Should disease management mirror dentistry?
After smoking and obesity, poor diet is the largest contributor to Australia’s disease burden, yet it is uncommon for patients to be offered personalised, nutrition-related interventions when seeking health care.
For people with chronic disease management plans, only 1–2% of allied health services include referrals to Accredited Practising Dietitians (APDs); and for pregnant women there are no routine APD referrals.
One side effect of this is that intakes of discretionary (aka ‘energy-dense, nutrient-poor’) foods are twice that recommended by the Australian Guide to Healthy Eating, contributing half the burden of heart disease. The burden of conditions like bowel cancer, diabetes and stroke would also reduce by up to 25% if healthy eating habits were the default.
Laureate Professor Clare Collins, Director of the Food and Nutrition Research Program at the Hunter Medical Research Institute and the University of Newcastle, would like to see dietary check-ups introduced to our healthcare system in a model that more closely mirrors dentistry.
She believes several key events should trigger a nutrition intervention, particularly early pregnancy and the detection of a chronic disease risk.
“If I was in charge of the health department, I would introduce a Medicare item that would allow people to have dietary check-ups at these key life stages,” she told Hospital + Healthcare.
“At present, the system only offers this to people who already live with chronic disease — and even then it can be an afterthought.
“Yes, we see dietitians central in management of kidney disease and diabetes, but so many other conditions are falling through the cracks.
“The role nutrition currently plays in disease management pales in comparison to its impact on disease burden.”
Collins believes more work is also needed to ensure medical colleagues are giving evidence-based messages surrounding dietary intake. She says nutrition is an ostensibly complex area, with many of the latest research findings unintuitive.
“It’s possible that some of our medical colleagues are contributing to misinformation. Some may not know the answers but are having a crack at giving advice. Then there are those who were trained many years ago, who may not be abreast with the latest guidelines.”
Among the most surprising of recent findings is that the under-consumption of legumes, like beans and chickpeas, poses the highest dietary risk factor to chronic disease. The second-highest dietary risk factor is a diet low in wholegrains or fibre.
“These findings are unintuitive — and a challenge to comprehend, particularly amid guidelines for carbohydrate consumption. Yes, people do need to watch their highly processed carb intake, but choosing bread that is so full of wholegrain that it tastes nutty is important. There is great benefit to come from working more closely with allied health teams and medical colleagues on this front.”
While nutrition information leaflets can be useful, Collins believes they are only adequate for certain patient groups. She said referring doctors should be skilled at identifying who needs additional nutrition support.
“If someone is really interested in nutrition and appears to be good at finding information, a leaflet might work for them. If someone appears desperate for advice and their HBA1 is off the Richter scale, a referral to an APD is needed. Our medical colleagues will be best placed to judge that.”
That said, many doctors may be overestimating their patients’ knowledge in the realm of nutrition, Collins argued.
“It is common for people with obesity to be told to go off and lose weight. What we might not realise is that many of these patients have never been given adequate nutrition advice from a suitably qualified professional.
“A large portion of the public is unaware that we have moved on from the nutrition pyramid that was produced decades ago and that nutrition counselling includes support for realistic goal setting and support for change in food behaviours.”
Huge potential for improvement
Collins says under-representing nutrition in chronic disease management is doing a disservice to patients, and that a greater emphasis on diet is a missing piece of the disease prevention jigsaw.
“If a miracle were to happen and the entire population were to suddenly start following the current recommended nutrition guidelines, then we would see a 50% reduction in disease burden related to heart disease and 25% drop in diabetes burden.”
Collins would also like to see nutrition play a greater role in the management of mental health, given a recent finding that dietary improvements are effective in depression.
“This is a big missed opportunity. If you aren’t eating healthily, a poorer sense of wellbeing is the first thing you will feel. You won’t feel like you are running on all cylinders. We now know that improving people’s diets can dramatically improve wellbeing, and we are under-serving people by withholding this evidence-based advice.
“I hope to see our future healthcare system giving nutrition the attention and funding it deserves,” she concluded.
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