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 Table of Contents  
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 38-45

Association of pharmacotherapy with clinicians' nutritional counseling practices to diabetic and hypertensive patients

1 Department of Adult Nursing, College of Nursing, University of Duhok, Duhok, Iraq
2 Avrocity Family Medicine Center, Duhok General Directorate of Health, University of Duhok, Duhok, Iraq
3 Department of Family and Community Medicine, College of Medicine, University of Duhok, Duhok, Iraq
4 Department of Internal Medicine, Azadi Teaching Hospital, Iraqi Kurdistan, Iraq

Date of Submission27-Apr-2021
Date of Acceptance21-May-2021
Date of Web Publication26-Jul-2021

Correspondence Address:
Mr. Deldar Morad Abdulah
Department of Adult Nursing, College of Nursing, University of Duhok, Duhok
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jphpc.jphpc_7_21

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Background: Nutrition counseling is an important tool for encouraging healthy nutrition behaviors among individuals. The nutritional imbalance is rising worldwide, leading to the emergence of various diseases. Physicians have an important role in impeding healthy nutrition in patients. Aims and Objectives: The role of patients prone to pharmacotherapy on nutritional counseling and management (NCM) practices of clinicians to patients with diabetes or hypertension in the routine clinical practice was explored in this study. Materials and Methods: In this cross-sectional study, a total of 267 clinicians, including family doctors, general practitioners, and internists were purposively included. The attitudes toward NCM and their practices in routine clinical working were examined through the self-reported technique. Results: The mean age of the physicians was 34.18 and had experience for 5 years. A small percentage of them have completed the nutrition training course (26.59%). The study showed that different kinds of NCM, including nutritional assessment, therapy, and education, were presented to diabetic and hypertensive patients. The majority of the physicians emphasized their role (88.1%) in promoting nutritional therapy. Besides, most of them (88.0%) mentioned that a high priority must be given to NCM in routine clinical practice. The prone of patients to pharmacotherapy rather than diet therapy was determined to be a barrier to the NCM to diabetic and hypertensive patients. Conclusions: This study showed that physicians had good attitudes toward NCM; however, the prone of the diabetic and hypertensive patients to pharmacotherapy rather than diet therapy impedes the NCM by clinicians.

Keywords: Attitudes, hypertension, nutritional counseling and management, pharmacotherapy, type 2 diabetes mellitus

How to cite this article:
Abdulah DM, Ahmed SK, Mustafa R, Saeed MS. Association of pharmacotherapy with clinicians' nutritional counseling practices to diabetic and hypertensive patients. J Public Health Prim Care 2021;2:38-45

How to cite this URL:
Abdulah DM, Ahmed SK, Mustafa R, Saeed MS. Association of pharmacotherapy with clinicians' nutritional counseling practices to diabetic and hypertensive patients. J Public Health Prim Care [serial online] 2021 [cited 2023 Feb 6];2:38-45. Available from: http://www.jphpc.org/text.asp?2021/2/2/38/322308

  Introduction Top

Nutrition counseling is an important tool for encouraging healthy nutrition behaviors among individuals. Nutrition is a crucial ingredient of health and development. Better nutrition is associated with improved health, a stronger immune system, safer pregnancy and childbirth, lower risk of noncommunicable diseases, and longevity. The role of nutrition in both healthy and nonhealthy participants is also well confirmed. The nutritional imbalance is rising worldwide, resulting in the emergence of various chronic diseases.[1]

The Middle East has witnessed considerable changes in lifestyles, including nutrition transition owing to urbanization over the last four decades. In this period, the traditional foods of the population have been replaced with the Western foods characterizing by fast foods with high fat, sugar, and salt accompanying by sedentary lifestyles and a reduction in physical activity.[2] The nutritional transition is rising due to urbanization, industrialization, and the changes in the economic status of the population. The evidence of literature shows that the rising incidence of obesity is posing a threat to the population to almost equal scale to that of under-nutrition. Undernutrition continues to be a significant issue, but the prevalence of overnutrition is rising as a significant problem; particularly in urban areas.[3]

There is an increasing trend in the prevalence of other lifestyle or nutrition-related diseases such as hypertension, diabetes mellitus, and cardiovascular diseases in Africa and the Middle East[4],[5] contributing to rising trends in the mortality and the morbidity of nonrelated non-communicable disease. Nutritional counseling has defined a type of assessment in which a counselor analyzes different health needs regarding the diets and physical exercises.[6]

Physicians play a strategic role in imparting nutrition advice to their patients during daily encounters in health-care settings. Moreover, they can play an essential role in reducing hypertension and diabetes complications by giving nutrition counseling. Dietary and physical activity changes are required not only to meet poor and overnutrition but also to prevent and manage several chronic diseases that arise in epidemic rates.[7]

The interest in the role of physicians as efficient and effective sources of the promotion of appropriate nutritional practices is rising. Therefore, it is so important to examine the obstacles in the way of a low practice of clinicians in nutritional counseling and management practice (NCM) in clinical settings. Al-Muammar[3] reported that only 7.9% of the clinicians practiced all aspects of NCM, including nutritional assessment, therapy, and education in Saudi Arabia. Russell and Roter[8] analyzed the 429 visits of 49 physicians and found that health promotion discussion was conducted in >53% lasted 4.5 min only. In particular that a considerable percentage of patients (48%) reported that they have not received the nutritional counseling or eat fewer higher-fat/high-cholesterol foods by remaining participants (52%).[9]

Given the emerging burden of chronic diseases associated with nutrition and lifestyle, physicians must pay their attention adequately to advise their patients appropriately, about nutrition and lifestyle. Physicians are believed to be the best and effective advisors/counselors for any health-related issues and are the most trusted. Therefore, it is significant to explore the clinicians' nutrition and lifestyle advice toward patients with hypertension or diabetes.

The focus of the previous studies conducted on nutritional counseling was a variety of chronic diseases with no specific concentration on limited medical specialties as some health conditions do not need nutritional counseling.[3] These kinds of efforts are noteworthy for an effective continuous medical education program on NCM. In the era of the rapidly growing prevalence of diabetes and hypertension, it is important to explore the present attitudes and practices of physicians.

NCM practices of clinicians to patients with diabetes or hypertension in the routine clinical practice, along with some barriers were explored in the present study. The role of patients prone to pharmacotherapy on NCM practices of clinicians to patients with diabetes or hypertension in the routine clinical practice was explored in this study. The authors expected that majority of the clinicians do not adhere to all aspects of NCM in their routine working in hospitals.

  Materials and Methods Top

Study design and sampling methods

A total of 267 clinicians with different education levels and specialties whether general practitioner, internist or family doctor of both gender and regardless of their sociodemographic perspectives and working conditions were purposively included in this cross-sectional study. The clinicians were invited from two hospitals and two family medicine centers from the public sector in Duhok city locations-Iraqi Kurdistan in 2018 following taking ethical approval from the corresponded ethics committee. The data were collected between October and December 2018.

The clinicians who participated in the study were working in multispecialty hospitals, including one general, one emergency hospital, and two specific centers of family medicine. In this study, family doctors, general practitioners, and internists were invited because these kinds of physicians manage adult diabetic and hypertensive patients in accordance with the local health system. These two hospitals and one family medicine center were selected as the diabetic and hypertensive patients are treated and managed in these hospitals, apart from the management of some patients by general practitioners in primary health centers. The clinicians were asked to answer the NCM the last year.

The clinicians who participated in this study were actively working in the public sector, either one of the four mentioned health settings. For the present study, a list of physicians working in the corresponded health settings (without contact information) was taken from the Duhok General Directorate of Health. Of the total 311 eligible doctors working in these three health settings and were invited into the study, 267 of them filled the questionnaire (response rate: 85.85%).

Measurement principles

The entire information of the present investigation, whether general or nutrition-specific information was obtained through filling an online self-administered structured questionnaire generated in Google Forms. The forms were sent to the clinicians through E-mail contact or their social media accounts following taking their E-mails by the snowballing technique. The questions on nutrition practice and attitude toward nutritional counseling were designed in accordance with the literature.[3] The persons' variables were age (year), gender (male/female), physician specialty, years of experience in medicine, and participation in a training course on nutrition therapy.

The attitudes questions were designed according to the literature,[3] and clinicians were asked to rate the questions on a 5-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree). The role within your specialty in promoting NCM practice, NCM practice must be part of the usual activities of a physician. The physicians are reluctant to NCM practice to diabetic/hypertensive patients in outpatient clinics. There is a limited time in outpatient clinic owing to heavy demand to perform the NCM to diabetic/hypertensive patients. Diabetic/hypertensive patients have not adherence to nutritional therapy. You find the NCM practice an easy task in your daily medical practice. There are sufficient educational courses in nutrition for diabetic or hypertensive patients. There is not sufficient evidence for the benefit from the NCM practice to diabetic/hypertensive patients. The physicians have not sufficient nutritional knowledge to implement NCM practice to patients. Physicians must give a high priority to NCM practice for diabetic and hypertensive patients. The diabetic/hypertensive patients are prone to pharmacotherapy rather than diet therapy. There are sufficient resources in the outpatient clinic to implement nutritional counseling. The estimated time required to fill the questionnaire was 10 min only.

Statistical methods

The frequency distribution was performed for descriptive purposes of the study, including general characteristics, attitudes toward nutritional counseling, and practice. The difference between NCM of diabetic and hypertensive patients was examined through the Pearson Chi-squared test. The barriers of NCM to diabetic and hypertensive patients were examined in the binary logistic regression model. The P < 0.05 was considered to reject the null hypothesis. The statistical calculations were performed by SPSS version 24:00 (IBM Corp., Armonk, NY).

Ethical aspects

The ethical clearance was taken from the corresponded local health ethics committee of Duhok General Directorate of Health registered as 12072017-5 on July 12, 2017. The clinicians were free to reject to participate in the study. The confidentiality of their personal information was guaranteed at the time of publication.

  Results Top

The mean age of the physicians who participated in this investigation was 34.18 years. The median experience of the physicians was 5.0 years. The majority of them were males (83.52%), and the male:female ratio was 5.07:1.0. Close to half of the participants (49.06%) were internists, followed by general physicians (41.95%), and a small percentage of family doctors (8.99%). A small percentage of the doctors have participated in a nutrition training course (26.59%), [Table 1].
Table 1: Baseline characteristcis of participants

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Prevalence of nutrition counseling and management

The study revealed that the clinicians who participated in the study adhered to national counseling to diabetic and hypertensive patients mostly through individual nutrition education, 37.3%, and 40.3%, respectively, followed by the nutritional assessment of patients upon medical and clinical examinations both to diabetic (4.5%) and hypertensive (9.0%) patients. However, a combination of the individual nutrition assessment, education, nutrition therapy, group nutrition education, and giving handouts were used by the clinicians to diabetics (22.4%) and hypertensive patients (22.4%). The time dedicated to the patients for nutritional assessment or education by clinicians was 5 min only [Table 2].
Table 2: Adherence and sort of nutritional counseling to diabetic and hypertensive patients

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Similarly, the most common sort of nutrition advice to diabetic and hypertensive patients was presenting general information about healthy eating, 23.9% and 14.9%, respectively, followed by nutritional advice in accordance with the disease and clinical presentations of both diabetic and hypertensive patients. The overall time dedicated to presenting these sorts of nutritional counseling was 5.0 min only. All aspects of NCM were performed by 13.4% only to both diabetic and hypertensive patients [Table 2].

Attitudes of clinicians

The majority of the clinicians accepted and emphasized (46.3%) the critical role of their specialties in the promotion of NCM to diabetic and hypertensive patients and accented that it must be a part of routine activities of a physician (98.5%). The participants reported that the clinicians are reluctant (62.6%) to NCM practice to outpatient clinics. However, most of them (86.6%) reported that there is a limited time in the outpatient clinic owing to heavy demand to perform nutrition counseling. Moreover, they reported that diabetic/hypertensive patients have not adherence to nutritional therapy (65.7%) [Table 3].
Table 3: Attitudes of clinicians towards nutritional counseling to diabetic and hypertensive patients

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Approximately, 61.2% of doctors agreed on the nutrition counseling and management practice as an easy task in their daily medical practice but mentioned that there not sufficient educational courses of nutrition for diabetic or hypertensive patients (80.6%). They accented on the evidence-based effect advantages of the NCM practice to diabetic/hypertensive patients (65.6%), [Table 3].

Based on the information taken from the doctors who participated in the present study, 52.3% of them believed that clinicians have not sufficient nutritional knowledge to implement NCM practice to their patients. Hence, the majority of them agreed that physicians must devote a high priority to NCM for diabetic and hypertensive patients (88%) despite insufficient resources in the outpatient clinic to implement nutritional counseling (59.7%). In general, more than two-thirds of the doctors (73.1) agree or strongly agree that the patients are more prone to pharmacotherapy rather than diet therapy [Table 3].

Barriers to nutrition counseling and management

In binary logistic regression, nutrition adherence of clinicians to diabetic/hypertensive patients was considered a dependent variable and general information and nutrition-related factors as the independent variable. The analysis showed that the physicians do not advise the diabetic/hypertensive patients to nutrition therapy since patients were prone to pharmacotherapy rather diet therapy (P = 0.044; odds ratio: 0.386; 0.152–0.976), as presented in [Table 4].
Table 4: Barriers of adherence of clinicians towards nutrition counseling to diabetic/hypertensive patients

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  Discussion Top

The attitudes and practice of family doctors, internists, and general practitioners toward NCM to diabetic and hypertensive patients, as well as, the impeding factors were determined in this study. The study found that the prone of patients to pharmacotherapy rather than diet therapy was determined to be a barrier to the NCM to diabetic and hypertensive patients.

The study revealed that different aspects of NCM, including nutritional assessment, therapy, individual nutrition education, group nutrition education, handouts practiced by clinicians in this region. Overall, all aspects of NCM, including nutritional assessment, treatment, and education, were practiced by 13.9% of the clinicians only. Of the total 267 physicians who participated in the present investigation, only 71 (26.59%) of them have completed a training course on nutritional counseling. The literature has shown that trained clinicians are more likely to practice NCM and deliver nutritional advice to patients.[10] We could not find this kind of association in this study (data not shown).

The nutritional practice has a low priority to clinicians in hospitals and outpatient clinics[11] and doctors are reluctant to address weight management conditions in patients who are not extremely overweight[12] and have not sufficient and effective role in the healthy eating promotion and physical activity adherence.[13] For example, Mellen et al.[14] reported that between 1999 and 2000, over 137 million patients visited with a diagnosis of hypertension, while nutrition and exercise counseling was delivered to 35% and 26% of visits, respectively. The low priority to the nutritional counseling whether due to inadequate time, knowledge, clinicians' self-efficacy, and skills[15] must be received special attention in the health system as the physicians are the most credible resource for medical information and have the best abilities to foster the patients to healthy lifestyles.

The study found that all aspects of NCM were performed by 13.4% only to both diabetic and hypertensive patients, and most of them perform a nutritional assessment. This finding raises the concern to the health system and education in this region despite a wide variety of evidence on the effectiveness of nutrition-based interventions[16] and despite the majority of them (68.7%) reported that NCM must be a part of the usual activities of a physician and positive way of the majority of them to the role of their specialties. The doctors in other regions have accented the critical role of dietary counseling as a significant responsibility of physicians.[3] Maybe clinicians do not give the top priority to the NCM as these kinds of interventions need a long-term period. For instance, Torres et al.[17] showed a reduction of 3.6 kg in weight of overweight hypertensive patients following 4 years. The national data of the US reveal that close to half of the diabetic patients received education on diabetes.[18] One study that included 18,000 diabetic patients reported that only 9.1% had at least one nutrition visit within 9 years.[19] Disease self-management, support, and nutrition therapy are the necessary components of diabetes care and improvement in diabetic patients.[20]

The prone of the diabetic and hypertensive patients to pharmacotherapy rather than diet therapy was determined to be the barrier for NCM in this investigation. More than 70% of the physicians who participated in this study agree or strongly agree that the patients prefer pharmacotherapy. Worku et al.[21] assessed the level of dietary practice and their related factors in T2DM patients and reported that the patients have a poor level of dietary practice. The strongest associated factor with the poor dietary practice was not getting nutrition education at hospitals. Good diabetes management is considered to be a balance between eating, exercise, and medication.[22] The lack of appropriate professional dietary assessment, follow-up, and advice by health-care providers are considered to be the main factors influencing dietary practice in T2DM patients.[23] The patients who get nutrition education follow the clinicians' advice and have better knowledge of the food disease association. Low level of educational status and lack of previous exposure to dietary education is determined to be the significant factors associated with nonadherence to dietary practice in T2DM patients.[24],[25],[26] Having nutrition education programs improve self-care dietary practices and glycemic control and enhance the knowledge and skills of patients to optimize their abilities to self-manage their diabetic nutrition. The shortage in the dietician/nutritionist and other trained health-care professionals in the principles of nutrition could be an important factor in giving low priority to nutrition in hospitals.

Regarding the hypertensive patients, Shim et al.[27] reported that most of the patients with hypertension limit the sodium intake and consume a healthy diet, 79.7%, and 77.5%, respectively. However, the adherence to diet management in normotensive and hypertensive was 34.0% and 35.5% only, respectively. The hypertensive patients were more likely to have lower dietary adherence scores compared to normotensive individuals. The hypertensive patients reported that they cannot change their dietary habits and had lower self-efficacy to change their diets. Health education and dietary management were determined to be two of the important factors associated with good dietary adherence in hypertensive patients.[27] The low adherence of hypertensive patients has been reported elsewhere. They have the best adherence to medication, followed by lifestyle modifications like drinking and physical activity and have the lowest adherence to a diet.[28],[29],[30] The hypertensive patients believe that a powerful drug enables them to address sufficiently the harmful effects of unhealthy habits.[31]

Apart from the knowledge, attitude, and perceived barriers associated with low adherence to dietary guidelines, physicians, health-care system, and society-related factors are determined to be the barriers for low adherence to dietary guidelines in hypertensive patients. A study reported that perceptions of physicians about hypertension treatment did not correspond to their practice.[32] Most physicians assess patients' medication adherence in primary care settings. The physicians provide limited counseling on lifestyle modifications.[33] In addition, time constraints and improper compensations are determined to be significant barriers to optimal blood pressure control through diet change. Inadequate use of diet services is determined to a physician-related barrier.[33],[34],[35]

Al-Kaabi et al.[36] assessed the dietary practices and risk factors in diabetic patients in United Arab Emirates. They reported that 76% of the patients did not know to distinguish clearly between low and high carbohydrate index food, and 24% of them read food labeling. Overall, the dietary practices of diabetic patients in the UAE are insufficient, despite the guidelines of the American Diabetes Association and the European Association for the study of Diabetes emphasize the important role of diet and exercise in the management of all stages of T2DM.[37] The studies have reported that diabetic patients have various cycles of weight loss and relapse before managing to maintain their weight loss. Therefore, the doctors should consistently educate and encourage therapeutic lifestyle changes.[38]

Although most of the doctors who participated in this study mentioned that a high priority must be given to NCM to diabetic and hypertensive patients, it is unclear that to what extent they practice it in routine clinical counseling settings.

The literature has determined lack of time, patient noncompliance,[39] insufficient teaching materials, lack of counseling training, insufficient reimbursement, inadequate knowledge of doctors, and low confidence of physicians as perceived barriers.[40]

Hypertension must be received special attention from clinicians as it is a significant and independent risk factor for cardiovascular disease and diabetes.[41] Cardiovascular morbidity and mortality are lowered by the treatment of hypertension. However, the studies have shown that only 29% of patients have sufficiently controlled blood pressure as recommended by the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.[42]

It seems that the doctors whether family doctors, internists, or general practitioners have limited time to apply the NCM in the public clinical settings owing to heavy load and pressure as only 5 min were dedicated to this task in agreement with the literature.[8],[40] This period is so low to deliver the required nutrition information to the patients. Besides, all aspects of nutrition counseling are not practiced by clinicians, and some of them have focused on personal nutritional education only.

Moreover, the participants of the study reported that there, not sufficient resources in out-patient clinics to perform these kinds of interventions to diabetic or hypertensive patients. Medical directors and hospital managers should provide the required resources for diet therapy and nutrition education.

Low self-efficacy and insufficient training courses on nutrition for doctors have been mentioned to be impeding factors in the way of performing NCM.[43] The physicians with a lack of the confidence to assess, counsel, and manage nutritional issues are more reluctant to do so despite their strong belief in the role of nutritional counseling.[44] Vetter et al.[45] reported that less than one-third of the clinicians is confident to assess the nutritional status of patients. The majority of the clinicians who participated in the current study were confident to perform nutrition counseling; however, the majority has not located this task in their priority and not received a training course. It has been confirmed that low self-confidence is associated with a lack of training and knowledge and perceived barriers.[40] The literature suggests that the training of physicians on nutrient aspects is not sufficient.[3] Some studies have reported that clinicians' habits seen by patients are predictors of preventive health issues.[40],[39]

The perceived barriers by general practitioners must be responded through the appropriate strategies. The clinicians who treat the chronic disease are required to receive sufficient specific nutrition therapy sessions. In addition, to solve the possible stress of the high load in clinics, it suggests that education of diabetic and hypertensive give to the trained nursing practitioners, physician assistants, and nutritionists.[14] However, the unique position of general practitioners to create awareness and motivation among patients must not be ignored.

The multiple visits of hypertensive and diabetic patients have provided a golden opportunity for nutritional counseling. Moreover, family doctors in primary health care could create a unique position of influence, could be effective in healthy lifestyle changes in diabetic and hypertensive patients.[46] The advice of family doctors may foster health-promoting behaviors. Special attention must be paid to the training of undergraduate student medicine regarding the nutritional management of chronic diseases through syllabus enrichment.

The caution must be paid in the interpretation of the findings of the present study as the cross-sectional study precludes us from making a causal pathway in factors of NCM in family doctors, internists, and general practitioners. In addition, the findings of the study may not generalizable to other clinical settings across the country as the sample was taken from three health settings only.

Relevance to the primary practice

The diet management of diabetic and hypertensive patients should be integrated with a combination of lifestyle modifications and medication in primary health care. The physicians and health-care providers in primary health care can be well equipped with the dietary management of diabetes and hypertension because the change in diet contributes to substantial reductions in the level of morbidity and mortality. The World Health Organization recommended the integration of diet, physical activity, and weight management services into primary care for noncommunicable diseases.[47]

  Conclusions Top

The current study showed that the physicians have a good attitude toward NCM; however, it is not practiced by the majority of them. The prone of the diabetic and hypertensive patients to pharmacotherapy was shown to impede the NCM by clinicians.


The authors of the study would like to present their deep thanks to the clinicians participated in the study.

Financial support and sponsorship

The authors were only financial supporters of the study.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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