NEWS AND VIEWS DOI: 10.1111/nbu.

12320

Are doctors nutritionists? What is the role

of doctors in providing nutrition advice?
M. Adamski, S. Gibson, M. Leech and H. Truby
Monash University, Melbourne, Australia

Abstract Diet and nutritional status impact on health outcomes. The global rise of diet-
related non-communicable diseases plus the double burden of obesity and
malnutrition means that it is imperative more than ever that all healthcare
professionals are able to provide at least basic evidence-based nutrition advice.
Improving an individual’s diet requires more than just information provision, it
requires consistent and long-term support to change and maintain new
behaviours. Doctors acknowledge that nutrition plays a crucial role in health and
agree that providing nutrition advice is part of their role. However, providing
sufficiently detailed nutrition advice that is relevant to a patient’s health goals,
useful for the patient, and that results in measurable changes, is not common in
practice settings. Numerous challenges and barriers have been identified for why
doctors do not provide nutrition recommendations to their patients. A lack of
nutrition education and training, time constraints during appointments, and
patients who have access to an ever-growing body of nutrition and health
information via the Internet and social media, together may explain why doctors
tend not to include nutrition advice in their care plans. This paper outlines both
short- and long-term strategies for improving doctors’ engagement with nutrition
interventions and collaborative working with dietitians in the context of
collaborative care. Having doctors support and advocate for evidenced-based
nutrition practice is a crucial element of the World Health Organization’s
Decade of Action on Nutrition achieving measurable success.

Keywords: doctors, general practitioners, medical curricula, medical profession, nutrition

education

With 2016 heralding the World Health Organization and obesity prevalent and sometimes concurrent
(WHO) Decade of Action on Nutrition (WHO 2017), (Gakidou et al. 2017). The health of the world’s pop-
the time has arrived to ensure that all health profes- ulation is impacted by long-term dietary patterns
sionals are able to provide at least basic evidence- (Liese et al. 2015), being implicated in the aetiology
based nutrition advice. This imperative is underpinned of diet-related non-communicable diseases such as
by the recognition that poor diet is the second leading type 2 diabetes. At the other end of the nutrition spec-
cause of death in the world, with both malnutrition trum, malnutrition is prevalent and impacts on many
physiological and biochemical processes in each body
Correspondence: Professor Helen Truby, Department of Nutrition,
system. Clinical nutrition, as defined by the European
Dietetics and Food, Monash University, Level 1 264 Ferntree Gully Society for Clinical Nutrition and Metabolism
Road, Notting Hill, Melbourne, Vic. 3168, Australia. (ESPEN), deals with ‘the prevention, diagnosis and
E-mail: helen.truby@monash.edu management of nutritional and metabolic changes

© 2018 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation Nutrition Bulletin, 43, 147–152 147
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
148 M. Adamski et al.

related to acute and chronic conditions caused by lack patients pose increasingly complex challenges for doc-
of or excess of energy and nutrients’. This wide scop- tors. Today’s patients are more likely to question med-
ing definition makes nutrition relevant to many condi- ical care they receive and seek information from other
tions and a key domain of doctors (Cederholm et al. sources of variable repute, such as articles on the
2017), as well as critical to supporting patient’s health Internet and health gurus on social media (Pollard
and quality of life, and impacting on health care costs. et al. 2015; Yiannakoulias et al. 2017). Although
Nutrition recommendations need to be implemented patients trust their doctor and hold their advice in
at an individual level, but social and environmental high regard (Ball et al. 2014; Walker et al. 2018),
factors can make it difficult for an individual to make their doctor might not have the time and skills to
the changes required to achieve these recommenda- effectively communicate optimal diet advice that can
tions. Improving an individual’s diet requires more enable their patients to make behavioural change.
than just information provision; typically, a number of Doctors acknowledge nutrition plays an important
strategies, such as social support and goal setting, are role in health and agree that providing nutrition advice
needed to change and maintain dietary behaviours. is part of their role (Ball et al. 2010; Kolasa & Rickett
One example of this is weight loss. There are a 2010; Mitchell et al. 2011; Crowley et al. 2015a).
plethora of different strategies that enable people to However, they are not always able to translate this pri-
lose weight but the physiological processes which ority into practice and provide sufficiently detailed and
drive weight re-gain in obesogenic environments mean sustained nutrition advice that results in meaningful
that the majority regain the lost weight (Coutinho changes (Kahan & Manson 2017). Dietary strategies
et al. 2017). A major challenge is how to prevent are viewed as adjunct therapy by some doctors even
weight re-gain. The US weight control registry pro- though for some conditions, such as type 2 diabetes,
vides valuable insight into the kinds of behaviours diet should be the first line management option
people adopt to successfully maintain a reduced body- (McGuire et al. 2016). In general practice in Australia,
weight. These include eating breakfast, consuming a dietary and lifestyle advice provided to ‘at risk’
diet low in fat, regular physical activity and weekly patients appears to be infrequent and inconsistent
self-monitoring of bodyweight (Wing & Hill 2001; (Harris et al. 2012; Britt et al. 2015; Ball et al. 2016).
National Weight Control Registry 2018). People may In an Australian study, Mulquiney et al. (2018)
require more support to maintain a lower bodyweight reported that out of 145 708 consultations (by 1124
than they do to lose weight in the first instance. The registrars), there were 227 190 problems/diagnoses and
impact of inexorable social forces, socioeconomic sta- out of these only 587 (0.26%) resulted in a referral to
tus, educational attainment, health inequity and psy- a dietitian/nutritionist. The most common conditions
chological underpinnings of addiction often cause for prompting a referral were obesity and type 2 dia-
doctors to feel nihilistic about their ability to modify betes. This study highlighted that the registrars’ rate of
‘lifestyle’ behaviours. referral to a dietitian/nutritionist was comparable with
Although prevention and treatment of illness and that of GPs (Mulquiney et al. 2018), suggesting that
disease are different constructs within health systems, referral for specialist dietary advice is not necessarily
diet is integral to both. This paper focusses on the ‘front of mind’ for all doctors. If doctors are not
impact that health professionals, and doctors in partic- directly providing dietary information and are not reg-
ular, can have on the treatment and prevention of ularly referring patients to diet specialists, it perhaps is
diet-related health conditions. not surprising that information and support are sought
from alternative sources such as the media and Internet
(Cash et al. 2015; Hoffman & Tan 2015).
Doctors and nutrition advice: What is
happening now?
Nutrition: The contested space
Doctors, especially general practitioners (GPs), are
required to have detailed knowledge and practical The explosion of interest from social media, TV pro-
application of medical science through advice, pre- grammes, celebrity chefs, alternative practitioners
scriptions and implementation of standardised care and the commercial dieting industry in promoting
plans provided to the patient. Competing demands for ‘wellbeing’ through food influences consumer food
doctors’ professional development time in relation to choices. Additionally, food companies and retailers
new care guidelines, changes to drug prescribing prac- employ effective marketing strategies to influence pur-
tices and new technologies is common. Additionally, chasing habits, which can have impact on health. For

© 2018 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation Nutrition Bulletin, 43, 147–152
 Are doctors nutritionists? 149

example, there is strong evidence for a positive rela- accreditation in providing dietary counselling services
tionship between childhood obesity and exposure to and medical nutrition therapy to patients. It is therefore
food marketing (Mazur et al. 2017). Competing in understandable that doctors report having a lack of
this crowded and commercialised environment are evi- confidence and knowledge or indeed the complex skills
dence-based government health promotion messages, required for effective, person-centred nutrition coun-
front- and back-of-pack labelling systems, and portion selling (Mitchell et al. 2011; Kahan & Manson 2017).
size guides, which often fail to resonate with con- A survey of New Zealand medical students, registrars
sumers (Persoskie et al. 2017). Explaining the often and GPs suggested that confidence in providing nutri-
complex and nuanced science underpinning dietary tion advice was positively related to experience (Crow-
advice (e.g. the relationship between different types of ley et al. 2015a). Thus a doctor’s confidence in
fat and cardiovascular outcomes) is challenging and providing nutrition advice is likely to vary across their
failure to communicate this effectively can result in career and be dependent not only on their knowledge
consumer confusion (Diekman & Malcolm 2009). For but also their specialty, and possibly their proximity to
health professionals, maintaining currency in knowl- dietitians in their work environment.
edge about developments in the many disciplines of
nutrition science is challenging; expecting doctors to
Time constraints
have any more than basic nutrition knowledge is unre-
alistic but they must grapple with many questions that In Australia and New Zealand, doctors consistently
their patients ask and within very limited time. report that they do not have adequate consultation
time to provide nutrition advice (Ball et al. 2010;
Mitchell et al. 2011). Australian GPs have reported
Challenges and barriers for doctors in
spending between 1–5 minutes discussing the patient’s
providing nutrition advice
diet, when and if they provided nutrition advice
(Mitchell et al. 2011). Supporting behaviour change
Education/training in nutrition
for chronic disease requires rapport development with
Globally, medical curricula have been described as lack- patients, and an understanding of individual’s psycho-
ing sufficient nutrition education (Daley et al. 2016; social needs and how to motivate them to change; this
Frantz et al. 2016; Mogre et al. 2018). A lack of nutri- will take significantly more time than is available in a
tion education within medical training has been high- typical 15-minute general practice appointment (Britt
lighted as a major barrier for doctors to provide et al. 2002; Michie et al. 2011).
nutrition advice (Ball et al. 2010; Cuerda et al. 2017; In many countries, the funding model for doctors’
Kahan & Manson 2017). Studies in the US have time and resources is skewed towards rewarding
described nutrition education within medical degrees as ‘treatment’ with little or no financial reward for ‘pre-
insufficient and highlighted the lack of standardised vention’. Currently, many medical appointments have
competencies, resulting in nutrition education ranging no allocation of time for providing nutrition advice
across medical programmes from none, to short lectures, (Kahan & Manson 2017). If extra time is required to
to nutrition rotations (Daley et al. 2016; Frantz et al. provide nutrition advice to patients, how would this
2016). A recent study from Ghana explored medical stu- be implemented and funded?
dents’ opinions on nutrition education within medical
curriculum (Mogre et al. 2018). The students described
How can doctors provide nutrition advice,
nutrition education as inadequate for various reasons,
without being nutritionists?
including the low priority of nutrition education and
poor translation to clinical practice. A systematic review investigating the effectiveness of
Nutrition science and its translation via dietetic prac- nutrition care provided by GPs highlighted that doc-
tice is complex and can be regarded as both a science tors have potential to improve their patient’s dietary
and an art. The art requires individually tailored and habits by providing nutrition advice (Ball et al. 2013).
motivating communication of nutrition science into Nudging patients to take the first steps to manage
practical food and drink guidance for an individual, their diet and adopt dietary change could be a key role
accounting for their relevant medical, social and cul- of doctors. Communicating clear and consistent evi-
tural circumstances. Dietetics programmes typically dence-based nutrition advice and advocating the
involve either 4-year Bachelor’s or 2-year Master’s importance of good nutrition and healthy eating beha-
level training to develop competence and enable viours enables doctors to be key influencers in the

© 2018 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation Nutrition Bulletin, 43, 147–152
150 M. Adamski et al.

contested food and wellness space. Doctors’ medical nutrition science as a highly valued, specialist field of
training and basic nutrition education provide them health. There is a need to advocate for dietitians, and
with the tools to recognise ‘at risk’ patients and refer the role they can play in patient care, as well as to
them to trained specialists, such as dietitians, who increase dietitians’ awareness of the challenges doctors
have the time, funding, knowledge and practical skills face in providing nutrition advice to patients. Dietitians
to provide effective medical nutrition therapy and eli- should work with doctors at both the individual and
cit behaviour change (Sialvera et al. 2017). Doctors policy level to support implementation of effective
can also signpost patients to evidenced-based nutrition nutrition advice within medical practice in a sustainable
resources, such as those provided online and in print way. Future work should focus on the development of
by leading nutrition authorities (e.g. Dietitians Associ- professional standards for nutrition education and train-
ation of Australia, and the British Dietetic Association ing, frameworks for implementation of nutrition educa-
and British Nutrition Foundation in the UK). tion at undergraduate, graduate and professional
Eating behaviours and food choices are influenced development level, development of nutrition best prac-
by an individual’s cultural, social, economic and tice guidelines for the medical profession, and develop-
health priorities, and changing entrenched behaviours ment and provision of resources to support the
require ongoing expert support and time (NHMRC overhaul of current medical education and practice. Sig-
2013). As a multidisciplinary team is required for the nificant work has already begun with the Need for
successful management of many chronic health condi- Nutrition Education/Innovation Programme (NNEdPro).
tions, embedding collaborative care into the medical NNEdPro brings together international experts in
curricula will help doctors to identify when the input nutrition and medical education, along with expert
of other health professionals, such as dietitians, could health bodies and leading universities, to develop, pro-
be valuable (Kent & Maddock 2017). As part of a vide and evaluate nutrition education in healthcare
multidisciplinary team, doctors can provide the essen- systems. NNEdPro works with a range of key stake-
tial diagnosis, initial advice and recommendations and holders to ensure medical, healthcare and public
co-ordinate overall treatment plans, while avoiding health professionals have access to nutrition education
some of the challenges that come with the provision and that they have appropriate knowledge, skills and
of specialist nutrition-related advice, such as the need attitudes to provide effective care and advice to
for time and specialist knowledge. patients and the public. Additionally, NNEdPro is
working towards nutrition as a key element embedded
into the medical/healthcare systems (NNEdPro 2018).
The way forward
For doctors to be able to provide nutrition advice and
Nutrition science and medical curricula
recognise the need for referral for more specialist
nutrition therapy, the nutrition knowledge and prac- Integration of the fundamentals of nutrition science
tice gap within the medical profession needs to be and dietetics throughout all medical curricula should
bridged. A systems approach is required with involve- be a priority so doctors are equipped with a basic
ment from nutrition experts and authorities, such as understanding of nutrition and its key role in all
dietitians, education specialists, such as universities, health outcomes. Doctors require the knowledge and
and key opinion leaders from the medical profession. skills to provide the first response and initiate basic
Education must be easily accessible, relevant and use- nutrition advice as well as influencing future beha-
ful to medical professionals; doctors need to be able viours by recognising when referral is required and
to apply nutrition knowledge to their own practice. encouraging patients to seek specialised support
This requires education to be specifically targeted to (Kahan & Manson 2017). While guidelines for under-
the medical profession and to be applicable in the graduate medical curricula have been developed for
context of significant time pressure. some countries, such as the US, the UK, Australia,
Canada and New Zealand (Crowley et al. 2015b),
these are not necessarily mandatory.
Collaboration between nutrition and medical
professions
Nutrition education for doctors
Collaboration between the nutrition and medical pro-
fessions is essential. Leadership provided by expert col- Universities and nutrition education experts need to
laborations is paramount for increasing the profile of collaborate with the medical educators to develop

© 2018 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation Nutrition Bulletin, 43, 147–152
 Are doctors nutritionists? 151

targeted professional development for the medical So do doctors need to be nutritionists? No, but they
profession that support currency of practice and do need to play a role in reducing the health impact
upskill on ‘hot topics’. Education must be easily rele- of poor diet by recognising when and where diet is the
vant, accessible and flexible in delivery, plus be major underpinning factor in poor health, and devel-
accredited by appropriate medical and nutrition bod- oping the knowledge and skills to offer advice and/or
ies to assist doctors in identifying evidenced-based the confidence to refer on to those that do.
courses.
Not only do doctors require nutrition knowledge,
they also require practical skills and guidance on how Conflict of interest
to integrate nutrition advice into their own practice. MA, HT and SG are involved in the development and
Effective strategies include learning opportunities delivery of online nutrition education courses aimed at
where doctors can model their approach on nutrition healthcare professionals. HT is a senior collaborator
experts, improve their self-efficacy and build confi- at the Global Centre for Nutrition in Health, NNEdPro
dence in nutrition as an integral part of medical care network. MA is a member of the NNEdPro ANZ
(Mogre et al. 2016). Practical guidelines relevant to Steering Committee.
the medical profession are required so standards can
be set and all doctors can work to these guidelines.
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© 2018 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation Nutrition Bulletin, 43, 147–152