Prioritization of nutrition.

Prioritizing nutrition in practice was mixed, with some describing addressing nutrition with regularity, often dependent on the visit type or patient history. Even if addressing nutrition regularly, many described a limited amount of time spent (Fig 3). Competing priorities and health system constraints were predominant challenges that influence whether nutrition is addressed and the amount of time spent, with PCPs often describing having to fit in multiple tasks in a short visit (Fig 3).

“The number one issue is, like I’ve mentioned several times, is time…most of my visits are about 15 minutes. That also includes time with the patient, plus time that you’re supposed to write the note, put in orders, send medications, and it’s laughably impossible to do all of that. But that’s the way the system is currently.”

Uncommonly PCPs described intentionally starting with nutrition to emphasize importance. More often PCPs commented they try to address nutrition, but it frequently gets “glossed over” or “pushed down the priority ladder” due to time constraints and competing priorities. Some PCPs’ decision to address nutrition was based on patient body mass index (BMI).

“…if I was doing the best medicine I could…I’d be talking about nutrition…with pretty much all my patients, but I find myself doing it in a very reactionary type manner. So, if I notice someone’s overweight or underweight or obese…that’s mostly the times I find myself talking about it.”

Perceptions about brief dietary discussions varied. Some felt time constraints limited their ability to help patients make meaningful changes. On occasion, PCPs expressed concern that brief discussions were “not doing the patient any favors” or could unintentionally contribute to weight stigma by failing to assess “previous attempts at changing a diet.” In contrast, another PCP felt spending even a brief amount of time was beneficial:

“…even spending 2 or 3 minutes just talking about it with patients, I also think has value. Because I think sometimes just bringing it to the forefront of a patient’s thought processes can also have benefits.”

Some described nutrition discussions as a “luxury,” at times because patients had more resources. Others, whose practice was described as outside the traditional fee-for-service model, commented on having the good fortune of more time for nutrition. Due to time limitations, PCPs often described time-efficient approaches. This may look like targeting “low-hanging fruit” dietary behaviors they feel are easier changes to make or trying to “hit the highlights.” (Fig 3)

Reasons nutrition is discussed.

PCPs mentioned various reasons nutrition is discussed, varying by patient population. For adults, weight- and chronic disease-related conversations were common, either during annual physicals or problem visits, whereas in pediatrics the focus was more on prevention through well child visits along with healthy weight promotion, addressing parental questions/concerns, and picky eating counseling.

PCPs described patients commonly initiating dietary discussions, such as presenting with a nutrition-relevant chief complaint or patients seeking their advice about nutrition topics including what to eat, fad diets, supplements, or nutrition optimization for fitness. Patient-driven weight loss discussions were common, including asking about glucagon-like peptide-1 (GLP-1) therapy. In pediatrics, parents often ask questions about feeding or express concern about body size.

Approach to nutrition during patient encounters.

PCPs address nutrition in a variety of ways (Fig 3). Several describe their approach as variable depending on the patient, especially varying by developmental stages in pediatrics, while others describe a method or philosophy employed. How PCPs approach dietary assessment illustrates the variability and inconsistency. PCPs described several methods for assessment that were mostly informal questions, with a questionnaire being less commonly mentioned. A theme in PCPs’ descriptions of addressing nutrition was feeling their approach is fairly general or lacking in detail. Some begin with a general approach and may get into more specifics depending on the patient. The non-specific nature of their approach to nutrition was a common frustration as many feel they are not giving actionable guidance patients can easily implement.

Of PCPs who discussed dietary intervention in relation to pharmaceutical management, some PCPs described prioritizing medication first, especially given time limitations and competing priorities.

“I’ll spend the bulk of my time explaining…why I care about this illness…talking through what medication options there are…and then why someone’s not taking it…playing around with their insurance to try to get them an affordable medication. And then I feel like I end up trying to squeeze the diet and exercise in there very last…”

Occasionally PCPs described offering a lifestyle change trial or using nutrition in conjunction with medication. Some commented on medication as protecting patients from disease consequences but lifestyle change as a way for patients to have agency over managing their condition.

“I try to make this point to a lot of my patients with diabetes that…medicine does not cure diabetes. We’re really just managing secondary risks…At the end of the day, there’s no amount of medicine that I could give that outpaces poor lifestyle decisions, namely with diet. I really try to just set that up…putting it more into their ownership to hopefully recognize that they are in control of this journey, rather than it being on what I am prescribing them…”

Multiple PCPs described approaches being informed by concern for judgment or stigma about dietary behaviors or weight. Approaches to weight counseling in general were variable (Fig 3). Discussions about weight counseling reflected a tension between an emphasis on weight to address associated health risks and a concern about an overemphasis on weight harming patients. This tension is illustrated by contrasting reflections by two pediatricians. One grappled with concern about detrimental effects of obesity when parents request weight not be discussed:

“That’s one of the most challenging things I face with this because I feel like, as their doctor, if they weigh 240 pounds when they are 12 years old, there is nothing more important to their health…That is the thing that is going to kill them, to shorten their life, to make their life more miserable right now…if the fact that the parent is saying that, they clearly are already struggling with some body image issues…that’s something that I really struggle with.”

Another pediatrician struggled with causing harm when discussing weight:

“I am…aware of all the stigma, shame, and harm around [obesity] and the ways in which…people can have very unhelpful and harmful and shaming conversations, and so I just I try to be very, very, very thoughtful about how I frame all of these discussions…And that’s probably the most challenging thing is the low confidence that I’m going to be able to help instead of harm…”

PCP challenges and frustrations addressing nutrition.

PCPs described several pain points throughout the patient visit and across multiple levels that impact their ability to address nutrition with patients (Fig 3). Themes included time limitations/competing priorities and patient barriers to implementing recommendations. Beyond the clinician and patient levels, PCPs reflected on system-level challenges.

“…cultivating that interest…in limited time slots and a lot of other things to address is just difficult and it feels like you’re pushing a rock up a hill when the rest of the world has cheap, cheap, low-quality food readily advertised at you 24 hours a day…”

While participants described frustrations with their training, for some this was not the primary challenge as some PCPs described knowledge as only part of the problem. For example, this PCP describes the difficulties patients face changing dietary habits:

“I don’t know that…the times where we fail is necessarily because I lack in my knowledge…it’s just the challenges that come with habit…It’s very challenging for patients to change…People are overworked and stressed and it’s just tough sometimes to take the time to…do the things that are needed to do when it comes to nutrition.”

Due to system-level barriers, some expressed more training in nutrition may not make a difference. As one PCP described, “it feels like too big of a hill to climb.”

PCP experience with nutrition support and services.

PCPs reflected on their experience with nutrition support and services, including resources, referrals, and ancillary services to support patients with dietary change. In general, extra support is welcomed but inconsistent.

Whether, how, and what resources PCPs are using were variable with many challenges (Fig 3). Commentaries about resources reflected a gravitation toward ones that are more readily accessible, time-efficient, and easy to conceptualize. Regularity in using resources was variable, with some mentioning resources used often, at times for a specific condition. Preferences varied for using resources in clinic to support counseling versus sending the patient with a reinforcing handout. Examples of resources included visual aids (e.g., healthy plate), handouts on specific diets, and parental guidance resources. Uncommonly, PCPs mentioned resources embedded in the electronic health record system or programs connecting patients with healthy food. Many PCPs described not typically using resources or having limited to no access to them. PCPs expressed multiple frustrations with resources, including dissatisfaction with what they currently use and how much effort is required to find credible resources.

RDs were the predominant referral/ancillary service mentioned. PCPs often praised RDs as a helpful resource, especially for their expertise and time. In general, ease of RD utilization was variable with those with access to RDs in their clinic or health system typically describing their experience collaborating with RDs as easier or more positive (Fig 3). Several PCPs described challenges limiting their ability to rely on RDs for nutrition support, an experience one PCP described as “it ends up falling on me.” Access to RDs was a predominant barrier.

“…if I place the referral…I’m worried that patients are not actually gonna get the care or support because we don’t have that [nutrition] team as much anymore. I realized that I might be one of the few people that has an opportunity to help support patients with that.”

Another challenge PCPs commonly expressed was patient receptiveness to or not following through with referrals for a variety of reasons. This PCP describes the value of RD support considering time limitations and competing priorities but the reality that patients may only be willing or able to have a brief discussion with their PCP:

“In a visit when you’re trying to do medication management, make insulin changes, it’s really hard to have a detailed conversation with somebody about their diet. And that’s where having a separate dietitian appointment is really powerful for folks, but sometimes…they’ll only be comfortable with, or they only have time for the brief intervention you can do right in the room.”

Value of nutrition.

PCPs often expressed valuing nutrition, calling it “pretty powerful” or an “essential aspect of my patients’ lives.” Many described it as having an important role in primary care, especially for prevention or management of disease or reducing or eliminating medications. While PCPs expressed nutrition deserves more attention in practice and training, in reality it is a lower priority or challenging to address.

PCP satisfaction and self-perceived efficacy with their current approach.

When asked how well their current approach is going for them, several expressed it was not going well or they do not feel effective, multiple felt their approach was going “okay” or described a mixed experience, and a limited number described their current approach as going well. Many described efficacy as time- or patient-dependent, but for one PCP, success was measured by follow-through with their guiding framework:

“I’ve worked out a method where it doesn’t matter to me what the patient brings because I’m not measuring my success by whether they make the change that I’m recommending…I’m just measuring my success about whether I follow through with my principles of things like motivational interviewing…”

Multiple PCPs described seeing success in a minority of patients, and this was viewed by some PCPs as exciting and by others as not being very effective. Some expressed feeling resigned that “there’s not really much I can do” or that a brief intervention could be more harmful than helpful. This PCP expressed that despite the multiple challenges, at least they are doing something:

“Unfortunately, around here, the cheapest food is the lowest quality food and sometimes you feel powerless to address that in a clinical setting…it can be really frustrating…So focusing on little things that we can do in the clinic that can actually maybe get patients to change the way they’re doing things is…where we come in and can maybe in some cases actually move the needle just a little bit.”

PCP “delights” in addressing nutrition.

When asked what they find easy or exciting about addressing nutrition, PCPs expressed enjoyment in shared decision-making and relating to patients through conversations about food. PCPs also appreciate conveying the power of nutrition to give patients agency over their health.

“…something that resonates with me…is…we have control over some of these medical conditions without necessarily using medicine. And so I think patients feel empowered once they realize, hey, just by changing what I eat or changing my approach to certain things, I could potentially reverse this condition or significantly impact this condition, or even come off some medications….We don’t always get a chance to ‘de-prescribe’ medicines.”

Some PCPs described enjoyment in sharing in patient excitement, success, or “Aha moments,” when patients make the connection that dietary change can help them feel better and improve their health.

PCP role in addressing nutrition.

PCP perceptions of their role in addressing nutrition varied, and PCPs described multiple factors influencing their role. Fig 4 schematically delineates the variable PCP perceptions of their role, perceived relative importance of PCPs advising about nutrition, and identified factors influencing PCP perceptions of their role. When asked how important it is to them to be able to comfortably advise their patients about nutrition versus referring to a specialist, PCPs overwhelmingly expressed that it is important to them to have the ability to advise patients in nutrition, with rare exception. Reasons for the importance of PCPs advising varied, described as a want, a need, or both. For some, the importance depended on the ease of RD utilization. The following characterizations of the PCP role in addressing nutrition provide examples of the variability of PCP perceptions of their role and illustrate many of the influencing factors outlined in Fig 4.

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Fig 4. PCP Participant perceptions about their role in addressing nutrition.

This schematic outlines the relative importance expressed by PCP participants regarding their ability to comfortably advise their patients about nutrition and a variety of factors influencing their perceptions. The predominant sentiment was that it is important to them to be able to advise in nutrition, reflected by the larger font size. Less commonly, PCPs described the importance as dependent on how easy their experience is with RD utilization or that it is not important for them to advise. A large portion of factors influencing PCP perception place nutrition advising within the scope of their practice. Representative quotes for many of the influencing factors are provided. Abbreviations: PCP (primary care physician), RD (registered dietitian).

https://doi.org/10.1371/journal.pone.0354813.g004

1. I. “Fits very well into what being a primary care doctor means to me”

Some PCPs, regardless of RD utilization challenges, described the need or desire to advise patients in nutrition, often perceiving this as part of their job. Reasons described by PCPs that characterized dietary counseling as within the scope of their practice included patient preferences or expectations, how frequently nutrition comes up, and perceiving nutrition as aligning with their role as a generalist.

“That’s like our bread and butter is thinking through how we can help keep patients healthy and just develop healthy lifestyles. So I think it’s super important…”

PCPs also described RDs as the specialist they as generalists could refer to, especially to give patients more time and detailed guidance. The concept of PCPs at least starting the conversation about nutrition, whether or not RD support was an option, emerged as a theme.

1. II. “They may only have me”

RD utilization challenges were a common reason PCPs felt it is important for them to comfortably advise their patients about nutrition.

“…a lot of times when we put the referral in, it either never goes through, as in the patient never schedules the appointment, or they go once and they don’t go back because it was a cost-limiting factor. And so I think it’s really important from a primary care perspective that I have some tools and education to be able to provide that…I think the barriers to having that done consistently are high enough that being able to do it in primary care makes a lot more sense.”

1. III. “Not enough time just to talk about medical things”

Some PCPs described dietary counseling as not a good use of their time due to health system barriers.

“I think in my ideal way that our medical system would work and the format that I would like to practice in, it would be really great if I had greater confidence and ability there. I think the reality of our system as everyone’s getting more specialized, and also, frankly, patients tend to get more sick, I don’t see getting to be able to do that where it makes sense with the time I have available with my patients.”

Uncommonly, PCPs characterized nutrition as outside the scope of their practice, especially given how the health system is structured with PCPs facing competing priorities and time constraints.

1. IV. “It’s both referring and talking about it myself”

Several PCPs described their role in nutrition as a balance of advising and referring, with PCPs and RDs having distinct and important roles, often with the PCP getting the “ball rolling.” However, despite many PCPs wanting to involve RDs, at times that brief intervention starting the conversation is the only option for patients due to RD utilization barriers. Adding to the complexity, some PCPs expressed concern about patients receiving conflicting recommendations and wanting to be on the same page with RDs.

“…if the question is how important is it for me to be able to address it period, that’s super important. If it’s I wanna do it, and I don’t want nutritionists involved, I don’t think that’s the case. Again, I would love for that resource to be more utilized and for us to find a way to be on the same page about that. I’m not opposed to working on that hand in hand.”

PCPs recognize their role is distinct from RDs but also value addressing nutrition themselves.

“I know that I’m not a dietitian, but I would just like to have [dietary counseling] be a consistent part of my visits with patients, too.”

A. PCP role: PCPs need clearly defined expectations for their role as a generalist in addressing nutrition that prioritizes the importance of nutrition in their patients’ health and matches the reality of clinical practice demands.

Despite how often PCPs are addressing nutrition, whether patient- or physician-initiated, the role and responsibility of PCPs in addressing nutrition lacks clarity, as Fig 4 demonstrates. Findings from this study support nutrition as within the scope of primary care practice for physicians to address in routine patient care, and dietary guidance as a means to prevent or treat disease already aligns with the definition of medical practice set by the Federation of State Medical Boards [43]. PCPs value nutrition, and patients expect their physician to advise them in nutrition. While they value the expertise of RDs, when available, PCPs also recognize they may be the only ones to counsel patients about diet given RD utilization challenges, a sentiment previously shared by medical trainees [35]. RD access limitations have been reported by other PCPs [44]. While PCPs expressed that nutrition is an important aspect of primary care and that they can motivate patients to make dietary changes, they repeatedly conveyed the low priority of nutrition in training and clinical practice, characterized in both domains as getting pushed to the end, glossed over, or lacking in specifics to give practical guidance to patients. The lack of prioritizing nutrition, especially in clinical curricula, may influence trainee attitudes about their role in dietary counseling by signaling to trainees that nutrition is outside the scope of their practice [45]. In systems-based medical curricula [46], integrating nutrition throughout presents challenges to prioritizing nutrition as nutrition influences multiple organ system, such as cardiovascular [47] and endocrine [48], and subsequently nutrition may be “sprinkled” throughout, as one PCP described. How PCPs are accessing nutrition resources for use in practice reflects a similar pattern of resources not concentrated in any one easy-to-find place.

Another reason nutrition may be less prioritized is that PCPs have clear roles in diagnosis and treatment, reflected by PCPs prioritizing “medical things” or “doctor things.” PCPs have responsibilities that other team members cannot take on, and it makes sense to delegate nutrition care, deserving of more time and attention that RDs are equipped to provide, to the nutrition expert. However, current challenges with RD utilization make this only an option for some patients, and, with the frequency that nutrition comes up, PCPs need to be equipped with frameworks and strategies to discuss diet with patients that they can implement regularly. Additionally, while the RD is the nutrition specialist, dietetics is a profession and training path outside of the traditional medical specialization trajectory of medical school, residency, and fellowship that is familiar to physicians and that promotes learning from and regular interaction with the specialist. The lack of overlap in training paths could contribute to silos between dietetics and medicine, which may hinder collaboration and contribute to a discontinuity of care with nutrition, as PCPs expressed concern about patients receiving conflicting advice.

B. Nutrition training and guiding frameworks: PCPs need formal training in guiding frameworks and strategies to approach the prevention and management of common diet-related chronic diseases that aligns with a clearly defined and realistic role in addressing nutrition with patients.

Findings align with the longstanding recognition that physicians are inadequately trained in nutrition [9,10,45,49], despite patient expectations [50]. Recent cross-sectional studies document no evidence of improved nutrition knowledge among PCPs more proximal to training compared to more distal [51] and no association between how often physicians give nutrition advice and how long they have been in practice [52], suggesting a continued need to consider and address how physicians are trained in nutrition. Results from this study add to the picture a deeper understanding of the consequences of deficiencies in formal nutrition training in medicine, namely that physicians are resorting to learning nutrition knowledge they need on their own in informal, ad hoc ways. PCPs are already busy, adding to the challenge of learning and keeping up to date with nutrition. Deficiencies in nutrition training and subsequent self-directed learning also contribute to variations and inconsistencies in recommendations and approaches, as PCPs are not being trained in guiding frameworks and strategies for dietary counseling, particularly in dietary counseling for risk reduction related to chronic diseases they are commonly managing. For example, an area demonstrating a need for formal training in a guiding evidence-based and health-promoting framework is weight counseling, given the tension expressed by PCPs trying to promote health and minimize harm, as weight stigma in health care and how physicians are trained in weight management are known problems [53–55].

Aligning with the variability of approaches reported by PCPs in this study, medical trainees have expressed frustration with lacking a guiding framework for dietary counseling [35]. Fig 5 depicts a self-perpetuating loop between the lack of formal training, lack of guiding frameworks/strategies, and lack of clarity in the PCP’s role in addressing nutrition. These deficiencies are especially notable for commonly managed chronic diseases. Clearly defining the role of the PCP can help break this cycle and inform guiding dietary counseling frameworks and strategies for the generalist and subsequently help distill realistic and priority nutrition competencies for physicians to be taught in a more systematized way. Moreover, establishing guiding frameworks for dietary counseling for health promotion and chronic disease risk reduction for the generalist in primary care can serve as a benchmark for PCPs to measure success, judging themselves based on whether they follow through with the guiding principles expected of them, which in turn can improve PCP confidence and satisfaction addressing nutrition. Given the predominant pain point of patient motivation, assessing patient readiness to change and motivational interviewing (MI) are important skills physicians are introduced to in medical training and ones that can be harnessed for dietary counseling training as it helps physicians recognize readiness to change, align expectations accordingly, and work more effectively in tandem with RDs. MI can also reduce shame and stigma in addressing dietary behaviors [55]. While RDs are highly skilled in MI [56], it is often the PCP who sees patients in the early stages of readiness to change, and MI may even be useful for motivating patients to visit with RDs for more in-depth support.

C. Interprofessional collaboration: PCPs need improved strategies to more effectively collaborate with dietitians to support patients with nutrition care, clarified guidance for referring patients to the nutrition specialist, and practical frameworks and strategies for addressing nutrition as the generalist, especially when RD support is not an option.

Despite the interconnectedness between nutrition and health, results suggest dietetics and medicine are relatively siloed professions, beginning in medical training as previously discussed. In a recent survey of family physicians, 64% of participants reported not having an on-site RD [44], making it more challenging for PCPs and RDs to benefit from face-to-face interaction and regular communication that support a collaborative working relationship [57]. Disconnect is also reflected in our findings regarding PCP experiences with RD collaboration, such as PCPs lacking awareness of what RDs are recommending and expressing concerns about being “on the same page.” PCPs have previously reported uncertainty surrounding RD support and how to locate RD services as a barrier [44], while another study documented an appreciation for consistency and “having a shared language” in interprofessional team care [58]. Interprofessional education (IPE) and team-based care are emphasized in accreditation standards during medical training [33,59]; however, PCPs infrequently mentioned RD involvement in their formal training. In clinical practice, a clear understanding of roles is vital to fostering collaboration in interprofessional team-based care [57]. Clarity in expectations of physicians and subsequently in the dynamics of the physician-dietitian team approach can inform how RDs teach medical trainees through IPE and could improve RD utilization by supporting physicians with guidance for getting the “ball rolling,” making referrals, and more effectively endorsing RDs.

Given that results from this study support dietary counseling as within the scope of primary care practice, conceptualizing nutrition care as a spectrum of PCPs at least initiating dietary discussion and focusing on high-yield recommendations then referring to the specialist when appropriate may add clarity to the PCP’s role and improve RD utilization. In a recent survey, health care providers, the majority physicians, reported advising about nutrition more than referring to RDs for wellness promotion and chronic disease conditions, supporting the concept of PCPs as the generalist in the spectrum of nutrition care [52]. RDs have the time and expertise while PCPs have the longitudinal and trusted relationship with more opportunities to engage with patients on a regular basis. A shift from non-overlapping roles to a spectrum of team-based nutrition care would be beneficial as flexibility is needed based on what patients are willing and able to do, whether it’s a brief intervention with their PCP during a routine visit or RDs available in clinic for co-visits at no extra cost to the patient. Formal training of physicians in guiding frameworks and strategies for dietary counseling could support not only PCPs in those initial discussions and in brief dietary counseling but also patients in receiving continuity of nutrition care when seeing the specialist. Given that RD support is not always an option, general frameworks for addressing nutrition in primary care would better equip PCPs to support their patients in having greater agency of their health through diet.

Simultaneously, reforms to RD access are needed as PCPs repeatedly expressed frustration with the cost and insurance barriers to accessing RDs, a top barrier reported by PCPs previously [44], while those with RDs in their clinic described easier collaboration. RDs are increasingly more accessible for telehealth visits [60], which may add helpful flexibility for patients. Patient preferences for brief dietary discussions and not wanting to have a separate appointment are potential factors to consider in exploring and designing strategies to better utilize the valuable support RDs provide, such as through the MD-RD co-visit model that one participant described. Innovative models for dietetic support may help improve RD utilization, such as shared medical appointments with RDs [61], culinary medicine integration in RD support [56,62]. or RDs engaging with patients shopping for groceries [63].

D. System and societal factors: PCPs need frameworks, strategies, and improved resources for addressing nutrition within the context of system and societal barriers and for these barriers to be thoughtfully addressed through policy, systems, and environmental change strategies.

Multiple calls to action to address inadequacies in nutrition training in medicine address a critical and urgent need [9–14]; however, the results from this study highlight the need to simultaneously address system- and societal-level challenges. While PCPs continue to report that they need more formal training in nutrition, particularly in practical dietary counseling competencies, nutrition knowledge was not always the top concern compared to system- and societal-level barriers, an experience shared by other PCPs [20]. Limited time was a running theme as PCPs shared their experiences trying to fit in nutrition, in line with prior sentiments shared by PCPs over the past few decades [15,17,20,21,23], and this was related back to the health system and patient panel expectations. Of note, participants practicing outside the traditional fee-for-service model relished the extra time and flexibility to make nutrition more of a focus. The relationship between primary care delivery through alternative primary care models, such as value-based care and direct primary care, on quality of nutrition care is deserving of further exploration. Many RD utilization challenges related to health system barriers, such as insurance coverage constraints and the cost to patients as well as funding barriers to support RDs on staff, suggesting a need for health services, health payer, and policy reforms. Another predominant challenge was the impact of the food environment on patients’ abilities to make dietary changes, including the cost of food and an overabundance of inexpensive, ultra-processed foods readily accessible to patients that at times made PCPs feel powerless to effect change. Simultaneously, few PCPs reported offering resources connecting patients with food, such as Food is Medicine interventions, perhaps reflecting underutilization of a resource addressing many barriers patients face trying to follow their physician’s recommendations [64].