summarising all the evidence and over simplifying somewhat, I suggest that we can take it that these six points, fat, fruit, vegetables, ®bre, ®sh and alcohol, are reasonably agreed. They represent the six key messages we hope general practice can deliver. 1. Is there the opportunity? No system of offering advice on healthy eating and drinking can be effective if the providers do not have access to reasonably large proportions of the population. What are the facts? In the UK, 98% of the population is registered through the NHS with a general practitioner. Access is free at the time of consultation and all referrals made through the NHS are free to the patient. After initial registration, no further documentation is required of patients. General practitioners have an average contact, according to Government statistics based on a randomly selected survey of all the population, of ®ve consultations per patient per year (Of®ce for National Statistics, 1998). Since another national survey has shown that the average duration of a consultation with a general practitioner is 9.4 min (Review Body on Doctors' and Dentists' Remuneration, 1998), it is obvious that in Britain an NHS patient on average receives from a doctor in the practice 47 min per year (Pereira Gray, 1998). However, this is 47 min for the patients and another 47 min with the patient's wife or husband and another 47 min on average with each child. As patients stay registered with the same general practitioner for 11 y, it follows that patients average 11 6 47 ˆ 557 min (that is over nine h ˆ 540 h) with their general practice. Contact time with practice nurses, district nurses, health visitors, dentists and pharmacists are over and above this. In the UK, health visitors, who are in effect public health nurses, are attached to general practice and work from

them. I realise that arrangements are very different in different countries and health systems. However health visitors give a huge amount of dietary advice. In a general practice like mine, they lead on mother care and advice on infant management and diet. This big source of advice has been little evaluated. It is unwise to draw conclusions about the multi-professional primary health care team, until it has been evaluated as a team. It seems reasonable to conclude in terms of access and number of contacts that the opportunity is there. 2. Do primary care staff have the motivation? Motivation can be measured in various ways. Some general practitioners have been writing about the consequences of poor diet and doing something about it for many years. Thomas (1952) studied nutritional disorders for his MD thesis in 1952. Craddock was the ®rst general practitioner to write a book on this subject and his Obesity appeared as early as 1969. Craddock gave dietary advice himself and obtained impressive results in general practice. McMullen (1966) showed a general interest in advising the healthy in general practice. Another approach is to provide a service by a dietitian, within a general practice. One of the ®rst such reports was by Yorke et al, (1973). They showed that it was perfectly possible to provide such a service and patients took to it well. Whether general practitioners have the motivation to become involved with what Lalonde (1975) called life style changes, can now be answered de®nitively. Following a succession of Reports from General Practice in 1980 ± 1982, from the Royal College of General Practitioners (1982, 1984, 1986), personal prevention was soon incorporated into the work of the modern family doctor. Other bodies advising general practice include BMA (1986); Buttriss (1994, 1995) and Birkbeck (1998). Quite how much has been achieved is not often described but it includes: Personal preventive medicine Immunisation against polio, diphtheria, tetanus, whooping cough and meningitis, rubella in females and increasingly in males as well, tetanus immunisation for adults. Child health surveillance for all children. Antenatal care for pregnant women. Blood pressure screening for all adults. Cervical cytology for all adult women. Anti-smoking advice. Geriatric screening assessments for all population aged over 75 y. In¯uenza immunisation for the elderly. Family planning advice (70% of family planning in the UK NHS is provided in general practice). Effective coverage For many of these national programmes coverage for the whole population has exceeded 90%, for example with immunisations, and is approaching 95% in some areas. In others, like cervical cytology there is greater variation, but coverage rates of over 80% of all eligible women are achieved by 80% of general practices. Others vary between practices, but it is already clear that comprehensive national coverage of at risk populations, and in appropriate circumstances whole national populations, is

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now, thanks to desktop computing, a reality (Pereira Gray, 1997). The evidence is that, at least in the UK, general practice is extensively involved in personal preventive medicine. Secondly, general practice is already very much involved in seeking to promote life style changes among registered patients. The question then is what about diet alteration amongst life style changes such as smoking and exercise? 3. Evidence of effectiveness Evidence of effectiveness comes in two forms. First, implied competence arising from ®ndings from various surveys measuring, for example, the knowledge amongst either general practitoners, practice nurses, or the whole primary healthcare team. There have been studies on family doctor knowledge (Avenell et al, 1983) and effectiveness (Baron et al, 1990). Knowledge Thus Murray et al (1993) studied dietetic knowledge among members of the primary health care team. They had a `broad understanding of recommendations for healthy eating, but there was some confusion over speci®c aspects of these recommendations'. Earlier this year, Cadman & Findlay (1998) (both dietitians) reported on assessing practice nurses' change in nutrition knowledge following training from a primary care dietitian. They found that `nutrition knowledge increased considerably'. It seems, at present, that whilst there is always room for improvement in knowledge, ignorance about diet amongst members of primary care teams is not the main barrier to provision in primary care and learning about nutrition can be achieved. Altering behaviour in patients Wallace et al (1986) showed that in randomised control trial general practitioner intervention was effective in reducing alcohol consumption. What must be the acid test, is whether the patients actually alter their behaviour. Behavioural change is currently a big topic in medicine and amongst behavioural psychologists. It is hard to achieve and also the research methods are complicated to allow for in¯uences from outside the source studied and to measure real change accurately. Starting with patient reports, which are of course subjective, Simons (1990) in an unpublished PhD thesis found to her surprise that general practitioner advice when compared with that of an attached dietitian in the same practice was equally effective. She was not able to ®nd out why, but noted that the primary care practitioner talked with patients he knew, gave broad, simple principles and avoided detail. He worked in consultations of about ten minutes duration but of course saw patients repeatedly. The dietitian gave much detailed advice and her consultations lasted an average of half an hour. Objective evidence There is objective evidence that general practitioners respond to new research evidence and change their behaviour. The Scandinavian Simvastatin Survival Study (known colloquially as the 4S study) was published in 1994. General practitioners' prescribing of statins in the

UK sharply rose immediately afterwards and is continuing to do so. In almost all cases dietary advice will have been given previously as well as at the time of prescribing. The problem is that it has not been possible to identify the frequency, the competence, or the effect. These must therefore be research priorities for the future. Weight reduction is one possible objective measure and has been widely used. There is reasonable evidence that some practitioners can help patients lose weight, but patient self-help groups appear to achieve this more simply and at less cost to Health Services. Changes in blood levels More complicated advice is needed in diabetes and for example in the primary, secondary, and tertiary prevention of ischaemic heart disease. This involves discussions about saturated and polyunsaturated fats and other foods. Some impact can be made as the big British OXCHECK study showed, but the outputs were disappointing in terms of the resources expended. On the other hand Evans (1995) found that it was possible to lower mean serum cholesterol levels by 9.0% without any extra resource or nurses and by simply using usual medical contacts with general practitoners. Mant, the new Professor of General Practice at the University of Oxford, UK wrote in 1997 that it is possible to achieve: `Small changes in plasma cholesterol concentrations'. He considers the prime role is sensitising the patients consulting to public health messages and supplying written material at a time when patients are especially receptive. This raised the question as to how small is small. Professor Peto, a statistician, also from the University of Oxford has calculated that a 1% reduction in serum cholesterol will translate into a 3% fall in coronary thromboses. In that case, if Evans' 9% can be replicated then a 27% fall in heart attacks could be expected. Obstacles to the provision of dietetic advice in general practice Many surveys have identi®ed obstacles. These include time, loss of remuneration and concern about the value of the work. Drenthen (1997) in the Netherlands has summarised these after studying 118 general practitioners for 2 years. He thought medical school training taught mainly curative models of medical care and some practitioners wondered or doubted if their patients would welcome let alone accept advice about life style. In the UK this has been researched, Wallace & Haines (1984) found that patients would accept, and indeed expected, such advice from family doctors. There may be cultural issues as Drenthen has written `Dutch GPs show reluctance towards preventive work'. Hiddink et al (1995) from the Dutch Dairy Foundation on Nutrition and Health surveyed GPs' views on obstacles by questionnaire. They found a reported interest in education. The patients' opinions Whatever advice doctors and nurses may give, how much advice is accepted and how often patients will attend, depends to a considerable extent on the patients' health beliefs. Naslund et al (1994) working at the Karolinska Hospital, Stockholm showed that men not participating in a

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randomised study of dietary intervention in general practice were not more ignorant, indeed they knew more, but believed less in the bene®ts of diet. Conclusions Diet has emerged as a major determinant of health. A modern health system must accept the evidence that the health of western populations can be improved if people could be persuaded to eat more healthily. Much can be done by public health measures such as pricing mechanisms and taxes which are outside the scope of this lecture. People, at least in the UK, expect advice in primary care (Wallace & Haines, 1984) and it is effective (Wallace et al, 1984). Primary care certainly has the opportunity. The research so far suggests that it is not often taking it, but the research has been limited to surveys and questionnaires. What is obviously needed is detailed analysis of consultations, such as through video recording, to quantify exactly what advice is given, how much and what helps to make it happen. It is likely to be true, as Mant suggests, that supporting practitioners and primary care nurses with good high quality written handouts would help, but these are expensive and it is not yet clear who is to pay. Research should not be conducted only by specialist outreach teams. Active research leadership is needed by those skilled both in research and clinical general practice. Generalists do not think in the same way as specialists (Sweeney et al, 1998) and a generalist perspective is not an optional extra, but a fundamental requirement. It is probable that primary care is more effective than it is being given credit for at present. Some reports are encouraging and more needs to be done to generalise from successful models. Advice such as fat consumption in the UK is falling, as is the coronary thrombosis incidence rate. Research is needed to identify exactly how important and effective advice in primary care is. Acknowledgements Ð I would like to thank the Dairy Foundation on Nutrition and Health of the Netherlands for the kind invitation to come to Heelsum and deliver this lecture. I appreciated being part of an international seminar held in Amsterdam on research priorities in medicine in 1994. It is always a pleasure to come to the Netherlands and to meet medical colleagues and friends here. I would particularly like to thank Professor Christopher van Weel and his wife, Dr Evelyn Baumgarten-Van Weel, who are old friends in this country.

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