Heads up GPs, we can save $billions if we work together!

I write this post in response to an article published in the GP-subscribed Endocrinology Update with headline Dietitian referrals have limited benefit to patients (10-07-13).  

My post here is a shout-out to all GPs, nurse practitioners, and dietitians: we can be more effective together!  In this post, I’ll walk you through what I know, and the evidence I am aware of to argue dietitians ARE effective.  And are a strong adjunct service in the Australian community.

Michael Woodhead (author of the dietitians are ineffective article) my post is no reflection on your professional capabilities. You have a job to do, spunky headlines get the hits, I know that, we all know that.  The end. 

Wellllll, the end, except, that headline you’ve selected and the opening statement are accidentally powerful.  Don’t worry Michael, you are not in trouble, I know you didn’t mean it.

Like all health professionals, including GPs, we (dietitians) are in part restricted by the system within which we work.  Decoded: we are doing our best with what we have.  That is not a disclaimer.  It is a fact. 

First up, disclosure of interest: I am a dietitian.  I am doing a PhD about effectiveness of dietetic services in primary care.  I know we can do better.  My hypothesis is we can do better if we have accurate, reliable, and useful data available to us during our consult. 

You’d think it a minimum standard, to have accurate and reliable data, but it is not.  Dietitians often rely on patient-reported biochemistry measures, current drug type and dose, ability to exercise etc.  Having the right information at the right time creates an efficiency, which is a first step to report effectiveness.  This stuff will be in my thesis, but is an important point to make here so you know we know this is a problem. 

Right, enough about me…..  Alright then, one more thing.  Do you eat two fruit and five vegetables every day?  What is your body mass index?  Exercise for 60 minutes today?  Me neither.  But you’d know about my form.  It’s hard.  Lets keep perspective on our expectations.

My interpretation of the study by Spencer is slightly more positive than Michael’s.  The study is supportive evidence dietitians ARE effective.  If a dietitian can achieve a significant change in body weight and waist circumference, in an average of two sessions per client, well, that sounds pretty amazing to me!  Sure, it may not be clinically relevant at face value, or the matched metabolic improvements.  But consider this: if that person had not seen the dietitian, it is likely they would continue down the trajectory of gradual weight gain over years with associated burden of disease.  

Most important: The outcome a dietitian achieves is almost completely dependent on the client. The client, after being given their “food prescription” is to then exit the consultation room, pop down to the shop to buy the food prescribed, and when they are at the shop, ignore the cheaper, more satiating, desirable options.  The point: A food prescription is hard to fill.

  

Sorry Michael, your article content is important, albeit trumped up, so lets get back to it.  

Michael’s article reports on a study published this month in the Australian Journal of Primary health by Spencer and colleagues in Queensland.  The Queensland study reports on the interventions and outcomes of three dietitians providing a service in the community to clients on an EPC with type 2 diabetes.  Michael summarises the findings in his article titled “dietitian referrals have limited benefits for diabetes patients” and the opening statement of his article is:

"Millions of dollars are being wasted in Medicare-subsidised dietetic services for type 2 diabetes patients because of poor attendance and modest results in weight loss, research from Queensland suggests."

I say: dietitians cannot support people to achieve their health goals if that person doesn’t rock up to the appointment.  Right, that’s cleared that up then. 

Oh, wait.  Except I’d add, this opening statement tells me there is a problem with the system.  In particular, it is likely there is a problem with how we are selecting clients onto EPC.  Why are we waiting till they have “one or more” comorbidities?  What happened to prevention?  So dietitians are meant to help people who don’t rock up, and who have years and years of poor food habits formed, have little money, and are working with average culinary knowledge, skills, and, [often] limited capacity to get these pro-health food skills. 

It is no surprise to any health professional if I describe the clients eligible for the EPC appointments as “more complex” than full-fee paying clients.  EPC clients tend to have a number of health issues, and usually have gotten to this [unhealthy] point after many years of less nutritious culinary behaviours.  That is a generalisation of course.  There are many reasons individuals struggle with their health, food is one, but is most likely the biggest influence over time.  And then, EPC clients also have a less flexible food budget, as well as substandard food preparation, storage and cooking facilities, let alone a nice sun-filled room with a table to eat the lovingly prepared nutritious delights. 

Now, that challenge of navigating to only the foods prescribed goes for all of us, including me.  But for EPC clients, consistently prioritising the healthy options is possibly an even greater challenge.  In fact, part of my thesis hypothesises “low-income” is in itself a culture when it comes to choosing food.  What I mean is, low-income has it’s own set of “what is normal” – and what you see most often becomes YOUR normal.  A problem is the marketing strategies of nutrient poor food and drinks are targeted at the “low-income culture”.  What, you knew that already?  Ok, well, that is the sort of colourful, exciting, fun, propaganda a dietitians food prescription is up against.

I am not saying it is hopeless.  It is not. Ever. But we must recognise behaviour change is CHALLENGING.  It takes time.  Effort.  Strategic effort.  Together.  Whatever it takes.  Yeah.  Lets do it.  C’mon.

Stopping a trajectory is a good outcome too.  Small changes are good.  Very good. [Check out Carter, Moodie, and Swinburn’s ACE work].

Spencer (2013) is not the first paper to report data indicating dietitians are effective.  An economic analysis by the OECD reports the dietitian-GP partnership is potentially the most cost-effective long-term strategy to halt and reverse obesity (OECD 2009; 2010).  I have suggested the dietitian-GP cost-effectiveness found in the OECD analysis is BECAUSE the small changes in behaviour from one-on-one consultations with a dietitian make a measurable difference in health outcomes. Dietitians can make a measurable contribution to Australia’s health statistics - It is this hypothesis that will be a next phase in our research in an RCT.   

But wait, there is more.  Check this out:  A New Zealand study by Coppell and colleagues published in 2010 in the BMJ reports on an RCT (n=94) in people with type 2 diabetes.  All participants were on maximum OHGs.  The test group received intensive nutrition intervention with a dietitian (n=45).  Compared with the control group, the test group measured a 0.4% improvement in HbA1c (p<0.007)!  Again, on eyeballing that result, 0.4% feels clinically insignificant but the authors give the comparative analysis to you (like all good writers should):

"..the magnitude of the reduction in HbA1c is comparable with that seen in clinical trials when a new drug has been added to conventional agents"

I could conclude “dietitians to replace drugs”.  Would that be cost-effective….you bet! What say you Michael?  You want to use that heading?

@MDPStudy


Epilogue
To our medical colleagues: we see this as an opportunity to make improvements to work toward our shared health goals for individuals, communities and populations.  You coming with?

Tips du jour
1. There is good evidence dietitian-GP partnerships is a cost-effective option for Australia
2. Small changes in behaviour can achieve measurable changes in health
3. Supporting each other to create an efficient health service is the way to effectiveness 

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
Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM, Mann J.  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 2010, 341

Dalton A, Carter R, Dunt D.  The cost-effectiveness of GP-led beahavioural change involving weight reduction: implications for the prevention of diabetes.  Centre for Health Program Evaluation, Monash University.  Working Paper No. 65 1997

Organisation for Economic Co-operation and Development (OECD) Publications available at www.oecd.org 

Sassi F, Cecchini M, Lauer J, Chisholm D.  Improving lifestyles tackling obesity: the health and economic impact of prevention strategies.  OECD Health Working Papers No. 48

and

Sassi F.  Obesity and the economics of prevention: Fit not fat.  OECD 2010

Spencer L, O'Shea M-C, Ball L, Desbrow B, Leveritt M.  Attendance, weight, waist circumference outcomes of patients with type 2 diabetes receiving Medicare-subsidised dietetic services.  Australian Journal of Primary Health (2013) 

Small health changes are good!

In the early theoretical analysis for my thesis, I came across two key papers: the first is an economic analysis of lifestyle interventions by general practitioners for people with diabetes by Rob Carter and colleagues back in 1997 (Dalton 1997). The second is also an economic analysis, investigating treatment and prevention strategies for obesity commissioned and published by the OECD (Sassi 2009; 2010).

When I say "economic analysis" it means [loosely/broadly] a series of rational hypotheticals to understand what is happening, why, and with what consequences. How it works is you create an evidence-based hypothetical model of a service, or intervention, from the literature, and then you put into the model what you know for sure (from the evidence), then make evidence-informed rationalised assumptions to fill in the gaps to work out stuff like cost-effectiveness. Think of it as a mathematical sequence of events drawn from the literature: if I do this to x, what happens to y?

Or just take this message: economics is a science of decision-making; and health economics is a science of decision-making about health.

This kind of health economic modelling (econometrics) forms one part of the decision-making about health services. You can imagine if you were making decisions about funding one health service over another, the cost effectiveness of a service would be an important part of making that decision. Not the only part of course, and not always the most heavily weighted part of making decisions.

Imagine what happened if we only ever funded the most cost-effective services? What do you think such decision-making would do to equity and justice? This does not mean we blindly fund all health services, or that there should be a blanket fund to anything health. We are all accountable for our use of the scarce resources available, and to do our best to make informed judgements about what we do.

A special note for my dietitian colleagues: my work is about capturing what we do so we can report efficiency and effectiveness. If you feel anxious about this kind of reporting….read related blogs 1 and 2….and know I am here to hold hands as we get on top of this data stuff. Promise. Data will in fact raise and support our professional autonomy and credibility.

Right. Back to the “evidence small changes are good thing”. Carter’s work (Dalton 1997), and more recent, his teaming up with Boyd Swinburn, and Marg Moodie in the ACE series of economic modelling for obesity, consistently supports the early findings:

“…lifestyle changes that can be sustained over the longer period are better than dramatic changes that cannot be sustained”

Of course the body of work on the econometrics of prevention and treatment strategies for overweight and obesity are more detailed than this sweeping one-liner I have pulled out of the results. But having read across the literature, I can tell you there is something in the “small changes”. And in fact, Sassi’s work reports:

“The dietitian-GP partnership is potentially the most cost-effective long term strategy to halt and reverse obesity”

I hypothesised the dietitian-GP partnership came out on top is because of the intricacy of making
decisions about food: changing the know what to know how.  Dietitians are trained specifically to support behaviour change that is so completely individual driven, public health campaigns for prevention are not sufficient in the day to day challenges of “sticking to the two and five”.

Wait. Before you start tweeting “see small sustainable changes are better” remember how we practice to evidence, and we translate this evidence as suited to the person in front of us? What that means in this scenario is, the evidence suggests, “overall, small changes are good, and are likely cost-effective”. But we know as practitioners some people really do respond better to a dramatic change first, and then need the dietetic support to keep to it – what is best for this person at this time in this clinic with this dietitian? What is the client in front of me really telling me? Of all the options I know of to support this person to achieve their health goals, which ones will I pitch to this person as the MOST SUITABLE option at this time?

Epilogue
Evidence-based practice means the health professional brings all they know about all the evidence, and translates this to present the best option/s for what works for this person at this time. Data from that decision-making provides evidence of what works why/why not to inform clinical decision-making.

Tips du jour:
1. Small changes make a positive contribution to Australia’s health
2. Health economics is one part of the information needed to make decisions about health services

3. Dietitians can make a measurable impact on Australia's health statistics

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

Organisation for Economic Co-operation and Development (OECD) Publications available at www.oecd.org 

Sassi F, Cecchini M, Lauer J, Chisholm D.  Improving lifestyles tackling obesity: the health and economic impact of prevention strategies.  OECD Health Working Papers No. 48

and

Sassi F.  Obesity and the economics of prevention: Fit not fat.  OECD 2010

Dalton A, Carter R, Dunt D.  The cost-effectiveness of GP-led beahavioural change involving weight reduction: implications for the prevention of diabetes.  Centre for Health Program Evaluation, Monash University.  Working Paper No. 65 1997

Confessions of a dietitian

I am a dietitian, I have been a dietitian for about 16 years.  However, I have not done a one-on-one consultation with a client for probably eight years or more.  So in terms of what "dietitians do", well, I don't do that.  And I don't do that stuff because it is HARD.  There.  I said it.  It IS really hard supporting people to achieve their health goals.  And after years of research, observation, and sure, a bit of real-life practice, it has come down to this: it is hard because no matter what the dietitian does with each person during that consultation, it is that person, that individual, that then has to go out and navigate their way to making decisions about food three, four, even five times a day, and stick to an agreed "food prescription".  I'll explain further...

Dietitians are a counselling-based profession.  This means their role is as teacher-supporter-behavioural interventionist, but the actual work (the hardest bit) is up to the individual.  Compare this for example with a physiotherapist, a physical-based profession, where in the 15 or 20 minute consultation the "problem" can be alleviated.  The work is "done" on the spot, and the person exits with a clear gain in physical health.  Similarly, a doctor will write a prescription, you take that prescription, head to the pharmacy, decision-making is limited to which pharmacy (usually the closest) and then whether you choose a "cheaper brand" of the specific medicine.  Sure, you have to take the medicine....but how hard is that?  Rhetorical.  This is not a test.

I expect any dietitian reading this is hoping I clarify two things I've written in that opening paragraph.  Lets sort these out first so we can clear our heads for the real message.

1. What "dietitians do"

Dietitians do lots of things.  Heaps.  One-on-one consultations is one service that is simply "classically" representative of our profession.  Given Australia's chronic health statistics and projections for getting worse, one-on-one food and behaviour counselling is, and probably should be, the main service people see in the community as representative of the profession of dietetics.  But sure, we do lots of other stuff...research, policy, legislation....highly trained, smart, funny etc...

2. "Food prescription"

Writing out a "food prescription" for a client is a strategy, one strategy of many, that may be what the person in front of us needs at a particular time in their health journey.  Like many professions, dietitians don't want to be labelled or boxed into terms like "food nazi" or giving a "prescriptive diet".  But in fact, thinking about our service in these terms is what led me to draw parallels between what we (dietitians) do, and what other professions, like doctors and physios, do.  So, food is a dietitians intervention, our medicine.

When someone is not at their healthiest, making healthier food choices can help to alleviate or manage the problem: a dietitian "prescribes" foods that will make the person healthy.  We give a "food prescription" and then that person has to go out and get those foods and "take" the medicine prescribed.  Sounds easy, but, compared with the [two] decisions for getting a prescription (i.e which pharmacy and which brand of medicine), making decisions about food are far more challenging.  There is so much noise in the process from knowing what to eat, and actually eating it.  In every moment a decision is made about food, the process is a series of trade-offs influenced by many things, the price of food is just one of these.  There is the HARD bit, consistently sticking to the prescribed foods when the path to anything except the prescribed foods is more appealing.

What do we know for sure? Australian's are in the worst shape ever.  You know the stats: just over two in three Australian adults are above a healthy weight; ranked in the worlds "worst third" for body weight; diabetes set to increase and has some pretty awful associated health problems (AIHW 2012; Baker IDI 2012).  Dietitians, the experts in what to eat to be healthy, are well positioned to make a significant contribution to halting and reversing these health statistics.

Right. Here is me, one of these experts, trained to know and subscribe to the scientific evidence of what to eat to be healthy: eat two fruit, five veg, drink water (no other drinks), have a body mass index (BMI) at or below 25kg/m2, and do 60 minutes of moderate exercise every day.  The only one of these health benchmarks I meet is the BMI *yay genetics*!  Here is what bothered me when I was doing one-on-one consultations: if I can't achieve the health benchmarks, what chance do others have?  I could see my own inability to achieve what I should influenced what I did with clients. If they said "I don't have breakfast", I'd say "yeah neither do I".  If they said "gosh its too hot to exercise" I'd say "yeah I KNOW! It's outrageous".....or similar.  So I stopped doing, took a step back, and started questioning.

I became my own personal experiment: what is it about my decisions that divert me from the evidence?  This series of self-critique was the start of my work on the cost of healthy eating, the economics of decision-making to prioritise healthy eating, and a series of short vignettes on eating economics (to go into my thesis). And of course, the trolleys!  I've written about these preliminary ideas previously on my website (remember websites?) - but not in a blog....

It is this questioning of my own evidence-based prescription that brought me to my PhD - Can dietitians turn around the obesity epidemic? I really did wonder. And given how far Australians are from healthy eating (note the trolleys), is it reasonable to expect we CAN turn this around?  I believe we can, and there is evidence to support my belief.  It's coming....promise.


Epilogue
I know about stuff and I still struggle to eat to the evidence - but doing this research has allowed a "story" on decision-making about food that will contribute to what we know about the HARD bits, so we can be more effective.

What's that? Yes my eating is better thanks for asking.  I'm at one fruit, maybe four veg, and erm...one dairy.  Twenty minutes of intentional exercise a day....is it my fault I'm a fast runner?  And some incidental exercise - yes I take my housework seriously.

Tips du jour:
Erm....

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 Institute of Health and Welfare (AIHW). Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra: AIHW  Available online at www.aihw.gov.au/publication

Australian Institute of Health and Welfare (AIHW). Australia’s food & nutrition 2012. Cat. no. PHE 163. Canberra: AIHWAustralia's Food & Nutrition  Available online at www.aihw.gov.au/publication

Baker IDI.  Diabetes: the silent pandemic and it's impact on Australia 2012  Available online at www.diabetesaustralia.com.au 

National Health & Medical Research Council (NHMRC).  Australian Dietary Guidelines 2013.  Canberra NHMRC  Available online at www.nhmrc.gov.au   Note the analysis for the "trolleys" were based on the earlier Australian Dietary Guidelines 2003, which are now superseded by the 2013 version.  However, the 2013 revision would make little change to the "healthy spend" trolley.