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In the eyes of the public, family physicians (FPs) play an important role in providing dietary advice, and FPs appreciate their responsibility with regard to nutrition. This supplement contains the proceedings of the Third Heelsum International Workshop, Nutrition Guidance of Family Doctors Towards Best Practice, and examines the dynamics around nutrition guidance in primary care. Dealing with food, diet, and nutrition in the family practice setting—what individuals eat, how this influences their health status, and in what way food habits can be changed—is a meeting point of medical, behavioral, communication, epidemiologic, and nutritional perspectives. Experts from these backgrounds now have met 3 times since the first workshop in 1995 and share common interests that are further explored in this issue.
Critical in the cooperation of nutritionists, FPs, and behavioral scientists is the need for evidence that food and diet matter, and this issue was dominant in the workshop. Medical practitioners are obligated to account for the effectiveness of their interventions—evidence-based medicine—and this is certainly the case in family medicine. The source of evidence is basic and clinical research, and family medicine still suffers from the traditional focus of research on teaching hospitals: the maxim "the more common the health problem, the less it is researched" (1) still holds true today. Although there is a growing literature on the effects of food interventions, this has thus far had limited impact on clinical guidelines. In part, this is due to the available research: only a few nutrition interventions have studied the effects of food on hard clinical endpoints, in individuals, using a randomized controlled trial (RCT) design. To some extent, evidence-based medicine is synonymous with RCT, a methodology that has been developed to study the effectiveness of drug treatment. However, an RCT is not necessarily the most appropriate methodology to gain knowledge of intervening in eating habits and other aspects of lifestyle. Consequently, these interventions do not feature predominantly in evidence-based recommendations.
The 2-part response to this is straightforward. First, build the evidence surrounding diet-related interventions. This is a case of needing more clinical research in a wide variety of patient groups. A multidisciplinary approach in this is essential, as it is the modification of attitude and behavior with respect to eating that must produce the relevant biochemical and clinical changes. Multidisciplinary cooperation should change a biomedically preoccupied research culture, in which the RCT is considered the sole acceptable method. Eating, tasting, and other food-related aspects are part of the way individuals seek enjoyment every day. It is part of their cultural values, not just a nurturing of their bodily needs. These features are at loggerheads with RCT characteristics such as blinding and the use of placebo, where "food" is restricted to the mere feeding of physical requirements. This limits the feasibility of applying RCTs in testing nutrition and other lifestyle interventions. This should take nothing away from the need to apply rigorous methods in nutrition research, and a multidisciplinary approach can produce the lateral thinking needed to modify RCTs for nutritional interventions or develop adequate alternatives.
Second, better use must be made of available research to support the FP. This requires studies with a design that acknowledges the complexity of FP patient care (2). The Cochrane Collaboration was founded to explore in a comprehensive way biomedical research for clinical care. It developed a state-of-the-art methodology for systematic reviewing of the available biomedical literature. An important finding at the Third Heelsum Workshop was the virtual absence of nutrition in the currently available Cochrane reviews (3). Systematic reviews of nutrition interventions in the prevention and treatment of common diseases would enhance better use of available evidence, but this would require multidisciplinary cooperation. The participants in the 3 Heelsum Workshops since 1995 have over the years developed into a multidisciplinary network (the Heelsum Collaboration on General Practice Nutrition), including experts in primary care prevention (Europrev). On this basis, the initiative was taken to form an international group to work with the Cochrane Collaboration. These activities require a major effort that can be sustained through another important Heelsum-related development: the founding this year of a special chair of nutrition in family medicine in a Netherlands university. Of particular importance in the dissemination of guidelines for family doctors is the condensation of relevant information so that it can be quickly read during a busy consultation (4). To safeguard the application of new insights, it is important that the information is presented in a way that practitioners can use it directly in the conditions under which they practice. This "framing" to the specific circumstances of application should be carefully tested before it is presented on a larger scale to practitioners. It is also quite important to test specifically this presentation of evidence.
In developing a nutrition evidence base, several ground rules can be defined. A key feature of any intervention is its feasibility in patients’ daily eating routines. Only when integration in this sense is possible can effects on health status be expected. Integration into patients’ own daily habits requires tailoring to individual circumstances; by participating in this tailoring, patients become partners in rather than objects of care. They are empowered to help take care of their own health. The active involvement of patients is in fact a shift in paradigm, which is central in the approach of family medicine (5). A multidisciplinary approach, including disciplines with a longer standing tradition of an active involvement of patients, will facilitate this paradigm shift. Patients’ personal preferences will come to the fore. Rather than focusing on changing the whole world, nutritional interventions should focus on patients’ priorities as much as on the FPs’. This approach again requires lateral thinking and the use of nonmedical approaches such as Internet research, e-mail chats, and social role models and can help connect individual and public health approaches.
An important aspect of individual nutritional guidance is the background of the target group. In family medicine, a high-risk approach is generally promoted: care is focused on those at highest need who will benefit most from it. Unhealthy food habits are most likely in people with a persistent adverse lifestyle, but this is the group least likely to change. The effect size should, in other words, be related to the population under care. The same is true of the economically disadvantaged. Nutrition is linked to the so-called prevention paradox: effects of interventions may be small or even nonexistent on an individual level but be highly advantageous on a population level. Again, the effects that can be expected must be placed in the context of the intervention.
Nutrition education and communication methods, like diet and nutrition approaches themselves, must be evidence based. That means we need to know the relative efficacies of the different methods and to understand how they work. Strong progress has been made in the past few years in effectiveness research of computer-based instruction (both to first-year medical students in the United States and to FP trainees in the Netherlands), of patient information letters in the Netherlands, and of tailored nutrition education with heavy use of modern computer technology. The basis for understanding the nutrition interaction between the FP and the patient has improved because of qualitative and quantitative research projects.
The future will be a challenge because there will be so many research and communication opportunities, which makes it all the more important to review the progress that has been made. In 2004, when the Heelsum International Workshop will be organized for the fourth time, there will be an excellent opportunity to learn how FPs and nutritionists have responded to the challenges and made use of these opportunities.
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