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1 From the Sardenya Primary Care Center, Barcelona, Spain (CB); La Mina Primary Care Center, Sant Adrià del Besós, Spain (RC); Cangas Primary Care Center, Pontevedra, Spain (RP); Las Calesas Primary Care Center, Madrid (PK); the Medical University of Lodz, Lodz, Poland (MG-C); and the Department of Family Medicine, University of Malta, Malta (MRS).
2 Presented at the Third Heelsum International Workshop, held in Heelsum, the Netherlands, December 10–12, 2001.
3 Supported by a grant from the Programme of Prevention and Health Promotion of the Spanish Society of Family and Community Medicine.
4 Reprints not available. Address correspondence to Carlos Brotons, Sardenya Primary Care Center, C/Sardenya 466, 08025 Barcelona, Spain. E-mail: cbrotons{at}eapsardenya.net.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Objective: The objective was to assess GPs’ knowledge and attitudes in implementing preventive and health promotion activities and to describe tools used by European GPs in advising patients about dietary practices.
Design: A postal survey was mailed to 1976 GPs from 10 GP national colleges to obtain information about beliefs and attitudes in prevention and health promotion, and an e-mail survey was sent to 15 GPs representing national colleges to obtain information about dietary guidelines.
Results: In the postal survey, 45% of GPs reported estimating body mass in clinical practice, and 60% reported advising overweight patients to lose weight. Fifty-eight percent answered that they felt minimally effective or ineffective in helping patients achieve or maintain normal weight.
In the e-mail survey, only 4 colleges out of 15 reported that they had published their own dietary tools, although 10 out of 15 answered that GPs use some nutritional/dietary recommendations in the office when seeing patients. Eleven out of 15 answered that both the nurse and the GP advise patients about dietary practices, with 4 answering that GPs were the only ones who advise patients. Only 5 delegates answered that they can refer their patients to trained nutrition specialists.
Conclusions: GPs think that obesity is not easy to handle in practice. Most GPs have dietary tools in the office and think that nurses play an important role in advising patients.
Key Words: Dietary tools • obesity • general practitioners • Europe
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The objective of this study undertaken by EUROPREV was, first, to assess the knowledge and attitudes of European GPs in implementing preventive and health promotion activities in primary care as part of another project, particularly in advising overweight and sedentary patients, and second, to describe the tools used by GPs in advising patients about dietary practices.
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SUBJECTS AND METHODS |
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The first survey was carried out by mail from June to December 2000, using a prepaid addressed envelope. A pretested questionnaire was developed that included the following parts: (1) demographic and professional data (10 questions); (2) 2 clinical scenarios with a list of different preventive and health promotion activities and 2 different columns for responses—beliefs and attitudes in practice (34 questions); (3) items related to barriers to implementing preventive activities (6 questions); and (4) items concerning personal health behavior (21 for GP males and 25 for GP females). The questionnaire was translated and adapted from English into the different national languages, being piloted by 10 GPs in each country. A random sample of GPs was selected from databases that listed GPs from national colleges of each country.
With an estimated true proportion of 0.5 (the most conservative estimate), the maximum acceptable difference of 0.05, and an alpha error of 0.05, the required sample size was calculated per country according to the number of GPs affiliated with each college. Assuming a minimum rate of participation of 50%, sample size was increased to compensate for anticipated loss. This was done by multiplying the sample size by the quantity 1/(1 - d), where d is the anticipated loss. In some countries, such as Malta, the questionnaire was sent to all the physicians, because of the reduced number of GPs listed.
The second survey was done from June to September 2001. A short questionnaire of 5 questions was sent out to 28 EUROPREV delegates by e-mail, with the objective of obtaining information about nutritional/dietary tools recommended by national colleges, about advising and using special written dietary recommendations in practice, and about referring patients to specialists.
All collected questionnaires were sent back to the coordinating and data management center at the EUROPREV secretariat, ensuring a centralized data entry and analysis by one research technician specifically employed for this project. Statistical methods were limited to the computation of means and standard deviations for continuous variables, percentages for categorical variables, and comparisons for categorical variables using chi-square at the 0.05 level of significance. All the analyses were done using the Stata program (version 5.0; Stata Corporation, College Station, TX).
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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. The 2 clinical scenarios are illustrated in Figure 1. The results of the questions related to the estimation of body mass index (BMI), the advice to lose weight and to obtain physical exercise, and the measurement of serum cholesterol, asking, first, if GPs believe it should be done, and, second, if GPs do it in practice are shown in Table 2. Fifty-six percent of GPs answered that the implementation of prevention and health promotion activities is difficult, 58% answered that they felt minimally effective or ineffective in helping patients achieve or maintain normal weight, and 53% answered that they felt minimally effective or ineffective in helping patients practice regular physical exercise.
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Fifteen EUROPREV delegates representing the GP national colleges of Austria, Croatia, Georgia, Greece, Ireland, Malta, the Netherlands, Poland, Portugal, Russia, Slovakia, Slovenia, Spain, Switzerland, and the United Kingdom answered the e-mail questionnaire.
Four colleges recommend their own dietary or nutritional tools, although none of them were specific nutrition/dietary guidelines; instead, they were integrated into other condition guidelines such as hypertension, diabetes, and dyslipidemia. Nevertheless, 10 delegates out of 15 answered that GPs use some nutritional/dietary recommendations in the office when seeing patients, and when asked who does this, 4 answered the GPs themselves, and 11 answered both the nurse and the GP. Ten delegates out of 15 answered that they provide their patients with special written dietary recommendations (eg, a diet that contains1500 kcal per day, or 2000 kcal per day). Only 5 delegates answered that they can refer their patients to trained nutrition specialists, with the major reason why they cannot do this being the absence of reimbursement.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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60% of patients, but in practice they do it in only 45% of patients. Asked about advising overweight patients to lose weight, GPs believe this activity should be done in 85% of patients, but again, this percentage falls in practice to 60% of patients. This also happens with the other 2 activities advised (increasing physical exercise and quitting smoking), and it is not so clear with the measurement of total cholesterol, perhaps reflecting the fact that GPs would rather order tests than give verbal advice. Other studies that evaluated preventive services in routine general practice have shown similar results to ours, and when primary care physicians were asked if weight was checked, 42% answered that they did this activity in practice (4). These results illustrate that some GPs may think that measuring weight, height, and BMI is a waste of time, because overweight and obese patients may be the worst group of patients on whom to test the success of dietary advice. Also, resources in primary care are limited, and if a GP or a nurse spends 5 min of a 10-min consultation on dietary advice, this will result in 5 min less to spend on the rest of the consultation.
We observed that more than half of the GPs were skeptical about helping patients achieve or maintain normal weight. Other surveys have shown similar results, with, for instance, in Canada (5) 48% of primary care physicians believing that dietary change has little effect and more than half stating that interventions for obesity have limited effect (after adequate training and support). In the United Kingdom, another study (6) showed that 50% of GPs felt potentially effective (after adequate training and support) in helping patients avoid excess calories, although only 20% felt currently effective.
Our network of GPs’ colleges also has the possibility to obtain and share useful information from national colleges of GPs enrolled in EUROPREV and compare not only organizational health services but also guides and tools used for prevention and health promotion in clinical practice. Although we studied European GPs, the results do not represent all countries of Europe, and therefore we would welcome information from additional national colleges.
It is clear from our results that most of the national colleges do not have their own dietary/nutritional tools; however, they usually use recommendations developed by other institutions and provide the patients with specially written information. This fact is important because previous studies have shown that, in 16% of presenting episodes of illness, nutritional guidelines must be considered as an essential part of treatment (7). Also, our results indicate that nurses play an important role in advising patients about desirable dietary practices. However, when GPs and nurses do not have the time, knowledge, or skills to advise their patients, it is not easy to refer them to a professional qualified in nutrition for more detailed dietary counseling because referral to dietitians is usually not covered by medical insurance. Surveys such as this are in large part based on self-reporting by GPs and reflect what GPs think they do or should do. More objective evidence (eg, chart audits) is needed to see what GPs actually do; for this reason, it is crucial that GPs systematically record most relevant preventive and health promotion activities.
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ACKNOWLEDGMENTS |
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The EUROPREV network includes the following individuals and institutions (which participated in this study): Celia Björkelund (The Swedish Association of General Practice), Carlos Brotons, Ramon Ciurana, Pilar Kloppe, Rosa Piñeiro (Spanish Society of Family and Community Medicine), Eva Jurgova (Slovak Society of General Practice), Mateja Bulc (Slovenian Medical Association), Artur Mierzecki, Maciek Godycki-Cwirko (The College of Family Physicians in Poland), Liivia Pullerits (Estonian Family Doctors Association), Jasna Vuchak (Croatian Association of Family Physicians), Mario R Sammut (Malta College of Family Doctors), Mary Sheehan (Irish College of General Practitioners), Revaz Tataradze (Georgia Association of General Practitioners and Family Physicians), Ton Drenthen (Dutch College of General Practioners), Godfrey Fowler (Royal College of General Practitioners), Elena V Frolova (St-Petersburg Medical Academy of Postgraduate Study), Christos Lionis, Lefteris A Thireos (Greek Association of General Practitioners), Carlos Martins (Portuguese Association of General Practitioners), Ingrid Pichler (Austrian Society of General Practice and Family Medicine), and Maxime Mancini (Swiss Association of General Practitioners).
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This article has been cited by other articles:
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  A S. Truswell, G. J Hiddink, and J. Blom Nutrition guidance by family doctors in a changing world: problems, opportunities, and future possibilities Am. J. Clinical Nutrition, April 1, 2003; 77(4): 1089S - 1092. [Abstract] [Full Text] [PDF]
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