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1 From the Human Nutrition Unit, the University of Sydney, Sydney, Australia; Nutrition Education through Health Professionals, Communication and Innovation Studies, Wageningen University Research, Wageningen, the Netherlands.
2 Presented at the Third Heelsum International Workshop, held in Heelsum, the Netherlands, December 10–12, 2001. 3 Reprints not available. Address correspondence to AS Truswell, Human Nutrition Unit, Biochemistry Building 408, University of Sydney, NSW 2006 Sydney, Australia. E-mail: s.truswell{at}biochem.usyd.edu.au.
ABSTRACT
During the Third Heelsum International Workshop, Nutrition Guidance of Family Doctors Towards Best Practice, December 10–12, 2001, Heelsum, the Netherlands, 17 papers were presented. Each paper was discussed by all the participants at the workshop. These discussions were tape-recorded, transcribed, rearranged into topics, and summarized here.
There are situations that call for nutrition advice to be given by general practitioners (GPs). GPs are trusted, they are not selling any particular food, and patients accept that their GPs may talk to them about diet. Compared with dietitians, GPs have much less time to advise about diet, so they must condense information. It is easier for a GP to give dietary advice if the patient is registered on the practice’s list and if the GP can be paid for preventive work.
Six topics seemed to be particularly new and challenging in our changing world: (1) Use of dietary supplements, herbal preparations, and functional foods; (2) patients as partners; (3) computers in practices; (4) evidence-based medicine; (5) the Internet; and (6) the obesity epidemic. These topics were reported as problems and then discussed as opportunities. The aim of the Heelsum Collaboration on General Practice Nutrition was to facilitate the nutrition work of GPs in their practices by researching the problems and barriers and by testing solutions. In line with this aim, some suggestions for research are provided.
Key Words:
INTRODUCTION
During the Third Heelsum International Workshop, Nutrition Guidance of Family Doctors Towards Best Practice, December 10–12, 2001, Heelsum, the Netherlands, 17 papers were presented (1–17). After the presentation of each paper, it was discussed by all the participants at the workshop.
This article summarizes the discussions that followed the presentations by invited authors, who were mostly invited as representatives of organizations of primary care physicians from 10 different countries. In additional special discussion sessions, we addressed the problems and opportunities of nutrition guidance by family doctors in a changing world, including use of dietary supplements, herbal preparations, and functional foods; patients as partners; computers in practices; evidence-based medicine; the Internet; and the obesity epidemic. Then we drew conclusions on what to do in the future: use the computer for nutrition guidance, make nutrition part of the specialist training for general practice, advise only some patients about nutrition, delegate and refer, have the best (most up-to-date) guidelines, respond to the Internet-savvy patient, and establish a policy on obesity. Last but not least, some suggestions for research were given. These discussions were tape-recorded, transcribed, rearranged into topics, and summarized by the authors of this article.
There are situations where appropriate nutrition advice should be given by general practitioners (GPs). GPs are trusted, they are not selling any particular food, and patients accept that their GPs may talk to them about diet. Compared with dietitians, GPs have much less time to advise about diet, so they must condense information. It is easier for a GP to give dietary advice if the patient is registered on the practice’s list and if the GP can be paid for preventive work.
The terms "family doctor," "general practitioner," "primary care physician," "family physician," and "general physician" are used interchangeably here and elsewhere in papers from this workshop.
In this article, these topics are reported as problems and then discussed as opportunities. The aim of the Heelsum Collaboration on General Practice Nutrition (1) is to facilitate the nutrition work of GPs in their practices by researching the problems and barriers and by testing solutions, also with appropriately designed research. In line with this aim, some suggestions for research are summarized.
THE NEED FOR NUTRITION ADVICE IN GENERAL PRACTICE
For some diseases—for example, coronary heart disease (CHD), diabetes, hypertension, obesity, and celiac disease—dietary change is part of the management. And extra attention must be paid to nutrition at different stages of life: pregnancy, lactation, infancy, menopause, and old age. The GP has to be able to give nutritional advice in all these situations, and some patients expect advice or an opinion from their doctor on whether their usual diet conforms to current research and public health advice.
Consumers reported in focus groups (15) that their GP is the health professional they expect to advise on diet. There are many more family doctors than dietitians or graduate nutritionists. Doctors are trusted. Their function is to help those who consult them to get healthy and stay healthy. It is acceptable for the family doctor to talk about diet, even if it seems remote from the presenting symptom. But it is easier to prescribe a medicine than to describe a diet, and it takes less time. GPs cannot follow the full procedure that a good dietitian uses, asking about what the patient usually eats and drinks, offering a new food plan, suggesting products and foods, and explaining how to prepare them so that they are tasty (18). The doctor’s role is to know the principles of the recommended diets for major diseases and for general health—the things that matter and those that do not. Some important dietary advice can be very concise. Think of a situation where the doctor notices that a patient is putting on weight. The doctor’s advice will be along the following lines: "You don’t want to be any fatter. It spoils your appearance and fitness. Find ways to eat less overall; eat no fried foods; and eat more vegetables and fruit. Come back next month and we’ll weigh you again" (18). A little more detailed advice is provided at the next visit (18). The patient may not be at the responsive stages of change (19), but the doctor has done all that can be expected. A printed sheet of information can often back up concise messages like this.
STRUCTURES DIFFER BETWEEN COUNTRIES
GPs around the world work under different conditions, and these conditions affect their ability to advise their patients about nutrition. For example, in the Netherlands, the United Kingdom, and Canada, patients are registered with one doctor or practice. They can change their doctor, but this requires paperwork and finding a practice with space on its list. This system makes it much easier for advice to be given step by step over time, and for reliable follow-up. Usually the whole family is on the same doctor’s list. The opportunities for lifestyle advice, including nutritional advice, are better with this system because behavior change is a process that takes time (19). Reinforcement of the behavior change is more likely when the doctor has a registered list of patients.
If there is no formal attachment of patients to a practice, patients in countries such as the United States and Australia can shop around from doctor to doctor. This makes it difficult for the doctor to bring up the matter of weight or to follow through on complex dietary change. In some countries such as the Netherlands, the United Kingdom, and Australia, GPs act as gatekeepers for access by patients to medical specialists and dietitians. But in Germany a patient can go directly to a specialist.
It also makes a difference for nutrition advice whether the GP is paid for preventive work or only for dietary curative work, whether payment for a long consultation is proportionate to the time spent, and whether the health insurance or national health service pays for a dietitian working with a general practice.
PROBLEMS AND OPPORTUNITIES IN A CHANGING WORLD
Use of dietary supplements, herbal preparations, and functional foods
Dietary supplements and herbal products come under the same legislative regulations in the United States, whereas functional foods are more strictly regulated (2). Probably even less is taught about these groups of products than about nutrition in undergraduate medical schools. Herbal products do not appear in textbooks of nutrition, but nutritionists in the United States have recently been taking a serious interest in them. Considerable numbers of people are taking these products, but they may not tell their GP about herbal products, believing that the GP would not approve. The patient may not know exactly what herbs to use or avoid, and the GP does not have easily accessible information. This situation is different for vitamins and functional foods. The patient expects an opinion from the doctor about these and is disappointed if the doctor seems uninformed. Also, foods go in and out of fashion, although not always because of scientific evidence. This adds to the doctor’s bewilderment about nutrition.
Patients as partners
Today’s patients in general practice tend to be more egalitarian, informed, and demanding than patients of 2 generations ago. They have in their heads a lot of information about medicine and disease from the television, newspapers, and magazines. They may come with a question about a new cure for cancer discussed on a television show that the busy doctor did not see. Patients can have more information about foods and nutrition (not always scientific) than their GP. In recommending a dietary change, it helps for the GP to know how the patient thinks about foods in a multicultural society. The partnership model of communication for medical management (5) seems to be suitable for cooperating on dietary change.
Computers in practices
Computers’ first use in medical practices was for the accounts, insurance payments, reminders, and so on in the receptionist’s office. But now computers are in many a GP’s consulting room. Some doctors look at the patient and the computer alternately. Some share the computer screen with the patient. Some concentrate on the patient and use the computer only at the end of the patient’s visit. The computer is changing the one-on-one interaction of doctor and patient. It may dilute the doctor’s authority, but it has the potential to supplement the doctor’s evidence base.
Evidence-based medicine
The purest evidence-based medicine, with meta-analyses from randomized controlled trials (RCTs) of drugs to treat diseases, is mandatory for the pharmaceutical industry. GPs are exposed to its methods and language in their journals, at drug representative visits, and at industry-sponsored dinners. Practicing with the best available evidence can also lessen the risk of litigation. Evidence-based nutrition looks very different. For example, it is hard to imagine large RCTs of the protective effects of broccoli against cancer. Diets are very complex. If one component is increased or decreased, there are compensatory changes in the rest. The most likely RCTs relevant to diet are with pure food components that are handled like pharmaceuticals, and the result of some of these trials may clash with observational epidemiology.
The Internet
Medical information in most types of media is in the sender-to-receiver mode (5). The consumer plays a passive role, can hear incompletely, and can misunderstand, forget, or ignore. Now, with the Internet, computer-literate consumers can search many websites for information (correct or incorrect) about their disease, their diet, or the disease of someone they care about. Consumers can then visit their family doctor loaded up with well-understood reliable information, confusing and conflicting information, or unscientific alternative material. Most doctors have only limited time to spend on the Internet and do not always know how reliable a website’s information is.
The obesity epidemic
In all the countries where people can afford to have their own family doctors, there is a new epidemic of nutritional excess that is more difficult to treat than malnutrition or micronutrient deficiency. A large proportion of the patients in most practices are overweight, and many are obese. Obesity management is, at least partly, by dietary change, but the results are discouraging. No one likes a string of failures, so GPs may give up telling people to lose weight. If doctors cannot handle the biggest nutrition problem in affluent communities, this reduces their feeling of self-efficacy with nutrition.
WHAT TO DO
Use the computer for nutrition guidance
When the patient is in the GP’s consulting room, time can be saved if the doctor can print out well-written, reliable nutrition advice for the particular diagnosis. The Netherlands College of General Practitioners (Nederlands Huisartsen Genootschap) is working on providing this written advice (9). In Australia, the North Sydney Area Health Service runs "Health Fax," material written by A Stewart Truswell that is available for free to doctors by e-mail on nutrition management for major nutrition-related conditions. The material comes as a doctor’s sheet and/or a patient sheet.
Make nutrition part of the specialist training for general practice
Maiburg et al (6) presented the impressive results of computer-based instruction in a GP’s postgraduate training course. By using computer software, the student can learn at times that the teacher is not available, at the student’s own pace. The program used case studies for the instruction. Half the students who took the nutrition program were found afterward to have a higher score than controls in a theory exam, but, more convincingly, to perform better with standardized patients. In the Netherlands, negotiations are far advanced to establish a chair of Nutrition in Family Medicine at a university that has a GP training course.
Advise only some patients about nutrition
Some diseases are not related to diet. The family doctor is generally expected to give nutrition advice for secondary prevention. General primary prevention advice on a healthy diet is the responsibility of public health authorities, though the doctor may be asked about it. The Stages of Change Model in health education (19) means that some people are not going to respond to advice to change their lifestyle. The doctor can often predict whether nutrition advice will be taken seriously before allocating time for it.
Delegate and refer
Nurses, when available, can help with more of the detail work of dietary advice (12). Where a patient is anxious about the dietary prescription or where it must be very precise (eg, celiac disease, phenylketonuria), the GP refers the patient to a dietitian. Under favorable conditions, more of the patient’s nutrition management can be shared with a dietitian. This is likely to occur when health funds help the patient pay for the dietitian’s time and when the dietitian is allied to the practice and communicates regularly with the doctor.
Have the best (most up-to-date) guidelines
Dietitians and some practice nurses can be expected to handle dietary details. Doctors should possess and use dietary guidelines, which are based on all the evidence, RCTs, and observational epidemiology, and set out the principles of diet for different conditions. Brotons et al (12) found that most GP organizations report using dietary guidelines. In Ontario, Canada, the medical schools are cooperating to find and disseminate the best of the available guidelines (4). The best guidelines have to be relatively brief, evidence based (as far as possible), up-to-date, and practical. For background reading, a few books especially written for family doctors were shown at the last Heelsum workshop (20), including Truswell’s ABC of Nutrition (4th ed) (18).
Respond to the Internet-savvy patient
There are different ways the GP can react to patients who are using the Internet to find out more about their disease or diet or to check up on their doctor (5). The main problem with the doctor discussing Internet findings with patients is the extra time it may take. Other patients without access or competence to search the Internet may need more of the doctor’s time because they have less information to help them. Nutrition and health are among the fastest-growing areas of interest and are the main topics many people search for when surfing the Internet (21). Some websites are obviously unreliable, selling a product or a deviant philosophy or lacking scientific credibility. There are also reliable, evidence-based sites run by governments or nongovernmental organizations, some more up-to-date and easy to understand than others. There is an urgent need for research into which websites are the best for GPs to recommend to patients who want to use the Internet to improve or maintain their health.
Establish a policy on obesity
The GP is not responsible for the epidemic of obesity. We live in a complex Western world with an abundance of food and many people who lack physical exercise. GPs alone cannot treat all the overweight and obese people and must not blame themselves if greed and sloth often prove too strong. The situation is analogous to tobacco smoking (16). The rest of society has to swing into line with public health and community measures, as happened with the campaign against smoking. Nevertheless, obesity is much easier to prevent than cure, overweight is better than obesity, and obesity is better than gross obesity. GPs have a duty to weigh their patients regularly, tell them their body mass index (BMI), and speak up. For example, they might say: "You’re overweight. Don’t let yourself get any fatter" (18).
WHAT SHOULD BE THE ESSENTIAL NUTRITION KNOWLEDGE FOR A GP?
During our workshop, 2 groups were asked to discuss the question, What should be the essential nutrition knowledge for a GP? The groups came back with different answers. One group thought that the answer was dependent on the specific situation the GP works in. This group strongly felt that motivation of the GP is important. The other group came back with more substantial recommendations, such as the following:
SUGGESTIONS FOR RESEARCH
The workshop ended with a discussion of specific areas for future research. These included the following:
REFERENCES