Key process features of personalized diet counselling in metabolic syndrome: secondary analysis of feasibility study in primary care.

BACKGROUND: Personalized diet counselling, as part of lifestyle change programs for cardiometabolic risk conditions (combinations of prediabetes or type 2 diabetes, hypertension, dyslipidemia and high waist circumference) has been shown to reduce progression to type 2 diabetes overall. To identify key process of care measures that could be linked to changes in diet, we undertook a secondary analysis of a Canadian pre-post study of lifestyle treatment of metabolic syndrome (MetS). Diet counselling process measures were documented and association with diet quality changes after 3 months were assessed. Results of the primary study showed 19% reversal of MetS after 1 year. METHODS: Registered dietitians (RDs) reported on contact time, specific food behaviour goals (FBG), behaviour change techniques (BCT; adapted from the Michie CALO-RE taxonomy) and teaching resources at each contact. Diet quality was measured by 2005 Canadian Healthy Eating Index (HEI-C) and assessed for possible associations with individual BCT and FBG. RESULTS: Food behaviour goals associated with improved HEI-C at 3 months were: poultry more than red meat, increased plant protein, increased fish, increased olive oil, increased fruits and vegetables, eating breakfast, increased milk and alternatives, healthier fats, healthier snacks and increased nuts, with an adverse association noted for more use (> 2 times/ 3 months) of the balanced meal concept (F test; p < 0.001). Of 16 BCT, goal setting accounted for 15% of all BCT recorded, yet more goal setting (> 3 times/3 months) was associated with poorer HEI-C at 3 months (F test; p = 0.007). Only self-monitoring, feedback on performance and focus on past success were associated with improved HEI-C. CONCLUSIONS: These results identify key aspects of process that impact diet quality. Documentation of both FBG and BCT is highly relevant in diet counselling and a summary diet quality score is a promising target for assessing short-term counselling success.

Empathy in Medical Education: Its Nature and Nurture - a Qualitative Study of the Views of Students and Tutors.

Context: Medical education is committed to teaching patient centred communication and empathy. However, quantitative research suggests empathy scores tend to decline as students progress through medical school. In qualitative terms, there is a need to better understand how students and tutors view the practice and teaching of clinical empathy and the phenomenon of empathic erosion. Methods: Working within a constructivist paradigm, researchers thematically analysed the individual interview data from a purposive sample of 13 senior students and 9 tutors. Results: The four major themes were as follows: (1) 'the nature of empathy', including the concept of the innate empathy that students already possess at the beginning of medical school; (2) 'beyond the formal curriculum' and the central importance of role modelling; (3) 'the formal curriculum and the tick-box influence of assessments'; and (4) the 'durability of empathy', including ethical erosion and resilience. A garden model of empathy development is proposed - beginning with the innate seeds of empathy that students bring to medical school, the flowering of empathy is a fragile process, subject to both enablers and barriers in the formal, informal, and hidden curricula. Conclusion: This study provides insights into empathic erosion in medical school, including the problems of negative role modelling and the limitations of an assessment system that rewards 'tick-box' representations of empathy, rather than true acts of compassion. It also identifies factors that should enable the flowering of empathy, such as new pedagogical approaches to resilience and a role for the arts and humanities.

Developing the role of midwives as 'contraceptive champions' to support early access to effective postnatal contraception for women.

OBJECTIVE: To evaluate the acceptability of the new contraceptive champion role to the first hospital and community midwives in NHS Lothian trained in this role. DESIGN: Health service evaluation. POPULATION: Hospital and community midwives trained as contraceptive champions, NHS Lothian, Scotland, UK. METHODS: Qualitative research: 1:1 semi-structured interviews (baseline and follow-up) with five contraceptive champions. MAIN OUTCOME MEASURE: Qualitative data on views of the new contraceptive champions on the first 6 months of the role. RESULTS: All contraceptive champions stated increased confidence in their knowledge of postnatal contraception. They reported that women had not questioned the role of midwives in inserting contraceptive implants postnatally in hospital and at home. Midwife colleagues and hospital doctors had been supportive. CONCLUSION: The new role of contraceptive champion is reported by midwives to have been well received in its first year by women, the midwives themselves and their healthcare colleagues.

Antenatal contraception counselling and provision of contraception after delivery for first-time young mothers enrolled with a Family Nurse Partnership programme.

OBJECTIVE: To evaluate antenatal contraceptive counselling and provision of postpartum contraception on contraceptive choices of first-time teenage mothers enrolled with a Family Nurse Partnership (FNP) programme. DESIGN: Health service research evaluation. POPULATION: Cohort of FNP clients (n=195), Scotland, UK. METHODS: Antenatal contraceptive counselling and provision of chosen method from the hospital. Evaluation consisted of (i) self-administered questionnaires of FNP clients and (ii) interviews with FNP clients and FNP nurses. MAIN OUTCOME MEASURES: FNP client views on intervention. Secondary outcomes included: contraceptive choice antenatally, at day 10 postpartum, 3 and 12 months after delivery, and views of FNP nurses on the intervention. RESULTS: Antenatal questionnaires were completed by 118/195 (61%) clients. 96/118 (81%) agreed that it was very or quite helpful to receive antenatal contraceptive counselling and 80/118 (68%) were planning to use a long-acting reversible method of contraception (LARC). 97/121 (80%) wished to receive contraception before leaving the hospital. 104/195 (53%) completed a questionnaire at day 10 postpartum, of which 33 (32%) indicated that they had received contraception from the hospital. FNP nurses expressed frustration when contraception was not provided; this was usually attributed to the busy workload of the maternity department. CONCLUSIONS: Antenatal contraceptive counselling was appreciated by FNP clients and they expressed a preference for contraception provision following delivery. Over two-thirds planned to use a LARC method but many did not receive this from the hospital. Further interventions are required to ensure that the provision of postpartum contraception is prioritised for this group of young women.

Nutrient intake and dietary quality changes within a personalized lifestyle intervention program for metabolic syndrome in primary care.

A team-based 12-month lifestyle program for the treatment of metabolic syndrome (MetS) (involving physicians, registered dietitians (RDs), and kinesiologists) was previously shown to reverse MetS in 19% of patients (95% confidence interval, 14% to 24%). This work evaluates changes in nutrient intake and diet quality over 12 months (n = 205). Individualized diet counselling was provided by 14 RDs at 3 centres. Two 24-h recalls, the Canadian Healthy Eating Index (HEI-C), and the Mediterranean Diet Score (MDS) were completed at each time point. Total energy intake decreased by 145 ± 586 kcal (mean ± SD) over 3 months with an additional 76 ± 452 kcal decrease over 3-12 months. HEI-C improved from 58 ± 15 to 69 ± 12 at 3 months and was maintained at 12 months. Similarly, MDS (n = 144) improved from 4.8 ± 1.2 to 6.2 ± 1.9 at 3 months and was maintained at 12 months. Changes were specific to certain food groups, with increased intake of fruits, vegetables, and nuts and decreased intake of "other foods" and "commercial baked goods" being the most prominent changes. There was limited change in intake of olive oil, fish, and legumes. Exploratory analysis suggested that poorer diet quality at baseline was associated with greater dietary changes as assessed by HEI-C. Novelty Multiple dietary assessment tools provided rich information on food intake changes in an intervention for metabolic syndrome. Improvements in diet were achieved by 3 months and maintained to 12 months. The results provide a basis for further dietary change implementation studies in the Canadian context.

Does behaviour modification affect post-stroke risk factor control? Three-year follow-up of a randomized controlled trial.

OBJECTIVE: Little is known about the long-term effectiveness after stroke of interventions for behaviour modification and ensuring concordance with therapies. We describe a follow-up study of a previous randomized controlled trial of a brief period of behaviour modification. The aim of this study was to determine outcomes three years after the initial intervention. DESIGN: Survivors of the original cohort were contacted and asked to attend for follow-up interview, within a geriatric day hospital. This study was carried out in the Geriatric Day Hospital at Stobhill Hospital, Balornock Road, Glasgow. INTERVENTIONS: Details of risk factor control, including blood pressure, cholesterol levels and diabetic control, were assessed. Questionnaires used in the initial study were repeated including the Geriatric Depression Scale score, Euroqol Perceived Health Status and Stroke Services Satisfaction Questionnaire. MAIN MEASURES: Primary outcome was collective risk factor control. Clinical outcomes including recurrent cerebrovascular events, medication persistence and perceived health status were also recorded. RESULTS: Mean length of follow-up was 3.6 years (SD 0.43). Of the 205 patients enrolled in the initial study, 102 patients attended for repeat interview(49 intervention/53 control). There were no significant differences in the percentage of controlled risk factors between groups (intervention 51.7% versus control 55.9%, P = 0.53). Similarities were observed in the number of recurrent clinical events and medication persistence between groups. No overall difference was observed in perceived health status, satisfaction with care or depression scores. CONCLUSIONS: Brief intervention with respect to behaviour modification and risk factor control does not appear to have any long-term benefit. These results must be cautiously interpreted in light of the small study number and further research is required.