Working in primary care can be a tough job. Weaving conversations about nutrition, physical activity, and sleep into a 10-minute consult can be even harder. Dr Sally Crane discusses how she does this routinely and how she motivates her patients to make small behaviour changes that work and are sustainable.
Dr Sally Crane is a General Practitioner who enjoys working closely with children with allergies, restrictive eating habits and weight concerns. Sally collaborates with families to promote and normalise healthy eating habits and enjoyment of food and activity.
Working in primary care can be a tough job. Weaving conversations about nutrition, physical activity, and sleep into a 10-minute consult can be even harder. Dr Sally Crane discusses how she does this routinely and how she motivates her patients to make small behaviour changes that work and are sustainable.
Dr Sally Crane is a General Practitioner who enjoys working closely with children with allergies, restrictive eating habits and weight concerns. Sally collaborates with families to promote and normalise healthy eating habits and enjoyment of food and activity.
Health and Wellbeing Queensland acknowledges the Yuggera and Turrbal people and the traditional custodians on the lands on which this podcast was recorded and the traditional custodians on the lands of borders on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia's First Nations people.
[Upbeat music]
Dr Sally Crane [speaking over music]: We as healthcare professionals know very well that it's very difficult to get patients to change behaviours, because it's hard and it feels unachievable.
Sam: Welcome to the Clinician’s Guide to Healthy Kids, a podcast series for health professionals brought to you by Health and Wellbeing Queensland's Clinician’s Hub. I am your host, Dr Sam Manger and in this series, we will be diving deep into the topics that matter most in childhood weight management. We will be talking to Queensland experts across a variety of topics, including sleep, disordered eating in higher weight children, prevention and healthy growth with healthy diets.
Sam: Let's get started! Today we're diving further into the ‘how’ and empowering families to make healthy changes. We have learned what questions we can ask to assess health behaviours that relate to food, to activity and to sleep but translating this into tangible goals can feel difficult. Everyone knows we should make goals that are smart – those are Specific, Measurable, Attainable, Relevant and Time specific, but putting this into practice can be, yes, a little trickier. So, to help us we've invited Dr Sally Crane along to discuss.
Sally is a General Practitioner who enjoys working closely with children with allergies, restrictive eating habits and weight concerns. Sally collaborates with families to promote and normalise healthy eating habits and the enjoyment of food and activity. Perfect person to have. Thank you so much for joining us, Sally.
Sally: Thanks, Sam.
Sam: So, Sally, tell us a little bit more about yourself and why you're interested in this area?
Sally: Sam, I’m a GP, as you mentioned, practising part time in Brisbane’s Bayside area and I've spent over a decade working with families and children of all ages. My original special interest was in allergy management and young children. However, as my patients themselves have grown up, I've really learned to enjoy helping them and their families to develop healthy eating habits and activity levels. I'm a mother of 2 school-aged children, both of whom developed allergies in early infancy, and so I understand the difficulties in managing food restrictions and eating behaviours and recognise the challenge of encouraging kids to make healthy choices.
Sam: That's great. Thanks, so, you obviously bring a combination of professional experience and lived experiences, as well as, as a mother of 2, that's very useful. So how important is family focused health behaviours in the prevention and management of unhealthy weight gain in children?
Sally: I think it's imperative that any strategies that you plan to implement involve the entire family. Whilst the primary issue may be with one child, there usually are a number of underlying factors within the family unit that may tend to promote unhealthy weight gain. So, if we can encourage these behaviour changes to incorporate the entire family, then I do believe you're more likely to have a positive outcome in the long run.
Sam: And, of course, when people present to their health professional – they're often, you know – the family will be there or at least a parent will be there. So, what do you find are your, say, top 3 conversation starters when they're in the clinic to start opening up that conversation, that dialogue, and introduce health in a weight neutral way?
Sally: This is tricky, Sam, I think a lot of this comes with practice and just developing communication skills, in general. But a question I like to use, particularly with middle school-aged children is: What sort of things make you feel healthy and strong? This takes the focus away from food and weight and all the negativity that we don't want to promote. And it's always interesting to hear the answers to that question, but more often than not, the children tend to identify a particular sport or exercise – the topics of which can be really helpful to build rapport and then to move on in conversation with.
Sam: Yeah, that's a really great tip, especially around rapport because we obviously need to develop that relationship before we open up to potentially more sensitive topics. And you mentioned there around using a strengths-based approach. So, what do they actually enjoy or what do they feel strong in and that sort of stuff. So, you’re opening up, making it much more comfortable as well there too.
Sally: Yes, that's right. And so secondly, another conversation starter could be: What does healthy look like to you? Again, giving you a focus point that perhaps leads to a goal that the child or family may wish to attain. And thirdly, you know: What foods do you enjoy eating that also make you feel healthy? This leads into a positive conversation about food, and then focus more on the strengths around, you know, food and activity.
Sam: Okay, that's great. So, strengths-based approach: What does healthy look like to you and what foods do you enjoy? So, very much starting in that that positive frame, yeah. So how do you use behaviour change in weight management in your clinic and practice?
Sally: Generally, my focus here will be on the family, not just the child. So, this may involve strategizing daily routines, including regular mealtimes and consistency with meals. I like to encourage families to sit down together for at least one meal of the day, if that's possible, and I know that feels completely impossible often to families. I try to engage children to identify a few activities that they enjoy and then promote these being implemented into their daily routines.
For families, again encouraging daily and weekly planning can be really helpful, for example, meal planning for the upcoming week, planning around busy days and scheduling exercise and sport. We need to make that routine a part of their daily schedule again. Most importantly, this all needs to be part of a collaborative consultation in order to best encourage behaviour change. So, I do like to encourage the families to really come up with this planning. I don't want it to come from me.
Sam: Mm-hmm. So, when you're actually in a consult, you'll be saying how can we, you know, build this into our life? What are the barriers? What are the practical facilitators to this? So, you'll ask the question, but encourage them to come up with the answer, rather than it being a sort of prescriptive exercise.
Sally: Absolutely. Again, we need to focus on that family environment because families are busy! We have to make it work for everyone!
Sam: Yeah, and it's usually unique. And that leads us really to the next common point you mentioned that it can be hard to do this. So, talk us through why change behaviour can be difficult, can be hard for families.
Sally: I think it's hard for families, and for us as well, and we as healthcare professionals know very well that it's very difficult to get patients to change behaviours. Because it's hard and it feels unachievable, both for families and for us. Kids have learned behaviours and they don't understand why changes need to happen. Socioeconomic factors need to be considered. And as I mentioned earlier, parents are busy, families are busier than ever. So, understanding all the knowledge that needs to be involved – access, financial strain, time constraints – these all contribute to the difficulty in changing behaviour. But I think with time and support and building good rapport we are best placed to make positive changes happen.
Sam: Yeah. You mentioned the knowledge. There are obviously varying tiers to behaviours, isn’t there, and one is knowledge and certainly having some good resources or good professionals that we can refer to build in that knowledge. And then having ongoing support with people, regular follow up and reviewing those barriers and reflecting. And seeing where those activities are – you mentioned activities before – that families can do. Do you mean things like, you know, cooking activities or food preparation activities? Things related to food or do you just mean any family activity is a good activity?
Sally: I think any family activity is great because if they're, you know, encouraging a positive wellbeing, then that will assist in any aspect here. But certainly, you know, get children involved in cooking with mum or dad and activities that are outside the home. I'm a big promoter of Parkrun. I think it's fabulous for children. But you know, going for bike rides, doing anything, but these all need to be planned into a routine. I think if we don't schedule these activities, they don't happen. We don't prioritise it.
Sam: Yeah, I think it's very interesting that because we often think with these conversations that we have to go direct. We have to talk specifically and direct about weight but often wellbeing is a very indirect path. There's lots of things that we do in our life that encourage wellbeing, social connection, and the activity or you know whatever it is, that then indirectly comes into building the wellbeing of a family and then being more open and able to talk about – you know, what are we eating tonight, let's cook together, let's do this together. It flows into that as opposed to feeling that it's almost artificial and sort of synthetic and a sort of A to B approach, so that makes a lot of sense.
So, what would you say to someone who's not ready though to change their health behaviours? Like how do we approach the apparently unmotivated patient? In particular, you know, young people can be cautious but families in particular.
Sally: These consultations can be particularly hard, but I think we can still make a positive change. This, of course, will depend on your rapport with the patient and family and this will all take time and I think this takes practice for any clinician. We all know how to employ our motivational interviewing techniques. Often in these circumstances, I will just let them know about support services and options that are available to them, and I'll leave the door open for those patients to follow up with me at any time. Depending on the child or family though, I might say: What if I give you just one goal to focus on before I see you next? They're usually open to it, particularly the child.
So, whether this is just making one little change to their diet or adding in an activity or something that brings happiness to the child. Again, focusing on wellbeing – it doesn't matter, it just provides a check-in point, a goal and positivity and it reminds them that you're there to support them.
Sam: Yeah, that's great. I think with this, there’s a few things, when I think about ‘unmotivated’ because there's almost stigma associated with that. Because I think everyone's motivated in something, you know. Right now, you may not be motivated to change your food habits but you may be motivated in other aspects. And as we just said, wellbeing can often be an indirect path that you take.
So, you can start improving someone’s family time by playing games together, for example, but then that makes dinner time a lot easier because there's more harmony in the family. So, it doesn't even have to be: ‘Okay, you're not motivated about changing your food intake, for example, therefore, we'll give up’, you know, hands in the air, sort of thing. It's a case of, actually: ‘Let's find out – going back to your original points around the conversation starters – what are the things you enjoy? What is a strength-based approach? What does health look like to you? Because then you can actually find out where people are motivated, and then get there, whichever way, you know, but as long as you can get that ball rolling in that direction, people often, once they get a taste of health, they'll often want a little bit more.
And I think it's important also as clinicians, we can feel a little bit– when we are responded to with seemingly unmotivated behaviour – it can feel a bit disheartening as a clinician and it's quite important for us to remember that, you know, different seeds take different times to germinate, you know, not everyone will just change the second you've recommended it. And we need to, one, be patient with our patients but be patient with ourselves as well. I think there's a self-care aspect here, and a little bit of a ‘practice what we preach’ aspect as well. As you said it can be hard for us to change behaviour so when we learn to improve our own health as well, then we'll notice actually, there are ways, you know, lived experience pops into that too. We’ll be back after this short break.
Community message [narrated by a man with upbeat music in background]: The Gather + Grow program focuses on improving food insecurity in remote Aboriginal and Torres Strait Islander communities in the Torres Strait, Cape York and Lower Gulf regions of Queensland. They are working hard to build the capacity and capability of remote food stores and engage with communities and community organisations to identify priorities and lead actions that will improve access to healthy food and drinks. Find out more on the Health and Wellbeing Queensland website by searching ‘Gather + Grow’.
Sam: And now back to the show! Do you find things like games or even competitions within a family are a fun thing to start? Because they often talk about gamification in behaviour change.
Sally: Oh, I think I haven't tried it myself, but I think it could be really useful. I guess, again it is sort of creating goals in a way and it's providing a challenge and it's fun! Kids love that and if they get to challenge their parents even better! That's fantastic for them and that can be in any form, whether it's games in the home, or again, perhaps setting goals outside, whether they're sporting activity games. That can be helpful as well.
Sam: Yeah. So, who can do the most jumps in a day or something? I'm sure they'd beat their parents. That's always a good motivating factor!
Sally: They’ll all beat the parents!
Sam: What are your top 3 phrases you try and avoid using when trying to motivate children or their families?
Sally: I think overall it's important to use sensitive language and we've talked about this in previous podcasts, and this just avoids any blame or stigmatisation. And I don't know if they are phrases, as such, but I do avoid words that signify poor choices. For example, ‘bad food’ or ‘junk food’ and instead focus on words, such as, ‘sometimes foods’, or again, we go back to those foods that make you feel healthy. I usually always avoid focus on weight. I say ‘usually’ because there are exceptions to this and that may be when a child is particularly underweight and there’s necessity to monitor their gains. But also, never using the words ‘fat’, ‘skinny’, any other phrases that may have a negative impact on body image is particularly important.
Sam: So, you've mentioned a few words there around – obviously some words there [such as] ‘fat’, ‘skinny’ – that hopefully goes without saying but it's good to say anyway. But ‘weight‘ is a hard one to avoid using, especially when we're in some ways encouraging weight to be a sixth vital sign as it were. So how do you flip that? What words do you use instead? Or what key phrases do you find work well in this conversation and dialogue that you're having?
Sally: So, it's again, it's quite tricky. I think it will really come down to the patient, to be honest, and you know, it might come down to how they're feeling in their clothes or how they're feeling within their activities. So, are you feeling healthy? Do you feel like you have lots of energy? Do you feel comfortable in what you're wearing? You know, again, when we go back to their goals and focus, and [ask] have they been able to achieve that goal – say that's a sporting goal or another activity goal. You would like to hope that's come from then, perhaps that weight management. I don't want to say, ‘loss of weight’, but perhaps that's because their weight is better managed, their diet is better managed. Again, this will all come down to, I think, the rapport you have.
Sam: I think the ‘feel’ question is a good one though because we often are talking about: How do you or what do you think about this or what is this? And they're obviously valid questions to some degree but as we've clearly identified in this conversation that sometimes thoughts cannot always be positive about – you know – one's perception or their opinion of their own life or health behaviours. And so, ‘feeling’ is a very interesting question because it's such a visceral question like: So, how do I feel about this? You know, how do I feel about my body? Or how would I feel about my health? How do I feel about my lifestyle? That opens up, I think, a much more open question, that is less judgemental because you're curious and you're sort of inviting their responses, as opposed to, perhaps, when you say something like: What do you think about your weight? As it sounds like you have got this foregone conclusion there.
Sally: There's already judgement there, yeah.
Sam: There's already judgement inbuilt in that question. So, how do you feel about your health and other aspects? This is a nice open question. So, follow up. It is really important for any goals made – and we've made that clear already – but we know how busy many GPs like yourself are, and myself of course. So how frequently would you try and review someone after they've made their health behaviour change goals with you?
Sally: I would suggest review appointments quite soon after setting goals in those initial appointments. And say 2-to-3-week scheduling – so short-term, achievable goals and early follow-up are more likely to keep patients accountable. I like to actually walk out to reception and book those appointments with them, and hopefully involve the nurse in that as well for the next appointment. But again, I think if they've got that very fast turnaround, this is more on their radar. They're actually more likely to turn up.
Sam: Yeah, I think it's one of the principles that I've seen consistent with behaviour change. It is such a simple thing but it is the concept of default. So, ‘it is not that you need these appointments’, but it is like I normalise with all my patients that ‘we're going through this healthy weight or health journey’. Then, I like to see to them every 2 weeks for a few months and then we will space it out, just to really make sure we can support you and get the ball rolling and see some early wins and successes and make you feel like you're going in the direction you want to go with your health.
That's quite important to highlight. I think, because sometimes, certainly, I remember in GP training many, many moons ago, was this idea that we do a script, you know, for hypertension or something, high blood pressure, and then say: ‘Well, that's got 5 repeats, so I'll see you in 6 months’. So, we've got this sort of 6-month attitude built into us, and we think that maybe health behaviour is similar. ‘You need to improve X health behaviour and I'll see you in 6 months’. It just doesn't work! Humans are so much more complex. We've got so many more competing challenges than that. Seeing someone in 6 months is very unlikely to lead to behaviour change. If we're going to really, sincerely do that, we have to see them on a much more regular basis and problem solve as things go, you know and reflect. We'll be back after this short message.
Community message [narrated by a woman with upbeat music]: Unhealthy weight is one of our greatest public health challenges. Two in 3 Queensland adults, and one in 4 children, live with overweight or obesity. We need to shift the dial. That’s why Health and Wellbeing Queensland has created Clinicians Hub for you, our clinical workforce. Clinician’s Hub is a digital ecosystem of initiatives, resources and tools, including this podcast series for multidisciplinary health professionals to support best practice prevention, identification, treatment and management of overweight or obesity and it offers a wide variety of clinical tools and training to help you transform health for children, adults and families. Find out how Clinician’s Hub can help you at hw.qld.gov.au/hub
Sam: And now back to the show! So, is it worth trying to make changes at a primary healthcare level? So, if we feel they still need to see a dietitian or go to a specialised weight management service?
Sally: Yes, absolutely, I believe so. Anecdotally, I would suggest that only about 25% of patients will actually make an appointment with a dietitian or other specialised weight management service and it's not enough. So, we need to be driving these initial changes until they're ready to move to that next step. So, involving other support people as well, such as, the teacher, kindergarten teacher, psychologist or booking case management plans, however it is, we really need to be driving the changes. But even as they move on to the next service – dietitian or specialised weight management services – our role is in primary healthcare. We are still those coordinators. We still need to be checking in and realistically, we are going to be hopefully these patients’ GPs for a really long time. So, they need to still be able to have that opportunity to step back in with us. They need to be able to feel supported by us and I think we can make some very positive changes with the right language.
Sam: Yeah, absolutely. You mentioned there – the case management and the case conference item numbers for those who are and aren't aware – that there are very valid options and they are reasonably well reimbursed for GPs (and now also since the last, I think, year or 2 due to some good lobbying, our allied health – dietitians, physios, etcetera – they can now also have an item number that they can claim, so it is much more fair for all). So, this is a really good tool to perhaps consider scheduling for some of your more complex patients – the basis of that is also good communication.
You know, we've got to be able to communicate and have not just one-line referrals off to our colleagues, our allied health colleagues, but actually thinking, you know, ‘what's the conversations we have and what are the goals that we set in this appointment’, so that there's a synchrony between the different plans. Because sometimes what you get in multidisciplinary care is everyone's got their own plans. What we're aiming for here is interdisciplinary care where we actually share the goals and the patient is obviously 100% on board with that, but each of the professionals are supporting it from their own level of expertise.
One thing I wonder about is – there's obviously our one-to-one care and we've been talking about that quite a bit – but I do wonder about how you might use the micro-environment. So, the shape or style or flow of your clinic itself, or even the other staff in the clinic to support, again, not just conversations around, you know, health, well, yes, but conversation about health changes, but, not just weight, but just overall wellbeing, especially with the paediatric or child adolescent populations. Is there anything you sort of do within your environments to make it more suitable or more facilitative?
Sally: I do like to try and involve our nurse and other staff within the practice. I don't think that's something that we actually do well, to be honest. I think that time is a big constraint there for a lot of GPs. But you know, it would take 5 minutes for say, the practice nurse to check in and just give some support. Again, it's just another positive face for that family, whether you've got a psychologist or other health professionals within your practice, I would absolutely involve all of those if you can. I think also, you know, particularly in my practice, we like to ensure that every patient knows one of the other doctors. So, just if they need someone as a backup, just to, you know, if I'm not there, they've got someone else they can check in with at any time.
Sam: That's a really nice idea! I like that, actually, because these days it's quite common for patients to have, you know, one or 2 GPs within a practice that they will see and I think it's a really nice idea, if you possibly can facilitate that introduction, kind of nice and early or at least show them the pictures and the bios [of the GPs] you know of who they're going to be seeing.
The nurse point is something I've really incorporated into my general practice in the last couple of years. It is to have that nurse blocked off, even just for half an hour, you know, once every 2 days or something, which is not a huge amount of time to block off, but just have quick 5-minute phone calls with patients who you have set these sort of goals. And just give them a call. Partly it's a behaviour change technique, just a simple support: ‘How are you going? Check in, problem solve. But it also just shows you care. And I think that's really important, because when the therapeutic relationship is strong, we know the evidence is quite clear that behaviour outcomes and psychological outcomes are better.
And, so simply demonstrating that it's not just a GP service, it's a primary care service, and we all care about the patient and their outcomes. So, this takes me to my next and last question, which is around: Do you have any favourite or key resources for listeners, who are clinicians or health professionals and/or patients? And partly, I'm thinking there also around the concept of social prescribing, which is obviously ‘prescribing’ to things in our community, so NGOs [non-government organisations] or community groups and, you know, family groups, mums' groups, you know, and dads’ groups, which can obviously, and quite commonly be, a very effective way to encourage health change and wellbeing.
Sally: Yeah, absolutely. I think it's really important that families are aware of mothers’ groups, family groups and often they can be accessed through the child health nurse. They're within your community, there's always bound to be some other support service. Often, they're free! I know, certainly in our area, we have exercise groups for families, and again, I mentioned Parkrun earlier, that's a great, easy, free prescription that can involve an entire family, and you don't have to be any particular fitness level to be involved in that. But I think also resources that the practitioner can use as well: the Raising Children website is very useful and the more recent Growing Good Habits website by Health and Wellbeing Queensland can be useful for both healthcare professionals and patients and families. Both of those provide links on healthy eating behaviours, physical activity, sleep requirements, etcetera. I think it's definitely worth spending some time scrolling through these and becoming familiar with those links so that you can share them with your patients, and I often do like to actually go through those [websites] with patients so that they know exactly where they’re looking.
Sam: Great! Alright! Well, thank you so much for your time, Sally. I'll just highlight a few little things there, which I think would be really useful things that I'm going to take home, and I hope the listeners out there will also take home. So, some of those points. Really starting early is around strengths-based questions: What does health look like? Having these open-ended questions and: What are the foods and the practices in your health that you actually enjoy? Encouraging a whole family approach, which can include planning or activities and make sure there's time for the family to be together. Considering what some of those barriers are, around, whether it's a knowledge problem or a habit, or, you know, where can we actually support what changes can we make.
Look after ourselves and practise what we preach is always important. And remembering that there's lots of things a person does in their life, so they may not be motivated in one area, but they will likely be motivated in others and if you can turn it into a bit of fun, fun is always good. Try and make it fun! And then of course, use our expert allied health colleagues, whether that's through case conferencing or any other process. And of course, our excellent practice nurses to support people and consider where you can refer and the beautiful services out there in the community. So, thank you once again, Sally for your time today.
Sally: Thanks Sam.
Sam: Today, we've been talking to Dr Sally Crane from Birkdale Medical Centre. For more information on today's topics, visit the Health and Wellbeing Queensland website at hw.qld.gov.au We’ll see you next time on the Clinician’s Guide to Healthy Kids!