4. Anticipatory Guidance
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Maria Scranton, MD
Austin Medical Education Program, Austin TX
Chris Kjolhede, MD
Bassett Memorial Hospital, Cooperstown, NY
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"THE PHYSICIAN GIVES MEDICAL ANSWERS TO MEDICAL QUESTIONS, BUT FOR THOSE ANSWERS TO AFFECT ANY CHANGE IN BEHAVIOR, THEY MUST CONTAIN AN APPECIATION FOR THE PATIENT'S AND FAMILY'S SOCIAL, PSYCHOLOGICAL, AND ECONOMIC CIRCUMSTANCES. OTHERWISE, ONE MIGHT JUST AS WELL BE CASTING WORDS INTO SPACE."
INTRODUCTION
The importance of nutrition and activity anticipatory guidance cannot be overemphasized. Good nutrition is a cornerstone of a healthy life. The Feeding Infants and Toddlers Study (FITS) of over 3,000 families with children 4 months to 2 years of age demonstrated how little parents appreciated good nutrition. Most of the children in FITS consumed more energy than needed, but they often had deficiencies of micronutrients as well. Some parents put soda in the bottles' of their 7-month-old infants. What is it that we can do to create a universal appreciation for the principals of good nutrition among the families we serve?
Each section that follows -- from newborn through young adult life -- begins with an educational module on nutritional anticipatory guidance. Each module has objectives, pre-test, nutritional information and a case study to help integrate the information into clinical practice.
As you will see, successful anticipatory guidance relies on the same principles of interviewing (history taking) and physical examination necessary for the practice in all fields of clinical medicine. Taking an accurate history is especially important in nutritional counseling in order to guide recommendations for behavioral changes. Here are the basics of interviewing as suggested by the eminent American psychologist, Carl Rogers:
PRINCIPLES OF GUIDANCE
1. Listen to the patient and parent,
2. Ask open ended questions,
3. Restate or confirm the history, and
4. Evaluate.
5. You are now, to use Carl Rodgers' phrase, "[In the] same place as the client." You will be trusted and likely to bring about change.
TEACHING CAPTION: With these steps, you will have a better chance to suggest changes needed for a healthier lifestyle.
The process begins with an intentionally open ended question. "Tell me how I can help you?" "or "Tell me your concern for `Johnny.' " The mid part of the interview, after you've established parental (or the older child/adolescent) concerns, will use more close-ended questions (answered "Yes," "No," or quantity) to obtain specific information. [Hyperlink to diet assessment] Principles of behavior change require careful selection of what can be attended to at any given time. Time constraints may force you to address other issues at another time; nevertheless, be sure to end the interview with the question "has this been of help?" This reinforces concern and sets up a need for a next visit.
The model for behavior change established by Prohaska includes determining whether a family is ready for change prior to giving advice. The direct question, "do you want to…." suffices. If they are not ready (usually determined by a glance away or a vague demurring), do not belabor your point. Simply remind the family of your concern and move on. If they are ready, help initiate small changes. Have frequent follow-up. Attempts at "big-bang" changes with a re-appointment in one year are a certain prescription for failure. Whether the change suggested is larger or smaller, be sure to pay close attention to the child's course. Expect desire to change to be followed by small successes and many lapses. This is not failure. It takes substantial effort to change behavior and food selection. It is almost an impossibility to change culturally determined food habits formed in childhood in any short period of time. It is an unfortunate reality that poverty determined food choices mask as a food culture.
Being culturally sensitive is an essential concern. The injunction to be "Culturally Competent" can be fulfilled using a model suggested by Glenn Flores (Table)
CAPTION: In many circumstances issues of cost as well as culture will affect food selection. Use as many resources as you have available, and be the families advocate in maintaining engagement with hearth, nutrition, and social services.
Working through the case studies in the modules of the Teacher's Guide will demonstrate these principles. For the most part, nutrition guidance is evidence based especially the information on nutritional requirements. As lifestyles change and new foods are developed, it becomes more difficult to find adequate long-term evidence based studies. While studies on office based anticipatory guidance that results in long-term behavioral change are rarely available, our mission (should you choose to accept it!) is to be a source for learning about nutritional guidance. We certainly have sufficient evidence to guide patients and their families in a common desire to live the healthiest lifestyle possible. It is our hope that these modules should aid you in your mission.
