Gerrit, this is a great question.

--Why don't medical providers refer patients for nutritional counselling for weight loss? As a psych provider, I send a note to the primary care provider asking for this referral (they are gatekeepers of referrals). I rarely see it done. (I work at a CMH)

--I refer patients to our RN who will teach them about low blood sugar i.e. what to do if it occurs, etc. as well as doing groups on nutrition. Some clinics use RN's to give injections and not teach health needs i.e. low B12, low iron effects on mood etc. and importance of getting it treated by primary medical provider.

I avoid weight gaining meds and, take people off meds that cause weight gain, as much as possible. Motivation is an issue in many of my patients, not from laziness, but from frontal lobe brain changes associated wtih the mental illness. Those with chronic pain need counselling for weight loss from someone who specializes in that and has time to spend with the person to customize a plan for someone that cannot exercise.

One Community Mental Health Department had a great dietician and helped a ton of my patients lose weight, through inidividualized plans and helped with shopping (use of food stamps and on a low budget). In 10 years at various places since, no dieticians are employed at the CMH's I have worked at. I don't know why.

I see PCP notes that indicate dietary couseling (box checked or told to avoid sugar) was done but people need more than that, at least my people do i.e. help shopping on a budget, fruits and veggies go bad fast and are expensive, disability prevents vigorous exercise, crime prevents going for walks.

I think insurance companies are mandating some nutritional counseling be done when BMI is abnormal in medical patients. I think there is a check box for me to do it as well but I can only do so much based upon the variables listed above. I wonder if they mandate any type of patient teaching requirements? I wish they would mandate diabetes education and weight loss referrals to nutritionists/dieticians more often.

I hope you continue research in this area because it is needed.

Dear Kelly,

Thank you very much for sharing your experiences as a psych provider at a CMH!

I wonder, you mentioned that in one Community Mental Health Department you worked in, they had a great dietician. and she helped patients a lot, how did that dietician arrive on that job? What is the difference between that Department and the Departments you worked afterwards?

I give an overview of what I found on Pubmed regarding the quality of wight-loss counseling in primary care by GPs, by PCPs, by dieticians and by practice nurses, and I give some general references.

1). Keywords GPs AND Quality of weight-loss counseling : 6 (Pubmed)

2). Add to 1). : AND Systematic Review : zero (Pubmed)

3). PCPs AND Quality of weight-loss counseling : 2 (Pubmed)

4). Add to 3). AND Systematic Review : zero (Pubmed)

5). Dieticians AND Quality of weight-loss counseling: 4 (Pubmed)

6). Practice Nurses (PNs) AND Quality of weight-loss counseling: 1 (Pubmed): van Dillen SM et al. Quality of weight-loss counseling by Dutch practice nurses in primary care: an observational study.

Eur J Clin Nutr. 2015 Jan;69(1):73-8

7). Keywords Primary care AND Quality of weight-loss counseling AND systematic Review : 18 (Pubmed)

General references :

- Present and Future of Nutrition Guidance / Lifestyle Advice in Primary Care (Written text (incl powerpoint) of Farewell lecture Wageningen University and Research, 9th Feb 2017 (doi 10.18174/412642;ISBN 978-94-6343-179-8

( Recorded by WURtv: https://wurtv.wur.nl/p2gplayer/Player.aspx?id=citqd9)

- Van Dillen SM, Noordman J, Van Dulmen S, Hiddink GJ. Setting Goal and Implementation Intentions in consultation between Practice Nurses and Patients with Overweight or obesity in General Practice. Public Health Nutr. 2015;18(16):3051-9.

- Van Dillen SM, Noordman J, Van Dulmen S, Hiddink GJ. Examining the content of weight, nutrition, and physical activity advices provided by Dutch practice nurses: analysis of video-taped consultations. Eur J Clin Nutr 2014 Jan;68(1):50-6.

- Van Dillen SM, Noordman J, Van Dulmen S, Hiddink GJ. Quality of weight loss counseling by Dutch practice nurses: an observational study. Eur J Clin Nutr. 2015 Jan;69(1):73-8.

- van Dillen SM, van Binsbergen JJ, Koelen MA, Hiddink GJ. Nutrition and physical activity guidance practices in general practice: A critical review. Patient Educ Couns. 2013 Feb;90(2):155-69.

- Van Dillen SM, Hiddink GJ & CMJ van Woerkum. Determinants of Dutch general practitioners` nutrition and physical activity guidance practices. Public Health Nutr 2013 Jul;16(7): 1321-31..

- Truswell AS, Hiddink GJ, Green LW, Roberts R & C van Weel. Practice-based evidence for weight management: alliance between primary care and public health. Family Practice 2012 April; 29, Suppl 1 i6-i9.

- Dijk E van, Kampen JK, Hiddink GJ, Renes RJ, Binsbergen JJ van, Woerkum van CM. A longitudinal study of changes in noticing and treating patients' overweight by Dutch GPs between 1997 and 2007. Fam Pract 2012 April; 29, Suppl 1 i61-i67.

-Truswell AS, Hiddink GJ & Chris van Weel: Editorial : Creating supportive environments for nutrition guidance : towards a synergy between Primary Care and Public Health. Family Practice 2008 Dec; 25, Suppl 1, i 7-9.

-Visser FN, Hiddink GJ, Koelen MA, Van Binsbergen JJ, Tobi H & CMJ van Woerkum. Longitudinal changes in task perceptions, self-efficacy, barriers and practices of nutrition education and treatment of overweight of General Practitioners. Family Practice 2008 Dec; 25, Suppl 1, i 105-111

-Fransen G, Hiddink GJ,Koelen MA,Van Dis SJ,Drenthen AJM,Van Binsbergen JJ & CMJ van Woerkum. The development of a minimal intervention strategy to address overweight and obesity in adult primary care patients in the Netherlands. Family Practice 2008 Dec; 25, Suppl 1, i 112-115

- Truswell AS, Hiddink GJ, van Binsbergen JJ, Kok F & C van Weel. Empowering family doctors and patients in nutrition communication. Eur J Clin Nutr 2005; 59: S1- S3.

- Truswell, AS, Hiddink GJ & J Blom. Nutrition guidance by family doctors in a changing world : problems, opportunities and future possibilities. Am J Clin Nutr 2003; 1089S-1092S.

Kelly, once again, thank you very much for sharing your experiences, because experiences tell sometimes much more than research articles!

Best wishes,

Gerrit J Hiddink

Dear Gerrit,

I think it is a very important question what you have asked. In my country dietary counseling is not a part of what we spect the PCP provides to an average patient. We can say the same about mental or psychological/psychiatric advice.

I'm very interesting in answer the main question about what is the quality of not only weight-loss, but dietary counseling in general in primary care. Would you like to participate in a project about it with us?

Best regards,

Dave S. Jervis

i'm not really sure whether there's really so little literature available. maybe you just need to broaden your search terms. could it be that "quality of weight-loss counseling" narrows down your search too much?

i remember searching pubmed for electronic aids (websites, mobile phone apps etc.) used in weight-loss interventions half a year ago, and i found a plethora of results! i guess many of these little helpers are used in the primary care setting, and their efficiency is obviously related to the "quality" of counseling (using the right tools probably makes for "better" counseling...). so i would expect "my" set of results to be more or less of a subset of what you're looking for...

Dear Dave,

Thank you very much for your answer.

You are very interested in answering the main question about what is the quality of not only weight-loss, but dietary counseling in general in primary care . So we are, and we published a number of articls in this field, f.e.

- van Dillen SM, van Binsbergen JJ, Koelen MA, Hiddink GJ. Nutrition and physical activity guidance practices in general practice: A critical review. Patient Educ Couns. 2013 Feb;90(2):155-69.

- Van Dillen SM, Hiddink GJ & CMJ van Woerkum. Determinants of Dutch general practitioners` nutrition and physical activity guidance practices. Public Health Nutr 2013 Jul;16(7): 1321-31..

- Truswell AS, Hiddink GJ, Green LW, Roberts R & C van Weel. Practice-based evidence for weight management: alliance between primary care and public health. Family Practice 2012 April; 29, Suppl 1 i6-i9.

- Dijk E van, Kampen JK, Hiddink GJ, Renes RJ, Binsbergen JJ van, Woerkum van CM. A longitudinal study of changes in noticing and treating patients' overweight by Dutch GPs between 1997 and 2007. Fam Pract 2012 April; 29, Suppl 1 i61-i67.

-Truswell AS, Hiddink GJ & Chris van Weel: Editorial : Creating supportive environments for nutrition guidance : towards a synergy between Primary Care and Public Health. Family Practice 2008 Dec; 25, Suppl 1, i 7-9.

-Visser FN, Hiddink GJ, Koelen MA, Van Binsbergen JJ, Tobi H & CMJ van Woerkum. Longitudinal changes in task perceptions, self-efficacy, barriers and practices of nutrition education and treatment of overweight of General Practitioners. Family Practice 2008 Dec; 25, Suppl 1, i 105-111

-Fransen G, Hiddink GJ,Koelen MA,Van Dis SJ,Drenthen AJM,Van Binsbergen JJ & CMJ van Woerkum. The development of a minimal intervention strategy to address overweight and obesity in adult primary care patients in the Netherlands. Family Practice 2008 Dec; 25, Suppl 1, i 112-115

- Truswell AS, Hiddink GJ, van Binsbergen JJ, Kok F & C van Weel. Empowering family doctors and patients in nutrition communication. Eur J Clin Nutr 2005; 59: S1- S3.

- Truswell, AS, Hiddink GJ & J Blom. Nutrition guidance by family doctors in a changing world : problems, opportunities and future possibilities. Am J Clin Nutr 2003; 1089S-1092S.

See also my ResearchGate account.

In principle, I am very interested in what you are doing in research, and are open to explore possiblities of working together, joining forces.

Dave, once again, thank you very much for your answer, and your invitation to participate in a project of your group.

Best wishes,

Gerrit J Hiddink

Hi Gerrit. Thanks for your quick response and interest to collaborate with us. We will review your articles and try to find some more. We will communicate with you soon for explore the possibility of work together in this passionate and important issue.

Best regards.

Dave S. Jervis -

I wonder, you mentioned that in one Community Mental Health Department you worked in, they had a great dietician. and she helped patients a lot, how did that dietician arrive on that job? What is the difference between that Department and the Departments you worked afterwards?

Per your above question, the mental health department hired the dietician to work there and bill insurance companies for her consultations, etc. The mental health department cares for mentally ill only and has therapists, case managers, peer advocates, Psych Providers, etc. some even hire occupational therapists (another great group to help with organization skills, keeping track of appointments, remembering medications, etc.) and some have PhD Psychologists to do neuropsych testing (these aren't in most CMH's anymore either, I have to refer to outside providers). All CMH's are the same basic idea but some don't hire dieticians or psychologists or OT's and they should. I would make a ton of referrals. It might be a billing issue but I'm not sure.

I love your study and it is greatly needed, keep up the good work!!!!!

Exactly right Gerrit,

The fact that overweight is detrimental to many people is known, but no real rules have been developed to incentivise patients in doing so. Information about the bad sides of obesity alone seems not to answer this question. There are some discussions about cost of health insurance related to BMI, charging more for flying by one airline, and more examples about sugar taxation, but I do not know of increased premium for this group of people.

We have to improve our systems.

Dear Thomas,

Thank you very much for your answer, and for your suggestion to broaden the search terms. It indeed could be that "quality of weight-loss counseling" narrows down my search too much.

On the other hand, in your searching of pubmed for electronic aids (websites, mobile phone apps etc.) used in weight-loss interventions half a year ago, you found a plethora of results! I think the problem is that the efficiency and effect of these helpers in relation to the quality of weight loss counseling has not yet been established .

Last year, Flodgren G, Gonçalves-Bradley DC, Summerbell CD. came with an update on the article " Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people. [Cochrane Database Syst Rev. 2010]. Their article is titled Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in children and adults with overweight or obesity.

Cochrane Database Syst Rev. 2017 Nov 30;11:CD000984. doi: 10.1002/14651858.CD000984.pub3.

This article shows the following not too positive results:

Abstract

BACKGROUND:The prevalence of overweight and obesity is increasing globally, an increase which has major implications for both population health and costs to health services. This is an update of a Cochrane Review of 2010.

OBJECTIVES: To assess the effects of strategies to change the behaviour of health professionals or the organisation of care compared to standard care, to promote weight reduction in children and adults with overweight or obesity.

SELECTION CRITERIA:

We considered randomised trials that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in children and adults with overweight or obesity.

DATA COLLECTION AND ANALYSIS:We used standard methodological procedures expected by Cochrane when conducting this review. We report the results for the professional interventions and the organisational interventions in seven 'Summary of findings' tables.

MAIN RESULTS: We identified 12 studies for inclusion in this review, seven of which evaluated interventions targeting healthcare professional and five targeting the organisation of care. Eight studies recruited adults with overweight or obesity and four recruited children with obesity. Eight studies had an overall high risk of bias, and four had a low risk of bias. In total, 139 practices provided care to 89,754 people, with a median follow-up of 12 months. Professional interventions Educational interventions aimed at general practitioners (GPs), may slightly reduce the weight of participants (mean difference (MD) -1.24 kg, 95% confidence interval (CI) -2.84 to 0.37; 3 studies, N = 1017 adults; low-certainty evidence).Tailoring interventions to improve GPs' compliance with obesity guidelines probably leads to little or no difference in weight loss(MD 0.05 (kg), 95% CI -0.32 to 0.41; 1 study, N = 49,807 adults; moderate-certainty evidence).It is uncertain if providing doctors with reminders results in a greater weight reduction than standard care (men: MD -11.20 kg, 95% CI -20.66 kg to -1.74 kg, and women: MD -1.30 kg, 95% CI [-7.34, 4.74] kg; 1 study, N = 90 adults; very low-certainty evidence).Providing clinicians with a clinical decision support (CDS) tool to assist with obesity management at the point of care leads to little or no difference in the body mass index (BMI) z-score of children (MD -0.08, 95% CI -0.15 to -0.01 in 378 children; moderate-certainty evidence), CDS tools may lead to little or no difference in weight loss in adults: MD -0.095 kg (-0.21 lbs), P = 0.47; 1 study, N = 35,665; low-certainty evidence. Organisational interventions Adults with overweight or obesity may lose more weight if the care was provided by a dietitian (by -5.60 kg, 95% CI -4.83 kg to -6.37 kg) or by a doctor-dietitian team (by -6.70 kg, 95% CI -7.52 kg to -5.88 kg; 1 study, N = 270 adults; low-certainty evidence). Shared care leads to little or no difference in the BMI z-score of children with obesity (adjusted MD -0.05, 95% CI -0.14 to 0.03; 1 study, N = 105 children; low-certainty evidence).Organisational restructuring of the delivery of primary care (i.e. introducing the chronic care model) may result in a slightly lower increase in the BMI of children who received care at intervention clinics (BMI change: adjusted MD -0.21, 95% CI -0.50 to 0.07; 1 study, unadjusted MD -0.18, 95% CI -0.20 to -0.16; N=473 participants; moderate-certainty evidence).Mail and phone interventions probably lead to little or no difference in weight loss in adults (mean weight change (kg) using mail: -0.36, 95% CI -1.18 to 0.46; phone: -0.44, 95% CI -1.26 to 0.38; 1 study, N = 1801 adults; moderate-certainty evidence). Care delivered by a nurse at a primary care clinic may lead to little or no difference in the BMI z-score in children (MD -0.02, 95% CI -0.16 to 0.12; 1 study, N = 52 children; very low-certainty evidence).Two studies reported data on cost effectiveness: one study favoured mail and standard care over telephone consultations, and the other study achieved weight loss at a modest cost in both intervention groups (doctor and doctor-dietitian). One study of shared care reported similar adverse effects in both groups.

AUTHORS' CONCLUSIONS:

We found little convincing evidence for a clinically-important effect on participants' weight or BMI of any of the evaluated interventions. While pooled results from three studies indicate that educational interventions targeting healthcare professionals may lead to a slight weight reduction in adults, the certainty of these results is low. Two trials evaluating CDS tools (unpooled results) for improved weight management suggest little or no effect on weight or BMI change in adults or children with overweight or obesity. Evidence for all the other interventions evaluated came mostly from single studies. The certainty of the included evidence varied from moderate to very low for the main outcomes (weight and BMI). All of the evaluated interventions would need further investigation to ascertain their strengths and limitations as effective strategies to change the behaviour of healthcare professionals or the organisation of care. As only two studies reported on cost, we know little about cost effectiveness across the evaluated interventions.

Dear Thomas, once again, thank you very much for your answer, and your critical and helpfull remarks.

Best wishes,

Gerrit J Hiddink

Dear Dave,

I look forward to our future exploration of possible collaboration in this important subject of quality of weight-loss counseling in primary care by GPs, PCPs, dieticians and practice nurses!

Best wishes,

Gerrit J Hiddink

Dear Kelly,

Thank you very much for answering my question to you: "

I wonder, you mentioned that in one Community Mental Health Department you worked in, they had a great dietician. and she helped patients a lot, how did that dietician arrive on that job? What is the difference between that Department and the Departments you worked afterwards?"

As I understand, the mental health department hired the dietician to work there and bill insurance companies for her consultations, etc.

You mentioned that all CMH's are the same basic idea but some don't hire dieticians or psychologists or OT's and they should. I agree with you, because I am in favor of a holistic approach.

I am sure you would make many referrals. May be it would be nice to explore the billing issue and have more information about this?

Once again, thank you very much for sharing your experience !

Best wishes,

Gerrit J Hiddink

Dear Richard,

Thank you very much for your answer.

Yes indeed, Information about the bad sides of obesity alone seems not to answer this question. There are indeed some discussions about cost of health insurance related to BMI, charging more for flying by one airline, and more examples about sugar taxation, all kinds of partly solutions, a kind of holistic approach over all sectors of life.

I agree with you that we have to improve our systems, for example by an alliance between Primary Care and Public Health, with regard to Practice-based evidence for weight management.

( Truswell AS, Hiddink GJ, Green LW, Roberts R, van Weel C. Practice-based evidence for weight management: alliance between primary care and public health. Fam Pract 2012 Apr;29 Suppl 1: i6-i9)

Once again, thank you very much for sharing your view !

Best wishes,

Gerrit J Hiddink

Do people with mental illness receive adequate smoking cessation advice? A systematic review and meta-analysis December 2014 · General Hospital Psychiatry 37(1) DOI · 10.1016/j.genhosppsych.2014.11.006 Alex J MitchellAlex J Mitchell · Davy VancampfortDavy Vancampfort · Marc De HertMarc De Hert · Brendon StubbsBrendon Stubbs (This was on this site you might find of interest.

Dear Kelly,

Thank you very much for sharing the systematic review and meta-analysis

Do people with mental illness receive adequate smoking cessation advice? (Dec 2014 · General Hospital Psychiatry 37(1) DOI · 10.1016/j.genhosppsych.2014.11.006

Alex J Mitchell · Davy Vancampfort · Marc De Hert · Brendon Stubbs

I really find this of interest!

Best wishes,

Gerrit J Hiddink

Most physicians I know whether primary care or specialists do not have the time or even the expertise to counsel patients to lose weight properly. As physicians, we're obligated to help patients get healthy and inform them regarding good diet and healthy lifestyle. The problem is not about the information about diet or the harm of obesity to one's health, but the problem is to change their lifestyle and behavior. I think most patients know that smoking can cause cancer and obesity MI, CVA, etc.., but they usually won't do anything until something bad happens to them. How does a busy primary care doctor or surgeon change patient's behavior? Not an easy task. It will require a behavior scientist or specialist and many office hours which most busy doctors do not have.

I fully agree with you Ben,

Time is most important in communicating the details about the disease, as well as creating interest with obese patients to normalise their weight. This is acknowledge by the MOH of Indonesia with their Regulation No 5 in the year 2014.

We are working out a program in our Information System (IS) to prompt doctors to discuss about this ruling, as well as to inform the patient about the degree of overweight, in line with the Regulation. Obesity should also be discussed, even if the patient is suffering from other diseases, most likely chronic diseases.

I agree with you that obesity is a complex disease needing other disciplines to approach the patient. Hence, we are working with psychiatrists, psychologist on top of the usual doctor, pharmacist, nurse occupations for the development of the IS. In my former reply, I also think that the government should show interest in promotion of health even with regulating fees for different stages of obesity.

Thanks Richard! I don't know about the health care system in your country. Maybe, we can exchange information and idea. Where are you practicing? Indonesia?

I am retired businessman with pharmacy degree and PhD in Strategic Management living in Melbourne. The health care system in Indonesia worries me, in the sense that doctors take too little time to explain health condition of the patient, and rarely communicate to pharmacist.

This is the reason, why we are working together in a university in Surabaya to develop small units with clinic and pharmacy in remote areas manned by one doctor and one pharmacist at the beginning to find out whether the theories of collaboration between these two health professionals can provide better focus to the patients and their diseases.

It will certainly be beneficial to exchange information with anybody incl. yourself Ben. Where are you practicing?

Dear Ben,

Thank you very much for sharing your experiences as a physician!

Indeed, most primary care physicians and medical specialists do not have the time or even the expertise to counsel patients to lose weight properly.

Physicians are obligated to help patients get healthy and inform them regarding good diet and healthy lifestyle. I agree with you that the problem is not about the information about diet or the harm of obesity to one's health, but the problem is to change their lifestyle and behavior!

Do you think it would be useful (or even necessary) to incorporate an obliged course on lifestyle and (nutrition and physical activity) behavior change in the medical curriculum?

From your experience, do you think a more confrontational communication style of primary care physicians would be useful to counsel patients to lose weight properly?

And my last question to you: When the authority of the primary care physician (PCP) is used, and the trust patients have in them, and the PCP then refers to a dietitian in the team or outside, would that be helpfull?

I think, because you are experienced, you are able to answer these questions from within the world of PCPs.

Best wishes,

Gerrit J Hiddink

Dear Richard,

I am very interested in your Information System (IS) to prompt doctors to discuss about the MOH of Indonesia`s Regulation No 5 in the year 2014., as well as to inform the patient about the degree of overweight, in line with the Regulation.

I understand that - because obesity is a complex disease needing other disciplines to approach the patient-- you are working with psychiatrists, psychologist on top of the usual doctor, pharmacist, nurse occupations for the development of the IS.

Are you satisfied on how this development works out in practice?

I think we can learn from your experiences!

I agree with you that government should show more interest in promotion of health, also for different stages of obesity.

Best wishes,

Gerrit J Hiddink

Thanks Gerrit for your interest in our project,

This is just at a preliminary stage. From literature studies we confirm the fact that patients Health Literacy (HeL) is still low, because doctors and pharmacists do not follow MOH Decision No 5 of 2014 yet. The idea is to prompt those academics with a IS program for the points mentioned and calculate KPI of their keeping up with the regulation.

The level of HeL would later confirm, whether these endeavours are useful for the patient in a longitudinal study. Our assumption is that patients in remote areas will work together with the health care academics, if their HeL level is higher and have better compliance with their therapy.

Our priority is to provide better health care in remote areas for all diseases. Obesity is only one of 145 diseases mentioned in the regulation, and dietitians are only concentrated in bigger cities. Therefore, we have to train those two academics at this early stage using expertise of specialists including psychologists, nursing and others from the university.

Of course we will publish the results accordingly to follow the idea of our presentation in ACIS 2012 in Geelong, Australia.

Richard.

Thank you, Richard and Gerrit !

I live and practice in the US. You raise three quite provocative questions. It's been way too many years since my medical school years, and I'm definitely out of touch with the current American medical school curriculum, but I will entertain you by speaking my mind.

Adding a course on how to communicate with patients and to listen not just to their complaints but to what they are not saying will be very beneficial in my opinion. That is the real art and science of medicine.

Confrontational style of communication may not work well because patients will simply change provider and stop coming if they don't like what they hear. If confrontation is needed, a simple plain and naked truth of the situation is usually better.

Referral to nutritionist is always welcome when the service is available. However, the bigger issue that I think we're facing is the content of the information being disseminated by everybody in both medical and non-medical fields. Who do you believe? Which information is real science and which one is bogus or just fad? Even within the medical fields, there is so many confusing and contradictory claims among ourselves. The vegan doctors will claim that animal products are really bad for you. The sugar buster diet doctors will tell you that carbohydrates are bad for you, and on and on, and on. There is too much information that's not correct or only very partially correct that are being thrown out there most of it because of there's a lot of money behind all the claims. What does the public think and do in this information age with the majority of information is fake? How about going back to our basic science classes in school and relearn the science behind biochemistry and human physiology and explain once and for all that to reach homeostasis, we need to have a fine balance of everything. Balance is what we need. We need both animal protein and carbs. The key issue is to balance everything in our lives.

I have just posted a question regarding fasting and ketogenic state over the weekend. I welcome your thoughts and input.

Interesting Ben,

In fact, as pharmacist I do have some knowledge about biochemicals. And I will limit my diets with one measurement only. Waist. So, responsible diet with no restrictions but limitation is good. A little bit of sugar in the meal, none in drinks, alcohol socially, and every now and then a good steak. As long as my body weight is OK and similar to it the waist is in order, than it is fine with me.

It is not necessary scientific, but a little bit of leisure is OK.

Indeed, the quality of doctors' consultations could be improved in line with available guidelines. The government, as well as doctors' association already provided each doctor with standards to explain the diagnosis during each consultation. How such is performed would need more in-depth study, so as to improve health condition of the patient. We are planning to conduct such study using software specifically written to monitor communication ability of doctors as well as pharmacists.

Dear Majordavid,

Thank you very much for your contribution!

When you do a PubMed search , indeed not many articles can be found.

"When something is worth to be done, it is also worth to be done in the best manner", I was teached , and therefore I believe that the quality of what we do is of utmost importance!

Once again, thank you for your contribution.

Best wishes,

Gerrit Hiddink

Dear Richard,

I agree with you that the quality of doctors' consultations could be improved in line with available guidelines. I believe the doctor need to be patient-centered, and to discuss with the patient the policy to be taken.

How this interaction will take place is indeed dependent of both the doctor and the patient ( nature of patients`complaint, patients`communication characteristics and so on), and as you correctly pointed out, will need more in-depht study.

I am very interested in your study using software specifically written to monitor communication ability of doctors as well as pharmacists.!

Thank you very much again for yourcontribution.

Best wishes,

Gerrit Hiddink

Absolutely Gerrit,

Our plan includes the measurement of Health Literacy (HeL) of patients on their first visit. Doctors would be able to gauge their speed of explaining the disease after the diagnosis has been made.

To prompt doctors about what points are to be discussed a program is planned to measure time utilised to explain each of those prompted topics.

We are in the process of writing both programs to calculate HeL and to communicate about the disease accordingly.

We could only get initial results earliest after one year from now.

Richard.

Dear Richard,

I believe the inclusion of the measurement of Health Literacy (HeL) of patients on their first visit is a vey good one! Therefore, doctors can communicate on the level that patients can understand. Explaining a disease after the diagnosis has been made is very dependent on Health Literacy of the patient.

You plan a program to measure time utilised to explain each of the prompted topics - points are to be discussed -, and that gives insight in the real world.

Please keep me informed when you have the first initial results in about a year time.

All the best with your research,

best wishes,

Gerrit Hiddink

Thanks for your confirmation of the idea. We will inform you in due course.

All the best,

Richard.