| COMMUNICATION |
| DANONE NUTRITION FORUM |
| DANONE CHAIR MONOGRAPH |
| NUTRITION NEWS |
| DANONE INTERNATIONAL PRIZE FOR NUTRITION |
DANONE NUTRITION FORUM
The 11th Danone Nutrition Forum
On October 17, 2009, in Tokyo, the Danone Institute of Japan organized the 11th Danone Nutrition Forum under the theme "Nutrition Guidance Required in a Clinical Setting". About 400 of dietitians, health professionals, educators and students participated.
 Program
"Nutrition Guidance Required in a Clinical Setting"
Opening Address
Keynote Lecture
"Desirable Dietary Counseling Skills in a Clinical Setting"
Symposium
1. "Specified Physical Checkup and Specified Health Guidance"
2. "Nutrition Guidance for Kidney Disease"
3. " Practice of Nutritional Education to Diabetic Patients at Clinic"
Panel Discussion
 |
|||||||||||||||||||||||||||
President, Danone Institute of Japan Professor of Medicine
Showa University School of Medicine
It is my great honor to announce the opening of the 11th Danone Nutrition Forum
cosponsored by the Danone Institute of Japan（ DIJ） and Japan Dietitians’ Association.
DIJ is one of the non-profit, scientific organizations established by the Danone Group,
a France-based global food company, and the objectives of DIJ are to support research
on health and nutrition and to provide health professionals with scientific information
on these subjects.
Up until now, the Forum has focused on various “health and nutrition” related
themes. This year, the Forum will deal with nutrition guidance required in a clinical
setting, which is recognized as being important not only for promoting health but also
for treating diseases.
For the keynote address, Ms. Yukiko Kawashima will talk about what kind of
nutrition guidance can promote changes in behavior. This will be followed by a
symposium and panel discussion on nutritional guidance that should be given
during “Japanese specific health checks”, nutritional guidance for renal diseases, and
outpatient nutritional guidance for diabetes.
Increasingly, it is recognized that nutritional guidance is important for the prevention
and treatment of diseases. Thus the theme of this forum should be a matter of interest
for all participants, and the discussion will be useful for your future endeavours.
Keynote Lecture
"Desirable Dietary Counseling Skills in a Clinical Setting"
St. Marianna University School of Medicine Hospital
Dietary counseling
The aim of dietary counseling is for clients to improve their nutritional status by
leading them to adopt a healthier eating behaviour. Ultimately, as a result, one can
prevent the onset of diseases or at least limit its effects or the likelihood of a relapse.
Such a result is achieved by the dietitian utilising various teaching methods to
provide clients with necessary nutritional knowledge and skills to modify their eating
behaviour.
Meanwhile, recent medical treatment has been shifting as patients are given more
initiative in treatment decisions, compared to previous times when all treatment
decisions were left with doctors. Following this trend, dietary counseling is also
changing from the dietitian “instructing” the client what to do, to instead utilising their
professional knowledge and skills to assist clients in their decision making.
Skills to promote behavioural modification
It is well known that applying various behavioural therapy techniques are useful in
changing and adopting a healthier eating behaviour.
Behavioural therapy is a form of psychotherapy which is a systemisation
of behavioural scientific theory and methods to improve one’s behaviour. It is
recommended in the health check up specifically programmed against metabolic
syndrome followed by specific health counseling scheme, has become effective since
2008, that the use of behavioural therapy technique.
Behavioural therapy technique used in dietary counseling
Below are some of the major techniques used in behavioural modification,
1. Operant reinforcement: The basic technique to increase desirable and to decrease
undesirable behaviour.
2. Stimulus control: A strategy to control the stimuli, which trigger the problem
behaviours, to reduce the occurrence of them.
3. Shaping: A strategy in which new and desirable behaviours are introduced slowly to
clients.
In addition, there are other methods which often used in behavioural therapy;
1. Goal setting
2. Self monitoring
3. Response prevention
4. Social skill training
5. Cognitive restructuring
6. Relapse prevention
7. Social support
By using the above methods, the dietitian initiates the dietary counseling process by
having the client set goals based on their readiness to change and self-efficacy (emphasis
on empowerment). As the counseling progresses the dietitian encourages the client
to monitor their behaviour and assists them to maintain and reinforce the improved
behaviour.
It is essential for the dietitian to understand the factors that trigger behaviours;
to raise a client’s motivation to change/improve their eating behaviours, and to
provide practical advice relevant to their situation. Utilising various behavioural
therapy techniques will enable the dietitian to guide their clients to achieve this more
effectively.
Symposium
1.Specified Physical Checkup and Specified Health Guidance
| . |
In this lecture, I introduce some interventions that urge the behavior modification executed in Kan-Kogyo Health Insurance Association.
About Kan-Kogyo Health Insurance Association
This association was established on April 1, 1958. It was a small health insurance association, composed of 308 pipe related companies and 3,844 insured emplayees. Today, this association grew up and composed with 983 companies, and 54,605 insured (March, 2009). This industry has characteristics of higher average age and higher medical expenses from the beginning. Therefore the geriatric diseases prevention program was introduced in 1960.
The services of disease prevention and health care
This association is providing various health care services, the physical checkup, health guidance (based on the Health Care Center), the events, and the campaigns, etc. “Walking campaign” was started in 1992. “Prevent-common cold campaign” was started in 1999. Taking the opportunity of “Healthy Japan 21(2000)”, services are rearranged systematically from the primary to the third-order prevention. The primary prevention program was strengthened as “Energy-up program” to prevent the lifestyle22 related diseases in 2002. In addition, several events for health and fitness are offered such as “Walkathon” and “Health-Festival”. Many insured people participate in these events. This year, 3,262 people participated “Walking campaign” (twice as much as last year), because one of the companies adopted it as a health care activity against metabolic syndrome for all employees.
46 full-time staff and 54 part-time doctors (March, 2009) are working for the Health Care Center that is engaged in the secondary prevention. From the specified checkup to the precise health examination, the follow-up observation, and the lifestyle improvement guidance are executed by special staff consistently. In 1993, the Health Guidance Room was opened; doctors, nurses, trainers, and the registered dietitians are working there.
One who has a risk of hyperglycemia, hypertension, dyslipidemia, etc., is given the guidance about nourishment, exercise and lifestyle. Recently, the educational program “Exercise Nourishment Treatment Course” is provided to the person with higher cholesterol, higher blood pressure, or the borderline type diabetes. This course was introduced by “Standard health checkup and health guidance program (final version)” in April, 2007*.
Specified health guidance
An existing health guidance system is modified and the new guidance program is developed to match the specified health guidance.
“Providing Information”: Information is sent with a result of health checkup and invitation of the participation of various campaigns and events such as “Energy-up program”.
“Motivational support”: Held in the Health Care Center by nurses and the public health nurses or when they visit the office.
“Positive support”: Started in September in 2008, based on “Exercise Nourishment Treatment Course”, adding the requirement for “support A/B of Positive support”. This support is composed of three time individual consultations (first time, after three months, and after six months) and interactive follow-up using facsimile.
*Ministry of Health, Labour and Welfare, Health Policy Beureau: Standard health checkup and health guidance program (final version), 2007 Metabolic
2.Nutrition Guidance for Kidney Disease
Attachment of Medical Department at Tokai University Hospital
| 1. | Chronic kidney disease : Present condition |
The causes leading to CKD are many and varied, including hypertension, diabetes, obesity, hyper-lipemia, and the natural ageing process. It is important to note that CKD is not simply a kidney disease but also regarded as heart disease as well, because it often leads to cardiovascular disease (CVD).
However, CKD is a disease that can be cured, and the most importance as treatment is control of blood pressure. In addition, the management of urine protein, a correction of anemia, and exclusion of the CKD progressing risk factors.
The treatment of CKD must begin with an assessment of and improvement in the quality of patients’ lifestyles. Cigarette smokers, overweight patients, and those enjoying high-salt diets must make changes for the sake of their health, and professional guidance from dieticians plays a vital role in helping to implement these changes. Working to find the appropriate diet for each individual patient, the dietician is vitally important in the effort to prevent the further advance of CKD.
| 2. | Nutrition assessment |
Considering all these influential factors, dieticians then make both indirect and direct assessments of each patient. An indirect and assessment includes questions about diet and lifestyle, while a direct assessment includes data on weight, height, and blood quality gained from clinical examinations. Finally, combining the data from both assessments, the dietician is able to assess each patient’s nutritional state, and create a plan appropriate to their needs.
| 3. | Nutrition guidance according to stage |
Patients in the first stages of CKD show improvement with modifications of their diet and lifestyle. For instance, those with a family history of hypertension are urged to decrease their salt intake to less than 6 gram a day. In addition, saturated fatty acids must be avoided, and the intake of fruits and vegetables increased. A non-smoking lifestyle, with 30 minutes of aerobic exercise daily and drinking only in moderation can lead to a significantly better Body Mass Index (BMI).
(2) CKD stage 3-4
As CKD progresses to the more severe stage, switching to a low-salt diet alone is insufficient. Protein restriction, energy replenishment, and restricted amounts of potassium, phosphorus, and liquids are also necessary, according to each patient’s need. Dieticians have a responsibility to explain clearly to their patients that their low-protein intake must be compensated for by the intake of energy from other sources, such as carbohydrates and lipids.
(3) CKD stage 5
In the severest stages of CKD, dialysis often becomes necessary, along with the continual restriction of sodium and protein. In severe cases, low-protein diets are supplemented with auxiliary nutrition foods. If dialysis is required, electrolytic management of liquid intake and potassium-phosphorus restriction is also necessary.
| 4. | An optimal nutrition guidance plan |
3.Practice of Nutritional Education to Diabetic Patients at Clinic
In some patients, nutritional education conducted by an enthusiastic registered dietitian may be good enough to keep good plasma glucose levels. On the other hand, many patients who have enough knowledge fail to practice.
This issue has been fully realized by myself after decades of nutritional practice to diabetic patients.
Supporting modification of lifestyle behavior is extremely difficult. Humans can conduct behavior modification not by being directed by others, but by decision of themselves.
It is important for registered dietitians in addition to acquisition of specialized knowledge, to help patients induce eagerness of solving problems by themselves. This coaching by registered dietitian is successfully conducted through the natural disposition of keeping good daily diet practice. Nutritional education is coaching rather than teaching. Theory of nutritional education is a part of curriculum for university students who learn to be qualif ied for registered dietitian in Japan. Duration of practice, however, is not long enough, and application to actual patients currently is not available. I would like to describe the methods of nutritional education that is targeted to behavior modification partly based on my own experience.
Counseling of nutrition to diabetic patients starts with psychological analysis, and it allows patients to achieve their goals. Practically, the methods include psychological approach advocated by Dr. Munakata, coaching by Dr. Yanagisawa, and health counseling by Dr. Ishii. The following key words have been advocated to achieve this 47 practice: asking right questions, listening, empathy, admiration, recognition, motivation, support, adherence, self-efficacy, self-care behavior, stages of change, coaching, health counseling, etc. Every method implies coaching by inducing willingness of patients and support them continuously rather than teaching.
When it comes to nutritional education in clinical routine visits, a practical point is to achieve satisfaction of patients within limited time. Most of such patients are new to a registered dietitian. Aside from the information from medical chart, doctors, and nurses, a personal character can be appreciated by facial expression, manner, what they ware, pitch and speed of voice of greeting, tone of voice (blunt, bad-tempered etc.). Although the first impression is important, it should be kept in mind that one should not be prejudiced. I myself made mistakes before. You must not discriminate any patients, but you must keep in mind a welcoming idea, “what can I do for you?” to every patients. It is desirable to establish mutual trust in first five minutes. Voluntary talk from patients is a key to success. Time of silence is preciously used to think and organize the story.
The steps of nutritional education start from confirmation of patient’s idea, followed by guidance, listing, and empathy. Once a patient stated their own determination “I will start _ today”, support continuously their decision. The following steps are practically recommended:
1) Ask what the patient feels about cause of the disease and current data.
2) Ask if the patient accepts your proposal of explanation and instruction.
3) Use open questions.
“How do you think?” “What is your concern?” “What do you think about your problems?”
4) Proceed after acknowledgement.
5) Accept any remark without denying.
6) Respond by thinking of the patient.
7) Support a patient to determine a practical thing (even trivial things).
8) Sincerely admire and say something that recognizes the patient’s efforts.
These kind of methods may be useful for self-learning process as well. The specialist of nutritional education may be available in some districts. The above methods would be the way for daily practice of nutritional education. Efficacy assessment of these nutritional education methods to diabetic patients is to be discussed.
- 10th Forum (11.10.2008)
- "Metabolic syndrome and Dietary Education"
- 9th Forum (6.10.2007)
- "Nutrition and Dietary Education for Infants and Children"
- 8th Forum (21.10.2006)
- "The Prospects for Registered Dietitians and Dietitians"
- 7th Forum (1.10.2005)
- "Childhood Nutrition and Nutritional Education for Children"
- 6th Forum (23.10.2004)
- "Roles of Supplements in Health and Nutrition Care"
- 5th Forum (18.10.2003)
- "New Role of Dietitians"- Response to the Changing Health, Medical and Nursing
Care -
- 4th Forum (16.11.2002)
- "New Educational System for Dietitians"
- 3rd Forum (17.11.2001)
- "Prevention of Life-style Related Disease - the large intestine in nutrition
and diseases -"
- 2nd Forum (4.11.2000)
- "Nutrition and Health in Aging Society"
- 1st Forum (13.11.1999)
- "Nutrition of Childhood and the Role of Nutritionists - for prevention of life-style related diseases -"
