1. Background
Among health professionals in primary care settings, general physicians (GPs) are credible sources for providing nutritional information to improve dietary habits (1, 2), because of the chances of patients’ first point of contact (3). However, although GPs support the nutritional interventions that are highly prioritized (4), their ability to prescribe accurate dietary recommendations to manage the chronic disease is still under question (5, 6). Metabolic syndrome (MetS) is a constellation of risk factors for developing cardiovascular disease (7). The prevalence of MetS is rapidly increasing among the Iranian population (8). According to the Ministry of Health and Medical Education of Iran, the management of MetS is a physician’s task.
2. Objectives
The present study was conducted to assess the nutritional knowledge, attitudes, and practices of GPs in Tehran, Iran, regarding MetS and its nutritional management.
3. Methods
This cross-sectional study was conducted in July 2019 in Tehran. Participants were recruited among GPs working in health centers affiliated to the Shahid Beheshti University of Medical Sciences.
The sample size was calculated considering alpha = 5%, d = 0.1, power = 0.95, P (the ratio of people with high practice) = 0.46, and possible attrition =20% and using the following formula:
A total of 542 GPs were invited to participate in the study, of whom 500 cases returned completed self-administered questionnaires. This study was approved by the Ethics Committee of the Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences (No: IR.SBMU.ENDOCRINE.REC.1397.093). Written informed consent was obtained from all GPs.
The “Nutrition and MetS” questionnaire was developed by a panel of expert dietitians, according to dietary guidelines (9). The questionnaire included 22 questions categorized into four sections, including:
(i) Questions regarding demographic characteristics
(ii) Six questions assessing knowledge about MetS (Table 1)
(iii) Ten questions assessing nutritional attitude toward controlling MetS (Table 2)
(iv) A case study designed to assess the practice of physicians
Table 1.Responses to the Nutritional Knowledge Toward MetS by General Practitionersa
| Variables | No. | % |
|---|---|---|
| Can you define the MetS? | 157 | 31.4 |
| Can you define the risk factors of the MetS? | 126 | 25.2 |
| Can you define the complications of the MetS? | 109 | 21.8 |
| Do you review the patient’s medical history to determine if the patient has a MetS? | 11 | 2.2 |
| Do you provide nutrition recommendations for patients with MetS? | ||
| Yes (correct response) | 58 | 11.6 |
| No, why? | 442 | 88.4 |
| This is not the responsibility of physicians | 312 | 62.4 |
| Lack of time | 356 | 71.2 |
| Limited nutritional knowledge | 401 | 80.2 |
| Feeling unskilled in providing nutrition recommendation | 15 | 0.03 |
| Lack of belief in the efficacy of diet therapy | 73 | 14.6 |
| Do you refer the patient with MetS to a dietitian? (yes) | 304 | 60.8 |
Abbreviation: MetS, metabolic syndrome.
aCorrect response
Table 2.Responses to the Nutritional Attitude Toward MetS by General Practitioners
| Agree (%) | Neutral (%) | Disagree (%) | Correct Answer | |
|---|---|---|---|---|
| There are well-established associations between dietary patterns and MetS. | 69.4 | 20.4 | 10.2 | Agree |
| Weight loss is the most important method to improve MetS. | 80.4 | 0.6 | 19.0 | Agree |
| High-fat intake is the major cause of MetS than a high-carbohydrate diet. | 81.6 | 0.0 | 18.4 | Disagree |
| A low-sodium diet can improve MetS. | 21.2 | 16.4 | 62.4 | Agree |
| Consumption of fruits and vegetables, including five or more servings per day, is recommended for controlling MetS. | 21.4 | 10.6 | 68.0 | Agree |
| Limited intakes of starchy vegetables are recommended for controlling MetS. | 71.6 | 7.8 | 20.6 | Disagree |
| Consuming grain‐based foods, including whole- and refined-grain products, is recommended for controlling MetS. | 82.4 | 0.8 | 16.8 | Disagree |
| Limited intakes of foods with a high content of cholesterol are recommended for controlling MetS. | 100.0 | 0.0 | 0.0 | Agree |
| Limited intakes of high-fat dairy products are recommended for controlling MetS. | 97.0 | 1.8 | 1.2 | Agree |
| Replacing legumes with red meat is recommended for controlling MetS. | 95.0 | 0.4 | 0.1 | Agree |
Abbreviation: MetS, metabolic syndrome.
Physicians were asked to list seven dietary recommendations based on published guidelines (9) for improving healthy dietary patterns. For the case study, a group of dietitians assessed the quality of the dietary recommendations suggested by physicians, which included:
1. Consumption of various fruits and vegetables
2. Consumption of a variety of whole-grain products
3. Consumption of fat-free and low-fat dairy products
4. Replacing high-fat meat, red meat, and processed meat by fish, legumes, poultry, and lean meats
5. Limiting salt intake to less than 6 g/day
6. Limiting intake of foods with a high content of cholesterol
7. Maintain a healthy body weight
The quality of the dietary recommendations suggested by physicians was assessed. Any recommendation following the dieticians’ advice received one point and those that were not advised by dietitians received no point. Scores of each physician were calculated by summing up the points. Scores for the practice of physicians were categorized as low nutritional practice (0 - 3 points) and high nutritional practice (4 - 7 points).
4. Results
The mean age of the participants was 42.8 ± 6.6 years, and most of them were married (72.6 %) and female (58.0%). Regarding the knowledge of participants about MetS (Table 1), a high proportion of GPs could not define MetS and its risk factors and complications. Most GPs did not review the patient’s medical history to determine if the patient had MetS. In addition, they did not provide nutritional recommendations for patients with MetS because they thought that this was not their responsibility and also due to lack of time and limited nutrition knowledge. Over 60% of GPs reported that they refer the MetS patients to dietitians. Regarding the attitudes of GPs about MetS (Table 2), most GPs believed that there was an established association between dietary patterns and MetS and weight loss improved MetS. However, their attitude toward the details of macronutrient and micronutrient intakes for the prevention and treatment of MetS was incorrect. Regarding the dietary recommendations based on dietary guidelines, a wide range of recommendations for controlling MetS were reported by GPs. Over half of them recommended reducing cholesterol intake, consuming low-fat dairy products, and maintenance of healthy body weight. Approximately 30% of GPs recommended consumption of varieties of grain products as well as fruits, vegetables, while less than a quarter of GPs recommended replacing high-fat meat, red meat, and processed meat by legumes, fish, and poultry, and a reduction in salt intake.
In the case history, over half of GPs recommended reducing cholesterol intake, consuming low-fat dairy products, and maintenance of healthy body weight. Approximately 30% of GPs recommended consumption of a variety of grain products as well as fruits, vegetables, while less than a quarter of them recommended replacing high-fat meat, red meat, and processed meat by legumes, fish, and poultry, and reducing salt intake.
5. Discussion
Our results showed that the vast majority of GPs were not familiar with the definition of MetS and its complications, and also they were not knowledgeable about healthy diet principles and guidelines to recommend patients with MetS. Consistent with previous studies (1, 4, 5), in this study, although GPs were informed about the importance of a healthy diet and weight control in the management of MetS, their attitude and practice regarding the details of a healthy diet, such as intakes of macronutrients and micronutrients and food groups for the prevention and treatment of the MetS were inadequate. Our findings indicated the urgent need for basic education regarding healthy dietary diet among GPs for the prevention of MetS. Overall, increasing the nutritional knowledge of GPs can enhance their performance in nutritional recommendations to MetS’ patients (10). The current study demonstrated the paradox among GPs, despite their duties in addressing the MetS epidemic according to the guidelines of the Ministry of Health and Medical Education of Iran, inadequate attitude and practice regarding nutrition is an obstacle for providing optimum nutritional counseling by GPs.
