SNAP

Chapter 1

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

  1. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2013–14. General practice series no.36. Sydney:Sydney University Press; 2014.
  2. Australian Bureau of Statistics. Australian Health Survey: Physical Activity 2011–12. Cat. no. 4364.0.55.004. Canberra: ABS;2013.
  3. Australian Institute of Health and Welfare. Tobacco smoking (NDSHS 2013 key findings). [Accessed 15 September 2014].
  4. Australian Bureau of Statistics. Australian Health Survey: Updated results 2011–2012. Cat no. 4364.0.55.003. Canberra: ABS;2013. [Accessed 15 September 2014].
  5. Australian Institute of Health and Welfare. Tobacco smoking. 10 July 2014].
  6. Peto R, Lopez PR, Boreham J, Thun M, Heath C. Morbidity from smoking in developed countries 1950–2000. Oxford: Oxford University Press; 1994.
  7. English DR, Holman CD, Milne E, et al. The quantification of drug caused morbidity and mortality in Australia. Canberra: Commonwealth Department of Health and Human Services; 1995.
  8. 8. Australian Bureau of Statistics. Profiles of Health, Australia 2011–13. Cat no. 4338.0. Canberra: ABS; 2014.
  9. World Health Organization. The optimal duration of exclusive breastfeeding: A systematic review. Geneva: WHO. [Accessed 10 July 2014].
  10. 10. Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD. The burden of disease and injury in Australia 2003, PHE 82.Canberra: AIHW; 2007. [Accessed 10 July 2014].
  11. Australian Institute of Health and Welfare. Australia’s food and nutrition 2012: in brief. [Accessed 10 July 2014].
  12. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alchol. Canberra: NHMRC; 2009. [Accessed 10 July 2014].
  13. Australian Institute of Health and Welfare. Risk factors contributing to chronic disease. Cat No. PHE 157. Canberra: AIHW;2012. [Accessed 10 July 2014].
  14. Australian Institute of Health and Welfare. Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra:AIHW; 2012. [Accessed 10 July 2014].
  15. Australian Institute of Health and Welfare. Cardiovascular disease: Australian facts 2011. Cardiovascular disease series. CVD 53. Canberra: AIHW; 2011.
  16. Waters AM, Moon L. Socioeconomic inequalities in cardiovascular disease in Australia. AIHW bulletin no. 37. Cat. no. AUS 74. Canberra: AIHW; 2006.
  17. Harris M, Furler J. How can primary care increase equity in health? NSW Public Health Bull 2002;13(3):35–8.
  18. Dosh SA, Holtrop JS, Torres T, Arnold AK, Baumann J, White LL. Changing organizational constructs into functional tools: an assessment of the 5 A’s in primary care practices. Ann Fam Med 2005;3 Suppl 2:S50–2.
  19. Hung DY, Rundall TG, Tallia AF, Cohen DJ, Halpin HA, Crabtree BF. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors. Milbank Q 2007;85(1):69–91.
  20. Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol 2009;64(6):527–37.
  21. Lupu AM, Stewart AL, O’Neil C. Comparison of active-learning strategies for motivational interviewing skills, knowledge, and confidence in first-year pharmacy students. Am J Pharm Educ 2012;76(2):28.
  22. Daeppen JB, Fortini C, Bertholet N, et al. Training medical students to conduct motivational interviewing: a randomized controlled trial. Patient Educ Couns 2012;87(3):313–8.
  23. Anstiss T. Motivational interviewing in primary care. J Clin Psychol Med Settings 2009;16(1):87–93.
  24. Hinz JG. Teaching dental students motivational interviewing techniques: analysis of a third-year class assignment. J Dent Educ 2010;74(12):1351–6.
  25. White LL, Gazewood JD, Mounsey AL. Teaching students behavior change skills: description and assessment of a new Motivational interviewing curriculum. Med Teach 2007;29(4):e67–71.
  26. Burke PJ, Da Silva JD, Vaughan BL, Knight JR. Training high school counselors on the use of motivational interviewing to screen for substance abuse. Subst Abus 2005;26(3–4):31–4.Butler CC, Simpson SA, Hood K, et al. Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial. BMJ 2013;346:f1191.
  27. Teixeira PJ, Silva MN, Mata J, Palmeira AL, Markland D. Motivation, self-determination, and long-term weight control. Int J Behav Nutr Phys Act 2012;9:22.
  28. Taggart J, Williams A, Dennis S, et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract 2012;13:49.
  29. Macdonald P, Hibbs R, Corfield F, Treasure J. The use of motivational interviewing in eating disorders: a systematic review. Psychiatry Res 2012;200(1):1–11.
  30. Hardcastle S, Blake N, Hagger MS. The effectiveness of a motivational interviewing primary-care based intervention on physical activity and predictors of change in a disadvantaged community. J Behav Med 2012;35(3):318–33.
  31. Chilton R, Pires-Yfantouda R, Wylie M. A systematic review of motivational interviewing within musculoskeletal health. Psychol Health Med 2012;17(4):392–407.
  32. Soderlund LL, Madson MB, Rubak S, Nilsen P. A systematic review of motivational interviewing training for general health care practitioners. Patient Educ Couns 2011;84(1):16–26.
  33. Smedslund G, Berg RC, Hammerstrom KT, et al. Motivational interviewing for substance abuse. Cochrane Database Syst Rev 2011;5:CD008063.
  34. Jensen CD, Cushing CC, Aylward BS, Craig JT, Sorell DM, Steele RG. Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. J Consult Clin Psychol 2011;79(4):433–40.
  35. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ, Campbell TS, Hemmelgarn BR. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev 2011;12(9):709–23.
  36. Lai DT, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev 2010(1):CD006936.
  37. Sharing Health Care: Guidelines for General Practitioners working with Chronic Conditions Melbourne: The Royal Australian College of General Practitioners; 2001.
  38. Nutbeam D. Building health literacy in Australia. Med J Aust 2009;191(10):525–6.
  39. von Wagner C, Steptoe A, Wolf MS, Wardle J. Health literacy and health actions: a review and a framework from health psychology. Health Educ Behav 2009;36(5):860–77.
  40. Australian Bureau of Statistics. Health literacy. Canberra: ABS; 2006.
  41. Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med 2008;23(5):561–6.
  42. Royal College of General Practitioners. Health Literacy: Report from an RCGP-led literacy workshop [Accessed 9 August 2014].
  43. DeWalt D, Callhan L, Hawk V, et al. Health literacy universal precautions toolkit. Rockville: Agency for Healthcare Research and Quality; 2010. [Accessed 9 August 2014].
  44. United States Department of Health and Human Services. Physical activity guidelines advisory committee report. Washington DC: US DHHS; 2008. [Accessed 9 August 2014].
  45. Supporting smoking cessation: a guide for health professionals. Melbourne: The Royal Australian College of General Practitioners; 2014. [Accessed 9 August 2014].
  46. Higgins K, Cooper-Stanbury M, Williams P. Statistics on drug use in Australia 1998. Drug statistics series. Cat. no. PHE 16. Canberra: AIHW; 2000. [Accessed 9 August 2014].
  47. Hill DJ, White VM, Scollo MM. Smoking behaviours of Australian adults in 1995: trends and concerns. Med J Aust 1998;168(5):209–13. [Accessed 9 August 2014].
  48. The Tobacco Use and Dependence Clinical Practice Guideline Panel and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. JAMA 2000;283(24):3244–54. [Accessed 9 August 2014].
  49. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013;5:CD000165. [Accessed 9 August 2014].
  50. Hughes JR. A quantitative estimate of the clinical significance of treating tobacco dependence. Am J Prev Med 2010;39(3):285–6. [Accessed 9 August 2014].
  51. Wynn A, Coleman T, Barrett S, Wilson A. Factors associated with the provision of anti-smoking advice in general practice consultations. Br J Gen Pract 2002;52(485):997–9. [Accessed 9 August 2014].
  52. He J, Vupputuri S, Allen K, Prerost MR, Hughes J, Whelton PK. Passive smoking and the risk of coronary heart disease--a meta-analysis of epidemiologic studies. N Engl J Med 1999;340(12):920–6. [Accessed 9 August 2014].
  53. World Health Organization. Report on passive smoking and children. Geneva: WHO; 2000. [Accessed 9 August 2014].
  54. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;11:CD000146. [Accessed 9 August 2014].
  55. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;5:CD009329. [Accessed 9 August 2014].
  56. Gibbons RD, Mann JJ. Varenicline, smoking cessation, and neuropsychiatric adverse events. Am J Psychiatry [Accessed 9 August 2014].
  57. 2013;170(12):1460–7. [Accessed 9 August 2014].
  58. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2014;1:CD000031. [Accessed 9 August 2014].
  59. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Canberra: NHMRC; 2013. [Accessed 9 August 2014].
  60. Welborn TA, Dhaliwal SS, Bennett SA. Waist-hip ratio is the dominant risk factor predicting cardiovascular death in Australia. Med J Aust 2003;179(11–12):580–5. [Accessed 9 August 2014].
  61. Wang Y, Rimm EB, Stampfer MJ, Willett WC, Hu FB. Comparison of abdominal adiposity and overall obesity in predicting risk of type 2 diabetes among men. Am J Clin Nutr 2005;81(3):555–63. [Accessed 9 August 2014].
  62. World Health Organization Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363(9403):157–63. [Accessed 9 August 2014].
  63. National Health and Medical Research Council. Australian dietary guidelines. Canberra: NHMRC; 2013. [Accessed 9 August 2014].
  64. Steptoe A, Perkins-Porras L, McKay C, Rink E, Hilton S, Cappuccio FP. Behavioural counselling to increase consumption of fruit and vegetables in low income adults: randomised trial. BMJ 2003;326(7394):855. [Accessed 9 August 2014].
  65. Miller M, Pollard C, D. P. A public health nutrition campaign to promote fruit and vegetables in Australia. In: Worsley A, editor. Multidisciplinary approach to food choice Proceedings of Food Choice Conference. Adelaide: University of Adelaide; 1993. [Accessed 9 August 2014].
  66. Bhattarai N, Prevost AT, Wright AJ, Charlton J, Rudisill C, Gulliford MC. Effectiveness of interventions to promote healthy diet in primary care: systematic review and meta-analysis of randomised controlled trials. BMC Public Health 2013;13:1203. [Accessed 9 August 2014].
  67. Ammerman AS, Lindquist CH, Lohr KN, Hersey J. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Prev Med 2002;35(1):25–41. [Accessed 9 August 2014].
  68. Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev 2008(2):CD007176. [Accessed 9 August 2014].
  69. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:i–xii, 1–253. [Accessed 9 August 2014].
  70. Guidelines for preventive activities in general practice, 8th edn. Melbourne: The Royal Australian College of General Practitioners; 2013. [Accessed 9 August 2014].
  71. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158(16):1789–95. [Accessed 9 August 2014].
  72. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT—the alcohol use disorders identification test: guidelines for use in primary care, 2nd edn. Geneva: World Health Organization; 2001. [Accessed 10 July 2014].
  73. Pilling S, Yesufu-Udechuku A, Taylor C, Drummond C, Guideline Development G. Diagnosis, assessment, and management of harmful drinking and alcohol dependence: summary of NICE guidance. BMJ 2011;342:d700. [Accessed 10 July 2014].
  74. Department of Health and Ageing. Guidelines for the Treatment of Alcohol Problems. Canberra: DoHA; 2009. [Accessed 10 July 2014].
  75. Tam CW, Zwar N, Markham R. Australian general practitioner perceptions of the detection and screening of at-risk drinking,and the role of the AUDIT-C: a qualitative study. BMC Fam Pract 2013;14:121. [Accessed 10 July 2014].
  76. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med 2003;163(7):821–9. [Accessed 10 July 2014].
  77. Rehm J, Room R, Taylor B. Method for moderation: measuring lifetime risk of alcohol-attributable mortality as a basis for drinking guidelines. Int J Methods Psychiatr Res 2008;17(3):141–51. [Accessed 10 July 2014].
  78. Pluijm SM, Smit JH, Tromp EA, et al. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos Int 2006;17(3):417–25. [Accessed 10 July 2014].
  79. Fletcher PC, Hirdes JP. Risk factor for accidental injuries within senior citizens’ homes: analysis of the Canadian Survey on Ageing and Independence. J Gerontol Nurs 2005;31(2):49–57. [Accessed 10 July 2014].
  80. Aira M, Hartikainen S, Sulkava R. Community prevalence of alcohol use and concomitant use of medication--a source of possible risk in the elderly aged 75 and older? Int J Geriatr Psychiatry 2005;20(7):680–5. [Accessed 10 July 2014].
  81. Foxcroft DR, Ireland D, Lister-Sharp DJ, Lowe G, Breen R. Longer-term primary prevention for alcohol misuse in young people: Cochrane systematic review. Int J Epidemiol 2005;34:758–9. [Accessed 10 July 2014].
  82. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J, Force USPST. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140(7):557–68. [Accessed 10 July 2014].
  83. Ballesteros J, Gonzalez-Pinto A, Querejeta I, Arino J. Brief interventions for hazardous drinkers delivered in primary care are equally effective in men and women. Addiction 2004;99(1):103–8. [Accessed 10 July 2014].
  84. Ballesteros J, Duffy JC, Querejeta I, Arino J, Gonzalez-Pinto A. Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcohol Clin Exp Res 2004;28(4):608–18. [Accessed 10 July 2014].
  85. Fell JC, Voas RB. The effectiveness of reducing illegal blood alcohol concentration (BAC) limits for driving: evidence for lowering the limit to .05 BAC. J Safety Res 2006;37(3):233–43. [Accessed 10 July 2014].
  86. Taylor B, Irving HM, Kanteres F, et al. The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together. Drug Alcohol Depend 2010;110(1–2):108–16. [Accessed 10 July 2014].
  87. Lunetta P, Smith GS, Penttila A, Sajantila A. Unintentional drowning in Finland 1970-2000: a population-based study. Int J Epidemiol 2004;33(5):1053–63. [Accessed 10 July 2014].
  88. Driscoll TR, Harrison JE, Steenkamp M. Alcohol and drowning in Australia. Inj Control Saf Promot 2004;11(3):175–81. [Accessed 10 July 2014].
  89. Kaye S, Darke S. Non-fatal cocaine overdose among injecting and non-injecting cocaine users in Sydney, Australia. Addiction 2004;99(10):1315–22. [Accessed 10 July 2014].
  90. O’Kane CJ, Tutt DC, Bauer LA. Cannabis and driving: a new perspective. Emerg Med (Fremantle) 2002;14(3):296–303. [Accessed 10 July 2014].
  91. Sullivan LE, Fiellin DA, O’Connor PG. The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med 2005;118(4):330–41. [Accessed 10 July 2014].
  92. Morris EP, Stewart SH, Ham LS. The relationship between social anxiety disorder and alcohol use disorders: a critical review. Clin Psychol Rev 2005;25(6):734–60. [Accessed 10 July 2014].
  93. Abrams K, Kushner M, Medina KL, Voight A. The pharmacologic and expectancy effects of alcohol on social anxiety in individuals with social phobia. Drug Alcohol Depend 2001;64(2):219–31. [Accessed 10 July 2014].
  94. Moore AA, Whiteman EJ, Ward KT. Risks of combined alcohol/medication use in older adults. Am J Geriatr Pharmacother 2007;5(1):64–74. [Accessed 10 July 2014].
  95. Weathermon R, Crabb DW. Alcohol and medication interactions. Alcohol Res Health 1999;23(1):40–54. [Accessed 10 July 2014].
  96. Odendaal HJ, Steyn DW, Elliott A, Burd L. Combined effects of cigarette smoking and alcohol consumption on perinatal outcome. Gynecol Obstet Invest 2009;67(1):1–8. [Accessed 10 July 2014].
  97. Rehm J, Baliunas D, Borges GL, et al. The relation between different dimensions of alcohol consumption and burden of disease: an overview. Addiction 2010;105(5):817–43. [Accessed 10 July 2014].
  98. Australian Health Ministers’ Advisory Council. Clinical Practice Guidelines: Antenatal Care – Module 1. Canberra: Australian Government Department of Health and Ageing; 2012. [Accessed 10 July 2014].
  99. Kaner EF, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: a systematic review. Drug Alcohol Rev 2009;28(3):301–23. [Accessed 10 July 2014].
  100. Apodaca TR, Longabaugh R. Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction 2009;104(5):705–15. [Accessed 10 July 2014].
  101. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four metaanalyses. J Clin Psychol 2009;65(11):1232–45. [Accessed 10 July 2014].
  102. Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med 2005;165(9):986–95. [Accessed 10 July 2014].
  103. Raistrick D, Heather N, Godfrey C. Review of the effectiveness of treatment for alcohol problems. London: National Treatment Agency for Substance Misuse; 2006. [Accessed 10 July 2014].
  104. Department of Health and Ageing. Quick Reference Guide to the Treatment of Alcohol Problems: Companion Document to The Guidelines for the Treatment of Alcohol Problems. Canberra: DoHA; 2009. [Accessed 10 July 2014].
  105. National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115. London: NICE; 2011. [Accessed 10 July 2014].
  106. Brown W, Bauman A, Bull F, Burton N. Development of evidence-based physical activity recommendations for adults (18–64 years). Report prepared for the Australian Government Department of Health, August 2012. [Accessed 10 July 2014].
  107. Bauman A, Bellew B, Vita P, Brown W, Owen N. Getting Australia active: towards better practice for the promotion of physical activity. Melbourne: National Public Health Partnership; 2002. [Accessed 10 July 2014].
  108. Winzenberg T, Shaw KA. Screening for physical inactivity in general practice - a test of diagnostic accuracy. Aust Fam Physician 2011;40(1–2):57–61. [Accessed 10 July 2014].
  109. Ridgers ND, Timperio A, Crawford D, Salmon J. Validity of a brief self-report instrument for assessing compliance with physical activity guidelines amongst adolescents. J Sci Med Sport 2012;15(2):136–41. [Accessed 10 July 2014].
  110. Tudor-Locke C, Craig CL, Brown WJ, et al. How many steps/day are enough? For adults. Int J Behav Nutr Phys Act 2011;8:79. [Accessed 10 July 2014].
  111. Tudor-Locke C, Craig CL, Beets MW, et al. How many steps/day are enough? For children and adolescents. Int J Behav Nutr Phys Act 2011;8:78. [Accessed 10 July 2014].
  112. Tudor-Locke C, Craig CL, Aoyagi Y, et al. How many steps/day are enough? For older adults and special populations. Int J Behav Nutr Phys Act 2011;8:80. [Accessed 10 July 2014].
  113. Schmidt MD, Cleland VJ, Shaw K, Dwyer T, Venn AJ. Cardiometabolic risk in younger and older adults across an index of ambulatory activity. Am J Prev Med 2009;37(4):278–84. [Accessed 10 July 2014].
  114. Department of Health and Ageing. National physical activity recommendations for children 0-5 years. Canberra: Department of Health and Ageing; 2012. [Accessed 10 July 2014].
  115. Okely AD, Salmon J, Trost SG, Hinkley T. Discussion paper for the development of physical activity recommendations for children under five years. Canberra: Department of Health and Ageing; 2008. [Accessed 10 July 2014].
  116. Department of Health and Ageing. National physical activity and sedentary behaviour guidelines for children (5–12 years). Canberra: Department of Health and Ageing; 2012. [Accessed 10 July 2014].
  117. Okely AD, Salmon J, Vella SA, et al. A Systematic Review to update the Australian Physical Activity Guidelines for Children and Young People. Report prepared for the Australian Government Department of Health and Ageing, June 2012. [Accessed 10 July 2014].
  118. Okely AD, Salmon J, Vella SA, et al. A Systematic Review to Inform the Australian Sedentary Behaviour Guidelines for Children and Young People. Report prepared for the Australian Government Department of Health and Ageing, June 2012. [Accessed 10 July 2014].
  119. Department of Health and Ageing. National physical activity and sedentary behaviour guidelines for young people (13–17 years). Canberra: Department of Health and Ageing; 2012. [Accessed 10 July 2014].
  120. Department of Health and Ageing. National physical activity and sedentary behaviour guidelines for adults (18–64 years). Canberra: Department of Health and Ageing; 2012. [Accessed 10 July 2014].
  121. Department of Health and Ageing. National Physical activity recommendations for older Australians (65 years and older). Canberra: Department of Health and Ageing; 2012. [Accessed 16 January 2015].
  122. Sims J, Hill K, Hunt S, et al. National physical activity recommendations for older Australians: Discussion document. Canberra: Australian Government Department of Health and Ageing; 2006. [Accessed 16 January 2015].
  123. Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344:e1389. [Accessed 16 January 2015].
  124. Kolt GS, Schofield GM, Kerse N, Garrett N, Ashton T, Patel A. Healthy Steps trial: pedometer-based advice and physical activity for low-active older adults. Ann Fam Med 2012;10(3):206–12. [Accessed 16 January 2015].
  125. Prince SA, Saunders TJ, Gresty K, Reid RD. A comparison of the effectiveness of physical activity and sedentary behaviour interventions in reducing sedentary time in adults: a systematic review and meta-analysis of controlled trials. Obes Rev 2014. [Accessed 16 January 2015].
  126. American College of Sports Medicine, American Heart Association. Exercise and acute cardiovascular events: placing the risks into perspective. Med Sci Sports Exerc 2007;39(5):886–97. [Accessed 16 January 2015].
  127. Cleland V, Granados A, Crawford D, Winzenberg T, Ball K. Effectiveness of interventions to promote physical activity among socioeconomically disadvantaged women: a systematic review and meta-analysis. Obes Rev 2013;14(3):197–212. [Accessed 16 January 2015].
  128. Pavey T, Taylor A, Hillsdon M, et al. Levels and predictors of exercise referral scheme uptake and adherence: a systematic review. J Epidemiol Community Health 2012;66(8):737–44. [Accessed 16 January 2015].
  129. Jordan JL, Holden MA, Mason EE, Foster NE. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2010(1):CD005956. [Accessed 16 January 2015].
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log

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.

Related documents

Advertising