Dietary Advice in British General Practice

Dietary advice in British General Practice

D Pereira Gray1*

1Professor 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 These two key publications combined had the effect of focusing attention on non-infectious causes of disease. There is an old Chinese aphorism that `We are what we Recent ideas such as from Dickerson (1998) suggest that eat'. On the whole this was relatively ignored until the last `There now seems to be suf®cient evidence to justify 25 y, but nowadays it is increasingly recognised in the rest serious attention being given to a relationship between of the world that there lies within these ®ve simple words a food, nutrition, and truancy, expulsion from school and profound truth. anti-social or violent behaviour'. 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 Diet infectious disease dominated the medical agenda. Small In a whole variety of ways, the incidence and prevalence of pox was a worldwide scourge, and my father, working as a disease is now being linked to the way people eat. More- family doctor in Exeter, in the South West of England, saw over this relationship holds for many of the most important diphtheria as a major problem. I have talked with older diseases of our time, namely those from which the greatest women patients in our general practice, who tell me of number of people die. In particular, dietary habits have diphtheria causing three deaths in a single family in a single been linked with the incidence and prevalence of diseases epidemic. Even in my lifetime, tuberculosis and poliomy- and death rates for ischaemic heart disease and cancer, the elitis were big medical problems. two principal causes of death in the Western world (Aus- toker, 1994).

De®nitions Behaviour Food is such a big issue and includes such a wide variety of Two big steps occurred in medical thinking within a year of substances, that it is necessary within the con®nes of a each other. First Lalonde (1975), a Minister of Health in single lecture to draw some boundaries. Canada, published the Lalonde report. In summary, this First, although controversial, I will not include alcohol. showed that by then the evidence was that human beha- Secondly, I am including dental caries, although the con- viour in general was a major determinant of illness and dition is managed mainly by dentists not doctors, because death. Of course this was behaviour in general and not just of the link with eating sugar. Thirdly, I will brie¯y include dietary behaviour, but the point was made in a report that breast feeding, which is usually considered separately, but had worldwide impact. by de®nition is an important form of human feeding. The very next year McKeown (1976) writing from the Finally, I will not touch on beef consumption, which UK, published The Role of Medicine ± Dream Mirage or seems to be a special case and has political rami®cations. Nemesis. This put the issue another way round and empha- sised the in¯uence of the environment on health and disease. 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 *Correspondence to: D Pereira Gray, Professor of General Practice, nutrition and health from a British point of view. Where the University of Exeter, Barrack Road, Exeter, EX2 5DW, Devon, UK multicultural nature of British society seems particularly Dietary advice in British General Practice D Pereira Gray S4 relevant, then I will comment brie¯y on ethnic issues. I Anaemia in children apologise that I cannot read Dutch and I never cease to I will argue later that overnutrition is becoming a bigger admire the way colleagues in the Netherlands often are problem in the Western World. However, whilst thinking ¯uent in at least four European languages. I am dealing about children I must mention the work of a general primarily with policies and publications in the United practitioner in the South West of England (James et al, Kingdom, as this is what I have been asked to do. 1995) who has written three articles over a few years in In doing so, I have drawn heavily on a Committee of the the British Medical Journal all showing that anaemia in British Government called the Committee On Medical children is a signi®cant problem in his general practice in Aspects of Food and Nutrition Policy. This is usually Bristol, that it is commoner in certain ethnic groups, and abbreviated to COMA. It is traditionally chaired by the that it can be diagnosed and treated in general practice. 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 Caries Godfrey Fowler, OBE, Emeritus Professor of General Practice at the University of Oxford (COMA, 1989; The opinion for several years in the UK is that dietary sugar 1991a,b; 1992; 1993; 1994a,b; 1995, 1996, 1997, 1998a,b). 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, Breast feeding for example by the Sugar Bureau (1998) Food Safety Information Bulletin: The Sugar Bureau Submission Bulle- It is obvious that breast feeding is the natural source of tin 94. nourishment for babies, but substantial cultural and orga- This has not affected government policy, which remains nisational factors inhibit breast feeding for many mothers as originally stated and children's medicines are being all round the world. altered to reduce the sugar content. 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, espe- Obesity cially in developing countries. Our health promotion slogan is `Breast is best'. This is Obesity has been a growing problem for many years. By because of the balance of the composition of human milk 1993, 13% of men and 15% of women (OPCS, 1993) were and the transfer of protective substances thought to be obese and over half of the British population was over- mainly antibodies. Breast-fed children are measurably weight. By 1996, the Health Survey of England showed healthier, develop fewer infections, and are less likely to 16% of men and 17% of women were obese (Prescott- become obese. Clarke & Primatesta, 1996). At least in the UK, obesity is In fact in the UK, we have sharp differences in breast getting worse. feeding rates both by geographical area, by ethnic group, Since more than half of the population is now over- and by social classes. weight, 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 Geographical areas serious pockets of undernutrition especially in association In 1995, initial breast feeding rates were 68% in England with the presence of poverty and hospital admission for and Wales, 55% in Scotland, and signi®cantly lower, being example. 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. Nutritional advice in general practice and primary care By 6 weeks after the baby's birth, breast feeding was continuing in 65 ± 66% in England, Scotland and Wales but Primary care has emerged as the dominant issue in health- was less in Northern Ireland (COMA, 1995). care 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 Ethnic factors organisations in the USA and now new changes in France, Ethnic factors are important (Qureshi, 1989). COMA all con®rm that governments increasingly realise the central (1997) reported that 10% of Bangladeshi babies, 18% of importance of the primary health component of national Indian, 24% of Pakistani, and 38% of white babies were health systems. only ever bottle fed. To answer the main question given to me by the organisers of this conference, namely whether primary Trends care can be expected to deliver dietary advice it is neces- The most important ®gure is the trend in the proportion of sary to seek out the key facts. mothers breast feeding. This fortunately shows a slow but Three subsidiary questions arise: does primary care have progressive increase in the proportion of babies being the opportunity (both in terms of contacts and in time), do breast fed (Martin, 1978; Martin & Monk, 1982; Martin primary care staff have the motivation, and do they have & White, 1988; Martin et al, 1992). the ability to provide appropriate care about eating? I propose to tackle each of those in turn. I apologise, Folate intake in pregnancy since I cannot read Dutch, and your Journal Huisarts en In 1995, 75% of mothers knew that their intake of folic acid Wetenschap, I have to rely on British statistics. Never- in early pregnancy `could be good for them and their baby' theless, there is a wealth of material con®rming the close (COMA, 1997). alliance both in philosophy and in practice between Dutch Dietary advice in British General Practice D Pereira Gray S5 and British general practitoners, so I hope the conclusion them. I realise that arrangements are very different in will be of interest and relevant to colleagues here in the different countries and health systems. However health Netherlands. visitors give a huge amount of dietary advice. First we need to de®ne who in the UK we include as In a general practice like mine, they lead on mother care primary care staff. For the purpose of this lecture, I include and advice on infant management and diet. This big source district nurses, general medical practitioners, health visitors of advice has been little evaluated. It is unwise to draw (public health nurses working from general practices) and conclusions about the multi-professional primary health practice nurses. All these normally work together in the care team, until it has been evaluated as a team. primary health care teams. It seems reasonable to conclude in terms of access and In addition, working in primary care, but outside these number of contacts that the opportunity is there. teams are dentists and pharmacists. 2. Do primary care staff have the motivation? The key advice Motivation can be measured in various ways. Some general Before we can study role or effectiveness, it is necessary to practitioners have been writing about the consequences of determine if there is any consistency or consolidation in poor diet and doing something about it for many years. terms of the research evidence about eating and health. It Thomas (1952) studied nutritional disorders for his MD would be easy to give a lecture about this one part of the thesis in 1952. Craddock was the ®rst general practitioner topic and I refrain from doing so in order to tackle the topic to write a book on this subject and his Obesity appeared as you have given me, namely the relationship and the role of early as 1969. Craddock gave dietary advice himself and primary care. Suf®ce it to say that research in a whole range obtained impressive results in general practice. McMullen of major diseases, notably ischaemic heart disease, dia- (1966) showed a general interest in advising the healthy in betes, and cancer is all leading in the same direction and general practice. fortunately actually agreeing. It follows that some golden Another approach is to provide a service by a dietitian, principles have emerged: within a general practice. One of the ®rst such reports was People should eat less fat and preferably not more than by Yorke et al, (1973). They showed that it was perfectly 30% of their energy requirement. possible to provide such a service and patients took to it Vegetables and fruit are under-eaten and have substan- well. tial health promoting properties. Our diets should include Whether general practitioners have the motivation to more ®bre; ®sh can be eaten with bene®t; alcohol if taken become involved with what Lalonde (1975) called life style in moderation is not harmful. changes, can now be answered de®nitively. Following a Without summarising all the evidence and over simpli- succession of Reports from General Practice in 1980 ± fying somewhat, I suggest that we can take it that these six 1982, from the Royal College of General Practitioners points, fat, fruit, vegetables, ®bre, ®sh and alcohol, are (1982, 1984, 1986), personal prevention was soon incorpo- reasonably agreed. They represent the six key messages we rated into the work of the modern family doctor. Other hope general practice can deliver. bodies advising general practice include BMA (1986); Buttriss (1994, 1995) and Birkbeck (1998). 1. Is there the opportunity? Quite how much has been achieved is not often No system of offering advice on healthy eating and drink- described but it includes: ing can be effective if the providers do not have access to reasonably large proportions of the population. What are Personal preventive medicine the facts? Immunisation against polio, diphtheria, tetanus, whooping In the UK, 98% of the population is registered through cough and meningitis, rubella in females and increasingly the NHS with a general practitioner. Access is free at the in males as well, tetanus immunisation for adults. time of consultation and all referrals made through the NHS Child health surveillance for all children. are free to the patient. After initial registration, no further Antenatal care for pregnant women. documentation is required of patients. General practitioners Blood pressure screening for all adults. have an average contact, according to Government statis- Cervical cytology for all adult women. tics based on a randomly selected survey of all the popula- Anti-smoking advice. tion, of ®ve consultations per patient per year (Of®ce for Geriatric screening assessments for all population aged National Statistics, 1998). Since another national survey over 75 y. has shown that the average duration of a consultation with a In¯uenza immunisation for the elderly. general practitioner is 9.4 min (Review Body on Doctors' Family planning advice (70% of family planning in the and Dentists' Remuneration, 1998), it is obvious that in UK NHS is provided in general practice). 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 Effective coverage 47 min with the patient's wife or husband and another For many of these national programmes coverage for the 47 min on average with each child. As patients stay whole population has exceeded 90%, for example with registered with the same general practitioner for 11 y, it immunisations, and is approaching 95% in some areas. follows that patients average 11 6 47 557 min (that is In others, like cervical cytology there is greater varia- over nine h 540 h) with their general practice. tion, but coverage rates of over 80% of all eligible women Contact time with practice nurses, district nurses, health are achieved by 80% of general practices. visitors, dentists and pharmacists are over and above this. Others vary between practices, but it is already clear that In the UK, health visitors, who are in effect public health comprehensive national coverage of at risk populations, and nurses, are attached to general practice and work from in appropriate circumstances whole national populations, is Dietary advice in British General Practice D Pereira Gray S6 now, thanks to desktop computing, a reality (Pereira Gray, UK sharply rose immediately afterwards and is continuing 1997). to do so. The evidence is that, at least in the UK, general practice In almost all cases dietary advice will have been given is extensively involved in personal preventive medicine. previously as well as at the time of prescribing. The Secondly, general practice is already very much involved in problem is that it has not been possible to identify the seeking to promote life style changes among registered frequency, the competence, or the effect. These must patients. The question then is what about diet alteration therefore be research priorities for the future. amongst life style changes such as smoking and exercise? Weight reduction is one possible objective measure and has been widely used. There is reasonable evidence that 3. Evidence of effectiveness some practitioners can help patients lose weight, but patient Evidence of effectiveness comes in two forms. First, self-help groups appear to achieve this more simply and at implied competence arising from ®ndings from various less cost to Health Services. surveys measuring, for example, the knowledge amongst either general practitoners, practice nurses, or the whole Changes in blood levels primary healthcare team. There have been studies on family More complicated advice is needed in diabetes and for doctor knowledge (Avenell et al, 1983) and effectiveness example in the primary, secondary, and tertiary prevention (Baron et al, 1990). of ischaemic heart disease. This involves discussions about saturated and polyunsaturated fats and other foods. Some Knowledge impact can be made as the big British OXCHECK study Thus Murray et al (1993) studied dietetic knowledge showed, but the outputs were disappointing in terms of the among members of the primary health care team. They resources expended. had a `broad understanding of recommendations for healthy On the other hand Evans (1995) found that it was eating, but there was some confusion over speci®c aspects possible to lower mean serum cholesterol levels by 9.0% of these recommendations'. without any extra resource or nurses and by simply using Earlier this year, Cadman & Findlay (1998) (both usual medical contacts with general practitoners. dietitians) reported on assessing practice nurses' change Mant, the new Professor of General Practice at the in nutrition knowledge following training from a primary University of Oxford, UK wrote in 1997 that it is possible care dietitian. They found that `nutrition knowledge to achieve: `Small changes in plasma cholesterol concen- increased considerably'. trations'. He considers the prime role is sensitising the It seems, at present, that whilst there is always room for patients consulting to public health messages and supplying improvement in knowledge, ignorance about diet amongst written material at a time when patients are especially members of primary care teams is not the main barrier to receptive. provision in primary care and learning about nutrition can This raised the question as to how small is small. be achieved. Professor Peto, a statistician, also from the University of Oxford has calculated that a 1% reduction in serum Altering behaviour in patients cholesterol will translate into a 3% fall in coronary throm- Wallace et al (1986) showed that in randomised control boses. In that case, if Evans' 9% can be replicated then a trial general practitioner intervention was effective in 27% fall in heart attacks could be expected. reducing alcohol consumption. What must be the acid test, is whether the patients Obstacles to the provision of dietetic advice in general actually alter their behaviour. Behavioural change is cur- practice rently a big topic in medicine and amongst behavioural Many surveys have identi®ed obstacles. These include psychologists. It is hard to achieve and also the research time, loss of remuneration and concern about the value of methods are complicated to allow for in¯uences from the work. Drenthen (1997) in the Netherlands has sum- outside the source studied and to measure real change marised these after studying 118 general practitioners for 2 accurately. years. He thought medical school training taught mainly Starting with patient reports, which are of course sub- curative models of medical care and some practitioners jective, Simons (1990) in an unpublished PhD thesis found wondered or doubted if their patients would welcome let to her surprise that general practitioner advice when com- alone accept advice about life style. In the UK this has been pared with that of an attached dietitian in the same practice researched, Wallace & Haines (1984) found that patients was equally effective. would accept, and indeed expected, such advice from She was not able to ®nd out why, but noted that the family doctors. primary care practitioner talked with patients he knew, There may be cultural issues as Drenthen has written gave broad, simple principles and avoided detail. He `Dutch GPs show reluctance towards preventive work'. worked in consultations of about ten minutes duration but Hiddink et al (1995) from the Dutch Dairy Foundation of course saw patients repeatedly. The dietitian gave much on Nutrition and Health surveyed GPs' views on obstacles detailed advice and her consultations lasted an average of by questionnaire. They found a reported interest in half an hour. education.

Objective evidence The patients' opinions There is objective evidence that general practitioners Whatever advice doctors and nurses may give, how much respond to new research evidence and change their beha- advice is accepted and how often patients will attend, viour. The Scandinavian Simvastatin Survival Study depends to a considerable extent on the patients' health (known colloquially as the 4S study) was published in beliefs. Naslund et al (1994) working at the Karolinska 1994. General practitioners' prescribing of statins in the Hospital, Stockholm showed that men not participating in a Dietary advice in British General Practice D Pereira Gray S7 randomised study of dietary intervention in general practice Committee on Medical Aspects of Food and Nutrition Policy (1989): were not more ignorant, indeed they knew more, but Dietary Sugar and Human Disease. Report of the Panel on Dietary Sugars. Report on Health and Social Subjects No. 37. London, HMSO. believed less in the bene®ts of diet. Committee on Medical Aspects of Food and Nutrition Policy (1991a): The Forti®cation of Yellow Fats with Vitamins A and D. Report of the Working Group on the Forti®cation of Yellow Fats. Report on Health Conclusions and Social Subjects No. 40. London, HMSO. Committee on Medical Aspects of Food and Nutrition Policy (1991b): Diet has emerged as a major determinant of health. A Dietary Reference Values for Food Energy and Nutrients for the United modern health system must accept the evidence that the Kingdom. Report of the Panel on Dietary Reference Values. Report on health of western populations can be improved if people Health and Social Subjects No. 41. London, HMSO. could be persuaded to eat more healthily. Committee on Medical Aspects of Food and Nutrition Policy (1992): The Nutrition of Elderly People. Report of the Working Group on the Much can be done by public health measures such as Nutrition of Elderly People. Report on Health and Social Subjects pricing mechanisms and taxes which are outside the scope No. 43. London, HMSO. of this lecture. Committee on Medical Aspects of Food and Nutrition Policy (1993): The People, at least in the UK, expect advice in primary care Nutritional Assessment of Novel Foods and Processes. COMA Report (Wallace & Haines, 1984) and it is effective (Wallace et al, on Novel Foods. Report on Health and Social Subjects No. 44. London, HMSO. 1984). Primary care certainly has the opportunity. The Committee on Medical Aspects of Food and Nutrition Policy (1994a): research so far suggests that it is not often taking it, but Weaning and the Weaning Diet. Report of the COMA Working Group the research has been limited to surveys and questionnaires. on the Weaning Diet. Report on Health and Social Subjects No. 45. What is obviously needed is detailed analysis of consulta- London, HMSO. Committee on Medical Aspects of Food and Nutrition Policy (1994b): tions, such as through video recording, to quantify exactly Nutritional Aspects of Cardiovascular Disease. Report on Health and what advice is given, how much and what helps to make it Social Subjects No 46. London, HMSO. happen. Committee on Medical Aspects of Food and Nutrition Policy (1995): It is likely to be true, as Mant suggests, that supporting Infant Feeding. London, The Stationery Of®ce. practitioners and primary care nurses with good high Committee on Medical Aspects of Food and Nutrition Policy (1996): Guidelines on the Nutritional Assessment of Infant Formulas. Report of quality written handouts would help, but these are expen- the COMA Working Group on the Nutritional Assessment of Infant sive and it is not yet clear who is to pay. Formulas. Report on Health and Social Subjects No. 47. London, The Research should not be conducted only by specialist Stationery Of®ce. outreach teams. Active research leadership is needed by Committee on Medical Aspects of Food and Nutrition Policy (1997): Infant Feeding in Asian Families. London. those skilled both in research and clinical general practice. Committee on Medical Aspects of Food and Nutrition Policy (1998a): Generalists do not think in the same way as specialists COMA Annual Report 1997. Chairman Sir Kenneth Calman. London, (Sweeney et al, 1998) and a generalist perspective is not an Department of Health. optional extra, but a fundamental requirement. Committee on Medical Aspects of Food and Nutrition Policy (1998b). It is probable that primary care is more effective than it Nutritional Aspects of the Development of Cancer. Report of the COMA Working Group on Diet and Cancer. Report on Health and Social is being given credit for at present. Some reports are Subjects No. 48. London, The Stationery Of®ce. encouraging and more needs to be done to generalise Craddock D (1969): Obesity and its Management. Edinburgh, Churchill from successful models. Advice such as fat consumption Livingstone. in the UK is falling, as is the coronary thrombosis incidence Drenthen T (1997): Challenges to prevention in Dutch general practice Am. J. Clin. Nutr. 65, (Suppl.) S1943 ± S1945. rate. Research is needed to identify exactly how important Dickerson JWT (1998). Food, nutrition, antisocial behaviour and crimin- and effective advice in primary care is. ality. J. Royal Soc. Health 118, 224 ± 225. Evans PH (1995). Hyperlipidaemia in General Practice. MPhil disserta- Acknowledgements Ð I would like to thank the Dairy Foundation on tion. Exeter, University of Exeter. Nutrition and Health of the Netherlands for the kind invitation to come Hiddink GJ, Hautvast JG, Van Woerkum CM, Fieren CJ & Van't Hof MA to Heelsum and deliver this lecture. 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