Background
Methods
Settings and participants
Data collection
Data analysis
Results
Profession | n |
Family physicians | 7 |
Nurse Practitioners | 13 |
Experience in profession (years) | n |
≤ 5 | 6 |
6–15 | 9 |
15–25 | 2 |
≥ 25 | 3 |
Self-identified gender | n |
Female | 16 |
Male | 4 |
Experience in organization (years) | n |
≤ 1 | 2 |
2–5 | 8 |
6–10 | 7 |
≥ 11 | 3 |
Screening
“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
“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
Approaching the topic of nutrition
“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
“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
“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
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.“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
Key enablers | Examples of quotes from primary care providers |
Chronic disease diagnosis | “Sadly, when people have a chronic illness, it is much easier to talk about nutrition. I find the blood pressure helps, if there is an increase; I talk about weight, diet, and exercise.” CHC, NP – participant 20 |
Patients showing interest | “I would say a lot of times patients actually bring up the topic if I am talking to them about their cholesterol, they will ask what they can do that is not medication. If I am talking about diabetes or cholesterol, I let them know about the non-medical management, which is obviously the preferred route because there are no side effects as opposed to medications that have side effects.” CHC, FP– participant 17 |
Dietitian on site | “If somebody is coming in and they are here for a prescription renewal, it’s hard to focus time but because I do have the option to refer them to the dietitian, it’s a huge help.” NPLC, NP – participant 1 |
Out of normal range blood test markers | “If cholesterol is elevated, glucose is elevated, fatty liver based on lab results, regardless of the age of the person. If none of these issues are there, it is possible that I would not bring it up.” NPLC, FP – participant 9 |
Having access to handouts | “I like handouts because sometimes I know they are not necessarily listening and taking in the information as I am giving them. Let’s say their blood pressure is out of whack and they don’t want to come back to see the dietitian, I will print out the handout.” NPLC, NP – participant 1 |
Trusting relationship with the patient | “A trusting relationship between the health professional and the patient is number one.” CHC, NP – participant 19 |
The whole family has obesity | “When more than one family member has obesity, it is easier to bring up the topic of nutrition.” FHT, NP – participant 12 |
Key barriers | Examples of quotes from primary care providers |
Lack of time | “Time consuming and we only have 15-min appointments so sometimes there is no time.” FHT, NP - participant 14 |
Patients not open to discussing it | “There are many clients who don’t want to hear about it. They’re unstably housed, they’re in abusive relationships, they have a lot of priorities and talking about nutrition and weight management is not among them.” CHC, NP – participant 18 |
Lack of rapport with the client | “Sometimes it’s the rapport. Some patients don’t care to interact.” NPLC, NP – participant 1 |
Competing demands | “They just have so many complex issues, mostly psychosocial issues that are predominant in their daily lives that nutrition is not something I can bring up.” CHC, NP – participant 19 |
Patient perceiving they already know what they need to change | “Some patients will say: yeah yeah, I’ve been told all this before, I know what to do, I just need to do it.” NPLC, NP – Participant 3 |
Low comfort level of provider to address nutrition | “Some providers may not be as comfortable because they think it is a sensitive topic but really if you just open a dialogue about it often times it will be OK to talk about it (nutrition).” NPLC, NP – Participant 2 |
Patients not understanding the implications of excess body weight | “I think that some patients may not understand some of the health consequences that could occur due to excess weight and unhealthy lifestyle behaviours” NPLC, NP – Participant 7 |
Dietetic referrals
Approaching the dietetic referral
“Explaining in more detail why the referral is being made and how important it is in disease management and prevention and explain that lifestyle changes can really affect a lot of organs and multiple diseases.” FHT, FP – participant 15
“If I think that their diabetes is out of control because of their weight I will explain that this is getting out of control because no matter what we give you {medication}, you’re intake is going to super exceed that. … We talk about the complications. … So I think it’s general counselling on what the weight is doing to their health.” FHT, FP – participant 10
“I actually changed my technique when it comes to referring to the RD. If I give them the option, more often they are going to decline. I’ve actually changed how I bring it up. I say: I would like you to see the RD, I think she would be able to give you some good advice, I think she can give a good assessment of how your diet could be affecting your weight, cholesterol, blood pressure.” NPLC, NP – participant 1
“I feel that they understand the importance over time. So if they are coming in for back pain, and then another time for knee pain, or trouble sleeping. When they start complaining about different things then I can kind of rule out everything else and come back on the topic of nutrition and their weight. Sometimes the light goes off and they say: oh really, I didn’t realize it was that important, I didn’t realize how many aspects of my mental wellness or physical wellness that are contributed to that (nutrition and diet).” CHC, NP – participant 19
Instances in which a dietetic referral was provided
Themes | Examples of quotes from primary care providers |
---|---|
Patient asking for the dietetic referral | “If they are asking about weight loss I would then tell them that we have a RD for some counselling regarding weight.” CHC, NP – participant 20 |
Patient was diagnosed with a chronic disease | “So any new diagnosis I automatically refer to the dietitian. For example, any of the triad of cardiac disease, renal failure disease, diabetes, the lipids; those types of patients I refer.” NPLC, NP – participant 5 “There are only one and a half FTE {Full Time Equivalent} RDs so you want to prioritize people and so secondary and tertiary prevention usually takes a hold. Patients are more motivated when they’re sick and in medicine we don’t value prevention as much.” FHT, FP – participant 10 |
Patient showing motivation or readiness to change | “Their readiness to change. I don’t go on weight or BMI. It is their readiness. It is the same as smoking; I would never refer for smoking cessation if they are not ready. I bring up the topic but then they have to bring it back up to me and show me that they are ready and committed and want to change. If not the failure rates are close to 100%.” FHT, FP – participant 15 |
Patient was at risk of developing a chronic disease | “I refer for weight management when it’s related to a medical problem or when they are at risk for a disease to develop” CHC, FP – participant 17 |
Patient with an elevated BMI | “Everyone that has an elevated BMI, or that come in specifically asking to see the dietitian.” NPLC, NP – participant 4 |
Patient experiencing pain related to obesity | “For people that are obese, it is something I will bring up, like those pain patients.” NPLC, NP – participant 1 |
Key enablers | Examples of quotes from primary care providers |
---|---|
Increasing access to a dietitian | “It’s very easy here to make a referral since we have a dietitian on site and she is pretty quick to see patients.” FHT, NP – Participant 12 “Access. How quickly they can be seen – not just location access, but also even how quickly they can get on the bandwagon. I find that sometimes if there are long delays – it wears off by the time they get in. Whereas if we have one (dietitian) on site and access is quick, I find it’s received well because of that.” NPLC, NP – participant 5 |
Increasing patient comfort | “Well it’s on site and it’s not a new environment where they have to meet strangers.” NPLC, NP – participant 6 |
Cost-free dietitian service at point of care | “They (dietitians) are in the building and it is free for the patient.” FHT, FP – Participant 15 |
Flexible schedule | “Being on site, free of charge, offered in the evenings so more availability for people working” FHT, FP – participant 14 |
Having a relationship with the dietitian | “Having a relationship with the dietitian. The more you know their abilities. I know the dietitian here is brilliant and I know that she is located in the clinic so that helps me sell it to the patient rather than saying ‘you might get an appointment in 3 months across the city’.” FHT, NP – participant 11 |
Key barriers | Examples of quotes from primary care providers |
None | “None here but in general it would be cost and transportation, but they are already in to see us, we are ground floor, parking is free, easy access, senior access, wheelchair access. We worked hard to bring down the barriers.” FHT, FP – participant 15 |
Wait times | “The wait time is 2 weeks so that is sometimes not soon enough because it gives patients time to change their mind but I think it is still good.” CHC, NP – participant 19 |
Not thinking about making a dietetic referral | “Not thinking of it or making assumptions that the patient would not be interested. But it would still be good to offer it.” NPLC, FP – participant 9 |
Patient not buying in | “Barriers include patient factors such as patients not buying in.” CHC, FP – participant 21 |
Patients’ negative perception of the session with the dietitian | “The lecture that people think they’re going to get and the shame element about being overweight.” NPLC, NP – participant 6 |
Requires the patient to come in again | “It would require another appointment.” NPLC, NP – participant 4 |
Patients not showing interest | “Some people just aren’t interested; they have hang-ups around weight and dieting and don’t want to talk about it.” CHC, NP – Participant 18 |
Patients’ lack of time | “Those are typically the working group, that their time is fairly limited with family and work so they want a quick in and out, give me the information and I will do the work.” CHC, NP – Participant 19 |
Reinforcing the healthy eating advice
“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