Overall, this study demonstrates that most primary care providers believe that the DASH diet effectively reduces blood pressure compared to adding a medication. However, provider- perceived patient-characteristics, time, and lack or perceived lack of accessible patient education materials limit the provision of DASH diet counseling in pre-hypertension and hypertension patients likely to benefit.
Most physicians perceived lack of patient motivation (90%) and ability to implement the DASH diet (86%) as significant barriers, which is consistent with previous studies of physician views towards nutritional advice. 11, 12 Although physician perceptions do not necessarily reflect actual patient motivation and ability, there is evidence of some truth to this viewpoint, at least in some populations. A study evaluating DASH diet acceptability and adherence in an African American community of low socioeconomic status patients identified cost, personal preference of food, poor availability of healthier food stores, and cultural aspects as barriers to DASH diet adherence 15. However, such barriers may be surmountable. A randomized pilot trial assessing DASH diet adherence for under-resourced communities reported that an intervention involving multiple peer-group sessions involving shared DASH diet meal plans, grocery shopping ideas, and budget management increased fruit and vegetable intake compared to a control group who only received a DASH diet educational packet 16. Thus, to improve the patient's ability to implement the DASH diet, a healthcare team and even supportive peer programs should be developed to provide individualized plans for patients to follow.
Lack of time for patient education is a frequent barrier, with 71% of providers reporting it as a barrier to DASH diet counseling comparable to other studies where 76–81% of providers report this as a barrier to dietary counseling 12–14, 17–19, 21. One study estimated that providing USPSTF recommended nutritional counseling points requires 8 minutes 18, which is one third to one half of a general clinic visit, which takes 16–30 minutes according to 2016 CDC statistics 20. This indicates that lack of time is a significant practice barrier, and delivery all the services recommended by USPSTF may simply not be feasible 18. Thus, developing a toolkit and resources are potential sources to facilitate the physician's nutritional counseling efforts in limited time.
Development of effective and accessible educational resources seems like a logical solution to this issue and was supported by survey respondents. Interestingly, educational resources, including the DASH diet, already existed in their EHR, in Spanish and English, with the ability to attach to an after visit summary or print out directly, but were apparently unknown to the 32 survey respondents, given 66% reported their absence as a significant practice barrier. This study did not examine why physicians were not utilizing resources that already exist, but this is likely not unique to our institution. One study reported the resources and tools are not individualized to the institutions or easily disseminated to the patient, providers, and all other practices 21, causing difficulties for practitioners to locate resources. More focused research should evaluate the low uptake of existing tools and resources.
Deficiencies in nutrition training was identified as a barrier by just 38% of the physicians, which is somewhat less than the 46–59% of primary care providers in Croatia and Switzerland considering this a significant barrier 11,12. In U.S medical schools, students and most educators consider current nutritional education inadequate, despite the efforts and developments of nutritional counseling programs for the past decades 19, 21. Providers universally endorsed access to dieticians to provide nutritional counseling, in accordance to a previous study where 84.9% of physicians considered dietician involvement to be beneficial for sodium counseling in hypertension patients 17. In addition to more detailed dietary and nutrition expertise, a dietician also provides an extension to provider education, addressing the barrier of provider time. In one study demonstrated that dietician’s involvement in outpatient settings for DASH diet and exercise counseling program improved patient’s cholesterol, blood pressure, and weight management 22. Similarly, a PREMIER study showed better uptake of the DASH diet, achieved dietary reference index (DRI) recommendation in most nutrients, and reduced blood pressure in participants with multiple group sessions led by dietitians compared to control group 30-minute counseling session 23. Thus, dieticians provide positive outcomes to patient’s DASH diet uptake. Meanwhile, further research should be conducted to identify strategies and the benefits in dietician's participation in the U.S primary care settings.
This study is limited by a relatively small sample of university-based primary care practitioners. Second, this survey was built and responded by the provider's perspective, limiting the view of the patients' side. A provider’s perceived patient barriers may be influenced by their own biases, and may not accurately reflect the motivation, means, grit, and resourcefulness of their patients. More studies need to focus on the patient's perceived barriers and the actual patient barriers to confirm the result that we found. Third, the cross-sectional survey does not provide the relationship between the cause and effect of the response, limiting analysis of the result. However, this study has multiple supportive studies to mitigate this problem.