Prevention of chronic disease
The smoking, nutrition, alcohol and physical activity (SNAP) risk factors are common among patients attending general practice. They contribute significantly to the burden of disease, largely due to their effect on the incidence and complications of chronic diseases such as diabetes, cardiovascular disease, chronic respiratory disease, and some cancers. A detailed description of the appropriate interventions is covered in the SNAP guidelines.198
Each of these risk factors may interact with each other throughout the lifecycle. Therefore it is important not to deal with each risk factor in isolation. The ‘absolute risk’ approach being advocated by the National Vascular Disease Prevention Alliance addresses assessment and intervention of an individual risk factor within the context of the ‘absolute risk’ that the patient will have a vascular event in the next 5 years.
It is important to tailor the intervention to the patient’s readiness to change199 as well as using behavioural counselling approaches such as motivational interviewing. This is described in pages 8 and 9 of the SNAP guidelines. Strategies which increase the likelihood of lifestyle change include motivational interviewing and the use of patient held records (see the ‘green book’ for more details).200 A common approach across these risk factors is the ‘5As approach’201 which includes:
- ASK – all patients about smoking, nutrition, alcohol or physical activity
- ASSESS – readiness to change, dependence (smoking and alcohol)
- ADVISE – brief, nonjudgmental advice with patient education materials (eg. Lifescripts) and motivational interviewing
- ASSIST – by providing motivational counselling and a prescription (Lifescript or pharmacotherapy if indicated for nicotine or alcohol dependence)
- ARRANGE – referral telephone support services, group lifestyle programs or individual provider (eg. dietician or exercise physiologist) and a regular follow up visit.
Health inequality
Disadvantaged groups have significantly higher rates of smoking, alcohol use, poorer diets and lower levels of physical activity. Most disadvantaged groups have significantly higher smoking rates.97,202,203 In 2004–2005, 50% of Aboriginal and Torres Strait Islander adults were daily or regular smokers.204 Effective interventions in these groups vary from those where there is little current evidence (eg. Aboriginal and Torres Strait Islander populations) to those where there is both good evidence coupled with an acknowledgment that such groups present special challenges.
Aboriginal people, Torres Strait Islanders, and Pacific Islanders have higher rates of overweight and obesity, as well as a higher incidence of vascular disease.159 Aboriginal and Torres Strait Islander communities in remote regions face significant access barriers to nutritious and affordable food.205 Nutritious food tends to cost more in rural and remote areas; cost may also be an issue in low SES groups.
Low income groups are less likely to be offered interventions to prevent overweight206 (see Introduction). Improvements in physical activity for Aboriginal and Torres Strait Islander patients may be achieved by linking health advice with locally available and appropriate community sport and recreation programs, as well as social support programs (eg. group activities).207
Many disadvantaged groups have higher levels of risky drinking208–211 and the reasons for this are often complex.212,213 For example, stigmatisation and poverty may increase the harm associated with a given level of alcohol use. Experiencing disadvantage may not lead to an increased risk of substance abuse.209 Culture and societal ‘framing’ of how alcohol is perceived also have a strong impact on the use and abuse of alcohol.214
Risky alcohol use is also frequently associated with mental health issues215,216 and having both may not be readily recognised and may reduce access to, and receipt of, treatment services.217 Alcohol has tended to produce a greater burden of harms in more socially disadvantaged groups,210 partly through the more hazardous pattern of drinking218 and partly through the associated poverty associated with low SES.213 Recognition and treatment is also impeded by the social stigma associated with problematic use of alcohol.213,219
© The Royal Australian College of General Practitioners
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