Introduction

Understanding risk factors can help patients identify the lifestyle changes needed to make a positive difference. While conducting a health assessment, the GP team member can discuss interventions with the patient. Once agreed, and where appropriate, the interventions can then be summarised on a management plan and discussed in subsequent consultations. When interventions are jointly planned and negotiated, and information is shared between doctor and patient, the patient is more likely to be empowered and therefore committed to following the agreed plan.

Working with patients forms the basis of sustainable behaviour change as it involves patients in making decisions related to their health-improvement goals. The RACGP’s Putting prevention into practice (the Green book) includes a more detailed section on the principles of patient self-management that can be applied in this context.

A GP can utilise an MBS health assessment item to undertake a more comprehensive assessment of a patient with complex care needs. Health assessments also permit the needs of specific groups (eg. Aboriginal and Torres Strait Islander peoples, refugees and aged care residents) to be addressed in a targeted and culturally appropriate manner.

A GP Management Plan and Team Care Arrangement under Medicare’s Chronic Disease Management (CDM) GP services (formerly Enhanced Primary Care) may be appropriate for patients with a chronic or terminal medical condition and complex care needs. These act as comprehensive, longitudinal plans for patient care. While they are not appropriate for patients who are merely ‘at risk’ of disease, they can be an important tool for managing risk factors and interventions for those patients who already have chronic medical conditions and complex needs. The review of care plans is critically important as it provides an opportunity to review their implementation and effectiveness with the patient.

Refer to Chapter 5 for information and links to MBS items and templates that can be used for SNAP, such as a healthcare assessment and a chronic disease management plan.

This guide has been designed to assist general practitioners (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 covers:

• why these risk factors are important and why general practice is a key location to influence SNAP risk factor behaviour in adults
• how to assess whether a patient is ready to make lifestyle changes
• a five-step model, the 5As (ask, assess, advise, assist, arrange), for detection, assessment and management of SNAP risk factors
• effective clinical strategies for SNAP risk factors (including overweight and obesity) using the 5As model
• establishing the business case for assessing and managing lifestyle-related risk factors in the general practice setting
• practical business strategies to apply the SNAP approach to general practice
• useful resources, tools and referral services.

The SNAP guide does not specifically examine risk factors in children and adolescents.

Development of the SNAP guide

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.

Further information on preventive care in general practice can be found in the RACGP’s Guidelines for preventive activities in general practice (8th edition) (the Red book).

The SNAP risk factors are common among patients attending general practice. Of adult patients attending general practice encounters in 2013–14:¹

• 62.7% were overweight (34.9%) or obese (27.8%)
• 13.5% were daily smokers, 2.3% were occasional smokers, 28.6% were previous smokers
• 23% drank ‘at risk’ levels of alcohol
• around 50% had at least one of the above three risk factors.

Australian adults spent an average of approximately 30 minutes per day doing physical activity in 2011–12. However, only 43% of adults did at least 30 minutes of moderate intensity physical activity on most days.²

Each of the SNAP risk factors is associated with many diseases and often interrelate throughout the lifecycle. It is therefore important to manage risk factors collectively and not in isolation. The ‘absolute risk’ approach, and the associated absolute cardiovascular disease (CVD) risk calculator was developed by the National Vascular Disease Prevention Alliance. It attempts to place assessment and intervention of an individual risk factor within the context of the ‘absolute risk’ that the patient will have a cardiovascular event in the next five years. The online calculator is referred to throughout this guide.

The format of this edition is similar to the first, but the new online presentation offers a more practical and navigable guide. Resources are available with hyperlinks to allow for ease of reference.

The sections have been extensively updated and reformatted to align with current RACGP publications. Content has also been updated to be consistent with the latest Australian guidelines (smoking, obesity, nutrition, alcohol, physical activity). Chapter 4 includes new systems for practice organisation and incorporates information based on the latest Medicare Benefits Schedule (MBS). 

Understanding risk factors can help patients identify the lifestyle changes needed to make a positive difference. While conducting a health assessment, the GP team member can discuss interventions with the patient. Once agreed, and where appropriate, the interventions can then be summarised on a management plan and discussed in subsequent consultations. When interventions are jointly planned and negotiated, and information is shared between doctor and patient, the patient is more likely to be empowered and therefore committed to following the agreed plan.

Working with patients forms the basis of sustainable behaviour change as it involves patients in making decisions related to their health-improvement goals. The RACGP’s Putting prevention into practice (the Green book) includes a more detailed section on the principles of patient self-management that can be applied in this context.

A GP can utilise an MBS health assessment item to undertake a more comprehensive assessment of a patient with complex care needs. Health assessments also permit the needs of specific groups (eg. Aboriginal and Torres Strait Islander peoples, refugees and aged care residents) to be addressed in a targeted and culturally appropriate manner.

A GP Management Plan and Team Care Arrangement under Medicare’s Chronic Disease Management (CDM) GP services (formerly Enhanced Primary Care) may be appropriate for patients with a chronic or terminal medical condition and complex care needs. These act as comprehensive, longitudinal plans for patient care. While they are not appropriate for patients who are merely ‘at risk’ of disease, they can be an important tool for managing risk factors and interventions for those patients who already have chronic medical conditions and complex needs. The review of care plans is critically important as it provides an opportunity to review their implementation and effectiveness with the patient.

Refer to Chapter 5 for information and links to MBS items and templates that can be used for SNAP, such as a healthcare assessment and a chronic disease management plan.

Smoking

Recent years have seen daily smoking in Australia decline among people aged 14 and older, from 15.1% in 2010 to 12.85% in 2013.³ Those most likely to smoke are aged 40–49 (16.2%).⁴ The rates of daily smoking among people aged 18–49 have dropped significantly, from 24.7% in 2001 to 14.9% in 2013. However, daily smoking rates in people aged 60 and older have changed little between 2001 (11.3%) and 2013 (11.6%).³

Smoking kills an estimated 19,000 Australians every year and is the risk factor responsible for the greatest burden of disease in the country (9.7%).⁵ Smoking is estimated to kill approximately half of all long-term users,⁶ causing 40% of deaths in men and 20% of deaths in women before the age of 65.⁷

Overweight and obesity

In 2011–12, 62.8% of Australians aged 18 and older were overweight (35.3%) or obese (27.5%), while 25.7% of Australian children aged 5–17 were either overweight or obese, with the prevalence of both increasing.⁸ These are comparable with the rates seen in general practice (refer to Section 1.1).

Nutrition

Diet is a key contributor to optimum health throughout every stage of the lifespan. Exclusive breastfeeding for at least the first six months of life offers considerable health benefits to infants and, in the long term, to children and adults.⁹ Diets low in fruit and vegetables have been causally linked to cancer and CVD, accounting for 2.1% of the total burden of disease and injury in Australia in 2003.¹⁰ Most Australians (91%) do not eat enough vegetables and only half eat enough fruit.¹¹

Alcohol

Alcohol consumption accounted for 3.3% of the total burden of disease and injury in Australia in 2003.¹⁰ However, this figure may be an underestimate.¹² Even though moderate alcohol intake may have beneficial effects at middle and older ages, alcohol is harmful when consumed in excess at all ages.¹⁰ Alcohol is responsible for the majority of drug-related deaths and hospital episodes among people aged 15–34, causing more deaths and hospitalisations in this age group than tobacco or all illicit drugs.¹²

Physical activity

Physical inactivity is responsible for nearly 7% of the total burden of disease and injury and accounted for approximately 13,500 deaths in Australia in 2003.¹⁰ Based on data from the 2007–08 National Health Survey, almost 60% of Australians aged 15 and older do not undertake sufficient physical activity to confer a health benefit.¹³ Physical activity is an important part of a healthy lifestyle. It may reduce the risk of developing conditions such as CVD, diabetes and certain types of cancer.

Health inequalities

There are significant health inequalities in Australia and people’s risk factors can vary according to where they live. People living in more disadvantaged areas have more risk factors (eg. obesity, risky/high-risk alcohol consumption, daily smoking, physical inactivity, high blood pressure, insufficient consumption of fruit, vegetables and whole milk). For example, 27% of people living in areas of least disadvantage report having four or more risk factors compared with 46% who live in the most disadvantaged areas.¹⁴

People from low socioeconomic backgrounds, people living in rural and remote areas, and Aboriginal and Torres Strait Islander peoples are at greater risk of CVD than the general population.¹⁵ While a study has shown that CVD death rates fell for all socioeconomic groups between 1992–2002, the proportion of CVD deaths due to socioeconomic inequality increased.¹⁶ Socioeconomically disadvantaged people make greater use of primary and secondary health services such as doctors, hospitals and outpatient clinics and are at higher risk of chronic disease.¹⁷