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Clinical guidelines

SNAP Guide

Nutrition

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

3.3.1 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.

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

Question

Answer

Level of evidence and strength of recommendation

What preventive action should be recommended?

Patients should be encouraged and supported to follow dietary recommendations,67 and advised to eat five serves of vegetables (or more, depending on age and life stage) and two serves of fruit per day.63

II–B (effect of intervention)67

Should vitamin supplementation be recommended for asymptomatic people?

Vitamin supplementation is not of established value in individuals without signs or symptoms of deficiency disorders (with the exception of folate in pregnancy).

Note: Prevalence of nutritional deficiency is high in groups such as alcoholics and elderly people who live alone and in institutions.

PP

Should asymptomatic people take beta-carotene or other antioxidants?

There is insufficient information to show this results in improved health outcomes for the general population.68

PP

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 fat

and 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. Nutrition: number of serves (used in the Australian Dietary Guidelines)63

Food group

Number of daily serves for adults aged 19–50

 

Male

Female

Bread, cereals, rice, pasta, noodles

6

6 (8.5 pregnancy, 9 breastfeeding)

Vegetables, legumes

6

5 (7.5 pregnancy)

Fruit

2

2

Milk, yoghurt, cheese

2.5

2.5

Meat, fish, poultry, eggs, nuts

3

2.5 (3.5 pregnancy, 2.5 breastfeeding)

Details of sample serves can be found at the Australian Guide to Healthy Eating website (www.eatforhealth.gov.au).

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. Visit http://strokefoundation.com.au/site/media/AbsoluteCVD_GL_webready.pdf for more information.

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.

3.3.3 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 (www.daa.asn.au) 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. Visit www.nutritionaustralia.org for more information. A range of useful information and resources on nutrition is also available at www.eatforhealth.gov.au

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.

References

  1. National Health and Medical Research Council. Australian dietary guidelines. Canberra: NHMRC; 2013.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.

 

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