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AWARENESS AND SELF-REPORTED KNOWLEDGE AND TRAINING ON NUTRITION IN OLDER PEOPLE AMONG PRIMARY CARE PRACTITIONERS

 

L. Rodríguez-Mañas1,2, J.M. Moreno-Villares3, J. Álvarez Hernández4, A.A. Romero Secín5,6,
M.L. López Díaz-Ufano6,7, F. Suárez González6,8, A. Costa-Grille1, J. López-Miranda9, J.M. Fernández-Garcia6,10, on behalf of the Working Group on Nutrition in Older People-DANONE Institute

 

1. Servicio de Geriatría, Hospital Universitario de Getafe, Getafe, Spain; 2. CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain; 3. Clínica Universidad de Navarra, Madrid, Spain; 4. Servicio de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain; 5. Centro de Salud Ventanielles, Oviedo, Spain; 6. Working Group on Nutrition. Sociedad Española de Medicina Rural y Generalista (SEMERGEN), Spain; 7. Centro de Salud de Reyes Católicos. San Sebastián de los Reyes. Universidad Europea de Madrid, Spain; 8. Centro de Salud de San Roque, Badajoz. Universidad de Extremadura, Spain; 9. Lipids and Atherosclerosis Unit, Department of Internal Medicine, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain. CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; 10. Centro de Salud de Valga, Pontevedra. Universidad de Santiago de Compostela, Spain

Corresponding Author: Leocadio Rodríguez-Mañas, Servicio de Geriatría, Hospìtal Universitario de Getafe, Ctra. de Toledo, Km 12.5; 28905-Getafe, Spain. leocadio.rodriguez@salud.madrid.org

J Frailty Aging 2024;in press
Published online February 6, 2024, http://dx.doi.org/10.14283/jfa.2024.11

 


Abstract

OBJECTIVES: To assess the awareness and training of primary care physicians on nutrition in older patients.
DESIGN: Observational, real-world data survey.
SETTING: Primary Care.
PARTICIPANTS: One hundred sixty-two physicians, generalists and specialists, working in primary care.
MEASUREMENTS: Participants received an online questionnaire with 18 questions concerning the importance of nutrition, degree of knowledge, needs, and training in nutrition. The results were evaluated using univariate descriptive analysis, with a percentage for each chosen answer. Logistic regression models were used to evaluate if answers were related to training in nutrition and professional experience.
RESULTS: 43.2% of participants reported that nutrition is very important in individuals over 65 years old, and 90% were aware of the importance of nutrition in healthy aging. Nutritional problems affect 30 to 50% of patients, according to 44.7% of participants. 89.2% agree about the need for nutritional assessment in older patients; however, the professionals believe they should be better prepared. Two out of three respondents consider the training received in nutrition during their undergraduate course or continuing medical education as deficient. Time of professional practice was mainly associated with conceptual facts, while continuing medical education did with practical issues, mainly the use of screening and diagnostic tools [FRAIL (OR: 3.16; 95%IC: 1.55-6.46), MNA-SF (OR: 6.455; 95%IC: 2.980-13.981) and SARC-F (OR: 3.063; 95%IC: 1.284-7.309)].
CONCLUSION: Although primary care professionals are aware of the importance of nutrition in older patients, there are still gaps in daily practice that could be improved by developing educational strategies.

Key words: Nutrition, frailty, older patients, primary care, medical education.


 

Introduction

Healthy aging has become one of the current challenges for health systems and several national and international organizations have promoted various initiatives in this area (1-3). One of these strategies is based on the concept of “intrinsic capacity”, defined as the “Combination of all the physical and mental capacities that a person has” (2). At the same time, the need for training among healthcare professionals is enhanced in several of the documents as a pillar to achieve a healthy aging (4-7), focused on function and not on illness, and is built on the principles of providing anticipatory and preventive, comprehensive, continuous and coordinated care (8).
The first pillar of the WHO document (“Aligning health systems to the needs of the older populations they now serve”) establishes the importance of “ensuring sustainable and adequately trained health professionals”, for which it sets out two priority actions: 1) providing training on aging and age-related conditions for all health professionals and 2) ensuring geriatric and gerontological core competencies in all health-related educational plans (6). This need has recently been reaffirmed in a document presented on 26 April 2022, which reports data from a survey on the needs for the implementation of the Integrated Care for Older People (ICOPE) program (9). Regardless of the level of income and healthcare organization in these countries, training is the most urgent requirement. A condition that was already highlighted decades ago in nutrition and primary care (10, 11).
Nutritional status is one of the domains (vitality) of intrinsic capacity established by the WHO (12). Considerable evidence reflects the relationship between older people’s nutritional and functional status (13). Primary care is essential to promote healthy lifestyles and nutrition in the 21st century (3). The training of physicians in nutrition during the medical degree is insufficient for its real importance (10, 11).
Moreover, the recently launched Vienna International Declaration on the Human Right to Nutritional Care, endorsed by the four main international associations of clinical nutrition, ASPEN (American Society of Parenteral and Enteral Nutrition), ESPEN (European Society of Clinical Nutrition and Metabolism), FELANPE (Federación Latinoamericana de Terapia Nutricional, Nutrición Clínica y Metabolismo and PENSA (Parenteral and Enteral Nutrition Society of Asia), plus the European Federation of Association of Dietitians (EFAD), the European Forum of Patients and another 75 associations from the whole world, highlight, in its bullet 3.2, that “Clinical nutrition education and research is a fundamental axis of the respect and the fulfillment of the right to nutritional care” (14).
This study aimed to assess the degree of awareness of the importance of nutrition and the functional status in older patients among primary care physicians in Spain, their degree of knowledge, and self-perception of different aspects related to training needs.

 

Methods

Study population

Doctors working in Primary Care (General practitioners, doctors specialized in Family and Community Medicine, pediatricians and internists) in Spain were contacted between July and December 2021 through the database of the Spanish Society of Primary Care Doctors (SEMERGEN). Two waves of mailing were carried out, sending a cover letter explaining the aims of the study, the time needed to complete the questionnaire and the possibility of implementing strategies to improve the lacks of knowledge among the members of the Society. Those accepting to participate received questionnaires that were completed online, individually, and anonymously.
Sample size was determined taking into account a previous study (15). In that study the authors made a survey quite similar to the ours among geriatricians (n=40) in several EU countries. Taking into account that our survey was going to be implemented in a broader population (those clinicians practicing in Primary Care) we increased the sample size up to four times.

Outcomes

The primary outcome is to evaluate the degree of awareness of the importance of nutrition and the functional status in older patients among primary care physicians in Spain.
Regarding secondary outcomes, the aims are to evaluate their degree of knowledge, and self-perception of different aspects related to training needs.
Both primary and secondary outcomes were assessed by a questionnaire shown in Appendix 1.

Questionnaire

The questionnaire was developed by experts from different fields (primary care, nutrition experts, dieticians, endocrinologists, geriatricians) pertaining to the Working Group on Aging of the DANONE Foundation. Questionnaire was initially composed by 23 questions (sentences to which the participants should tell their degree of agreement/disagreement) plus three additional ones with data about affiliation and built by the group of experts described in methods. The questionnaire was discussed by the group of experts and modified taking into account the following aspects:
1) Questionnaire should not take more than 10 minutes to be filled, to promote participation
2) It should be divided in three sections, one per each one of the three aims of the study
3) The majority of them should have only one answer/one sentence to be agreed

The second version of the questionnaire was sent to the Working Group on Nutrition of the Sociedad Española de Medicina Rural y Generalista (SEMERGEN) to get its inputs after being tested among their components to assess its feasibility. SEMERGEN reduced the questionnaire to 17 questions. After a final round inside the expert group, the final questionnaire got its final form, fitting the requirements previously commented and approved also by SEMERGEN.
It consisted of 18 questions distributed in three blocks: A) Professional affiliation and characteristics of the participant (3 questions), B) Importance of nutrition and degree of knowledge about it (10 questions), and C) Needs and Good Practices in nutrition (5 questions) (Annex 1). Depending on the characteristics of each question, the answers could be single or multiple choice from a panel of 3-5 options. The importance or degree of agreement with the statement was scored between 1 and 5, where 1 represents «total disagreement» and 5 «total agreement», following the Likert method (16). The online survey was sent to each participant once and conducted using the CAWI (Computer Assisted Web Interviewing) method, applying the structured questionnaire lasting approximately 5 minutes.

Statistical analysis

The results were evaluated using univariate descriptive analysis, calculating the percentage of subjects who responded to each option. For some of the responses, differences that might exist according to the type of training received, years of professional practice, and/or having recently received specific training in nutrition were assessed using logistic regression models. All analysis was computed using the statistical package R for windows (version 3.6.1).

 

Results

One hundred sixty-two physicians from primary care answered the questionnaire. The participants’ characteristics are described in Table 1. The rates of response to the questions was indeed quite high ranging from 97.0-98.8%. Of the 162 participants, 115 (70.9%) were general practitioners or family and community medicine physicians, and 42 (25.9%) had other specialties. 45.3% had more than 25 years of practice, and 15.7% had less than five years. Among all participants, 46.5% claimed to have received some training in nutrition in the last three years; 42.6% reported that more than half of their patients had a nutritional problem, and 44.7% said that 30-50% of their patients had a nutritional problem.

Table 1. Characteristics of participants

 

Importance of nutrition and level of knowledge

Although 46.9% declared that nutrition is equally important at all ages, 43.2% reported that it is very important in individuals over 65 and 33.3% in children from 4 to 14 years old. The sum of the percentages exceeds 100% because up to three options were allowed for the same question.
78.9% of practitioners affirmed that they give great importance to the nutritional aspects of older patients, an importance that increases with professional experience and shows a tendency to rise in those who have received formal training in the last three years, without reaching statistical significance in any of these cases.
They were 86.3% to believe that the relevance of nutrition in older people will increase in the future based on three main reasons: the growth of the older population (29.5%), the poor nutritional habits of currently aging populations (22%), and the impact of nutrition on quality of life (11%).
Two out of three respondents (64.2%) consider that nutrition training during their undergraduate and continuing education is deficient, and 21% consider nutrition important only in some specialties. Similar percentages were found when asked about training in geriatrics: 66.3% consider it deficient, and 21.3% think it is important only in some specialties (Table 2). Differences were observed according to years of professional practice, reaching 80% for both questions in those with the shortest experience (less than five years).

Table 2. Perceived importance of nutrition and geriatrics in current medical education.

 

Regarding the limitations in their training, the professionals believe that they should be better prepared to adapt their clinical practice according to common characteristics and difficulties of older people: specific diets for chronic pathologies or specific deficits, intolerances or allergies, dementia, fractures, pressure ulcers, dysphagia, or enteral nutrition, among others. They believe in using standardized parameters or measurement scales and effective communication with patients and caregivers in a simple manner.
When asked about some nutrition concepts relevant to their practice, more than 90% were aware of the importance of nutrition in healthy aging (96.3%), the role of the Mediterranean diet in preventing functional decline (93.2%), or the convenience of combining nutrition and physical exercise (96.3%). Although 75.8% were aware that the optimal body mass index (BMI) changes over time and that frequently a decrease in intake coincide with an increase in BMI during aging, 78.8% of the participants believed that overweight is a major risk factor for functional decline in older people, showing an inverse relationship with years of experience [Odds ratio (OR): 0.96; 95%IC: 0.94-1.00), especially for those with >25 years of professional practice (OR: 0.164; 95%IC: 0.034-0.779). Only 18.6% gave more importance to abdominal circumference than BMI as an indicator of risk of functional impairment (Figure 1).

Figure 1. Percentage of agreement (strongly agree + agree) and disagreement (strongly disagree + disagree) among primary care professionals (in dark blue) about different aspects of the relationship between ageing and nutrition (n=161)

 

Changes associated with the aging process itself, including taste and smell, were identified as the main factors related to the risk of changes in eating habits during aging by 50.7% of respondents. All professionals with more than five years of practice recognized this phenomenon.
23.3% of participants believe that medication does not influence dietary habits or that implementing dietary changes outweighed the costs of the consequences of poor nutritional status. However, 89.2% agree about the need for nutritional assessment in older patients, including those in the public setting (Figure 2).

Figure 2. Use of diagnostic tools related to nutrition and frailty used by primary care physicians

 

Nutrition needs and good practice

More than half of the participants (54.7%) identified functional impairment as the main risk for poor nutrition, followed by 27.3% who pointed to the quality of life. Again, years of practice showed a continuous, direct relationship with the answer chosen (OR: 1.031 per year of practice; 95%IC: 1.001-1.062), although any of the categories reached a significant difference by itself. Other options, such as cognitive impairment, hospitalization, health care costs, or death, did not reach more than 13%.
Most respondents considered very important a quantitative and qualitative evaluation of diet (90.1%), the evaluation of swallowing (87.6%), and the monitoring of functional evolution in patients undergoing weight loss programs (86.3%) considering the risk of loss of muscle mass. However, a practice as simple as the examination of dentition was considered very relevant by only three out of four (76.3%) respondents, mainly in the groups with a practice experience between 5 and 25 years.

These responses showed no relevant differences depending on the training on nutrition received in the last three years.
Regarding the use of screening or rapid and simple diagnostic tools, around seven out of ten hardly use tools to diagnose frailty (FRAIL) and malnutrition (MNA-SF) (69.1% and 68.4%, respectively); but, above all, 82% do not use them for the diagnosis of sarcopenia (SARC-F). Only 1.9%, 7.7%, and 1.9% systematically use the FRAIL, the MNA-SF, and the SARC-F, respectively (Figure 2). Training in the last three years increases the likelihood of using these tools, both for FRAIL (OR: 3.167; 95%IC: 1.552-6.465), MNA-SF (OR: 6.455; 95%IC: 2.980-13.981) and SARC-F (OR: 3.063; 95%IC: 1.284-7.309). In contrast, there was no clear association between using these tools and years of professional practice.
In the dietary analysis, 68% of the professionals stated not having the necessary tools for a correct dietary assessment of their older patients, while 15% said they have everything they need. This response was related to having received recent training, showing a much lower risk of not having the tools (OR: 0.459; 95%IC: 0.237-0.888). Respondents identified the difficulty in convincing older people (53.1%), the presence of chronic diseases (45.7%), and the absence of guidelines on nutrition for the older from authorities and scientific societies (34.6%) as the main barriers to introducing changes in the nutritional and dietary habits of their older patients.

 

Discussion

Implementing programs and models of care for older people have in one of their basic pillars the training of the personnel in charge of making them possible, and putting them into practice (14). To plan and achieve adequate training, especially for those who are already outside a regular training circuit, it is advisable to know the importance that these professionals give to the subject in their daily practice, as well as their self-perceived training needs in each of these topics. One of the professional groups where these characteristics converge is physicians working at the first level of care (primary care) in aspects associated with nutrition and its consequences for older patients. The characteristics of primary care due to its proximity to the patient, longitudinally, accessibility, and holistic vision makes the family doctor an eligible professional to receive adequate training in nutrition for all age groups, especially those over 65. This study aims to yield data of interest for developing training programs adapted to professional profiles and needs.
The reason for focusing the assessment on the role of nutrition in functioning is that nutrition is usually considered a key factor in the complex etiology of functional decline, including frailty and its key component, sarcopenia (17, 18), a major aspect in older patients. In addition, inadequate nutritional intake is one of the most important modifiable risk factors for frailty, opening the possibility of preventing and treating it (19).
Even though nutrition has a meaningful role in health in all age groups, two clear trends of increased concern are observed in this study: physicians dedicate significant attention to nutrition at younger ages (from 4 to 14 years), less as age progresses, up to 40 years, and then rising again in patients over 60. Nutrition will become gradually more important in the care of older patients because of the benefits of an adequate diet on function and quality of life in the aging population. The importance of correct nutritional habits, the Mediterranean diet, and physical exercise programs are aspects that primary care doctors consider most appropriate and necessary for healthy aging.
However, this high importance given by health professionals to nutrition for older patients is unbalanced with the current medical training. Two out of three professionals consulted believe nutrition and geriatrics should receive more attention in medical school and continuing medical education programs. One in five believes that this importance, when it is assumed, only occurs in certain specialties. These data are consistent with the systematic review published by Crawley et al. in 2019 (20), which demonstrated deficiencies in nutrition education, knowledge, skills, and confidence to implement nutrition care, and with the ESPEN position paper about nutritional education in medical schools (21).
Most physicians consulted in this survey correctly identified functional impairment and worsening quality of life as the main consequences of inadequate nutrition in older patients and showed a broad knowledge of the nutritional status of this population. However, some aspects are not well known or generate confusion among them, including the role of BMI as a risk factor and its changes during the aging process, the role of medication affecting nutritional habits, or the socioeconomic impact of measures to correct dietary habits and improve nutritional status.
Perhaps the most significant training deficits are observed in the non-regular use of simple validated tools for functional assessment, nutritional status, and body composition (sarcopenia), with the possibility of underdiagnosing important risk factors in older people. Most of these professionals reported not having the tools to evaluate dietary composition in their routine clinical practice. Screening for these entities does not consist of isolated questions or the subjective view of the professional; it should be supported by reliable and validated scales (22).
The main barriers to managing proper nutrition in older patients are the difficulty in convincing them to change their eating habits and the high prevalence of chronic pathologies in this population.
The second purpose of this work was to assess the influence of professional experience (measured by years of practice) and continuing education on the aspects considered in the survey. Time in practice was associated mainly with conceptual aspects (relationship between poor nutrition and quality of life, role of BMI as a risk factor, part of changes related to aging with nutritional habits and deficits). A recent (last three years) completion of training courses was directly related to practical aspects, less difficulty in adequately assessing the nutritional and functional status, and greater use of screening/diagnostic tools for frailty, malnutrition, and sarcopenia. These findings increase its relevance if, as shown in recent studies, physicians use to overestimate their knowledge about nutrition (23, 24).
The study strengths include the multidisciplinary team involved in developing the questionnaire, including primary care, nutrition experts, dieticians, endocrinologists, geriatricians, and the access to real-world data providing information with a broader spectrum than controlled trials.
Regarding study limitations, the absence of non-medical professionals (nursing, social workers, pharmacists…) who play a relevant role in nutrition in primary care does not allow to extrapolate the situation to other professional groups, limiting the generalizability of the results to the physicians. In addition, the questionnaire was anonymous, so we did not collect information about gender, age or geographic location, that could provide some additional information about the profile of the professionals targeted for training.
This survey highlights the interest and importance primary care doctors give to nutrition in older patients. Taken together, the results of this study open new avenues for interventions in order to achieve the objectives designed by several national and international bodies to improve the quality of life of older people, by contributing to healthy aging. Our results underscore the presence of several gaps of knowledge both in the field of frailty and nutrition that act as barriers to get those objectives, providing some clues to overcome them. Training focused on the identified gaps such as concepts, diagnostic tools, and general management, could improve patients’ nutritional and functional status. In conclusion, general practitioners and other primary care specialties are aware of nutrition’s impact on healthy aging, but medical education must be revised.

 

Funding sources: Unrestricted Research Grant from Instituto DANONE, Spain.

Ethical statement: This study complies with the current local laws concerning the conduction of studies in Spain.

Conflict of interest: None.

Contribution of authors: LRM participated in conceiving the study, designing the questionnaire, analyzing the data, and writing the drafts and final version of the manuscript. JMM and JAH participated in designing the questionnaire and writing the drafts and final version of the manuscript. JMFG participated in recruiting participants and collecting the responses, data analysis, and the writing of the drafts and final version of the manuscript. AARS, MLLD-U and FSG participated in recruiting participants and collecting the responses and writing the drafts of the manuscript. JLM participated in conceiving the study and designing the questionnaire. All authors approved the final version of this manuscript.

 

SUPPLEMENTARY MATERIAL

 

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