Regular ArticleBarriers to Providing Nutrition Counseling by Physicians: A Survey of Primary Care Practitioners
Abstract
Background. Previous surveys have shown that there is a disparity between physicians′ beliefs about the importance of diet and nutrition in health maintenance and disease prevention and the actual delivery of nutrition counseling. The primary objective of this study was to assess the current attitudes, practice behavior, and barriers to the delivery of nutrition counseling by primary care physicians. Methods. A random-sample-mailed questionnaire was sent to 2,250 primary care physicians selected from the AMA masterfile from general practice, internal medicine, and pediatrics, representing self-employed, group, hospital, and HMO practices. Participants were stratified by age, gender, geographical region, and present employment. The main outcome measures were to determine time spent by physicians providing and percentage of patients receiving dietary counseling and to identify barriers to the delivery of nutrition counseling. Results. A 49% response rate (n = 1,103) was obtained. Results are presented for the 1,030 physicians (70% private practice) with complete data. Over two-thirds of physicians provide dietary counseling to 40% or less of patients and spend 5 or fewer min discussing dietary changes. Despite this pattern, nearly three-quarters of respondents feel that dietary counseling is important and is the responsibility of the physician. Ranking of perceived barriers to delivery of dietary counseling were lack of time, patient noncompliance, inadequate teaching materials, lack of counseling training, lack of knowledge, inadequate reimbursement, and low physician confidence. Conclusions. This survey suggests that multiple barriers exist that prevent the primary care practitioner from providing dietary counseling. A multifaceted approach will be needed to change physician counseling behavior.
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Mobile Application Increased Nutrition Knowledge Among Brazilian Physicians
2024, Journal of Nutrition Education and BehaviorTo assess whether using a Dietary Approaches to Stop Hypertension (DASH) diet recommendation application increases primary care physicians’ knowledge and dietary counseling skills.
A randomized controlled trial.
Brazilian public primary care service.
Two hundred and twenty-two physicians (intervention group: n = 111; control group: n = 111).
Thirty days of using the Dieta Dash application. The application provides information about nutritional recommendations for hypertension management.
Nutrition knowledge score. Secondary outcomes: self-assessment of knowledge, self-confidence, assessment of eating habits, and barriers to dietary counseling.
Linear mixed-effects models for repeated measures and generalized estimating equations for comparing changes between groups.
A total of 66.2% of participants completed the follow-up. There was no significant difference between the groups regarding the mean knowledge score (P = 0.15). The prevalence of high knowledge increased by 12% (prevalence ratio [PR] = 1.12; 95% confidence interval [CI], 1.00–1.25) in the intervention group and showed an improvement in the self-confidence assessment (PR = 1.21; 95% CI, 1.02–1.44), and increased assessment of eating habits (PR = 1.26; 95% CI, 1.10–1.55).
The Dieta Dash application helped address dietary counseling, improving knowledge and self-confidence. However, innovative strategies are needed to minimize the primary care barriers.
Clinical nutrition in primary care: ESPEN position paper
2024, Clinical NutritionPrimary care healthcare professionals (PCHPs) are pivotal in managing chronic diseases and present a unique opportunity for nutrition-related disease prevention. However, the active involvement of PCHPs in nutritional care is limited, influenced by factors like insufficient education, lack of resources, and time constraints. In this position paper The European Society for Clinical Nutrition and Metabolism (ESPEN) promotes the active engagement of PCHPs in nutritional care. We emphasize the importance of early detection of malnutrition by screening and diagnosis, particularly in all individuals presenting with risk factors such as older age, chronic disease, post-acute disease conditions and after hospitalization for any cause.
ESPEN proposes a strategic roadmap to empower PCHPs in clinical nutrition, focusing on education, tools, and multidisciplinary collaboration. The aim is to integrate nutrition into medical curricula, provide simple screening tools for primary care, and establish referral pathways to address malnutrition systematically.
In conclusion, we urge for collaboration with PCHP organizations to raise awareness, enhance nutrition skills, facilitate dietitian accessibility, establish multidisciplinary teams, and promote referral pathways, thereby addressing the underestimated clinical challenge of malnutrition in primary care.
The design and rationale of a multicenter real-world trial: The southeastern collaboration to improve blood pressure control in the US Black Belt – Addressing the triple threat
2023, Contemporary Clinical TrialsImpoverished African Americans (AA) with hypertension face poor health outcomes.
To conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension.
We engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months.
We recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000.
The PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms.
This trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension.
Evaluation of weight change and cardiometabolic risk factors in a real-world population of US adults with overweight or obesity
2023, Preventive MedicineWhether individuals in real-world settings are able to lose weight and improve cardiometabolic risk factors over time is unclear. We aimed to determine the management of and degree of body weight change over 2 years among individuals with overweight or obesity, and to assess associated changes in cardiometabolic risk factors and clinical outcomes. Using data from 11 large health systems within the Patient-Centered Outcomes Research Network in the U.S., we collected the following data on adults with a recorded BMI ≥25 kg/m2 between January 1, 2016 and December 31, 2016: body-mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDLC), triglycerides and glycated hemoglobin (HbA1c). We found that among 882,712 individuals with BMI ≥25 kg/m2 (median age 59 years; 56% female), 52% maintained stable weight over 2 years and 1.3% utilized weight loss pharmacotherapy. Weight loss of 10% was associated with small but significant lowering of mean SBP (−2.69 mmHg [95% CI -2.88, −2.50]), DBP (−1.26 mmHg [95% CI -1.35, −1.18]), LDL-C (−2.60 mg/dL [95% CI -3.14, −2.05]), and HbA1c (−0.27% [95% CI -0.35, −0.19]) in the same 12 months. However, these changes were not sustained over the following year. In this study of adults with BMI ≥25 kg/m2, the majority had stable weight over 2 years, pharmacotherapies for weight loss were under-used, and small changes in cardiometabolic risk factors with weight loss were not sustained, possibly due to failure to maintain weight loss.
Telemonitoring the use of CPAP devices and remote feedback on device data effectively optimizes CPAP adherence in patients with OSA.
Can expanding the scope of telemonitoring and remote feedback to body weight (BW), BP, and physical activity enhance efforts for BW reduction in Patients with OSA receiving CPAP?
Participants were recruited from patients at 16 sleep centers in Japan with OSA and obesity who were receiving CPAP therapy. Obesity was defined as a BMI of ≥ 25 kg/m2, based on Japanese obesity guidelines. Implementation of CPAP telemonitoring was enhanced with electronic scales, BP monitors, and pedometers that could transmit data from devices wirelessly. Participants were randomized to the multimodal telemonitoring group or the usual CPAP telemonitoring group and were followed up for 6 months. Attending physicians provided monthly telephone feedback calls to the usual CPAP telemonitoring group on CPAP data obtained remotely. In the multimodal telemonitoring group, physicians additionally encouraged participants to reduce their BW, after sharing the remotely obtained data on BW, BP, and step count. The primary outcome was set as ≥ 3% BW reduction from baseline.
One hundred sixty-eight participants (BMI, 31.7 ± 4.9 kg/m2) completed the study, and ≥ 3% BW reduction occurred in 33 of 84 participants (39.3%) and 21 of 84 participants (25.0%) in the multimodal telemonitoring and usual CPAP telemonitoring groups, respectively (P = .047). Whereas no significant differences were found between the two groups in the change in office and home BP, daily step counts during the study period were significantly higher in the multimodal telemonitoring group than in the usual CPAP telemonitoring group (4,767 steps/d [interquartile range (IQR), 2,864-6,617 steps/d] vs 3,592 steps/d [IQR, 2,117-5,383 steps/d]; P = .02)
Multimodal telemonitoring may enhance BW reduction efforts in patients with OSA and obesity.
UMIN Clinical Trials Registry; No.: UMIN000033607; URL: www.umin.ac.jp/ctr/index.htm
Opportunities and Lessons Learned to Support Didactic Experiential Learning through a Nutrition Education and Counseling Pilot at a Federally Qualified Health Center
2022, Journal of the Academy of Nutrition and Dietetics