This post is by Claire Nichols, Co-founder of Kalix and Accredited Practising Dietitian. These are my personal thoughts about the article “Doubt over dietitian referrals for diabetes”. In Australia, over the last few weeks there has been much discussion about the effectiveness of Medicare-subsidised dietetic services (EPC plans) for Type 2 Diabetic patients. This came about after the publication of an article in the Australian Doctor titled “Doubt over dietitian referrals for diabetes”
It’s sad dietitians need to defend their role in the management of diabetes patients. Other than IDNT online, I do some private practice work and the vast majority of my patients are Type 2 Diabetics on EPC plans. From my personal experience, these patients have complex nutrition issues with many social, environmental, behavioural and economic influences. The 1-5 appointments (2 is my average) allowed on a EPC plan, is no where near enough. Sure, there is time to provide a bit of nutrition education, set some goals then review their progress. But to equip these patients with the knowledge and skills they need to make and then maintain nutrition related behaviour change long term, many more appointments are required.
But do I think I ‘m not effective as a dietitian? No, of course not. I know I am effective! But does everyone else know this? No, maybe not. The Australian study by Ball et al (2013) examined 38 individuals’ with chronic diseases (or high risk of) preferences for receiving nutrition care. General practitioners were the preferred provider of nutrition care (n=21) not dietitians! GPs were thought to give the “most trustworthy and personalised nutrition care'” as they had “the most detailed understanding of participants’ medical conditions.” Dietitians were second (n= 12) but there was confusion about the differences between dietitians and nutritionists. Dietitians were also perceived by some be overly strict, some participants “…referred to dietitians as health professionals that ‘punish’ individuals through restrictive eating, and also use negative counselling styles.” We all know that ‘food nazi’ stereotype.
Doubt over dietitian referrals for diabetes
The author of the offending article, a medical journalist called Michael Woodhead, based his piece on a research paper by Spencer et al (2013) published in the Australian Journal of Primary Health. The paper is titled “Attendance, weight and waist circumference outcomes of patients with type 2 diabetes receiving Medicare-subsidised dietetic services” and briefly, it is a prospective observational study conducted over a 9 month period in 2011. Three private practice dietitians in Queensland were involved. The participants in the study were 129 Type 2 Diabetes referred to the dietitans on EPC plans. Mr Woodhead argues that because most of the participants failed to achieve 5% loss of body weight over an average of 2 appointments, the benefits of attending the appointments were “limited.” The other point he makes is, the non-attendance rate was high (29%), and “high rates of non-attendance have the potential to cost several hundred million dollars per year.” Yes, GPs receive money for developing EPC plans, but I am yet to receive a Medicare payment for seeing a patient after they fail to attend.
So, patients never fail to attend GP appointments? No, of course not, non-attendance is a major issue for everyone in healthcare. A systematic review found the non-attendance rate in US primary care ranged from 5 to 55% (George & Rubin 2003). An Australian randomised controlled trial comparing the different methods for following up diabetic patients, had a 65% drop out rate for GP care (the drop out rate for clinic care was 47% and 28% for shared care) (Hoskins et al 1993).
The benefits of dietetic care
I also disagree with Mr Woodhead’s first point, that the benefits of dietetic care to participants were “limited”. Five out of the 51 participants (9.8%) who returned for review appointments and had their weight remeasured (60 returned within the study period but 9 did not have their weight remeasured) lost greater than 5% of body weight. That’s a great result! Overall the average amount of weight loss between first and last appointment was 1.9 +/-2.9 kg. Participants who attended more than two consultations lost significantly more weight than those who attended two only (3.7 +/-4.2kg vs -1.1+/-1.6 kg, respectively). Unfortunately the study did not report blood glucose measures, HbA1c, blood lipids or blood pressure measurements, so it is unknown whether the participants achieved metabolic improvements. In another study, participants (Type 2 Diabetics on diabetic medication with HbA1c >7% and at least 2 co-morbidities) undergoing dietetic intervention achieved significant improvements in glycaemic control despite the amount of weight loss equalling less than 5%. The group on average lost only 2.4kg over a 6 month period, but achieved a significant reduction in HbA1c (0.5%) compared to no change in the control group (diabetic medication only) (Coppell et al 2010). So sure, Spencer et al (2013) should have recorded glucose levels, HbA1c, blood pressure etc. But you have to remember, EPC appointments are often only 20 minutes long, it’s very hard, if not impossible to review patients’ goals, answer questions, provide education and take all these measurements within the time frame. Also, accessing reliable patient data in a private setting is difficult! As a dietitian, I cannot order blood tests. Yes, I can ask the patient’s GP nicely to order tests. It does not mean I receive a copy. Any results received are often self reported by patients. The likelihood that they are reported incorrectly is high. Also I don’t know how many times I have heard “oh I’m sorry I forgot my glucose monitoring book.”
Dietitans are effective
My interpretations of the findings of Spencer et al (2013) research is- Dietitans are effective. If patients were give more appointments with us, we would be even more effective! While, Mr Woodhead’s article may be damaging short-term, the silver lining is-We are now talking about how we can do things better! We are talking about how we can include more research in private practice and how we can align research and the needs of dietitians in private practice better. That’s fantastic!
Ball, L., Desbrow, B., Leveritt, M. (2013), An exploration of individuals’ preferences for nutrition care from Australian primary care health professionals, Australian Journal of Primary Health, [Online]
Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM and Mann J (2010), Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment- Lifestyle Over and Above Drugs in Diabetes Study (LOADD): randomised controlled trial BMJ: 341:c3337.
George A and Rubin G (2003), Non-attendance in general practice: a systematic review and its implications for access to primary health care. Family Practice; 20: 178–184.
Hoskins, P.L., Fowler, P.M., Constantino, M., Forrest, J., Yue, D.K. and Turtle, J.R. (1993), Sharing the Care of Diabetic Patients between Hospital and General Practitioners: Does it Work?. Diabetic Medicine, 10: 81–86.
Spencer L, O’Shea M-C, Ball L, Desbrow B and Leveritt M (2013), Attendance, weight, waist circumference outcomes of patients with type 2 diabetes receiving Medicare-subsidised dietetic services, Australian Journal of Primary Health [Online].
Woodhead, Michael (2013), Doubt over dietitian referrals for diabetes, Australian Doctor, https://www.australiandoctor.com.au/news/latest-news/doubt-over-dietitian-referrals-for-diabetes [contact-form]