Dietitians: as effective as clinical trials

Yesterday I started writing this article here (the one you are reading now) but ended up writing about some other stuff as a prelude: Confessions of a dietitian.  Today I am going to add to the discussion on the effectiveness of dietitians. 

Put the trolleys in your mind (from yesterdays post, or here).  One trolley illustrates what the evidence says should be in our trolley to be healthy (proportions of fruit, veg, lean meat, dairy, extras etc), the other trolley is what Australians actually put in their trolley.  There is clearly a gap (and a rather big one) between what the evidence says to eat - ADG trolley, and what we do eat - Real-life trolley.  The evidence-based (ADG) healthy trolley is what dietitians are trained to support people to achieve.  But when you look at the real-life trolley, where would you start in trying to get people to achieve the healthy trolley? 

Here is an excerpt from an early version of my thesis' abstract:

A problem for dietitians is that there is an expectation their service will achieve the evidence-based health benchmarks of a healthy body weight (BMI<25kg/m2), meet fruit and vegetable intake targets, as well as exercise recommendations.  The expectation of a dietetic service exists despite the scientific evidence that few or no interventions achieve such health targets (Franz 2007; Cochrane 2010).

The central tenet of this thesis is that it is likely dietitians do facilitate significant and measurable improvements to an individual’s health, even where the improvements achieved fall well short of the health benchmarks.  There is evidence the small health gains that are achieved may be clinically significant, and even cost-effective (Dalton 1997; Sassi 2009).

And then I go on in the abstract and introduction to talk about the problem my thesis is investigating which is about data: collecting and reporting data from practice.  Sure, I’ve simplified “the problem” for this blog, and also, so there is some material left to put in the final thesis *ahem*.  But whenever I have presented this work to dietitians, there is a real sense of anxiety about reporting data from practice.  This anxiety is because dietitians know when it comes to achieving health improvements, especially weight – it is HARD, and outcomes may not present as “effective” because the improvements are small, if any. 

The first point to make is: if we continue to not collect and report data, we continue to keep doing what we are doing (and hope no one asks what we are doing or notices our existence).  If we collect, report and understand that data, we can start to build a practice-generated evidence-base about what we do with this patient at this time in this clinic with this dietitian.  And we can then do better (see hypothesis).  To me, this IS evidence based practice AND translational research.  BAM.  Winning. 

I’ve tweeted this catch phrase previously: “no data = no problems.  but no solutions”

Not sure who first said it, but I took it from Chris Bain’s presentation we did together on a Vic State job (back in 2009).  Thanks Chris, I've changed your quote a bit, Voevodin-style….where are you by the way?

The second point is: halting further weight gain is an important outcome, and a contribution to Australia's health statistics.  Before doing this research, I was unconvinced "halting is good too" - but now, I am convinced it really is good.  Evidence coming.  I know, I am promising a lot.  

In the first few months of my thesis, I was exploring effectiveness of dietitians.  Published studies from practice was sparse as expected (given we aren’t routinely collecting data yet), sure there were some RCTs looking at dietetic services versus other health professional’s services, while other studies compared one diet over another, but none stood out as THE intervention for weight management.  No real surprise there either because the diet that works is the one you can stick to (Thomas 2008). 

My work was not intended to find THE weight loss strategy and then implement that system across dietetic services.  My work is to be a step toward developing a system to record and report whatever it is that dietitian does with that patient at that time, and have that data reported back to the dietitian in a way that automatically generates useful data to make clinical decisions: what works, why, and when to change/add/adjust. 

There are many strategies to support people to achieve their health goals.  Dietitians are trained to know all approaches, to critically assimilate the information, and then translate that information for the person in front of them. We simply want an efficient system to capture what is done in the iterative exchange of information during a consultation.

A system that generates the evidence from practice is also a [critical] reflective practice tool.  The “evidence” presented to the dietitian supports a “putting aside” of their own personal philosophical approach that may be lurking and inadvertently influencing practice (sure, I’m guilty).  But also allows a bravery to step outside our own attitudes, beliefs, and behaviour, because dietitians will now have in front of them accurate, reliable, meaningful data on which to make the next critical decision. 

Epilogue

There is more to say about effectiveness of dietitians - in particular to highlight points from Dalton 1997 and Sassi 2009, and explain some economic modelling of health services. That to come (probably next week).

PS. The data that went to build the trolleys was an analysis I did in 2010 using a previous paper we'd published (Kettings 2009) and then data from the ABS (2008) on household spending. Just so you know it's not made up....details will be in thesis or a later publication.

Tips du jour:

1. Embrace data, lets use it to our advantage

2. Practice-generated evidence is the new black lets be the first to do it

Other blogs by me

[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month 
The story of dietitians for professional integrity
What is professional integrity?

[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together

Evidence-based confessions of a dietitian

Dietitians: as effective as the evidence from clinical trials

Evidence small health changes are good

[Other stuff]

Time for a health bottom line
The power of consumers
NO juice for Australian babies
Contributing to understanding dietetic practice
Maximising online survey participation
An evidence-based food future?

References

Australian Bureau of Statistics (ABS). All data sourced from the ABS was sourced online from www.abs.gov.au The data used in the trolley analysis is from 2008: household spending. This data was also reported in Australia's Food & Nutrition by the AIHW 2012. 

Cochrane Collaboration. Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese adults (Review) The Cochrane Library Issue 12, 2010 (see also Cochrane Collaboration. Long term non-pharmacological weight loss interventions for adults with type 2 diabetes mellitus The Cochrane Library Issue 1, 2009; or any other review of weight loss interventions on Cochrane).

Dalton A, Carter R, Dunt D.  The cost-effectiveness of GP-led behavioural change involving weight reduction: implications for the prevention of diabetes.  Centre for Health Program Evaluation, Monash University Working Paper 65.  

Franz MJ, JJ VanWormer, AL Crain, JL Boucher, T Histon, W Caplan, JD Bowman and NP Pronk. Weight-loss outcomes: systematic review and meta-analysis of weight loss clinical trials with a minimum of 1-year follow-up. JADA 2007 107:1755-1767 

Kettings CM, AJ Sinclair and M Voevodin. A healthy diet consistent with Australian health recommendations is too expensive for welfare-dependent families Australian and New Zealand Journal of Public Health 2009; 33(6): 566-572

Sassi, F. et al. (2009), “Improving Lifestyles, Tackling Obesity: The Health and Economic Impact of Prevention Strategies”, OECD Health Working Papers, No. 48, OECD Publishing.
http://dx.doi.org/10.1787/220087432153

Thomas S, Hyde J, Karunaratne A, Kausman R, Komesaroff PA.  "They all work...when you stick to them" A qualitative investigation of dieting, weight loss, and physical exercise, in obese individuals.  Nutrition Journal 2008; 7:34