Nutrition care of older adults with chronic disease: attitudes and practices of physicians and patients.

Objectives: Eighty percent of older adults have at least one chronic disease. Most conditions could be improved with nutritional intervention. This scientific study assessed physician and patient knowledge of, and behaviors about nutrition, resulting in tools to guide physicians in nutrition management of chronic diseases.

Methods: Surveys were conducted of 300 practicing physicians and 600 older adults to identify current attitudes and practices regarding the role of nutrition in chronic disease management.

Results: Ninety percent of physicians surveyed recognize the relationship between nutrition and chronic disease. Yet nutrition care occurs only sporadically in primary care settings.

Conclusions: Most physicians are aware of nutrition in managing chronic disease, but a significant percentage do not routinely include nutrition in their practice. This research led to the development of tools to assist in identifying and managing the nutritional aspects of chronic disease.

Key Words: chronic disease, elderly, nutrition

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The purpose of this study was to identify current physician and patient knowledge and practices regarding nutrition's role in chronic disease management and the extent to which nutritional screening and intervention are implemented in medical practice. Our hypothesis was that although physicians recognize the importance of nutritional guidance for their elderly patients, they often lack a practical, office-based approach to the delivery of nutrition services. The role of nutrition in chronic disease incidence and management is well documented (1-9) as critical in the care of the elderly, and thus will not be extensively addressed in this article.

Separate nationwide surveys of both primary care physicians (October 2000) and older patients (November 2001) were conducted to evaluate current patient and physician awareness and behaviors regarding nutrition and chronic disease. The research was conducted by the Nutrition Screening Initiative (NSI), a multidisciplinary, multiorganizational partnership led by the American Academy of Family Physicians and the American Dietetic Association.

NSI commissioned the research to ascertain the attitudes, beliefs, and practices of both physicians and patients related to nutrition in chronic disease management in the elderly. Physicians were surveyed to 1) assess physician awareness of the role of nutrition in chronic disease management; 2) identify physician ability to use their nutrition knowledge in caring for older adult patients; and 3) determine mechanisms that would facilitate the incorporation of nutritional screening and intervention into practice. The patient population was tested to assess the following: 1) awareness of the role of nutrition in the incidence and management of chronic diseases; and 2) attitudes and practices regarding dietary modifications to improve their health.

Our review of the literature revealed a disconnect between the verbal commitment of physicians to the importance of nutrition in preventing and managing chronic diseases and their actual ability to provide nutritional evaluation and intervention in practice. Routine screening of nutritional status to identify those at increased risk, and intervention to optimize nutritional status and quality of life are urgent and growing needs in today's healthcare environment. Currently, approximately 12% of the US population is 65 years of age or older, but by the year 2030, the number of older adults is expected to double. (1) The incidence of chronic disease increases as age advances. Eighty percent of seniors have one chronic disease, and 50% have two or more. Of those with chronic diseases, 90% have a condition that could improve with nutritional intervention. (2)

The leading causes of death among seniors 65 years of age and older are heart disease, cancer, and stroke, with hypertension affecting one-third and diabetes 11% of people aged 70 years and older. The relationship between nutrition and both the prevention and treatment of these diseases is well documented and plays an important role in providing best practice. (3-9)

Traditionally neglected in the management of chronic disease, nutritional screening and intervention in the elderly have been shown to be cost-effective. (3,8) Frequently cited barriers in physician utilization and provision of nutrition services for patients include the lack of time with patients, the lack of patient interest, and the lack of professional training, particularly as it relates to counseling-based interventions. (10) Medical school curricula are packed with essential courses and training requirements, relegating nutrition to the "back-of-the-knowledge-bus." Twenty-eight percent to 30% of medical schools state they have a required nutrition course, but the length of the course varies from 1 hour to a full semester. The nature, content, and quality of nutrition education in medical schools and residency programs is highly variable and depends on the intent and expertise of the faculty and staff designated to provide that portion of the curriculum. (11) Once physicians begin practicing, they may recognize the need for nutritional screening and management of chronic conditions, but they lack the skills and the tools needed to incorporate this critical component of patient care efficiently and comprehensively into an office practice.

Materials and Methods

Study Organization and Design

In conjunction with the authors and NSI. The Mellman Group, a market research firm, was retained to assist in the design and administration of qualitative and quantitative research instruments.

The physician survey and focus group questions centered on chronic disease management and were instrumental in determining the appearance and content of the physician and patient education materials (Table 1). Survey and focus group questions for older adults were formulated to gauge public opinion regarding the link between nutrition and chronic disease management, and to identify preferred nutrition resources. The authors, NSI, and The Mellman Group had full access to all study data, and take responsibility for the integrity of the data and the accuracy of data interpretation (The Mellman Group, Inc., unpublished data, NSI: Washington, DC. August-November, 2000; July-November, 2001).

Physician Study Population

Nationwide telephone interviews were conducted with 300 randomly selected primary care physicians (150 family physicians, 75 general internists, and 75 geriatricians) between October and November 2000. Only data from physicians reporting a patient load of a minimum of 20 patients 65 years of age or older per week were included.

The study group of 300 physicians reported here was drawn from a population of 23,382 family physicians, 2,044 geriatricians, and 21,941 internists by random selection. Using these lists, roughly 1,000 calls connected with the identified physician or someone who could arrange a scheduled interview with the physician. Approximately 20 to 25% of those called did not meet the minimum patient care criteria of seeing 20 patients 65 years and older per week, and 40 to 50% of those called refused to participate. From these contacts, a total study group of 300 physicians was gathered who met the practice composition criteria and agreed to voluntarily participate in the study. To counter selection bias based on availability, interviews were scheduled by appointments where possible, and multiple attempts were made to reach each potential respondent.

Small focus groups of physicians were used to tailor the content of the questions in the survey and to provide qualitative data for the development of professional and patient education materials. Two focus groups of eight physicians each were conducted in Baltimore, MD during August 2000. Each group consisted of randomly selected physicians who met the patient caseload criteria listed above. One group consisted of physicians 45 years of age and younger, the second group, physicians older than 45 years of age.

Patient Study Population

Nationwide telephone interviews of 600 randomly selected, free-living Americans aged 60 years and older were conducted during November 2001. The study group of 600 older adults reported here was drawn from the general population using computer-generated random digit dialing. From these phone numbers, 3,500 calls connected with a person at the listed household. Approximately 35% refused to participate and 45% of those called did not meet the age criteria, rates which were consistent with national surveys at that time by The Mellman Group and others showing roughly 28% of the population to be 60 years and older. Names were called until a total study group of 600 older adults who agreed to voluntarily participate in the study was gathered. To counter selection bias based on availability, multiple attempts were made to reach each potential respondent.

Before the phone survey, two focus groups, each consisting of 12 people randomly selected from a national database, aged 65 years and older, were conducted in Baltimore, MD during July 2001. The purpose of the focus groups was to facilitate the development of a survey instrument and to obtain preliminary information regarding the content and format of physician-provided consumer education materials to address the nutrition management of selected chronic disease states common in older adults. One group included older individuals with or without chronic diseases. The second group included older adults with chronic disease and older caregivers.

Analytical Methods

As determined by sampling error and confidence intervals calculated under the standard assumption of normally distributed error, the margin of error for the physician survey sample as a whole is [+ or -]5.7% at the 95% confidence level. The margin of error for the older American survey population as a whole is [+ or -]3.5% at the 95% confidence level. The margin of error is higher in both the physician and older American subgroups. Focus group research cannot be projected to any larger group of individuals and should be considered as a qualitative reference.

Results

Physician Survey

Participating primary care physicians saw a median number of 50 (mean 63) patients age 65 and older per week, constituting a median of 59% (mean 58%) of their total practice. Seventy-eight percent of survey respondents were men.

The majority of surveyed physicians responded that nutrition plays either a "most important" (21%) or "major" (73%) role, in treating and managing illness and disease in the elderly (Fig. 1). The role of nutrition in preventing illness and disease in the elderly was reported as "most important" (26%) and "major" (70%)--rates similar to those regarding treatment and management.

Discussion about nutrition and diet occurred with varying frequency during routine visits between doctors and elderly patients and was not as common (or as important, as reported to surveyors) as other topics including current medications, the patient's chronic medical conditions, and complaints of aches and pains (Fig. 2). Medication management was reported as the primary issue in care management, most often determining the frequency of visits to the doctor.

To gain a more comprehensive understanding of a discussion between patients and physicians, we asked physicians for the most common nutrition questions asked by elderly patients. Vitamin and mineral supplements led the list (Fig. 3), followed by general diet questions and specific dietary content questions, eg, salt, sugar, and cholesterol.

Overall, 91% of physicians surveyed believe that scientific evidence supports an important role for nutrition in the treatment and management of chronic disease in the elderly. The connection between dietary interventions and specific diseases was greatest when diet played an obvious treatment role, eg, diabetes (98%), obesity (93%), osteoporosis (82%), and coronary heart disease (79%). An association with nutrition was not made as frequently by physicians assessing its use in the treatment and management of cancer (44%), chronic obstructive pulmonary disease (43%), dementia (34%), and pneumonia (25%). However, 95% of surveyed physicians believe that nutritional intervention was their responsibility.

Not all surveyed physicians regularly use dietitians in the care of their chronically ill older patients. Forty-six percent say they consult with a dietitian "all" (11%) or "most of the time" (35%), whereas 52% indicate that they use a dietitian much less frequently. Physicians (especially geriatricians) who have a larger older adult practice and those who have been in practice longer tend to use dietitians more frequently. The primary reasons mentioned for referring patients to a dietitian were for diabetes control (33%), for improving diet (14%), and for skilled help with underweight or overweight patients, as well as patient education (7-8% each).

[FIGURE 2 OMITTED]

Patient Survey

Surveyed older adults believe that nutrition is either very important (80%) or somewhat important (16%) in the management of their chronic disease. However, most often they depend on methods of treatment other than nutrition, eg, medication (81%) and exercise/activity (80%), to manage their chronic disease (Fig. 4). Older adults rely on information from their physician (80%), pharmacist (56%), health-related organization (48%), and dietitian (46%) most frequently when seeking nutritional guidance. They enter the physician-patient relationship with the strong expectation that their interest in obtaining nutritional information will be met. However, when asked about the frequency of nutritional guidance they actually receive from their doctor, 36% indicated "on a regular basis," 28% reported "only every now and then," and 27% reported either "seldom" or "never" (Fig. 5). The regularity of nutrition emphasis and advice dramatically jumps to 45 to 50% when applied to specific disease entities such as diabetes or osteoporosis.

Eighty-five percent of those surveyed stated they would "likely" (52%) or "somewhat likely" (33%) use a short, easyto-understand guide regarding nutritional care if provided by their physician. Surveyed seniors reported using nutrition more frequently to manage certain chronic diseases, eg, cancer (72%), dementia (79%), and hypertension (63%). It is noteworthy that although patients use nutritional strategies to manage diseases such as cancer and dementia, physicians appear to less frequently associate nutritional intervention with the management of these diseases.

[FIGURE 3 OMITTED]

Discussion

The data from both the physician and older adult surveys are in remarkable agreement with respect to the perceived role that nutrition plays in chronic disease management. Both physicians and older adults believe that nutrition is important in the prevention and management of chronic disease states and should be part of the patient-doctor discussion on a regular basis. The reported surveys, however, point out the disparity between physician knowledge of the importance of nutrition in chronic disease management and the likelihood that the physician will put this knowledge into action. Only one-third (30-36%) of physicians discuss diet and nutrition routinely with their elderly patients, and 36% of older Americans surveyed perceive that this is the case. The desire by 78% of older Americans for increased nutrition emphasis in interactions with physicians represents an opportunity to improve the nature and quality of care for older adults.

The attitude of physicians toward the role of nutrition in the treatment and management of disease appears to be moving toward greater recognition of its importance. When comparing the 2000 physician survey results with a similar survey conducted in 1993 by The Peter D. Hart Research Associates, Inc., the numbers reported in Figure 1 increased from 4% (1993) to 17% (2000) of those considering nutrition "most important" in managing chronic disease. There was a corresponding drop in physicians reporting nutrition's role as "minor" from 19% in 1993 to 4% in 2000 (The Mellman Group, Inc., unpublished data. NSI: Washington, DC. August-November, 2000; July-November, 2001).

Although progress has been made in physician acknowledgment of nutrition, surveyed physicians reported that nutrition was not "top of mind" during office visits (Fig. 2). The majority of physician time and emphasis is spent on medication management. Representative comments from focus groups included, "I don't necessarily address nutrition in every patient, only those who I feel don't get adequate nutrition on a regular basis," and "Nutrition usually comes in, but it's not typically in every visit. Diabetics, patients with high cholesterol or those who show weight loss are examples where I will discuss nutrition with them." Findings from other studies support our survey results. Marrero et al (12) found that when the chief complaint is diabetes, 62% of physicians refer patients for dietary counseling and 38% personally take more time to counsel patients on diet.

[FIGURE 4 OMITTED]

From our survey, it is clear that 95% of responding physicians regard the implementation of nutritional interventions as their responsibility. However, there are multiple recognized barriers to their successful implementation of nutritional assessment and care. Cornuz et al (10) reported that physician attitudes toward providing any type of preventive interventions (such as nutritional care) range from 93% for blood pressure control to 50% for nutritional counseling. Lack of professional physician training was a barrier to nutritional counseling as were lack of time and perceived lack of patient interest. A University of Washington study of family physicians found that self-reported nutrition proficiency is positively correlated with the perceived quality of nutrition training. (13)

Reimbursement for dietetic services is an oft-stated barrier to regular use of the dietitian by the physician. However, Medicare reimbursement is currently available for diabetes and predialysis renal disease, and private insurers are beginning to follow suit. Nutrition education and counseling are delivered by both the physician and the dietitian, although the nature and depth of services provided by each differs considerably. A demonstrated interest in nutritional status by the physician facilitates the work of the dietitian in educating patients regarding lifestyle interventions to improve health. It is incumbent upon physicians to recognize the role of the dietitian in the delivery of medical nutrition therapy to patients and to foster regular communication among physicians, dietetic professionals, and the patient to optimize patient outcomes.

[FIGURE 5 OMITTED]

Finally, physicians expressed strong interest in having materials to support patient nutrition education, and most preferred materials that are brief, could be easily copied and distributed, and contain disease-specific nutritional information.

Development of Educational Materials

Our survey findings, consistent with those previously published, (11, 14-19) have guided our development of succinct professional and consumer nutrition education materials for older adults with chronic disease. The format for both physician and patient nutrition education materials is tailored to the preferences of each group. Evidence-based clinical nutrition guidelines to manage the eight chronic diseases (see list below) were included in NSI's A Physician's Guide to Nutrition in Chronic Disease Management for Older Adults when they were available in the literature. (20) Food sources of nutrients and modifications to existing patterns of food intake are the preferred interventions recommended in the Guide under Treatment Options. However, for individuals unwilling or unable to eat, nutritional options include generic mention of oral, parenteral, and enteral nutritional supplements.

The manual addresses eight chronic disease states that affect millions of our nation's elderly: cancer, chronic obstructive pulmonary disease, congestive heart failure, coronary heart disease, dementia, diabetes mellitus, hypertension, and osteoporosis. For each disease, nutrition screening parameters, treatment options, therapeutic objectives, and outcome measures are identified in a brief format with the option to pursue more detailed information online at www.aafp.org/nsi or www.eatright.org. The Physician's Guide is available in PDF and PDA formats with more detailed, evidence-based compilations of documents that contributed to their development downloadable at the above Web sites.

The Physician's Guide also contains a patient information handout that can be personalized by the physician or care management team member for individual patients. Basic nutritional information related to healthy food choices with specific modifications for diseases are included, as well as reference to additional online resources for further patient education. Suggestions regarding a referral to a registered dietitian or qualified nutrition professional are consistent with those parameters cited in the US Preventive Services Task Force Report. (21)

Conclusion

The number of chronically ill seniors in the United States is predicted to dramatically increase between now and 2030. Evidence-based prevention and care must be the foundation of solutions targeting the health needs of older Americans. Physicians and a growing body of evidence-based literature recognize the importance of nutrition and the scientific base for its use in the prevention and treatment of chronic disease. Patients increasingly desire and expect physicians to assess their individual nutritional needs and to discuss diet and nutrition with them during routine office visits.

There is, however, considerable disparity between physicians' recognition of the importance of nutrition in managing the health care of a specific patient and the generally reported practice behaviors. Tools to assist in the recognition and management of nutritional aspects of chronic disease in the elderly are now available to meet the educational needs and preferences expressed by survey participants. A systematic approach to incorporating nutritional screening and intervention in the care of older people will enhance the likelihood of successful aging in our nation's elders. A tool to assist in this approach has been developed for use by physicians and patients. Primary care physicians, registered dietitians, and other health professionals must collaborate to become a nucleus in helping our nation's older adults to optimize nutrition and health.

Table 1. General content of NSI physicians and patient research

Physician series
  Knowledge, attitudes, and extent of training in nutrition
  Extent of incorporation of nutrition screening and intervention
    strategies into practice
  Preferences regarding content, format, and source of nutrition
    education materials for use in clinical settings
Older Americans series
  Understanding of the importance of nutrition to chronic disease
    management
  Personal strategies used to manage chronic disease states
  Frequency with which their physician provides nutrition screening and
    intervention
  Preferences regarding content and format of physician-provided
    nutrition education materials
  Willingness to see a registered dietitian or nutrition specialist for
    medical nutrition therapy, if prescribed

Fig. 1 Physicians' opinions about the importance of nutrition in
managing chronic disease.

most important  21%
major           73%
minor            4%
not much         1%

Note: Table made from bar graph.

Acknowledgments

The Nutrition Screening Initiative gratefully acknowledges the contributions of The Mellman Group, Inc., Washington, D.C., in the design and conduct of physician and consumer focus groups and survey methodology. The Peter D. Hart Research Associates, Inc., Washington, D.C. conducted the 1993 physician survey, "National Survey on Nutrition Screening and Treatment for the Elderly." The NSI recognizes (listed alphabetically) Johanna Dwyer, DSc, RD, Richard Ham, MD, Sandra Harmon-Weiss, MD, Eric Tangalos, MD, Jan Verderose, MS, RD, LDN, and Nancy Wellman, PhD, RD for their contributions to the development of A Physician's Guide to Nutrition in Chronic Disease Care for Older Adults.

Accepted October 20, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9706-0560

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RELATED ARTICLE: Key Points

* Chronic diseases affect 85% of older adults.

* Nine of 10 people with chronic diseases have a condition that could be improved with nutritional intervention.

* Surveyed physicians recognize the importance of nutrition in managing chronic disease, but do not routinely incorporate nutrition in their practice.

* Tools were developed based on the current research to assist physicians in identifying and managing the nutritional aspects of chronic disease.

John B. Coombs, MD, MNS, Albert Barrocas, MD, and Jane V. White, PHD, RD

From the Department of Family Medicine, University of Washington Academic Medical Center, Seattle, WA; Pendleton Memorial Methodist Hospital and Department of Surgery, Tulane University School of Medicine and Louisiana State School of Medicine, New Orleans, LA; and the Department of Family Medicine, Graduate School of Medicine, University of Tennessee--Knoxville, Knoxville, TN.

The Nutrition Screening Initiative (NSI) is funded in part through a grant from Ross Products Division, Abbott Laboratories, Abbott Park, IL. Dr. Coombs is writing on behalf of the NSI.

Reprint requests to Jane V. White, PhD, Department of Family Medicine, Graduate School of Medicine, University of Tennessee--Knoxville, 1924 Alcoa Highway, Knoxville, TN 37920. Email: [e-mail]