6/9/2017
What can be improved with regard to dietary assessment of people at high risk for cardiovascular diseases in the general practice in The Netherlands?
Camiri NC, Lopez V
University Medical Center Utrecht
For questions regarding this thesis project, an e-mail can be sent to: umcuproject@gmail.com.Table of Contents
PREFACE 3TERMINOLOGY 4
SUMMARY 5
INTRODUCTION 6
METHODS 8
RESULTS 11
DISCUSSION 15
CONCLUSION 19
RECOMMENDATIONS 20
REFERENCES 22
APPENDIX I: GENERAL PRACTICES IN WHICH THE PCP WERE WORKING 24
APPENDIX II: THE RATE YOUR PLATE TOOL 25
APPENDIX III: THE INTERVIEW SET-UPS 29
APPENDIX IV: THE INTERVIEW TRANSCRIPTS 33
Interview 1
33
Interview 2
37
Interview 3
41
Interview 4
43
Interview 5
46
Interview 6
50
Interview 7
54
Interview 8
57
Interview 9
61
Preface
Having conducted this research, we believe to have collected valuable and useful information with regard to prevention on the level of Cardiovascular Risk Management (CVRM). We managed to map out the current situation, restrictions and improvement opportunities regarding dietary assessment within CVRM consultations, which are pillars of CVRM optimization. It was a pleasure to work on this thesis project and we want to give our thank word to all our supervisors which provided us valuable feedback on sharpening the thesis and to all who cooperated. Also we gave a presentation in which the results were presented to the researchers in the Cardiovascular team of the Julius Centre of the UMCU. We would also like to thank them for their time and consideration. We are waiting with curiosity for integration of a Prior-To-Consultation Tool in the form of an app in CVRM consultations in The Netherlands and hope to see its positive effects on CVRM. May 20, 2017 Cagri Camiri, Valentina Lopez
Terminology
Term / abbreviation Definition cvd Cardiovascular Diseases CVRM Cardiovascular Risk Management GP(s)s General Practitioner(s) Pcp Primary Care Providers PN(s) Practice Nurse(s) RCTs Randomized Control Trials CIS (KIS) Chain Information System (In the Dutch language called: Keten Informatie Systeem) cvd-RP Cardio Vascular Disease-Risk Products (butter, hard-margarines, fatty meat, fatty milk products and fatty snacks) cvd-RN Cardio Vascular Disease-Risk Nutrients (saturated fat, trans fat, free sugars and sodium) GPIS (HIS) General Practice Information System (in the Dutch language called: Huisartsen Informatie Systeem) RYP Rate Your Plate PCT Prior-to-Consultation Tool POF Plate Of Five (In Dutch: de Schijf van Vijf)
Summary
Background: Cardiovascular diseases is a growing problem in the Netherlands. It is the most important cause of death in women, and second cause of death in men. In 2012, 15% of the Dutch population visited the General Practitioner for cardiovascular complaints or diseases. The Nederlandse Huisartsen Genootschap guideline addresses that dietary intake can modify cardiovascular risk. However, it is unknown what primary care providers do with regard to dietary assessment in Cardiovascular Risk Management consultations. Possibly there are barriers to make dietary assessment possible. The assumption is that primary care providers do not have time for dietary assessment and that they also lack the diet-related knowledge. Perhaps they lack a simple tool to help them with the dietary assessment. This research has taken a closer view on it. Research question: What can be improved with regard to dietary assessment of people at high risk for cardiovascular disease in the general practice in The Netherlands? Methods: For this research, interviews were conducted under primary care providers to collect information about the current way of dietary assessment in Cardiovascular Risk Management consultations in the general practice. In the interviews it was also asked what primary care providers think about their way of assessing diet, if they see room for improvement and how it can be improved. It was aimed to recruit 18 primary care providers. Eventually, 9 primary care providers were recruited. Furthermore, a systematic literature search was conducted to search for dietary assessment tools that are used in Cardiovascular Risk Management consultations in the general practice. Results: Primary care providers find dietary assessment important within Cardiovascular Risk Management, but that they do not have the same knowledge as a dietician to assess the diet specifically. Also they lack time to do so and procedures regarding dietary assessment are not always standardized in the general practices. Primary care providers find a tool, that can be used for dietary assessment before consultation, useful. One tool was found in literature: the ‘Rate Your Plate’. An American dietary assessment tool that easily can be filled in before consultation. Conclusion: A simple Prior-to-Consultation dietary assessment tool, like the Rate Your Plate (RYP) tool, is desired by primary care physicians for Cardiovascular Risk Management consultations as they believe it is a proper solution to tackle the restrictors ‘lack of time’ and ‘lack of standardization’. Keywords: primary care providers, Cardiovascular Risk Management, tool, general practice, diet
Introduction
The organization for which the research will be conducted is the University Medical Centre Utrecht (UMCU). The UMCU is one of the eight academic/ university hospitals in The Netherlands involved in a variety of (specialised) activities regarding health care. The Julius Centre is one of the 11 divisions of the UMCU and aims for a leading role in the acquisition and dissemination of knowledge in the field of Health Sciences and Primary Care. This is done by means of pioneering research on four research programs, by offering high quality teaching programs to (bio) medical students, researchers, clinicians and other health care professionals, and by providing academic primary health care (UMC Utrecht Julius Centrum, n.y.). The research “What can be improvement with regard to dietary assessment of people at high risk for cvd in the general practice in The Netherlands?” has been conducted in order of the Julius Center. In The Netherlands, Cardiovascular diseases (cvd) are the most important cause of death in women and second cause of death in men. In 2012, approximately 40.000 Dutch people lost their lives as a consequence of cvd what equals to 30% of the total amount of deaths in The Netherlands (Nederlands Huisartsen Genootschap, 2012). Research has shown that in 2012, 15% of the Dutch population visited the General Practitioner (GP) for cardiovascular complaints or diseases (CBS, 2016). Fortunately, many of the risk factors for cvd can be modified by behavioural change such as stop smoking, daily physical activity and dietary intake modification (Nederlands Huisartsen Genootschap, 2012) (Rees K, 2013) (Siervo M, 2015). The currently known detectable risk factors for cvd which can be modified by dietary intake modification are: high bloodpressure, hypercholesterolemia, hyperglycaemia, hypertriglyceridemia, overweight and obesity (Nederlands Huisartsen Genootschap, 2012). Therefore, emphasis on dietary intake has started to get an increasingly prominent role in cardiovascular prevention guidelines for GP (Nederlands Huisartsen Genootschap, 2012). With regard to dietary assessment, the NHG guideline (2012) recommends to assess diet and addresses between parantheses saturated fat, fish, vegetables, fruit, salt intake and alcohol). With regard to dietary treatment, it advises a diet according to the Richtlijnen Goede Voeding (RGV. Guidelines Healthy Food, in English) and The Nederlands Huisartsen Genootschap care module lifestyle food guideline. The exact advice is as follows (Nederlands Huisartsen Genootschap, n.y.): - Eat daily 150-200 gram vegetables and 200 gram of fruit - Eat daily 30-40 gram fibers - especially present in vegetables, fruit and grains. - Eat twice a week 100-150-gram fish, of which one-time fat fish. - Do not use more than seven times a day food products or drinks with easily fermentable sugars or acid. - Do not use more than 6 gram salt a day - Men: do not drink more than 2 glasses a day - Women: do not drink more than 1 glass a day However, it is unknown if pcp (primary care providers) pay attention to dietary assessment of patients who are at high risk of cvd, as recommended in the guidelines (Dillen, 2007). Furthermore, knowledge is lacking on whether pcp see room for improvement of dietary assessment in CVRM consultations in the general practice and what potential facilitators and barriers for pcp are. The Julius Centre speculates that the following factors can be barriers: lack of a simple tool, lack
To get insight in the abovementioned, interviews will be designed and conducted with pcp. Moreover, it is also unknown if there are practical instruments available for dietary assessment, if they are validated, which elements those are made of, and which barriers and facilitators are mentioned in literature. A literature search is needed to clarify this. This needs to be investigated in order to check if there are leads for improvement of dietary assessment to optimise health care provided to patients who are at high risk of cvd. Based on the results of the above mentioned, advice will be given on the type and content of a tool to improve dietary assessment in CVRM consultations in the general practice in The Netherlands. In order to investigate if there is need for a tool to improve dietary assessment in the general practice and to investigate which elements it should include, the following research question is set up: What can be improved with regard to dietary assessment of people at high risk for cvd in the General practice in The Netherlands? Sub-questions 1. Is there a discrepancy between how important pcp find dietary assessment within CVRM consultations and their current knowledge? 2. What do pcp currently do with regard to dietary assessment of people at high risk for cvd in primary care and is this in accordance with the advice in the CVRM guidelines? 3. Do pcp see restrictors for dietary assessment and do they desire improvement, if so, what are those restrictors and what can be improved? 4. Are there practical instruments available for facilitating dietary assessment of people at high risk for cvd that can be used by pcp, which elements do those consist of and are they validated? The overall aim of this research is to investigate if pcp would find it useful to have a tool that would aid diet-related assessment of people with a high risk profile for cvd, and to evaluate which elements should be included in such a tool. As a result, the GPs and Practice Nurses (PNs) are given more insight in the methods with which they can assess those people. The health related contribution of the tool, is that it is expected that it can help optimise CVRM related consultations on a region-wide level and possibly even on a nation-wide level. The society related relevance of the research is a decrease in the prevalence of (risk factors of) cvd. At the end of the project, June 2017, four sub-research questions will be answered in the form of a research paper (the final product) with recommendations for the development of a concept tool. After development of such a concept tool, it will be possible to set up a pilot study to gain more insight in the efficiency and effectiveness of the concept tool, and to evaluate the need for implementation on a larger scale. Reading guide: First, the methods used to conduct this research will be explained. Then, the results will be described, followed by the discussion and conclusion. Eventually, recommendations will be given.
Methods
This research includes an interview and a systematic literature search. Interview A structured interview was conducted to answer the first three sub-researchquestions. This kind of interview was chosen as beforehand there was an expectation of the kind of answers that were likely to be given (Brinkman, 2011). The following was aimed to be investigated by conducting the interviews: - Is there a discrepancy between how important pcp find dietary assessment within CVRM consultations and their current knowledge? - What do pcp currently do with regard to dietary assessment? - Do pcp know from each other what they are doing with regard to dietary assessment? - To what extent do pcp know what the guidelines for CVRM address about tackling risk factors of cvd for adults ((aged 19+) by diet? - Is the current method of dietary assessment by pcp in accordance with the guidelines? - Do pcp give general dietary advice themselves or do they refer people with a high risk of cvd to a dietician? - What are the experienced barriers and facilitators within dietary assessment; - Would pcp find improvement of the current method of dietary assessment useful? - What is needed to improve the current method of dietary assessment? - Are there differences between pcp groups (GPs, GPs specialized in CVRM and PNs)? Attention was paid to formulating the interview questions as concretely as possible, to optimize validity (Brinkman, 2011). One interview was set up for GPs and GPs specialized in CVRM and one for PNs. For the complete nterview set ups, see Appendix 3. Target group and recruitment A representative selection of respondents – pcp - were recruited via a personal network of a GP specialized in CVRM and a search on the search machine Google. The search phrase “huisartsenpraktijk (in English: general practice)”, followed by city names from the province Utrecht, was entered in Google, where after the respondents were approached via the e-mail addresses and telephone numbers addressed on the websites of the general practices. The search continued until all general practices in the province Utrecht addressed on Google were approached. It was aimed to recruit approximately six GPs, six GPs with a specialisation in CVRM, and six PNs. To achieve this, it was estimated to be sufficient to approach ten persons of each group. This amount was set, as it was a realistic amount to recruit in the amount of time that was reserved for conduction of the interviews. The inclusion and exclusion criteria for the interviewees are presented in table 1. Table 1: Inclusion and exclusion criteria for the interviewees Inclusion criteria Exclusion criteria GPs, GPs specialized in CVRM, and PNs involved in CVRM (around Utrecht) who are involved in the treatment of people (aged 19+) who are at a high risk of cvd in the Netherlands Diabetes Nurses, specialists not involved in CVRM treatment. When setting up the inclusion criteria attention was paid to include all disciplines that are involved
Interview circumstances The interviews were conducted with Dutch speaking pcp and voice-recorded with their approval. Recording was used in order to make listening to the interviewees afterwards possible. By doing so no any information was missed (Brinkman, 2011). The interviews took place telephonically, as pcp usually work during day-time and for that reason only have time during the evenings. The estimated time that was needed was between 20 minutes and 30 minutes. To assure good time-management, a stopwatch was used during the conduction of the interviews. Analysis of the interviews Hence, the transcripts of the interviews were typed out and analysed in the Dutch language to prevent misinterpretation. Those records were included in the research paper as Appendix 4. The computer program MAXQDA Analytics Pro 12.2.1 was used for the analysis (MAX QDA, n.y.) .The function of this program is that it is capable of labelling transcripts, ordering and categorizing data in order to facilitate conclusion-making. This was done and descriptive statistics were performed by this program, whereas calculations of the mean for the scale-questions, was done via the computer program Microsoft Excel. The results were described and presented in percentages or n-numbers (an amount of interviewees who said a particular fact). General information about the general practices – such as the amount of staff members and the amount of patients – was taken up in the form of a table in an Appendix. Systematic literature search The third and fourth sub research questions were answered by conducting a systematic literature search in international databases. The output of the systematic literature search was descriptive and mainly answered qualitative questions, see table 2 for more details. The exact types of research that were needed to answer the questions are shown in table 2. Note that there can be overlap within the types of research. A RCT for example, can contain descriptive pieces of text with which the first three questions can be answered. Table 2: Sub-sub research questions and types of research Question to be answered Qualitative or
quantitative origin Type of research needed 1. Are there practical instruments available for dietary assessment of people at high risk for cvd that can be used by GPs Qualitative Descriptive 2. Which elements do those available tools, if there are any, consist of; how many of them do not only measure dietary intake, but also give advice (including the type of advice)? Qualitative Quantitative Descriptive Evaluation studies 3. How many of the available tools are validated and for which populations within the people with a high risk for cvd are they meant? Quantitative
Qualitative Validity studies Observational studies
4. How effective are the tools and what are the factors
defining the effectiveness? Quantitative Qualitative RCTs
Search strategy
The following search phrase was used: (GP OR General Practitioner OR General Practice OR House Doctor OR Primary Care Physician OR PHP OR Primary Care Provider OR pcp OR Practice Nurse OR PN) AND (Tool OR Questionnaire OR Instrument OR Program OR App OR Apps OR Assessment OR Screening) AND (Food intake OR Diet OR Dietary evaluation OR Eating habits OR Eating pattern OR Dietary assessment) AND (risk at cvd OR risk at cardiovascular diseases OR cardiovascular diseases risk factors OR cvd risk factors OR CVRM OR cardiovascular risk management OR prevent*) AND (cvd or cardiovascular disease) NOT (medic* OR medication* OR drugs* OR statins OR ACE-inhibitors OR ARBs OR beta blockers OR diuretics OR angiotensin II receptor blockers OR bariatric OR stroke OR heart failure OR dement* OR leg ulcer OR thromboembolism OR cancer OR atherosclerosis OR Myocard* OR rheum* OR arthritis OR nerve OR retinopathy OR pulmonary vein OR lupus erythematous OR coronary heart disease OR atrial fibrillation OR pregnan*). Table 3: Criteria and filters for searching the articles Origin (database) PubMed, Cochrane Text availability (Free) full text articles Relevance Not older than ten years old (that is not older than from the year 2007 on) Species Humans Age Adult: 19+ years Language English Article types Clinical Trial, Evaluation Studies, Interview, Journal Article, Observational Studies, Meta-analysis, Practice Guideline, Randomized Controlled Trial, Systematic Review, Validation studies Selection of usable articles A total amount of 54 hits was found after using the abovementioned search phrase. During the selection, attention was paid to the use of the search terms in the titles of the articles. If the search terms were not included in the title of the article, the abstract was not read. If the search terms were in the article, a look was given to the abstract of that article. If the abstracts were useful, the article was read globally to be screened on whether or not it was really useful to answer the research questions. The selection of useful articles was made individually by the researchers and then coherence was checked. Non-coherent articles were further discussed and decided on. This was aimed for quality enhancement purposes. Quality check The quality of the found articles was checked explicitly with the quality checklists of Cochrane (Cochrane Netherlands, n.y.).
Results
A total amount of 9 interviews were conducted in April 2017 (see Appendix 4). Three GPs, four PNs and two GPs specialized in CVRM from general practices were interviewed. The details of the General practices in which the pcp were working are presented in Appendix I. The results are presented hereunder in the order of the set-up of the interviews.1. Importance of dietary assessment within CVRM consultations and CVRM related dietary
assessment knowledge of pcp
The conducted interviews showed that pcp rated the importance of dietary assessment within CVRM consultations with an 8,7 on a scale from zero to ten on average. The group of GPs and GPs specialized in CVRM gave an 8.6 on average and the grade that PNs gave was a 9.0 on average. In table 4 a clarification of why pcp find dietary assessment important is given.
Table 4: Reasons given for why pcp find dietary assessment important: that they consider it as an important factor in optimizing or maintaining health 56% that they prefer dietary over medical treatment, if possible 22% that they believe that diet can effect physical (dis)comfort 11% that they believe that diet can effect mental discomfort 11% that they believe that many patients lack knowledge about healthy food 11%
Pcp rated their dietary assessment related knowledge and having a sufficient amount of tools to assess food within CVRM consultations on average with a 6,0. The grade that the group of GPs and GPs specialized in CVRM gave was a 5,3, whereas PNs gave a 7,5. This difference could be explained by the fact that all GPs leave the dietary assessment over to their PNs. Fifty percent of the interviewees know more or less what is addressed about food in the CVRM guidelines of 2011. See table 5, for the explanation they gave for their grade. Table 5: explanations pcp gave for the grade they gave for their dietary assessment related knowledge and having a sufficient amount of tools that too little attention was paid to dietary assessment within the educational phase of the pcp 78% that there is a lack of tools 11% that dieticians are more capable to perform dietary assessment 22% Pcp believe that their knowledge is limited to provide general advice – that is, neither specialized, nor personal advice. ‘Personal’ refers here to taking the patient’s motivation to adjust their diet into account. Pcp evaluate diet globally and base it on experience throughout the years. Twenty-two percent of the interviewees mentioned that introducing more diet related colleges in the study to become pcp, could improve the diet related knowledge of pcp. This indicates that a discrepancy exists between how important pcp find dietary assessment within CVRM consultations and what their current knowledge is. PNs are the ones who perform the dietary assessment. They find dietary assessment important, but the grade they give themselves is not a 10
2. Current method of dietary assessment within CVRM consultations
First of all, GPs do not pay much attention to dietary assessment, as their PNs are performing the dietary assessment as they are the ones who have enough time to do so. A high concentration of cvd risk increasing blood values or a high bloodpressure, is the indication for pcps (44%) to ask food related questions. There are some methods which pcp use when assessing diet in CVRM consultations; see table 6. Table 6: what pcp do in CVRM related dietary assessment referring to a dietician (indications that the interviewees mentioned for referring to a dietician are presented in Appendix II) 100% testing the food related knowledge of the patient 22% asking how the patient is paying attention to cvd risk increasing food products 11% asking how the patient prepares/cooks food 11% referring to websites such as thuisarts.nl and voedingscentrum.nl 11% repeating questions regarding intake of food products to ensure therapy faith 11% The attention that PNs pay to each food product category within CVRM related consultations differs. They pay more attention to certain food products categories and less to others, see table 7. As GPs leave dietary consultation to their PN, in table 7 the emphasis is put on which food product categories PNs assess. The GPs are included in grey for reference. Table 7 shows that salt, fruit and vegetables are the only food product categories, that are assessed by 75% or more of the pcp. The remainder of the food product categories - coloured orange and red in table 7 - is assessed by less than half of the PNs. This clarifies that the majority of the food product categories addressed in the NGH/RGV guidelines do not get the attention they are recommended to get. Thus, the current way of dietary assessment is not entirely in accordance with the NHG/RGV guidelines.
Table 7: food product categories assessed by PN and GPs within CVRM related consultations
Food product category
PNs (% of total)
GPs (% of total)
Salt 4 (100 %) 5 (100 %) Fruit 3 (75 %) 2 (40 %) Vegetables 3 (75 %) 1 (20 %) Cheese 2 (50 %) 2 (40 %) Sugar 2 (50 %) 2 (40 %) Fish 2 (50 %) 1 (20 %) Butter 2 (50 %) - Convenience meals/snacks 2 (50 %) 3 (60 %) Licorice 1 (25 %) 3 (60 %) Baking fat 1 (25 %) - Coffee 1 (25 %) 1 (20 %) Meat 1 (25 %) 3 (60 %) Alcohol 1 (25 %) 2 (40 %)
Registering data
To insert all the records of the registered patients, a computer program, called “Huisartsen Informatie Systeem” (HIS) - General Practitioner Information System (GPIS) in English - is being used in the General practice. Besides, there is a computer program, called “Keten Informatie Systeem”In April 2017 two versions of CIS were being used by the interviewees: one in which the pcp is solely asked if there are specialties in the diet of the patient, and another, in which more profound diet related questions are advised to be asked. In this latter version, certain food products are advised to be assessed on intake quantities in grams per day. Those products are fish, fat fish, vegetables, fruit and salt. In contrast, the remainder of the incorporated food products are not being advised to be assessed on intake quantities in grams per day, but solely on if they are used ‘regularly’ or not. Those products are: butter, hard-margarines, fatty meat, fatty milk products and fatty snacks. An indication of what is seen as “regular”, however, is currently not given in the CIS. Pcp find the term ‘regularly’ a quite ambiguous term and believe that it would be advantageous to have answer options which indicate what exactly the term ‘regularly’ means (11%). Pcp mentioned that improved, concreter answer options, could give a better image of the patient’s diet. In addition, pcp find it important that the CIS advices the pcp to assess and subsequently enter the amounts of butter, hard-margarines, fatty meat, fatty milk products and fatty snacks into the system (11%).
Cooperation
All GPs know what sort of diet related questions their PNs are asking to the CVRM patients and which method they use to asses. Also they said (80%) that nutrition does not have a significant place in meetings with other disciplines. GPs (80%) mentioned that they do not experience a difference in diet related knowledge and treatment between their PNs. PNs (75%) experience the supervision provided by their GPs as good. Furthermore, pcp mentioned that the records of each patient are accessible via the GPIS by all pcp working the General practice. They consider the factors presented in table 8 as important with regard to improvement of internal and multidisciplinary cooperation within CVRM dietary assessment. Table 8: factors that pcp find important with regard to improvement of internal and multidisciplinary cooperation within CVRM dietary assessment a tool to make food discussable 11% organizing more internal dietary assessment related trainings 11% reporting the collected diet related data more specifically and more structured 11% planning in more meeting moments between the pcp to discuss food 11% having more contact with dieticians 11% Pcp (78%) believe that standardization of dietary assessment is favorable for treatment of CVRM patients as it will allow working more efficiently and will save time.3. Restrictors of dietary assessment, desired improvements and facilitators
Lack of time (55%), underreporting (33%) and lack of good structure in CVRM related consultations (33%) are difficulties that pcp experience in their current method of assessing diet. All GPs have ten minutes for each CVRM consultation. In those ten minutes they need to discuss a lot of (food and non-food related) subjects. As assessing one’s diet needs time, which GPs basically do not have, all GPs have dietary assessment be done by their PNs. More time - approximately 40 minutes in total per consultation according to one interviewee - is reserved for the CVRM consultations performed by PNs. If there would be a CIS in which dietary assessment was made concretely discussable, pcp would findAll pcp desire a PCT that also evaluates and 55% believe that it should be realistic to implement such a tool. Factors that need to be taken into account to introduce such a tool, according to pcp are: whether or not patients would like to fill in such a tool and if they eventually really fill it in (22%).
4. Tools in literature
When a closer view on literature is being applied to find out if tools for assessing dietary intake exist, the Rate Your Plate (RYP) tool, which is a paper based tool, comes forward (see Appendix III). The tool was mentioned and used in an article about a pilot study that has been conducted ‘to evaluate the feasibility and the effects on lipids and diet of a low-intensity dietary counseling intervention, provided by pcp in patients at high risk for cvd (Kulick D, 2013). The RYP tool is made to assess and evaluate diet on risk factors for cvd. On top of that, it also gives diet related advice. The RYP tool is an American food-frequency questionnaire that consists of 23 food categories with three columns for answering: column A gives the least healthy choice, column C gives the healthiest choice and column B is in between them. The focus lies in food products that contain fat: saturated fat and cholesterol. The patient can fill in the questionnaire, in the waiting room or at home. After the questionnaire is filled in, the provider can see quickly if the patient is eating healthy, or might need nutritional advice. A section for behavioral change and goal setting is also included in the RYP. If some changes can be made by the patient, the patient and the provider can set goals together to work on to achieve a healthy diet (Gans KM, 2000). A study has shown that the RYP tool is effective and reliable in measuring dietary fat and saturated fat intake. In this study the RYP was being compared with the Willett semi quantitative food frequency questionnaire. “Pearson product moment correlations of RYP score with Willett fat variables were - 0.59 for percent calories from total fat, - 0.45 for dietary cholesterol, - 0.56 for saturated fat, and - 0.65 for percent calories from saturated fat (P < .001 for all correlations)”. An outcome between 0.4 to 0.7 is seen as most acceptable for dietary assessment tools during calibration studies. This shows that the RYP tool is capable of reflecting dietary fat and saturated fat intake. Thus, a person’s score on the RYP tool can indicate whether their diet is relatively high or low in fat and saturated fat (Gans KM, 2000). The tool has been effectively integrated in primary care practices. RYP had been used successfully as part of a training program to improve pcp knowledge, and practices regarding cholesterol management and to increase their self-efficacy in providing nutrition counseling. Whereas the RYP is used in cardiac rehabilitation programs, the tool is also recommended as a qualitative tool for blood cholesterol management (Gans KM, 2000)
Discussion
The interviews that have been conducted show that the importance of dietary assessment within CVRM on average is being rated with an 8,7. Own knowledge and the availableness of tools with regard to dietary assessment within CVRM is being rated with a 6,0. This indicates that there is a discrepancy between those two grades. Pcp see room for improvement. Pcp believe that lack of ‘time’, ‘standardization’, ‘concrete answer options in the CIS’, and a ‘PCT’ are restrictors to assess diet in the General practice. Those factors are discussed hereunder. Lack of time Lack of time is seen as one of the most important factors that restrict dietary assessment within CVRM consultations. Existing dietary assessment methods are time consuming (England CY, 2017). The 24h-Recall, the Food-Frequency Questionnaire, Dietary History and Diet Journal are instruments that already exist in the Netherlands and are mainly used by dieticians and in scientific research. The 24h-Recall is time consuming and does not incorporate an evaluation part. Neither the Diet Journal and Dietary History do include an evaluation part. Without evaluation the pcp will not be able to conclude if the diet is in accordance with the diet related advice given in the CVRM guidelines. The food frequency, in contrast, does make measurement of the average food intake and evaluation easily possible (Vries de J.H.M, 2015). However, compared to the RYP tool, it does not include the motivational part that makes the patient formulate goals and check on the tool itself how much progress they make. Also, like the other instruments, it consumes time. Beside those instruments, a number of online dietary assessment instruments do exist (Franco RZ, 2016). However, it is a point of attention whether all the available apps are reliable and practical in use. One of those online instruments is the ‘Eetmeter’ (Eat Meter, in English). The ‘Eetmeter’ provides the patients the opportunity to fill in all food products and drinks they have consumed a day. The instrument indicates how much energy and nutrients the diet contains and compares the diet to what is being recommended by the “Schijf Van Vijf” – or The Plate of Five (POF) in English. The POF is a visual plate that shows recommendations for intake amounts of 5 food product categories. Advantage of the Eetmeter is, that the software is accessible at any desired moment. However, the Eetmeter does also need too much time to be filled in, as each food product needs be filled in by the patient and no food product category evaluation is being performed by the software (Eetmeter, n.y.). This makes it a less good option to be considered as well. All those instruments are specialized instruments and not screening instruments. Considering that pcp lack the knowledge to assess about diet profoundly and the fact that they have a limited amount of time to spend on dietary assessment within their CVRM consultations, it becomes clear that a screening instrument would be the right solution. The Prior-to-Consultation Tool Rate Your Plate seems be capable of tackling the restrictor ‘lack of time’, whilst it contains an evaluation part and even an part to motivate the patients to adhere to their goals. See header Lack of a Prior-to-Consultation Tool below for more information about it. Lack of standardization The current way of dietary assessment, done by pcp, is not entirely in accordance with what is addressed in the CVRM guideline (Nederlands Huisartsen Genootschap, 2012). The food product
Lack of concrete answer options in the CIS From a dietetics point of view, it is known that products such as butter/hard-margarines, salt, processed (red) meat, sugary drinks, fatty snacks and alcohol (to be called cvd-Risk Products or cvd-RP) contain relatively high amounts of saturated fat, trans fat, free sugars and sodium (to be called cvd-Risk Nutrients or cvd-RN) (Gezondheidsraad, 2015) (Nederlandse Diabetes Federatie, 2015). Those nutrients are highly capable of increasing the risk to get cvd. In the CIS the pcp is requested to address whether cvd-RP are being used, but not requested to address the amount of intake though, whereas insight in the intake of those products are important in CVRM assessment. Current answer options in CIS are ‘yes’, ‘no’ or ‘unknown’. This is not providing an accurate view of someone’s diet. To change the answer options in ‘0 times per week’, ‘1-2 times per week’ et cetera, would give a better insight in one’s diet. Insight in intake of the cvd-RP is important in order to get a clear view on risk factors in the patient’s diet, so adequate advice can be given. As earlier mentioned, many pcp do already assess and discuss the cvd-RP in the diet of their patients in their conversations. However, in the CIS they are not being asked to clearly indicate an intake amount. To make pcp find out what a patient’s intake of the cvd-RN is, without the help of tools, is basically not possible as pcp’ knowledge is limited and it is a process that would consume too much time. Lack of a Prior-to-Consultation Tool However, making pcp assess the intake amounts of the cvd-RP, could be possible by creating a sort of tool. A tool on which usage of certain food products can be selected and subsequently points can be added to get concluded what the risk factors in the diet of the patient are. Such a tool would be too time-consuming to apply during CVRM consultations, but letting the patients fill in such a Prior-to-Consultation Tool sounds as a realistic solution to pcp. The earlier restrictors “having a limited amount of time” and ‘’lack of standardization’’ can be tackled by such a solution. Linking the outcomes automatically to CIS would be idyllic. An additional advantage of having such a tool is, that showing the patient visually what their food-related risks are, could motivate them to visit a dietician to receive diet related treatment. Showing evidence – as is already being done for example with the CVRM risk assessment table - can be an effective strategy in the pre-contemplation stage of the changes of Motivational Interviewing (Dekker P, 2010). A PCT in the form of an app is likely to be used by a high amount of people as the amount of downloads of apps are very high, which indicates that there is good chance that people will desire to use it (Franco RZ, 2016). And for the patients who do not possess a computer or phone, a paper based version could be handed out as alternative. Matters to be considered, however, when choosing to introduce such an app, are: the costs, privacy protections, if the patient will want to fill in a questionnaire, if they will be fair with regard to the product amounts and frequencies they fill in, and if they will have a computer or smartphone on which the software can be installed. If those factors can be taken into account, it is highly likely that such a tool would contribute to improvement of dietary assessment of people at high risk for cvd. The elements that need to be captured in such a tool in order to achieve the aim of getting better insight in diet related risk factors and getting a better base to refer to a dietician are: - intake amount and frequency assessment of the cvd-RP; - an outcome that gives a comparison of the intake with what is being said in the guidelines; - and advice in the form of suggestions to modify diet and whether or not to visit a dietician. Not only would it be great to have such a PCT that assess diet in practice, a tool that can also monitor changes in the diet would be even greater. This would simplify dietary assessment in the general practice even more.
Fortunately, a practical tool to use as a Prior-to-Consultation Tool already exist: the RYP tool. The RYP could be a good design for the PCT as, except for alcohol, all food product categories that need to be assessed according to the NHG/RGV are being incorporated in the RYP. In table 9 a comparison of what the NHG/RGV guidelines and the RYP address about diet is presented. Only adding an alcohol category would make the RYP tool completely in accordance with what is being advised by the NHG/RGV guidelines. Although, the RYP is based on an American diet, it can easily be reformed to the Dutch eating standard by changing the American products by Dutch products. A pilot study needs to be put in practice to check whether the RYP tool can be used as a Prior-to-Consultation Tool. Such a PCT could also be considered to use in consultations different than CVRM, for example for COPD and malnutrition consultations, as it is known that diet also takes an important place in other diseases (Jonkers-Schuitema C, 2017) (Raeijmaekers NLM, 2017). Table 9: Comparison of what the NHG/RGV guidelines and the RYP address about diet Product category NHG/RGV RYP Vegetables and
fruit Eat daily 150-200 gram vegetables and 200 gram of fruit Fruit and vegetables is being incorporated in the RYP tool as one category. Five or more servings a day (one serving is seen as half a cup or a piece of fruit) is seen as healthy (colomn C). Fibers Eat daily 30-40 gram fibers - especially present in vegetables, fruit and grains. Intake amounts for fiber do not form an apart section of the RYP tool. However, the intake amount of fiber-rich products - vegetables, fruit and whole grain products - are forming categories in the RYP tool, which makes that a close view on fiber intake is being taken in the RYP tool. Fish Eat twice a week 100-150 gram fish, of which one time fat fish. Eat fish twice a week or more. Food products or drinks with easily fermentable sugars and acid. Do not use more than seven times a day food products or drinks with easily fermentable sugars or acid. Nothing is mentioned about this in the RYP tool. Salt Do not use more than 6 gram salt
a day There is no specific category for salt in the RYP tool. However, food product categories that can contain relatively high amount of salt - such as meat, breakfast meat, fish, soups, cheese, fried food and snacks - are being assessed with the RYP tool. Alcohol Men: do not drink more than 2 glasses a day Women: do not drink more than 1 glass a day Nothing is being said in the RYP tool about alcohol.
Strengths and weaknesses of the research Firstly, a strength of this research is that, despite the low number of conducted interviews, saturation was achieved in responses. This suggests that we have a complete overview of what pcp current methods with regard to dietary assessment are and what can be improved in it. Reasons for not having achieved the aimed amount of interviewees were: - that there was less response/interest as expected in the reserved time; - and that pcp could not allow time for a interview, particularly due to business in the general practice or less occupation as a consequence of national holiday. Another strength was that all specialists involved in diet related CVRM treatment were interviewed: GPs, PNs and GPs specialized in CVRM. This ensures a thorough view of the current way of dietary assessment within CVRM consultation. Moreover, the literature search outcome was just one article that addressed a tool for dietary assessment. This means that what has been researched about tools in the General practice is quite unique. However, there were also some weaknesses: Firstly, a significant amount of the interviewees works with the CIS of the producer Vital health, and few with other systems. The possibility that other available producers and their systems are being excluded in this research does exist. There can be systems that are not even mentioning the diet or are even concreter in diet then the one that is included in this research. Thinkable consequence of this is the likeliness that other possibly more efficient systems to take notes in are being overseen. Secondly, it is possible that only pcp that have more interest in food intake are included (selection bias). That means that a representative view is not given. This might have influenced the results of the research as those pcp possibly allow more time for dietary assessment in consultations and as the advice that they give is possibly better in compared to pcp with less interest in food. Also all interviewees are working in and near Utrecht. In one way that is representative, on the other hand, the question is ‘whether that can give a good representation of the whole country’. However, the fact that all pcp in The Netherlands work with one GPIS, increase the chance that the results of this research are generalizable to the pcp of The Netherlands (LHV, n.y.).
Conclusion
The research question was: What can be improved with regard to dietary assessment of people at high risk for cardiovascular disease in the general practice in The Netherlands? This research indicates that the following can be improved with regard to dietary assessment of people at high risk for cardiovascular disease in the general practice in The Netherlands: a concreter-answer-options update in the Chain Information System, and a simple Prior-to-Consultation Tool for dietary assessment to tackle down the restrictive factors ‘lack of time’ and ‘lack of standardization’.
What primary care providers currently do with regard to dietary assessment of people at high risk for cardiovascular disease in primary care, is overall in accordance with the advice in the guidelines. Although all primary care providers talk about food in their consults, it can be concluded that General Practitioners generally leave the dietary assessment to their Practice Nurses. Primary care providers seem to examine the intake of the following products in the Cardiovascular Risk Management related consultations: sugar, salt, fatty products, snacks, fatty meat intake. However, they do this globally, thus not assessing exact amounts. A tool to be filled in by the patients prior to the consultation in which intake amounts and frequency of food product intake can be selected and subsequently an evaluation and advice are given is desired. One practical instrument found in literature which takes such a form is the Rate Your Plate Tool.
Recommendations
For UMCU: - Introduction of the Rate Your Plate Tool as Prior-to-Consultation tool: It is highly recommended to introduce the Rate Your Plate tool (Appendix III) in the form of an app as a prior to consultation dietary assessment tool in CVRM consultations in general practices in The Netherlands. Such a tool can be filled in by CVRM patients prior to CVRM consultations by the use of an app. The Rate Your Plate Tool is the idyllic tool to be chosen, as it consists the elements that a Dutch Prior-to-Consultation tool needs to incorporate. The Rate Your Plate Tool needs to be translated into a Dutch version to make it usable in the Dutch practice. Except for some typical American food products (such as boca or garden burgers, wheaties), nothing needs to be changed in the tool to convert it into a version that is usable in The Netherlands. - Advice about the elements of a Prior-to-Consultation Tool: The elements that are recommended to be captured in a digital Prior-to-Consultation Tool in order to achieve the aim of getting better insight in diet related risk factors and getting a better base to refer to a dietician are the following ones: a) assessment of intake amount and frequency of cardiovascular risk products. (The only food product category that the Rate Your Plate tool lacks with regard to the advice that is mentioned in the Richtlijnen Goede Voeding guideline is alcohol); b) an outcome that gives a comparison of the intake with what is being addresed in the Nederlandse Huisartsen Genootschap and Richtlijnen Goede Voeding guidelines; c) advice in the form of suggestions to modify diet and whether or not to visit a dietician (the latter needs to be integrated into the Rate Your Plate Tool yet. We recommended to refer to a dietician if the patient scores 23 to 38 points); d) a diet monitoring element as it will simplify dietary assessment in the general practice even more (for realizing this, the app needs to save the record of the patient’s diet); e) and a motivational element. Since showing evidence – as is already being done for example with the CVRM risk assessment table - can be an effective strategy in the pre-contemplation stage of the changes of Motivational Interviewing (Dekker P, 2010)), showing the patient the risk factors in their diet visually by a tool is recommended. The Rate Your Plate tool can show the patient visually what the risk factors in their diet are and hence could motivate them to visit a dietician to receive diet related treatment. - Other matters to be considered, when choosing to introduce the Rate Your Plate Tool as a Prior-to-Consultation tool in the form of an app: - the costs (app development and maintenance etc); - privacy protections; - whether the patient will want to fill in a questionnaire; - whether the patients will be fair with regard to the product amounts and frequencies they fill in; - and whether the patients will have a computer or smartphone on which the software can be installed. For the Chain Information System: - More accurate frequency reporting: A change in the answer options by making selection of how many times a week a food product is being used - instead of presenting solely ‘yes’ or- Entering intake amounts: It is recommended to make entering amounts of cardiovascular risk products possible. From a dietetics point of view, it is known that products such as butter/hard-margarines, salt, processed (red) meat, sugary drinks, fatty snacks and alcohol (to be called cvd-Risk Products or cvd-RP) contain relatively high amounts of saturated fat, trans fat, free sugars and sodium (to be called cvd-Risk Nutrients or cvd-RN) (Gezondheidsraad, 2015) (Nederlandse Diabetes Federatie, 2015). Those nutrients are highly capable of increasing the risk to get cardiovascular diseases. In the CIS the pcp is requested to address whether cvd-RP are being used, but not requested to address the amount of intake though, whereas insight in the intake of those products are important in CVRM assessment. Current answer options in CIS are ‘yes’, ‘no’ or ‘unknown’. This is not providing an accurate view of someone’s diet. To change the answer options in ‘0 times per week’, ‘1-2 times per week’ et cetera, would give a better insight in one’s diet. Insight in intake of the cvd-RP is important in order to get a clear view on risk factors in the patient’s diet, so adequate advice can be given. Further research: - Patient’s desire to fill in a Prior-to-Consultation Tool: A pilot study is recommended to be performed to test whether patients would like to use such a Prior-to-Consultation Tool for optimization of their CVRM treatment, and to test the effectiveness of it. - A similar tool for other diseases: Conducting research on whether a Prior-to-Consultation dietary assessment tool is needed and desired for other diseases than cardiovascular diseases is recommended as it is known that diet can play an important role in other diseases as well.
