Nutrition care practices of primary care providers for weight management in multidisciplinary primary care settings in Ontario, Canada - a qualitative study

Using a purposive sampling technique, we began by approaching the director of each clinical setting in proximity to the research institution. Once permission was obtained from the clinical director, all primary care providers (PCPs) at each site were contacted via email. If interested, a consent form outlining the details of the study was provided to the PCP. Out of 15 NPs and 10 FPs who were approached, 13 and 7 accepted, respectively. Our sample included NPs and FPs working in 2 FHTs, 3 CHCs, and 1 NPLC. The higher number of NPs involved in this study was due to the inclusion of the NPLC setting, which is primarily comprised of NPs. The ratio of NPs to FPs is the same for the two other settings (3 NPs and 3 FPs). The recruitment and data collection occurred in Fall 2016 and Winter 2017. Each participant was given a 50-dollar Canadian coffee card as a token of appreciation for taking the time to participate in the study.

To test the interview protocol, a pilot test that included 4 PCPs was conducted. Data from the pilot test were not included in this study because the interview protocol was refined based on participants’ feedback to include more follow-up probes. The first inclusion criterion was: NPs and FPs who provide health care to adult patients. This is important as questions that were asked during the interview pertain to excess weight in adult patients. The second inclusion criterion was: NPs and FPs who had been working at the site for at least 6 months. This ensured that the health care professional had been working at the site for a considerable number of hours in order to accurately convey their practices at the clinical setting.

This qualitative study was based on in-depth individual semi-structured interviews. In order to allow for comparability between participants while allowing the interviewer to explore subjects of interest, the combination approach recommended by Patton was used [21]. As such, the interview began by using a standardized open-ended approach and ended with the interviewer being free to explore any subjects of interest during the latter parts of the interview [21]. The main topic areas covered in the interview guide were: 1) the screening tools used for determining which patients would benefit from nutrition counselling, 2) approaching the topic of nutrition and providing initial advice, 3) providing dietetic referrals, and 4) understanding message reinforcement practices (i.e., reinforcing healthy eating advice over time). Questions on barriers and enablers for approaching the topic of nutrition counselling for weight management and providing a dietetic referral were also asked. The interview guide was included as an additional file (Additional file 1).

The interviewer who conducted all the interviews (SA) was a dietitian and graduate student trained in qualitative research methods. A research assistant (RA) was also present during the interview and took detailed notes of the conversation as well as other context-information. The research assistant was an undergraduate student who wanted to gain experience in research. Her presence did not affect data collection as the research study mostly included notes taken by the  interviewer (SA). Both notes were compared after the interviews for training purposes but RA notes were not used for the analysis. Interviews were recorded with each participant’s written informed consent. Interview length ranged from 30 to 50 min. In the consent form, each participant had the option of providing a member check once data analysis was complete. Seven out of 20 participants were initially interested in member checking.

The interviews were transcribed verbatim and managed using NVivo software (QSR International Pty Ltd. Version 11). Investigator triangulation was used where researchers used various angles to interpret the data [22]. Two researchers (SA and IG) analyzed the data independently and discrepancies were resolved by including the perspective of a third researcher (IB). Emerging themes were discussed with the research team to minimize bias and maintain reflexivity [23]. An integrated approach was used where the literature review informed both the interview questions and deductive codes, while inductive codes emerged from the data collected. Examples of deductive codes under the theme “barriers for approaching the topic of nutrition” included “lack of time; lack of knowledge”. Nevertheless, to avoid forcing data under predetermined codes, inductive codes were also generated based on the interviewees’ responses.

Interviews from all clinical sites were coded together to achieve the main goal of understanding nutrition care practices in multidisciplinary settings, while maximizing diversity. The inductive analysis process consisted of starting with a line-by-line coding approach. Examples of line-by-line codes included “Body Mass Index and body weight”. Once all descriptive codes were identified, similar codes were grouped under 4 main categories (i.e., screening, approaching the topic of nutrition, dietetic referrals, and reinforcing the healthy eating advice). For instance, the codes “Body Mass Index and body weight” were grouped under the category “screening”. Codes changed and developed as more interviews were conducted and as field experience was gained. Constant comparative analysis was used to group major themes, which were then refined in an iterative process. Major themes and interpretations are provided with interview quotes along with the participant’s profession and place of work. Out of the seven participants who were initially interested in a member check (i.e., verifying the way in which the data were analyzed), four participants completed the member check. There were no revisions that needed to be made.

Participants were asked about how they screened for patients who would benefit from nutrition counselling. Although a particular screening tool was not used, the following measures, markers, or questions were used to screen patients: body mass index (BMI) or body weight, general questions on food intake, blood work tests results, the presence of chronic disease, and waist circumference.

“Dietary intake is always done in the context of weight. If the patient is skinny and has a poor diet we won’t talk about it. If the person is normal weight, we will not bring it up.” FHT, FP – participant 10

Most PCPs did not use an evidence-based screening tool to screen for patients who would benefit from nutrition counselling. Rather, participants mentioned asking general questions to assess diet. As one participant stated:

“I don’t use any tools because I am always dealing with multiple issues so it’s more of a time thing. In the general assessment I ask: ‘do you eat healthy?’ and then they say yes so then I challenge them and ask ‘what is healthy?’ and then they would say ‘I eat Wendy’s instead of McDonald’s and often it’s not really what I am looking for.” FHT, FP – participant 15

Participants enumerated many instances in which the topic of nutrition would be brought up as well as how they provided initial advice. The topic of nutrition in terms of weight management was discussed during: physical examinations, when the patient was diagnosed with a chronic disease such as diabetes or hypertension, when blood work indicated hypercholesterolemia or hyperglycemia, if BMI was over 30.0 kg/m², when patients brought it up, during menopause, every medical encounter, and during pregnancy.

As mentioned by most participants, the topic of nutrition was mostly brought up during physical examinations. Participants, however, also reported that these examinations were no longer conducted annually. Episodic care is now favoured where patients receive physicals every two to three years.

“The topic is usually brought up either if they’re in for an annual physical or a problem affected by obesity like diabetes, hypertension, or sleep apnea. Physicals are now every 2 or 3 years and I am going to stop them. Most family doctors are not doing them anymore and are moving towards episodic care.” FHT, FP – participant 14

Most participants felt that nutrition was discussed more in terms of management of chronic diseases rather than prevention. Many reasons for this occurrence were identified including fear of offending patients. However, they believed that a patient’s chronic disease diagnosis justified a discussion regarding nutrition.

“Quite commonly if we’re doing chronic disease management – diabetes, hypertension, lipid control – those types of things come up very early in the conversation. Some people associate weight discussion as a negative thing, instead of something that carries them forward into a positive role for their health management.” NPLC, NP – participant 5

Blood work test results indicating elevated blood cholesterol and/or glucose concentrations, high blood pressure, and an elevated BMI were also indicators that prompted PCPs to bring up the topic of nutrition.

“It’s usually during physicals if I see that their BMI is above 30 or if their A1C is in the diabetic or pre-diabetic range or if they have dyslipidemia.” CHC, FP – participant 21

The patients also seemed to play an important role in the discussion of nutrition as some were reported to be interested in learning more about healthy diets. This was especially the case when they were diagnosed with a chronic disease.

“Obviously sometimes patients will bring it up and say that weight is an issue and will say that they have problems with good diets or what they should eat. It happens quite frequently when people have early pre-diabetes or diabetes. When they get diagnosed more often they are overweight and the first question they ask is what should I be eating.” FHT, FP – participant 10

A patient being diagnosed with a chronic disease was the most mentioned enabler for approaching the topic of nutrition, whereas lack of time was the most important barrier. The enablers and barriers for approaching the topic of nutrition and supporting quotes are provided in Table 2.

Working in a multidisciplinary clinic and having tools to communicate, such as EHRs, seemed to increase the likelihood of PCPs reinforcing healthy eating advice in follow-up visits with patients. However, this was dependent on PCPs having the time to do so.

“If I have time we talk about what the RD suggested and I’ll see her note in the file and I’ll give a bit of positive reinforcement.”

FHT, FP – participant 14

“And also, the next time I see the person I say, “How did it go with the dietitian?” And if they need a follow up on what was discussed I can look it up in the EHR and I will see that she [dietitian] also assessed their readiness to change and likeliness to make the change, so I think it’s terrific for follow-up.” CHC, NP – participant 18

Questions on the screening process showed that most PCPs used objective measures, such as BMI and out of normal range blood test markers, for assessing which patients would benefit from further nutrition counselling. Some participants also seemed to ask subjective and non-validated questions to assess diet. The topic of nutrition was mostly brought up during physical examinations, which are infrequent now due to the shift towards episodic care. Similarly, due to competing demands and lack of time, nutrition care was provided when a patient was already diagnosed with a chronic disease or when the patients specifically asked diet-related questions. As for dietetic referral practices, some participants were aware that raising awareness before referring to a dietitian was important for patient adherence to nutrition counselling. However, they did not have adequate time to provide details regarding benefits of changing eating habits before providing a referral. Many enablers for providing a dietetic referral were listed, including the RD being on site and the service being cost-free for patients at point of access. While most participants felt that there were no barriers to providing a dietetic referral, some believed that the wait time to see the RD was an issue. PCPs felt that initiating nutrition counselling is time-sensitive and has to be done when patients are motivated. As such, some PCPs initiated the nutrition counselling themselves due to wait times. PCPs seemed to reinforce healthy eating advice in follow-up visits if time permitted. Reinforcing the dietitian’s message was facilitated with EHRs as PCPs were aware of what was discussed in nutrition counselling sessions.

Although current screening practices are aligned with the recommended guidelines on the prevention and management of obesity (e.g., BMI and blood markers) [2], it can raise an issue when thinking of screening for nutrition-related diseases that are not linked to excess weight. Some PCPs mentioned that utilizing screening tools to assess diet might not be feasible due to time constraints. Some were unsure which time-effective and evidence-based questions to ask their patients for assessing their diet. As most PCPs seemed to ask subjective questions, it is important to increase awareness about validated tools such as the Rapid Eating Assessment for Patients (REAP). REAP has been suggested as a tool for health professionals to quickly assess who would benefit from further nutrition counselling [24, 25].

Since most participants mentioned that the topic of nutrition was discussed during physical examinations, the move towards episodic care may decrease health promotion opportunities in primary care. Expecting patients to initiate the topic of nutrition may be an issue if patients are unaware of the consequences of a poor diet and its link to chronic diseases. Moreover, patients have expectations from the primary care provider to ask about weight and to address their concerns by suggesting appropriate measures [26, 27]. Approaching the topic of nutrition only when patients were diagnosed with a chronic disease has been shown in this study and in the literature [28‐30]. It also seemed that the discussion was more likely to occur as BMI increased, which is in line with previous findings [27, 31].

In contrast to what is suggested in the literature [32], some participants felt that raising awareness before referring patients to a dietitian had no influence on patient adherence to nutrition counselling. This may be due to the fact that some patients may already know the benefits of managing their weight but are unable to do so given the complexity of the condition and personal circumstances [26]. As highlighted in other studies, participating PCPs were more likely to bring up the topic if they had access to a free on-site dietetic referral option [15, 28]. As such, multidisciplinary clinics seemed to mitigate the barriers highlighted by PCPs working in non-multidisciplinary settings, and enabled PCPs to assist their patients with weight management [27, 33‐35]. Wait times and lack of accessibility were also highlighted in previous studies [36, 37]. PCPs not thinking about the referral, patients not buying in, patients’ negative perception of the RD session, and patients not wanting to come in were other barriers mentioned by PCPs. Some of these factors were also highlighted in previous studies [14, 38]. In contrast with previous international findings, none of these barriers included PCPs’ unwillingness to collaborate with other health professionals [39].

After consulting the dietitian and setting out individualized goals, it is recommended that PCPs reinforce these goals in follow-up visits [7, 40]. Given the importance that patients attribute to their PCP’s recommendations, it may help patients adhere to the nutrition care plan [41]. Having a dietitian on site and communication tools such as EHRs facilitated message reinforcement in follow-up visits. Studies have shown that not having a RD on site hinders communication, and in turn, prevents message reinforcement, [36, 37, 42] highlighting the importance of having support from allied health professionals to provide optimal care for obesity management [42, 43]. Although EHRs are perceived to play a role of a messenger [44], this study shows that message reinforcement occurs when PCPs have sufficient time during medical visits.

This study provides important insights on how PCPs working in relatively new multidisciplinary primary care settings provide nutrition care to adult patients with obesity. Understanding how PCPs address nutrition and elucidating the enablers and barriers for providing nutrition care is crucial to inform the optimization of chronic disease prevention and management. Although the sample size may seem small, it did allow the researchers to reach data saturation indicating that future interviews may not have revealed new information. Moreover, the inclusion of different types of primary care settings allowed for diversity. Findings from this study can be transferred to other similar settings.

This study has some limitations. Although we tried to reach diversity in terms of gender, the sample mostly consisted of females. This may limit applicability to males as research has shown a difference in clinical practice based on gender. As well, this study only included multidisciplinary settings where primary care providers had access to other health professionals. Findings from this study may not be transferred to PCPs working in non-multidisciplinary based clinics.