Promoting Healthy Lifestyles In Ontario Family Health Networks

Abstract

Purpose: Primary health care reform presents new opportunities for registered dietitians (RDs) to contribute to health promotion and disease prevention in family practices. Since this is an emerging area of RD practice, a health promotion specialist was contracted to conduct a needs assessment and develop a plan for implementing nutrition-focused healthy lifestyle activities.

Methods: The needs assessment was conducted as part of an Ontario-based demonstration project in three Family Health Networks (FHNs).

Results: The needs assessment revealed a lack of agreement about what types of activities should be undertaken, a lack of information on the population's needs, a lack of coordination with other agencies in the community, and barriers of time and resources. The health promotion specialist recommended that health care team members in each FHN develop a shared understanding of their goals, and undertake the entire planning and evaluation cycle. Specific strategies were suggested to increase awareness, to provide health education, and to improve environmental support.

Conclusions: A significant need exists for conceptual development, planning, testing, and evaluation of disease prevention and health promotion in family physician-based primary health care organizations. The findings may be useful to others interested in increasing the focus on health promotion and disease prevention in such practices.

(Can J Diet Prac Res 2006;67 Suppl:S39-S46)

R�sum�

Objectif. La r�forme des soins de sant� primaires offre aux di�t�tistes professionnelles (DP) de nouvelles possibilit�s de contribuer � la promotion de la sant� et � la pr�vention des maladies en m�decine familiale. Comme il s'agit d'un nouveau domaine de pratique di�t�tique, un sp�cialiste en promotion de la sant� a �t� engag� pour �valuer les besoins et �laborer un plan de mise en oeuvre d'activit�s ax�es sur l'alimentation saine.

M�thodes. L'�valuation des besoins faisait partie d'un projet exp�rimental men� dans trois r�seaux de sant� familiale (RSF) de l'Ontario.

R�sultats. L'�valuation des besoins a r�v�l� un d�saccord quant aux types d'activit�s � mettre en oeuvre, l'absence d'information sur les besoins de la population, un manque de coordination avec d'autres organismes de la collectivit� et des obstacles li�s au temps et aux ressources. Le sp�cialiste en promotion de la sant� a recommand� que les membres de l'�quipe de soins de sant� de chaque RSF s'entendent sur leurs buts et entreprennent un cycle complet de planification et d'�valuation. Des strat�gies particuli�res ont �t� sugg�r�es pour accro�tre la sensibilisation, fournir de l'�ducation en nutrition et am�liorer le soutien du milieu.

Conclusions. Des besoins importants se font sentir en mati�re d'�laboration de concepts, de planification, de contr�le et d'�valuation de la pr�vention des maladies et de la promotion de la sant� dans des organismes de soins de sant� primaires en m�decine familiale. Les r�sultats peuvent �tre utiles � ceux qui souhaitent accro�tre la place de la promotion de la sant� et de la pr�vention des maladies dans ces milieux.

(Rev can prat rech di�t�t 2006;67 Suppl:S39-S46)

INTRODUCTION

Because food and nutrition are basic requirements for life, diet is an important focus for health promotion and disease prevention activities. All Canadian commissions and reports on primary health care (PHC) reform have envisioned a role for the PHC sector to promote health and prevent disease, including efforts to promote healthy diets, as part of a restructured health system (1,2). The focus and nature of efforts to promote health and prevent disease have varied considerably to date, from a wide range of programs developed over the past 40 years in community health centres (1,3) to specific programs of immunization and disease screening by family physicians (FPs) (4).

Registered dietitians (RD), with their focus on nutrition and healthy lifestyles, can contribute to the development of health promotion and disease prevention programs across many types of PHC organizations, including teambased and interdisciplinary family practices. Little specific guidance is available in the literature, however, on "best practices" in such organizations (5).

This paper was developed as part of a multifaceted Ontario Primary Health Care Transition Fund project (2004-06) to develop an inter-disciplinary model for nutrition services in three Family Health Networks (FHNs) in Kingston, Stratford, and Parry Sound, Ontario. Selected aspects of nutrition services were evaluated. Key project deliverables included completion of a systematic literature review, a key informant survey, completion of a Delphi process to develop a template for interdisciplinary nutrition services, a human resources and costing analysis, evaluation of dietitian counselling services, and client satisfaction surveys.

Family Health Networks are organizations of three or more FPs and selected other health care professionals who provide 24-hour-a-day, seven-day-a-week access to PHC services, and are funded in a blended funding model; this model includes capitation (population-based funding of health care services) and incentives for specific prevention activities, such as immunizations and disease screening. Under the FHN initiative, patients have been encouraged to enroll as FHN members, but can opt to continue to see their physicians under a fee-for-service system. These FPs may practise in one or multiple locations. Other features include support for the development of electronic health record (EHR) systems (6).

This paper reviews recent conceptualizations of disease prevention and health promotion in family practice settings. It also provides the results of a needs assessment conducted hy a health promotion consultant, with recommendations for possible activities at three demonstration sites. The lessons learned may help RDs working in similar settings (7) to achieve their mandate for health promotion in ways that address the needs of their practices, and to complement the work of public health departments and other agencies.

Health promotion in primary health care

The definition of health promotion from the first international 1986 Ottawa Charter for Health Promotion (8) is still frequently cited. The charter defines health promotion as "the process of enabling people to increase control over, and to improve, their health" (8). According to this charter, health promotion involves

* a holistic view of health.

* a focus on participatory approaches.

* a focus on the determinants of health, such as the social, behavioural, economic, and environmental conditions that are the root causes of health and illness.

* building on existing strengths and assets, not just addressing health problems and deficits.

* using multiple complementary strategies to promote health at the individual and community levels.

The vision in the charter challenges all stakeholders in primary health care to "reorient services":

The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health. The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components. Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services, which refocuses on the total needs of the individual as a whole person (8).

Twenty years later, one of the goals of the Ontario Primary Health Care Transition Fund projects has been to increase disease prevention and health promotion in PHC organizations (9). An approach has been the development of indicators for assessing implementation and outcomes of such activities (10). While such work will inform future evaluation, implementation at the local level in FP-based primary care settings is still in the early stages. Among the many issues to be resolved are the appropriate focus and scope of health promotion and disease prevention activities in such practices. This was evident in the Delphi consensus process for die demonstration project (11). Participants in that process were drawn from a range of disciplines, and included representatives from relevant health professional groups in Ontario, the lead physicians and RDs from the three demonstration sites, and representatives from academia, support organizations, and the College of Dietitians of Ontario. The majority of participants rated more disease prevention than health promotion activities highly. A similar variety of perspectives was evident in a recent analysis of PHC documents from four countries (Canada, the United Kingdom, Australia, and New Zealand) (12):

Three distinct notions emerged in the evaluation questions around health promotion. The first is health promotion as a population health strategy that has traditionally been the domain of public health. The second is clinical preventive activities which include advice to adopt healthy behaviours or refrain from risky activities, and involve health professionals following clearly established clinical practice guidelines. The third is the promotion of better self-care, transferring the responsibility for health back to the individual (12).

Clearly, the conceptual basis for and scope of health promotion and disease prevention in interdisciplinary FP-based practice settings need further development. One conceptual framework, developed by Kletchko in New Zealand (Figure 1), suggests that health promotion should be integrated with the rest of the continuum of care (13). The roles of individual professionals and integrated teams also need to be defined to ensure creation of effective services for the population. Much additional work is needed to develop this area of primary care further in an evolving Canadian health care system.

NEEDS ASSESSMENT METHODS

The RDs in the three FHNs felt that they would benefit from consultation with a health promotion expert. A request for proposals was issued to contract with a consultant (C.P.) to conduct a needs assessment and recommend strategies for the RDs working at the three FHN sites. The consultant visited all three sites, conducted in-depth interviews with each RD, and held lunchtime focus groups with staff at two of the three sites. All staff members were invited to these group sessions. A semi-structured interview was administered and statements were recorded on paper to identify the gaps, barriers, and desired strategies for health promotion programming. At the third site, a self-administered questionnaire was developed and completed by many of the staff, as a focus group was not feasible. Each of the three RDs also completed a self-administered questionnaire. The consultant developed, administered, and analyzed all data.

NEEDS ASSESSMENT RESULTS

The sites

Each site differed with respect to geography and demographics. While limited information is available on FHN populations, recent analysis of Local Health Integration Networks (LHINs, the Ontario regions for health planning) showed that health and lifestyle issues are common in all three regions compared with Ontario as a whole (Figure 2) (14,15). Parry Sound is located in a northern rural area; Stratford and Kingston are more similar in that they are urban centres in southern Ontario. The majority of patients seen by the dietitians required one-on-one counselling as treatment for one or more health conditions (14).

Gaps in health promotion

Awareness strategies: Effective awareness strategies involve good health communication, which means that patients need to be exposed to healthrelated messaging frequently. The purpose of health messaging is to influence individuals, populations, and organizations positively to promote conditions conducive to human and environmental health (16). At all three FHN sites, use of health promotion awareness methods was limited to posters in the offices and some handouts, such as Canada's Food Guide to Healthy Eating (17) and other credible resources.

Education/skill building: Individuals need to develop knowledge, attitudes, behavioural skills, and confidence in order to adopt and maintain healthy lifestyles (18-20).

Health education is often done through one-to-one sessions or small groups or classes, which involve a more intense level of knowledge or skill development (i.e., attending multiple workshops or classes as opposed to reading a brochure). They are interactive, allowing for the continuous exchange of ideas, insights, and feedback between participants and facilitators. Health education sessions are often participant or learner-directed, thereby allowing for more flexibility in accommodating diverse needs and learning styles (21).

At all sites, the group health education opportunities for patients were directed at treating specific health issues, such as weight and dyslipidemia. Already successful strategies could be expanded.

Environmental supports: The creation of supportive environments is an important part of health promotion, which enables people to make healthy choices more effectively (16). Restaurants that serve healthy foods are an example of an environmental support.

Similarly, individuals need supportive follow-up in order to make appropriate lifestyle changes (22). Follow-up support groups that enhance health education opportunities and encourage the maintenance of behaviours could be useful at the three FHN sites. For instance, a support group offering healthy cooking classes once a week for six months would encourage and support participants' lifestyle change (23).

The FHNs may or may not provide environmental supports, but patients must be made aware of environmental supports in their community. At all three sites, the RDs had developed some informal links with outside community agencies and were aware of community programs.

Partnerships with outside agencies: At each site, formal partnerships with outside agencies appeared to be limited. When asked if the FHN partnered with any outside agencies, a physician from one site responded, "Whom would we partner with?" Another physician stated, "Our public health unit is not visible." Others cited time and resources as barriers to partnerships. In addition, some health professionals wanted the FHN to be a one-stop shopping centre for patients, while others felt the onus was on patients to search out their own health promotion information and environmental supports in the community. Whatever the reasons, few partnerships existed.

Behaviour change theories: Physicians and other health professional groups are currently providing screening and referrals for RD counselling, but procedures supporting behaviour change could be more effective. Health counsellors frequently do not properly evaluate patients' readiness for change. They may make incorrect assumptions about levels of preparedness and go ahead with high-energy, actionoriented programs that do not meet the level of change required for patients (24). Methods and tools for the family practice setting are needed to assess patients' readiness to make a change with their health, and to ensure appropriate health promotion (24-26).

Barriers to programming

A number of organizational and other barriers to health promotion and disease prevention programming were identified from the questionnaires, interviews, and focus groups. The following themes emerged from the needs assessment.

Competing priorities: Competing priorities for available time and resources are a barrier to health promotion programs in an environment in which treatment has priority. Several gaps in treatment services became evident during the project; these highlight the issues that dietitians and other team members must address in developing any health promotion initiative.

Physicians identified more nutrition counselling for people with diabetes as a major need. Diabetes services are provided at diabetes education centres throughout the province, so the assumption at the beginning of the demonstration project was that only small numbers of patients with diabetes would be referred to the FHN RD. Subsequently, about 10% of all patients referred for counselling had diabetes as the primary reason for counselling. These patients often had multiple comorbidities and required ongoing nutrition counselling and follow-up. This experience is consistent with the results of a recent national survey that identified FPs as the primary managers of type 2 diabetes (27). Nationally, individuals with type 2 diabetes visited their FPs an average of 8.2 times a year, and only 66% of patients had seen a diabetes educator.

Physicians identified another gap in nutrition services: ongoing support for overweight and obese individuals, who often had two to five comorbidities (e.g., dyslipidemia, hypertension, impaired glucose tolerance, gastrointestinal problems, mental illness, anemia, adult eating disorders, liver failure, calcium deficiency, a mood disorder, or a physical disability) (28).

Services for children also continue to be needed, especially for problems such as fussy eating, underweight, overweight, and eating disorders.

Time and resources: Time and resource issues are closely related to the competing priorities discussed above. Each RD cited time as a barrier; the majority of their time was spent counselling or treating clients rather than implementing health promotion strategies. This finding is supported by workload statistics (29). Almost every health care professional cited lack of funding as a barrier to having health promotion in his or her FHN. When asked about the ideal situation that would permit health promotion strategies in the FHN, appropriate funding was the first issue mentioned.

Each RD, but not every health care professional, also cited lack of appropriate health education resources as a barrier to implementing effective healthy lifestyle strategies in the FHN. While numerous resources are available, they are often not targeted to the needs of family practices and patients. A lack of credible resources was evident, whether the issue was fact sheets with Web site listings for patients or ways to include the SMART (specific, measurable, attainable, realistic, and timely) philosophy to help patients make a lifestyle change.

A common conceptual basis: As was found in the Delphi process and policy document review, different health care professionals had differing views of health promotion (30). A shared understanding of the FHN's role and priorities for disease prevention and health promotion must be developed, given the time and resources needed to implement quality health promotion programs.

Data availability for needs assessment: To define the target groups for health promotion strategies, an FHN population needs assessment is required. If health care practitioners can identify the gaps in their practices, they can begin to address them. This will improve with implementation of the EHR, as screening will become possible for existing conditions requiring nutrition or healthy living advice, or for patients with family histories of chronic conditions. For example, currently most medical offices can only use billing codes to estimate how many of their patients have diabetes; these offices may not have a method to monitor patients' progress with all the key indicators of health maintenance (e.g., body mass index, glycosylated hemoglobin levels).

Knowledge of community services: Finding and updating knowledge of community services for patients can be timeconsuming for an FHN because of patients' multiple health conditions and the many self-help, hospital, and private services available in each community. Many public health units attempt to help with this challenge. Some community agencies may aggressively target physicians to be sure they know about services, while others are not aggressive or lists are not close at hand when a patient is sitting in the treatment room. While this barrier can be addressed, it requires the FHN's ongoing commitment to maintain electronic lists and referral forms for immediate access.

PROGRAMMING STRATEGIES

The following strategies, many adapted from public health, are recommended as a starting point for health promotion programming. These strategies take into account the identified themes that emerged from the needs assessment. At this level, health promotion strategies usually fall within four general types of activities: activities to increase awareness, education and skills building, creating or reinforcing environmental support for change, and policy development (Figure 3).

1. Establish a practice database of conditions.

Dietitians could use the EHR to screen the FHN database for existing conditions requiring nutrition advice, or to identify patients at increased risk for chronic conditions. This database would be developed and analyzed with other FHN team members.

2. Establish a database of service providers.

To define gaps in service, the existing services in communities and regions need to be identified. If a service is not available or accessible, the FHN can partner with other agencies to foster or improve the identified service for patients, or initiate the health promotion or education strategy themselves.

3. Develop a plan.

Nutrition health promotion is a key skill of public health and community RDs (1). If their interests and skills permit, RDs may take the lead in developing the FHN health promotion plan, including facilitating the development of priorities and a shared understanding of terminology and the health promotion process. All FHN team members could consider taking a basic course in health promotion to increase their confidence in the subject and to update their knowledge of electronic media. Several courses exist, such as the Ontario Health Promotion Resource System course Health Promotion 101 (21). Other options include contacting the Dietitians of Canada (DC) Community Dietitians in Health Centres Network or public health nutritionists, or hiring a health promotion consultant, as was done for this project.

4. Improve and create partnerships.

Numerous resource sites and centres can assist RDs with their health promotion work. The availability of such centres varies across the country, but many also have Web sites (21,31).

Formal and informal partnerships can be cultivated with outside agencies, such as public health units, self-help organizations, agencies working with addictions, and fitness organizations associated with local government or free-standing groups (e.g., city recreation departments, the YMCA, Good Life Fitness). Supporting other agencies with their health promotion strategies can benefit the community and patients.

5. Develop strategies and activities.

Numerous specific strategies and activities can be developed. Some ideas, most adapted from public health, are listed in Table 1. A crude estimate of the resource needs for each strategy is provided. The FHN may also consider using or adapting the resources from food and/or pharmaceutical companies. For example, Kellogg Canada has joined forces with DC to create a health promotion resource designed for children, called Mission Nutrition(TM). Pharmaceutical companies have also developed many patient handouts over the years, and may be interested in supporting the development of health promotion resources. 6. Evaluate and build on success.

Development of a logic model for the FHN health promotion plan will help RDs to evaluate success and define future plans. This process entails setting clear goals and identifying target groups, and defining costs and measurable criteria for both processes and outcomes. A short-term iterative approach is recommended for the planning through evaluation stages, so that the FHN can build on each small success.

RELEVANCE TO PRACTICE

If the vision of a reformed PHC system is to be realized, conceptual development, planning, testing, and evaluation of health promotion programs are needed in family practice organizations and settings. As Tommy Douglas once said, "Let's not forget that the ultimate goal of Medicare must be to keep people well rather than just patching them up when they get sick... All these programs should be designed to keep people well - because in the long run it's cheaper than the current practice of only treating them after they have become sick" (32).

Acknowledgements

The authors gratefully acknowledge the staff at the three FHNs for their interest and participation. The commitment of each lead physician - Dr. Murray Overington, Kingston, Dr. Mark Wilkinson, Stratford, and Dr. Richard Woodhouse, Parry Sound - was especially appreciated, as they were instrumental in ensuring successful completion of the project. Funded by the Ontario Primary Health Care Transition Fund, 2004-2006. This report does not represent the official policy of the funding partners, the Ontario Ministry of Health and Long-Term Care, or other organizations.

[Sidebar]

Appropriate funding was the first issue mentioned.

[Sidebar]

Competing priorities for available time and resources are a barrier.

[Reference]

References

1. Community Dietitians in Health Centres Network. Community dieutians - misted food and nutrition experts. Toronto: Dietitians of Canada; 2004. Available at: http://www.dietitians.ca/pdf/ CDHC_role_paper_March2004.pdf. Accessed 1 Mar 2006.

2. Dietitians of Canada. The role of the registered dietitian in primary health care: a national perspective. Toronto: Dietitians of Canada; 2001. Available at: http://www.dietitians.ca. Accessed 1 Mar 2006.

3. Canadian Alliance of Community Health Centre Associations. 2006. Available at: http://www.cachca.ca. Accessed 30 May 2006.

4. Family health teams. Toronto: Ontario Ministry of Health and Long-Term Care; 2006. Available at: http://www.healtli.gov.on.ca/ transformation/fht/fht_mn.html. Accessed 13 Jan 2006.

5. Enhancing disease prevention and health promotion in Ontario's family health teams: die public health/primary health connection. Perth, ON: Perth District Health Unit; 2006. Available at: http://www.pdhn.on.ca/publications.asp. Accessed 31 May 2006.

6. Lamarche P, Beatilieu M-D, Pineault R, Contandriopoulos A-P, Denis J-L, Haggerty J. Choices for change: the path for restructuring primary healthcare services in Canada. Ottawa: Canadian Health Services Research Foundation; 2003. Available at: http://www.chsrf.ca/final_research/commissioned_research/ policy_synthesis/pdf/choices_for_change_e.pdf. Accessed 1 Mar 2006.

7. Davidson B, Dietrich L, Bratier P. Key informant interviews: dietitian services in current programs 2005. Toronto: Dietitians of Canada; Accessed 1 Jan 2005. Available at: http://www.dietitians.ca

8. First International Conference on Health Promotion. The Ottawa Charter for Health Promotion. World Health Organization; 1986. Available at: http://www.who.int/healthpromotion/conferences/ en/index.html. Accessed 30 May 2006.

9. McKendry R, Young E. National workshop on evaluation of primary healthcare renewal in Canada. Canadian Health Services Research Foundation; 2005. Available at: http://www.chsrf.ca/research_themes/ pdf/Summary_of_PHC_Workshop_e.pdf. Accessed 30 May 2006.

10. Martin C, HaggertyJ. Primary health care indicator development project: 1st Consensus Conference report on conference proceedings. Canadian Institute for Health Information; 2005. Available at: http://secure.cihi.ca/cihiweb/en/downloads/First_Consensus_ Conference_Report_EN.pdf. Accessed 30 May 2006.

11. Brauer P, Dietrich L, Davidson B. Practice management guide for new services in Ontario. Toronto: Dietitians of Canada; 2006.

12. Haggerty J, Martin C. Evaluating Primary Health Care in Canada: The Right Questions to Ask! Ottawa: Health Canada; 2005.

13. Kletchko S. A 'whole systems' framework - grouping populations of need with activities across the continuum of care. Calgary: Calgary Health Region; 2005. Available at: http://www.calgaryhealthregion.ca/clin/cme/conf/GlobalPerspectives onCDM2005. Accessed 1 Mar 2006.

14. Population health profiles. Toronto: Health System Intelligence Project, Ontario Ministry of Health and Long-Term Care; 2005. Available at: http://www.health.gov.on.ca/transfbrmation/ providers/information/resources/profiles/im_profiles.html. Accessed 18 Mar 2006.

15. Core indicators for public health in Ontario. Association of Public Health Epidemiologists in Ontario; 2006. Available at: http://www.apheo.ca/indicators/index.html. Accessed 30 May 2006.

16. Leger LS, Nutbeam D. Research into health promoting schools. J School Health 2000:70:2574).

17. Canada's food guide to healthy eating. Ottawa: Health Canada; 2006. Available at: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/ index_e.html. Accessed 30 May 2006.

18. Bracht N. Health promotion at the community level. Thousand Oaks, CA: Sage Publication; 1999.

19. Friedman H, DiMatteo R. Health psychology. Englewood Cliffs, NJ: Prentice-Hall; 1989.

20. Shephard RJ, Trudeau F. The legacy of physical education: influences on adult lifestyle. Pediatr Exerc Sci 2000:12:34-50.

21. Hyndman B, Hershfield L. Health promotion 101 (online course). Ontario Health Promotion Resource System; 2005. Available at: http://www.ohprs.ca/hpl01/main.htm. Accessed 3 Mar 2006.

22. Tappe MK, Duda JL, Mengesehmwald H. Personal investment predictors of adolescent motivational orientation toward exercise. Can J Sport Sci 1990; 15:185-92.

23. O'Donnell M, Harris J. Health promotion in the workplace. Albany, NY: Delmar Publishing; 1997.

24. Samuelson M. Stages of change: from theory to practice. Am J Health Promot. Making your health promotion program more effective collection; 1998. Available at http://www.healthpromotionjournal.com. Accessed 1 Mar 2006.

25. Bass PF, Stetson BA, Rising W, Wesley GC, Ritchie C. Development and evaluation of a nutrition and physical activity counseling module for first-year medical students. Med Educ Online [serial online]; 2004. Available at: http://www.med-ed-online.org. Accessed 8 Mar 2006.

26. O'Hea EL, Boudreaux ED, Jeffries SK, Taylor CLC, Scarinci IC, Brantley PJ. Stage of change movement across three health behaviors: The role of self-efficacy. Am J Health Promot 2004;19:94-102.

27. Harris SB, Ekoe JM, Zdanowicz Y, Webster-Bogaert S. Glycemic control and morbidity in the Canadian primary care setting (results of the Diabetes in Canada Evaluation Study). Diabet Res Clin Pract 2005;70:90-7.

28. Basrur S. 2004 Chief Medical Officer of Health report: healthy weights, healthy lives. Toronto: Ontario Ministry of Health and Long Term Care; 2004. Available at: http://www.health.gov.on.ca/ english/public/pub/ministry_reports/cmoh04_report/ healthy_weights_1 12404.pdf. Accessed 8 Mar 2006.

29. Witt J, Brauer P, Dietrich L, Davidson B. Estimation of Human Resource Needs and Costs of adding Registered Dietiu'ans to primary Care Networks. Can J Diet Prac Res 2006;67(Suppl):S30-S38.

30. Brauer P, Dietrich L, Davidson B. Nutrition in primary health care: using a Delphi process to design new interdisciplinary services. Can J Diet Prac Res 2006;67(Suppl):S14-S29.

31. Lyons RL. Healthy lifestyle: out of style? Edmonton: The shift [University of Alberta Centre for Health Promotion Studies]; 2000. Available at: http://www.chps.ualberta.ca/publications/ shift/vol3issl.pdf. Accessed 8 Mar 2006.

32. Douglas T. The Future of Medicare. Canadian Health Coalition; 1982 [cited 2006 20June]. Available from: http://www.healthcoalition.ca/tommy.html.

[Author Affiliation]

PAULA BRAUER, PhD, RD, Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON; THERESA SCHNEIDER, MPH, RD, Nutritional Assessment Services, Kingston, ON; CHRISTINE PREECE, BA, MHS, Preece Consulting, Sarnia, ON; DEBORAH NORTHMORE, RD, Stratford, ON; EVA WEST, RD, CDE, Bracebridge, ON; LINDA DIETRICH, MEd, RD, Dietitians of Canada, Toronto, ON; BRIDGET DAVIDSON, MHSc, RD, Nutrition and Research Consulting, Kitchener, ON

STEERING COMMITTEE

Paula Brauer, PhD, RD, Linda Dietrich, MEd, RD, Bridget Davidson, MHSc, RD, John Krauser, Primary Health Care Team, Ministry of Health and Long-Term Care, Toronto, ON, Karen Parsons, Primary Health Care Team, Ministry of Health and Long-Term Care, Kingston, ON