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The 4Ps of Nutrition: performance, power, policy and position Sandra Capra AM,PhD,FDAA Professor of Nutrition, University of Queensland Chair, International Confederation of Dietetic Associations. Nutrition is not just a pretty extra.

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The 4Ps of Nutrition:

performance, power, policy and position

Sandra Capra AM,PhD,FDAA

Professor of Nutrition, University of Queensland

Chair, International Confederation of Dietetic Associations

HNEH Quality Exposition


Nutrition is not just a pretty extra l.jpg
Nutrition is not just a pretty extra

  • I want to argue that nutrition is a fundamental to quality health care

  • I want to pose the argument that nutrition has been a “cinderella” in the health system for too long

  • I want to claim that errors in nutritional management through lack of resources and policies are heavy costs to the system and to the people.

HNEH Quality Exposition



Nutrition is a core foundation of health l.jpg
Nutrition is a core foundation of health

  • Underpins good health

  • Underpins reduction of chronic disease

  • Underpins quality services

  • Underpins quality of life

  • Is multidisciplinary

  • Is cheap

  • Is effective

HNEH Quality Exposition


Performance nutrition delivers l.jpg
Performance – nutrition delivers!

  • Nutrition as a strong performer in health and health care systems

  • Medical nutrition therapy

  • Functional nutrition therapy

  • Food service

  • Public interest in nutrition

  • But performance is perceived to be affected by

    • Invasion of the field by underqualified persons clouding the ‘truth’ and the evidence

    • Trivialising nutrition

HNEH Quality Exposition


Reducing stress increasing stress nutrition blog iqmatrix com l.jpg
Reducing stress – increasing stress- nutrition blog.iqmatrix.com

HNEH Quality Exposition




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  • The proportion of same-day separations increased between 1998–99 (47.9%) and 2007–08 (56.3%).

  • The average length of stay (including same-day separations) in hospitals was 3.3 days in 2006–07 and 2007–08.

  • Between 1998–99 and 2007–08, for patients staying at least one night:

    • average length of stay varied between 6.2 days and 6.5 days for public acute hospitals

    • average length of stay decreased from 5.9 days in 1998–99 to 5.4 days in 2007–08 for private hospitals

HNEH Quality Exposition


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But….. 1998–99 (47.9%) and 2007–08 (56.3%).

  • Those who enter with malnutrition stay longer – much longer.

  • Average LoS for those with malnutrition at entry is about double that of those who entry well nourished.

HNEH Quality Exposition


Http www aihw gov au publications hwe pahced03 33 estimates html l.jpg
http://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.htmlhttp://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.html

HNEH Quality Exposition


Functional and medical nutrition therapies l.jpg
Functional and Medical Nutritionhttp://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.htmlTherapies

http://www.feinberg.northwestern.edu/nutrition/images/AppleCutout.jpg

HNEH Quality Exposition


Anti inflammatory l.jpg
Anti-inflammatoryhttp://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.html

HNEH Quality Exposition


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HNEH Quality Expositionhttp://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.html


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Powerhttp://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.html

  • Nutrition as a powerful tool for health

  • Poor nutrition costs money

HNEH Quality Exposition


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WHOhttp://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.html

HNEH Quality Exposition


Http siteresources worldbank org intphaag images nutrition image1 gif l.jpg
http://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gifhttp://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gif

HNEH Quality Exposition


Policy l.jpg
Policyhttp://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gif

  • Setting systems that will deliver benefits

  • Nutrition on the policy agenda

  • The ACHS EquiP4 revisions under standard 1.5 “Organisation providing safe and care and services” includes a new standard 1.5.7 that concerns ensuring that nutritional needs are met, introducing screening and including nutrition in the care plans among other specified activities. These are currently under discussion.

HNEH Quality Exposition


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A Healthier Future for All Australianshttp://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gifNational Health and Hospitals Reform Commission Final Report June 2009

HNEH Quality Exposition


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HNEH Quality Expositionhttp://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gif


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Malnutrition now updated in DRGshttp://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gif

  • Malnutrition is the silent epidemic- 35%+ in health facilities, (www.daa.asn.au), 15% in HACC clients in community (Leggo et al 2008), 50% in RAC

  • The kind of malnutrition we see most is now recognised in the classification system –

    • disease induced malnutrition,

    • malnutrition in a land of plenty

    • Malnourished overweight persons

  • As a co-morbidity it affects the casemix weighting and therefore reimbursement systems.

  • The diagnosis must be by an APD

HNEH Quality Exposition


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Positionhttp://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gif

  • Positioning nutrition as a core health concern

  • Having the policy is not enough – it must be actioned

HNEH Quality Exposition


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Primary Health Care Reform in Australia Report to support Australia’s first national primary health care strategy

  • DoHA, 2009

Very little comfort here

These are poor

HNEH Quality Exposition


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HNEH Quality Exposition Australia’s first national primary health care strategy


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Source: Splett P. 1996 Australia’s first national primary health care strategy

HNEH Quality Exposition


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Have we the workforce to deliver? Australia’s first national primary health care strategy

  • We can do a good job and reduce errors mostly if there are enough qualified nutrition staff available

  • Nutrition is everyone’s business and is multidisciplinary

  • The professional nutrition staff should hold nationally recognised credentials. For nutrition this is the APD credential for any work that requires competence in medical nutrition therapy and foodservices in any form and in any setting.

HNEH Quality Exposition


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Source; Brown Capra and Williams ; Profile of the Australian dietetic workforce 1991-2005 Nutrition and Dietetics; 2006;63:166-178

HNEH Quality Exposition


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HNEH Quality Exposition dietetic workforce 1991-2005 Nutrition and Dietetics; 2006;63:166-178


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Standardised Terminology dietetic workforce 1991-2005 Nutrition and Dietetics; 2006;63:166-178

  • Errors relate to miscommunication in diagnoses and treatments

  • Electronic medical records are here/coming by 2012

  • They will

    • Facilitate information sharing

    • Provide nformation to measure desired outcomes

    • Document outcomes and therefore drive the evidence base and standards of practice.

  • We need to adopt the International Dietetics and Nutrition Terminology (IDNT)

HNEH Quality Exposition


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  • The lack of a standardized approach in nutrition language and terminology can lead to an inaccurate diagnosis which may then lead to inappropriate or ineffective nutrition interventions and lower quality.

  • When nutrition and dietetics interventions are solely based or described by a medical diagnosis, there can be ambiguity in both the cause of any nutrition issues and nutrition management

HNEH Quality Exposition


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HNEH Quality Exposition and terminology can lead to an inaccurate diagnosis which may then lead to inappropriate or ineffective nutrition interventions and lower quality.


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  • This contrasts with the “IFI” approach of the National Allied Health Classification Committee, which does not include sufficient terms or details to clearly identify what practitioners actually do. It adopts a functional approach, which groups many separate issues under single codes, leading to an inability to compare outcomes.

HNEH Quality Exposition


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  • b 530 Weight maintenance functions – Functions of maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity

    Source: IFI coding Manual for Pilot Project 2007

HNEH Quality Exposition


Food as the tool to deliver nutrition l.jpg
Food as the tool to deliver nutrition maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity

HNEH Quality Exposition


Food in health care is a treatment l.jpg
Food in health care is a treatment maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity

  • Calling foodservice a “hotel” service means that it can be forgotten

    • Treated as less important

    • Subjected to cost cutting at times

HNEH Quality Exposition


Would you eat these l.jpg
Would you eat these? maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity

HNEH Quality Exposition


My challenge l.jpg
My challenge maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity

  • http://www.youtube.com/watch?v=dqdYxy7kHns

    Make the services as good as this!!

HNEH Quality Exposition


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Nutrition –the 4Ps maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity

  • Recognise the performance of nutrition in healthcare

  • Recognise the power of nutrition to make a difference to quality services

  • Adopt policies to make a difference

  • Position nutrition services so they can deliver quality and excellence

  • Be a leader

HNEH Quality Exposition


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