SNAP

Chapter 3

Applying the 5As to each risk factor

Smoking, nutrition, alcohol, physical activity (SNAP)
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Ask and assess

Smoking status should be assessed for every patient aged 10 years and older.45 It is important to ask at every opportunity, especially if there is a related medical problem (eg. respiratory disease or CVD). Smoking status should be documented in the medical record.

The related health effects and the substantial cost are two key factors that trigger smokers to consider quitting. The Quit Now website’s online calculator, available at, can be used to estimate the cost of smoking and may be helpful to use with your patient.

Table 3.

Table 3.

Smoking: when, how and who to assess
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Nicotine dependence can be assessed by asking questions related to:46

  • number of minutes between waking to first cigarette
  • number of cigarettes per day
  • the type of cravings or withdrawal symptoms experienced in previous quit attempts.

Smoking within 30 minutes of waking, smoking more than 10 cigarettes per day and history of withdrawal symptoms in previous quit attempts are all markers of nicotine dependence.

According to the RACGP’s Red book,  pharmacotherapy for dependent smokers is proven to double the chances of successfully quitting.

Advise and assist

Patients who smoke, regardless of the amount, should be offered brief advice to stop smoking.49 Smoking cessation is well established as an effective intervention within the primary care setting. Simple, single-consultation advice from a physician results in 1–3% of smokers quitting and not relapsing for one year.50

This means the number needed to treat to prevent one excess death is 67 for minimal brief advice and 22 for optimal treatment (based on conservative assumptions that only 3% of people quit on their own, 6% quit with minimal treatment, 12% quit with optimal treatment and all quit after the age of 50).51

Table 4.

Table 4.

Smoking: what advice should be provided (and to whom)?
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Patients who are not interested in quitting should be offered brief advice on the risks of smoking and encouraged to consider quitting. Patients who are interested but unsure should be offered information on smoking cessation, including what is available to support smokers attempting to quit (Quitline, pharmacotherapy if they are nicotine-dependent) and a suggestion for a follow-up visit to discuss further.

Addressing beliefs about smoking and smoking cessation can help overcome barriers to quitting (refer to Table 5).

Table 5.

Table 5.

Smoking: addressing patient barriers to quitting46
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Smokers who are ready to quit should be assisted by:

  • agreeing on a quit date
  • identifying smoking triggers and discussing quitting strategies
  • providing self-help materials
  • prescribing pharmacotherapy based on clinical suitability and patient preference
  • arranging follow-up visits at 1–2 weeks to prevent relapse
  • considering referral to a quit program.

Pharmacotherapy

Tobacco use is most effectively treated with a comprehensive approach involving behavioural support and pharmacotherapy. Nicotine replacement therapy (NRT) increases quit rates by about 60% compared to placebo.46 All forms of NRT monotherapy have similar efficacy in increasing long-term cessation compared to placebo.

Combining the nicotine patch with an oral form of NRT is more effective than monotherapy and should be offered to smokers who are unable to quit or experience cravings or withdrawal symptoms despite monotherapy. Pre-cessation treatment with a nicotine patch, usually started two weeks prior to ‘quit day’, has also been shown to improve success rates compared to starting the patch on quit day.55 There are some contraindications, including recent onset of life-threatening arrhythmias, pregnancy or lactation. Caution should also be exercised in patients with recent acute myocardial infarction or severe or worsening angina pectoris, recent stroke and arrhythmia.

Varenicline is the most effective monotherapy, more than doubling sustained abstinence rates at six months’ follow-up compared to placebo.56 Nausea occurs in about 30% of users but can be minimised by gradually up-titrating the dose and having the tablets with food. Although there have been concerns about neuropsychiatric adverse effects with varenicline, evidence from a meta-analysis shows no increase in rates of suicidal events, depression, or aggression/agitation compared to placebo.57

Bupropion, when combined with behavioural support, has been shown to be effective in patients who are dependent.58 It is contraindicated in patients with allergy to bupropion, seizures, anorexia or bulimia, central nervous system (CNS) tumours or monoamine-oxidase inhibitor (MAOI) treatment within 14 days. It should be used with caution in patients who abuse alcohol, have experienced recent head trauma, have diabetes, renal impairment, patients who use stimulants or anorectic drugs, drugs that may lower seizure threshold and patients on NRT.

Patients with other drug and alcohol problems, or who are living with mental health issues may need particular support to reduce smoking. SANE Australia has materials for GPs and people who smoke and are living with mental issues. SANE Australia can be contacted on 1800 18 SANE (7263) or online. 

Arrange

Motivated patients who are physically or psychologically addicted to nicotine should be referred to a quit program 46 such as Quitline, a tobacco treatment specialist or local Quit programs. Patients with a chronic medical condition and complex needs may benefit from a GP Management Plan and Team Care Arrangement under Medicare’s CDM GP services (formerly Enhanced Primary Care). Refer to Chapter 4 and Chapter 5 for more information about what is available under Medicare, including links to MBS templates.

Quitline (13 78 48) is a telephone service that offers information and advice or counselling for people who want to quit smoking. Quitline can send patients a Quit Book or provide information on:

  • the best way to quit
  • coping with withdrawal symptoms
  • proactive telephone counselling
  • Quit courses and details of local organisations that provide individual help and counselling.

Visit Quit Now for more information.

The QUIT website

The QUIT website

Reproduced with permission from the Department of Health
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Reproduced with permission from the Department of Health

Refer to Chapter 5 for information on referral services and tools, such as a lung age calculator and where to locate a tobacco specialist.

Section 4.5.4 includes information on how to set up a practice directory.

Follow-up

Patients should be reviewed within one week, and again at one month, of stopping smoking in order to help increase the long-term chance of quitting. The practice information system should generate reminders or lists of patients who are overdue for follow-up (refer to Section 4.5.1). Most relapses occur within the first few weeks of quitting and patients should be counselled that they should not give up even if they have relapsed. It often takes a number of attempts to quit successfully. Relapse is associated with the severity of withdrawal symptoms and a number of other factors, such as stress and weight gain, so addressing these regularly will help the patient to remain tobacco-free. Strategies to deal with the habit of negative emotions also help patients to become long-term non-smokers.

People who are overweight have a higher risk of disease, including coronary heart disease, diabetes, dyslipidaemia, hypertension, and bone and joint disorders.

The presence of excess fat in the abdomen is an independent predictor of morbidity.

The patient’s health literacy and motivation to lose weight should be assessed in order to better target advice.

Blood pressure should be measured in all patients aged 18 and older, and lipids measured in patients aged 45 and older.

Interpretation of BMI values in children and adolescents aged 2–18 is based on sex-specific BMI percentile charts.

For further information on the management of obesity, refer to the NHMRC Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia

Advise, agree and assist

Patients who are overweight or obese should be offered individual education and skills training. Advice should be tailored to the degree of overweight.

Table 8. Nutrition: what advice should be provided (and to whom)?

Ask and assess

Body mass index (BMI) and waist circumference should be measured and noted in a patient’s medical record every two years.59 BMI on its own may be misleading, especially in older people and muscular individuals, and classifications may need to be adjusted for some ethnic groups.

Waist circumference is a strong predictor of health problems such as CVD, diabetes and metabolic syndrome.60,61 BMI may not correspond to the same degree of risk in different populations due, in part, to different body proportions. In Asian populations, for example, BMI greater than 23 may convey increased risk.62

Explanation of the patient’s risk should avoid terms such as ‘obese’, which may offend patients. Diet and physical activity should be assessed in all patients who are overweight or obese (refer to Section 3.3).

Waist circumference

An adult’s waist circumference is measured halfway between the inferior margin of the last rib and the crest of the ilium in the mid-axillary plane. The measurement is taken at the end of normal expiration.

Table 6.

Table 6.

Nutrition: waist circumference (adults)
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For children, a waist-to-height ratio of ≥ 0.5 may be used to guide consideration of the need for further assessment of cardiovascular risk in children.59

BMI

BMI is equal to body weight in kilograms divided by the square of height in metres. As previously mentioned, BMI on its own may be misleading, especially in older people and muscular individuals, and classifications may need to be adjusted for some ethnic groups.

Table 7

Table 7

Nutrition: healthy weight: BMI (kg/m2 )
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People who are overweight have a higher risk of disease, including coronary heart disease, diabetes, dyslipidaemia, hypertension, and bone and joint disorders.

The presence of excess fat in the abdomen is an independent predictor of morbidity.

The patient’s health literacy and motivation to lose weight should be assessed in order to better target advice.

Blood pressure should be measured in all patients aged 18 and older, and lipids measured in patients aged 45 and older. Interpretation of BMI values in children and adolescents aged 2–18 is based on sex-specific BMI percentile charts.

For further information on the management of obesity, refer to the NHMRC Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia.

Advise, agree and assist

Patients who are overweight or obese should be offered individual education and skills training. Advice should be tailored to the degree of overweight.

Table 8

Table 8

Nutrition: what advice should be provided (and to whom)?
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There is a range of treatment options for adults. Individual education and simple behavioural interventions are appropriate for some overweight patients, while behavioural approaches may be more appropriate for those with disordered eating patterns. Behaviour-change techniques include goal setting, self-monitoring of behaviour and progress, stimulus control (eg. recognising and avoiding triggers that prompt unplanned eating), cognitive restructuring (modifying unhelpful thoughts or thinking patterns) or problem-solving.59

Intensive interventions

Intensive interventions to support weight loss may be considered when an adult has a BMI of >30 kg/m2 or >27 kg/m2 with risk factors and/or comorbidities, or has been unsuccessful in reducing weight or preventing weight regain using lifestyle approaches. Intensive interactions may include:

  • very low-energy diets for 8–16 weeks under medical supervision, replacing one or more meals each day with foods or formulas that provide a specified number of kilojoules (eg. 1675–3350 kJ)
  • drug therapy – Orlistat may be considered as an adjunct to lifestyle interventions, taking into account the individual situation. Phentermine is registered for short-term use (eg. three months), but is associated with a range of side effects, such as hypertension, tachycardia and insomnia, and a risk of tolerance. The long-term safety of phentermine has also not been tested.

Arrange

People with obesity should have long-term contact with, and support from, healthcare professionals. Multidisciplinary care from appropriate services or an allied health professional, such as a dietitian and exercise physiologist, is recommended, especially in complex cases and for patients with morbid obesity.

Consult the ‘Find a Dietitian’ section of the Dietitians’ Association of Australia website or call 1800 812 942 to find a dietitian in your local area. Contact details of local dietetic services should be included in the practice directory (refer to Section 4.5.4).

Patients living with obesity who have a chronic medical condition and complex needs may benefit from a GP Management Plan and Team Care Arrangement, especially if other conditions are present. Aboriginal and Torres Strait Islander patients are eligible for annual health assessments, which may be followed by up to 10 occasions of service by a practice nurse or Aboriginal Health Worker (AHW) and five occasions of service from allied health providers (within one year). Refer to Chapter 5 for more information on health assessments and management plans, as well as for further referral services. Local private and public community programs may be appropriate.

Bariatric surgery may be considered in adults with a BMI of >40 kg/m2 or >35 kg/m2 with comorbidities that may improve with weight loss.59 Bariatric surgery should be part of an overall clinical pathway for adult weight management that is delivered by a multidisciplinary team (including surgeons, dietitians, nurses, psychologists and physicians) and includes planning for continuing follow-up. Although obesity rates are higher in rural areas, specialist services may not be available and access may require travel, increasing the cost to patients.

Referral to hospital or paediatric services may be considered for children and adolescents if:

  • they are aged 2–18 and have a BMI well above the 95th percentile on United States Centers for Disease Control and Prevention (CDC) growth charts or the 97th percentile on World Health Organization (WHO) growth charts
  • they are younger than two years, above the 97th percentile on WHO growth charts and gaining weight rapidly
  • they may have serious related comorbidities that require weight management (eg. sleep apnoea, orthopaedic problems, risk factors for CVD or type 2 diabetes, psychological distress)
  • an underlying medical or endocrine cause is suspected, or there are concerns about height and development.

Follow-up

The plan for weight loss should be reviewed after two weeks in order to determine its suitability for that individual and whether modification is required. The practice information system should generate reminders or lists of patients overdue for follow-up (refer to Section 4.5.1). Relapse and weight gain are common. Patients should be followed up at yearly intervals over five years after weight reduction is achieved.

The recent Australian Dietary Guidelines emphasise five ways to improve and maintain health:

  • Physical activity
  • Enjoy eating from the five food groups every day (vegetables, fruit, grains, lean meats and dairy)
  • Limit saturated fats, added salt, added sugar and alcohol
  • Encourage breastfeeding
  • Prepare and store food safely.63

Ask and assess

Diet is an important risk factor, independent of weight. The daily intake of fruit and vegetables is considered an important indicator in the Australian diet. Ask patients how many portions of fruit and vegetables are eaten in a day. Adults should consume at least five serves of vegetables and two serves of fruit each day.64,65 The amount varies for children and women who are breastfeeding. Ask about intake of dairy foods, especially in adolescent and young women, as this may be deficient.

Additional serves from the five food groups or discretionary choices may be appropriate for adults and children who are taller or more active in order to meet additional energy requirements.

Examples of a single serve

Fruit (a standard serve is approximately 150 g)

  • 1 medium-size apple, banana, orange or pear
  • 4 dried apricots or plums
  • 1 cup of canned or fresh fruit salad
  • ½ cup fruit juice with no added sugar (occasionally – most Australians drink too much fruit juice).

Vegetables (a standard serve is approximately 75 g)

  • ½ cup cooked vegetables
  • ½ medium potato, sweet potato, taro
  • 1 cup of salad vegetables
  • 1 medium tomato.

Note: Rice, pasta and hot chips do not count as a vegetable.

Other CVD risk factors and comorbid conditions should be assessed. Common medications associated with weight gain include:

  • atypical antipsychotics – clozapine, olanzapine, lithium, tricyclic antidepressants, including amitriptyline
  • beta-adrenergic blockers – propranolol, pizotifen
  • insulin – sulphonylureas, including chlorpropamide, glibenclamide and glimepiride, glipizide, thiazolidinediones, including pioglitazone
  • sodium valproate
  • anabolic steroids.

Advise and assist

While there is evidence that nutritional counselling is effective in changing diet, the role of the GP has not been adequately evaluated.66

Table 9.

Table 9.

Nutrition: what advice should be provided (and to whom)?
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GPs should recommend patients follow the Australian Dietary Guidelines,63 which apply to healthy Australians across all population groups from birth through to the age of 70. The guidelines provide evidence-based recommendations on how to best enjoy a healthy, balanced diet (from a variety of foods) and to optimise health, maintain healthy weight and reduce the risk of diet-related disease.

Note: The Australian Dietary Guidelines apply to those who are overweight but not to individuals with chronic health issues, including common health problems such as diabetes and obesity, or to the frail and elderly. Referral to a qualified practising dietitian is recommended for management of chronic health conditions.

The Australian Dietary Guidelines make five key recommendations:63

  • To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs.
  • Enjoy a wide variety of nutritious foods from these five food groups every day:
    • plenty of vegetables of different types and colours, and legumes/beans
    • fruit
    • grain (cereal) foods, mostly wholegrain and/or high-fibre varieties, such as bread, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley
    • lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans
    • milk, yoghurt, cheese and/or alternatives mostly reduced fatand drink plenty of water.
  • Limit intake of foods containing saturated fat, added salt, added sugars and alcohol
  • Encourage, support and promote breastfeeding
  • Care for your food; prepare and store it safely

Source: National Health and Medical Research Council.

Choosing amount and type of food

The minimum daily serve sizes required to achieve at least 70% of protein, vitamin and mineral requirements for adults 19-50 years are shown in Table 10.

Table 10

Table 10

Nutrition: number of serves (used in the Australian Dietary Guidelines) 63
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Details of sample serves can be found at the Australian Guide to Healthy Eating website.

Limiting food intake

Weight reduction can be achieved in a variety of ways. For example, by reducing fat (particularly saturated fat), carbohydrate, protein or alcohol intake, in combination with smaller serve sizes.69 Any changes must be maintainable over the long term. Fad diets are not recommended for long-term weight loss. People trying to reduce weight should also take care to:

  • limit saturated fats and moderate total fat intake
  • choose foods low in salt and not add salt to foods in cooking or at the table
  • limit alcohol intake if they choose to drink
  • limit intake of foods and drinks containing added sugars.

Patients should be encouraged to read food labels and limit consumption of processed foods that may be high in added salt and sugar.

Encouraging and supporting breastfeeding

Infants should be exclusively breastfed until around six months of age when solid foods are introduced (in any order, as long as iron-rich foods are included) and at a rate that suits the infant’s development. Iron-fortified cereals, pureed meat, vegetables, fruit and other nutritious foods will provide a variety of tastes and textures that should be encouraged. Breastfeeding should continue while solid foods are introduced until 12 months of age and beyond, for as long as the mother and child desire.

For babies whose mothers cannot breastfeed or who discontinue breastfeeding early, infant formulas will need to be used up to the age of 12 months, at which time cows’ milk (full-fat up to the age of two), combined with an adequate diet, will provide the required nutrients and energy.

Note: Low-fat diets are not recommended for children aged two years and younger.

Preparing and storing food safely

Food and drink contamination that may lead to food poisoning is an important health issue. Advise patients about food preparation, refrigeration and storage.

Specific advice

Patients with certain conditions may require specific dietary advice. Recommendations can be found at the Heart Foundation, Diabetes Australia, National Stroke Foundation, Cancer Council and the Kidney Health Australia (refer to Chapter 5).

Dietary advice for patients with abnormal lipids includes the restriction of foods with high quantities of polyunsaturated or monounsaturated fats. Further details on the management of these conditions are available in the National Vascular Disease Prevention Alliance’s Guidelines for the management of absolute cardiovascular risk. 

Patients with elevated blood pressure (systolic >130 or diastolic >85) should be offered advice on weight reduction, healthy eating (particularly dietary sodium intake), alcohol consumption, regular moderate physical activity and smoking cessation.

Arrange

People living with obesity or nutrition-related conditions should have long-term contact with, and support from, healthcare professionals. Multidisciplinary care from appropriate services or an allied health professional such as a dietitian is recommended, especially in complex cases and for patients with morbid obesity (PP).69

Consult the ‘Find a Dietitian’ section of the Dietitian Association of Australia website or phone 1800 812942 to find a dietitian in your local area. Contact details of local dietetic services should be included in the practice directory (Refer to Section 4.5.4).

The Heart Foundation has a phone service called Heartline (1300 36 27 87). Heartline is staffed by trained healthcare professionals who can provide information on CVD management, nutrition and healthy eating, blood pressure, smoking cessation and physical activity. Heartline also offers information on relevant support programs, as well as booklets on a range of topics.

Nutrition Australia provides a useful service for healthcare professionals and the general community. A range of useful information and resources on nutrition is also available on the eat for health website. 

Further information on referral services can also be found in Chapter 5.

Patients with nutrition-related conditions who have a chronic medical condition and complex needs may benefit from a GP Management Plan and Team Care Arrangement under Medicare’s CDM GP services (formerly Enhanced Primary Care). Refer to Chapter 4 and Chapter 5 for more information about what is available under Medicare, including links to MBS templates.

Follow-up

Patients should be reviewed every 2–3 months to help increase the chance of sustaining long-term dietary change. Practice information systems should generate reminders or lists of patients overdue for follow-up (refer to Section 4.5.1). Emphasis at follow-up should be on sustained change in diet and physical activity, rather than on repeatedly measuring weight (unless otherwise indicated for specific diseases, such as diabetes). Relapse and weight gain is common. Patients should be reviewed at yearly intervals over five years after weight reduction is achieved.

Ask and assess

All patients aged 15 years and older should be asked about the quantity and frequency of their alcohol intake,12,70 with the results logged in the patient record. The Alcohol Use Disorders Identification Test (AUDIT) or abbreviated, three-item AUDIT-C tool (Figure 2) can be utilised for this purpose.71,72

While formal assessment with such a tool is recommended in UK73 and Australian guidelines,74 GPs perceive barriers to its use.75

The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous drinkers or have active alcohol use disorders.

Each AUDIT-C question has a choice of five answers. It is scored on a scale of 0–12.

In men, a score of 4 or more, and in women, a score of 3 or more, is considered positive, optimal for identifying hazardous drinking or active alcohol use disorders. However, when the points are all from Question 1 alone (questions 2 and 3 are zero), it can be assumed that the patient is drinking below recommended limits and it is suggested the provider review the patient’s alcohol intake over recent months to confirm accuracy.76 Generally, the higher the score, the more likely it is that the patient’s drinking is affecting their safety.

Figure 2.

Figure 2.

The AUDIT-C tool
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AUDIT-C is based on The Alcohol Use Disorders Identification Test. Reproduced, with the permission of the publisher, from The Alcohol Use Disorders Identification Test: guidelines for use in primary care, AUDIT, second edition. Geneva: World Health Organization; 2000. P 17.[Accessed 22 January 2015].

As some patients may be sensitive to your questions, it is important to be non-judgmental. A careful systematic enquiry is the most valid indicator of the patient’s current level of alcohol consumption and is more reliable than using a number of laboratory tests, including gamma glutamyl transferase (GGT) and mean cell volume (MCV).12

The lifetime risk of harm from drinking alcohol increases with the amount consumed. The risk of an alcohol-related problem increases dramatically with an increase in the number of drinks consumed.77 For healthy men and women, drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury.12 Short-term risks stem from the risks of accidents and injuries occurring immediately after drinking.

Alcohol consumption is calculated from the amount of alcoholic beverages, such as beer, cider, wine, spirits and mixed drinks, typically consumed in a day, combined with the number of days per week in which alcohol is usually consumed. Alcohol consumption is most often measured in standard drinks. An Australian standard drink contains 10 g of alcohol, which is equivalent to 12.5 mL of alcohol.12

Figure 3

Figure 3

The Australian standard drink
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Reproduced with permission from: National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC, 2009. [Accessed 3 October 2014].
​
Table 11

Table 11

Alcohol: when, how and who to assess
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Advise and assist

Brief interventions to reduce alcohol consumption should be offered to all patients drinking at potentially risky or high-risk levels (A).12 People with at-risk patterns of alcohol consumption should be offered brief advice to reduce their intake,99 while people with high-risk use patterns should be provided with interventions using brief motivational interviewing.12,100,101

The number needed to treat (return on effort) using brief interventions is one in eight: eight hazardous drinkers need to be treated to produce one who will reduce drinking to low-risk levels.82,84,99,102,103 Patients are more likely to be responsive to changing their drinking if they see a connection between their drinking and a health problem, if they believe they can change and things will improve if they do.

Table 12

Table 12

Alcohol: what advice should be provided (and to whom)?
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Advice to patients and treatment options need to be tailored to patients’ needs and priorities.

Patients drinking at potentially risky or high-risk levels should be assessed according to their readiness to change their drinking pattern. Patients who are not ready should be offered information about the risks associated with their level of alcohol use. Avoid arguing with patients.

Patients who are ready should be provided with brief motivational counselling. Patients should be encouraged to set their own goals. Try to reach an agreement about the number of drinks per day and the number of alcohol-free days. Ask them to assess their own motivation and confidence in making a change.

Try to help patients to identify high-risk situations and encourage them to avoid these. Appropriate social support such as friends or family should be enlisted. Patients should also be given self-help material and information about available support services.

Assessment for assisted alcohol withdrawal

For those who typically score 20 or more on the AUDIT questionnaire or ≥5 on AUDIT–C,104 consider offering:

  • assessment for community-based assisted withdrawal
  • assessment and management in inpatient care if you have safety concerns (refer to criteria below) about a community-based assisted withdrawal.105

Consider inpatient or residential-assisted withdrawal if the person meets one or more of the following criteria:

  • Drinks more than 30 units of alcohol a day.
  • Has a score of more than 30 on the Severity of Alcohol Dependence Questionnaire (SADQ), which is a self-administered 20-item questionnaire designed by the WHO to measure severity of dependence on alcohol.
  • Has a history of epilepsy or withdrawal-related seizures or delirium tremens during previous assisted withdrawal programs.
  • Needs concurrent withdrawal from alcohol and benzodiazepines.
  • Regularly drinks 15–20 units of alcohol a day and has psychiatric or physical comorbidities (eg. chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or a learning disability or cognitive impairment.105

Interventions for moderate and severe alcohol dependence

After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate* or oral naltrexone* in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) that focuses specifically on alcohol misuse. Obtain and document informed consent before prescribing.105

Consider offering interventions to promote abstinence and prevent relapse as part of an intensive and structured community-based intervention for people with moderate and severe alcohol dependence who have:

  • very limited social support (eg. live alone or have very little contact with family or friends)
  • complex physical or psychiatric comorbidities
  • not responded to initial community-based interventions to promote abstinence or moderate drinking.105

* Contraindicated in pregnancy and severe liver or renal disease.

Arrange

Patients who have more severe problems with their alcohol consumption or who fail to respond to brief interventions should be referred to a local drug and alcohol counsellor or service. Patients who drink alcohol at high-risk or potentially risky levels who also have a chronic medical condition and complex needs may benefit from a GP Management Plan and Team Care Arrangement under Medicare’s CDM GP services (formerly Enhanced Primary Care). Refer to Chapter 4 and Chapter 5 for more information about what is available under Medicare, including links to MBS templates.

Table 13.

Table 13.

Alcohol: telephone information services
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Further referral services can be found in Chapter 5. A local directory of services for patients with alcohol services may be compiled for a general practice (refer to Section 4.5.4).

Follow-up

Patients should be reviewed 1–3 months after their first visit in order to monitor progress and review their goals. The practice information system should generate reminders or lists of patients overdue for follow-up (refer to Section 4.5.1). Most relapses in behaviour occur in the first few weeks and patients should be counselled that they should keep trying even if they have relapsed.

As defined in the most recent report106 supporting Australia’s physical activity and sedentary guidelines for adults, six terms apply to this section.

Physical activity – Any bodily movement produced by skeletal muscles that expends energy. This includes activities that use one or more large muscle groups for movement in the following domains:

  • Occupation (eg. paid and unpaid work)
  • Leisure (eg. organised activities such as sports, as well as exercise and recreational activities)
  • School (eg. physical education and active play during recess and lunch breaks)
  • Domestic (eg. house work, shopping and gardening)
  • Transport (eg. walking, cycling or skating to get to or from places).

Sedentary behaviours – Any waking activity that involves sitting or lying down, with little energy expenditure (ie. <1.5 metabolic equivalent), including in the following domains:

  • Occupational or educational (eg. sitting at work or school)
  • Leisure (eg. watching TV, reading, sewing, computer use, social networking)
  • Transport (eg. sitting in a car).

Metabolic equivalent (MET) – The unit used to define levels of activity, in multiples of resting metabolic rate. One MET is defined as energy expenditure at rest, usually equivalent to 3.5 mL of oxygen uptake per kilogram per minute.

Intensity –The rate of energy expenditure required for an activity, usually measured in METs. Physical activities are often divided into ‘light’, ‘moderate’ and ‘vigorous’ levels of intensity. Light activities include those that require standing up and moving around, with an energy expenditure of 1.6–2.9 METs. Moderate activities require some effort, but allow a conversation to be held (eg. brisk walking, gentle swimming, social tennis), with energy expenditure of 3.0–5.9 METs. Vigorous activities make you breathe harder or puff and pant, depending on fitness (eg. aerobics, jogging and some competitive sports), with energy expenditure equal to or greater than 6 METs.

Frequency – The number of times a behaviour (eg. walking, running, sitting) is carried out per day or per week.

Duration – The time spent in each session of a behaviour (eg. minutes of walking or sitting per session), or the total time spent in a behaviour in a specific period (eg. minutes of walking per week). Accumulation describes ‘collecting’ short bouts of a behaviour (eg. walking or sitting) to achieve a total amount of that behaviour over a specified time (eg. a day or a week).

Ask and assess

In assessing physical activity and sedentary behaviour, it is important to judge a patient’s level of activity against appropriate population recommendations. Australia’s physical activity and sedentary behaviour guidelines provide age-specific recommendations for both physical activity and sedentary behaviour. These are summarised in Table 15 in Section 3.5.2.

Table 14

Table 14

Physical activity: when, how and who to assess
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Methods of assessment

The optimal method of assessing physical activity and sedentary behaviour in general practice is unclear. Options include taking a history, brief questionnaires or structured verbal questioning and the use of objective measures of physical activity, such as pedometers.

History-taking should include the type, intensity, frequency and duration of bouts of physical activity. In addition, physical activity in all domains (occupation, domestic, leisure and transport) should be assessed, as well as the extent of sedentary behaviours. History-taking should also address barriers to, and facilitators of, physical activity in order to facilitate behavioural change.

Brief questionnaires/questions are not recommended as they appear to be less effective than history-taking for identifying adults at risk of not meeting physical activity guidelines.108 A brief questionnaire tested in adolescents against an accelerometer determined physical activity levels had sub-optimal diagnostic performance with low sensitivity.109

Pedometers are an option for measuring steps per day, with 10,000 steps suggested as a reasonable target for healthy adults.110 This may be higher in children (13,000–15,000 for boys, 11,000–12,000 for girls) and adolescents (10,000–11,700),111 but somewhat lower in older adults (7000–10,000).112 However, these estimates may be higher than necessary to be equivalent to physical activity recommendations and health benefits appear to accrue at lower levels of steps per day.113 It should also be noted that pedometers do not measure non-ambulatory physical activity, such as cycling or swimming.

Advise and assist

Provide age-specific advice on meeting recommended levels of physical activity and avoiding exceeding recommended levels of sedentary behaviour (refer to Table 15). The message that any physical activity is better than none is important. If a patient does not already engage in regular physical activity, they can be encouraged to start by doing some, and then gradually build up to the recommended amount.

Table 15.

Table 15.

Australia’s physical activity and sedentary behaviour guidelines for children, young people and adults
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Several interventions for improving physical activity in sedentary adults have been shown to be effective in primary care,123 resulting in a higher likelihood of achieving recommended levels of physical activity, or increasing physical activity (odds ratio 1.42 [95% confidence interval, 1.17–1.73], number needed to treat for one additional sedentary adult to meet guideline recommended levels of physical activity = 12). Most interventions included written materials and two or more sessions of physical activity advice or counselling, delivered face-to-face. Other intervention components included the use of written exercise prescriptions and supplementary advice or counselling by telephone. Exercise prescription has demonstrated effectiveness and using pedometers as part of exercise prescription may have additional benefits.124

Interventions targeting sedentary behaviour have not been tested in the general practice setting, but evidence suggests substantial reductions are possible when it is done in workplaces (eg. through use of sit–stand desks).125 Advice about reducing sedentary time at work should therefore be considered in relevant patients.

The health risks of moderate intensity physical activity are low. However, there are certain conditions that place patients at higher risk and require clinical assessment and supervision, including:

  • unstable angina
  • recent complicated myocardial infarction (within three months)
  • untreated heart failure or cardiomyopathy
  • resting heart rate >100
  • symptoms such as chest discomfort or shortness of breath on low exertion
  • severe aortic stenosis
  • uncontrolled diabetes
  • hypertension
  • unstable respiratory disease.

Sedentary individuals should be discouraged from undertaking sudden vigorous physical activity in favour of starting with moderate activity to reduce any transient increased risk of cardiovascular events.126

Arrange

Patients may be referred to cardiac rehabilitation or physical activity programs, or classes run by local community organisations. Some patient groups may particularly benefit from referral to group programs such as those for socioeconomically disadvantaged women.127

Examples of exercise programs for referring your patients:

  • Heartmoves is the Heart Foundation’s gentle physical activity program run by accredited exercise professionals and suitable for people with stable long-term health conditions such as heart disease, diabetes or obesity. 
  • Heartline (1300 36 27 87) is a telephone service staffed by trained healthcare professionals who provide information on CVD management, nutrition and healthy eating, blood pressure, smoking cessation and physical activity. Information on relevant support programs and information booklets on a range of topics is also available.
  • HEAL program is a lifestyle modification program designed to improve nutrition and physical activity and promote self-management for people who are overweight or obese with, or who are at risk of developing, a chronic disease. 

Information on local physical activity programs may also be available from your local council. State government departments of sport or recreation have databases of local sport and recreation organisations in each state/territory:

These should be included in a practice directory (refer to Section 4.5.4)

Refer to Chapter 5 for information on other exercise programs and resources.

Patients who are insufficiently active and who have a chronic medical condition and complex needs may benefit from referral to an accredited exercise physiologist or physiotherapist. For referral to an exercise physiologist, you can use the ‘find an exercise physiologist’ feature of the Exercise and Sports Science Australia (ESSA) website.

It should be noted that there is limited research examining the effectiveness of exercise referral. Moreover, adherence to such referrals is frequently poor (<50%).128 For a summary of the evidence and physical activity recommendations for multiple conditions, refer to ESSA’s position statements 

Patients who are insufficiently active and who have a chronic medical condition and complex needs may also benefit from a GP Management Plan and Team Care Arrangement under Medicare’s CDM GP services (formerly Enhanced Primary Care). Refer to Chapter 4 and Chapter 5 for more information about what is available under Medicare, including links to MBS templates.

Factsheets are a good way for general practice teams to provide their patients with information related to physical activity and various conditions. 

Follow-up

Patients should be reviewed at 3–6 month intervals, determined by the general practice team in line with the MBS. The practice information system should generate reminders or lists of patients overdue for follow-up (refer to Section 4.5.1).

Many patients find it difficult to sustain changes in physical activity, especially if it is not a regular part of their daily activity. Evidence from randomised controlled trials on techniques for improving adherence to physical activity promotion advice in primary care is limited. However, a systematic review of interventions to improve adherence to exercise for chronic musculoskeletal pain in adults suggests:129

  • the type of exercise prescribed (eg. aerobic versus resistance exercise) does not influence levels of exercise; therefore, patient preference should be considered in an attempt to motivate and initiate a new exercise program
  • interventions such as supervised or individualised exercise therapy may enhance adherence
  • incorporating specific adherence-enhancing strategies within an exercise program, such as positive reinforcement, goal-setting, feedback, development of problem-solving skills to overcome barriers to adherence and self-monitoring through use of an exercise plan, contract, and/or logbook, may have a positive impact on adherence.
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This guide has been designed to assist GPs and practice staff (the GP practice team) to work with patients on the lifestyle risk factors of smoking, nutrition, alcohol and physical activity (SNAP).

Organisations working with general practices, such as primary care organisations, public health services and other agencies that provide resources and training for primary healthcare staff, may also find this guide valuable.

The SNAP guide is based on the best available evidence at the time of publication. It adopts the most recent National Health and Medical Research Council (NHMRC) levels of evidence and grades of recommendations. Recommendations in the tables are graded according to levels of evidence and the strength of recommendation.

The levels of evidence are coded by the roman numerals I–IV, while the strength of recommendation is coded by the letters A–D. Practice points (PP) are employed where no good evidence is available.

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