Clinician Perspectives of Barriers and Enablers to Implementing the Mediterranean Dietary Pattern in Routine Care for Coronary Heart Disease and Type 2 Diabetes: A Qualitative Interview Study

Abstract

Background: Practice guidelines for coronary heart disease and type 2 diabetes recommend promoting the Mediterranean dietary pattern (MDP), which improves cardiometabolic risk markers and may prevent disease progression and complications. It is unknown to what extent the MDP is recommended in routine care for patients with these conditions, particularly in multiethnic settings.

Objective: The study aim was to explore multidisciplinary health care professionals' perspectives on recommending the MDP in routine care for patients with coronary heart disease or type 2 diabetes and barriers and enablers to its implementation.

Design: A qualitative description design was employed, utilizing semistructured individual interviews to collect data.

Participants and setting: Fifty-seven clinicians (21 nurses, 19 doctors, 13 dietitians, and 4 physiotherapists) routinely managing relevant patients across hospital and community settings in a metropolitan health service in Australia participated in interviews between November 2019 and March 2020.

Statistical analysis performed: Interviews were audiorecorded, transcribed verbatim, and analyzed using thematic analysis.

Results: Four overarching themes were identified highlighting that the MDP was not routinely recommended: current dietary practices (all clinicians perceived they had a role in dietary care but prioritization varied. There was a legacy of single nutrient-based strategies and disease silos); clinician-centered barriers to recommending MDP (limited MDP knowledge and practice skills and variable understanding and acceptance of evidence supporting its use. This was related to lack of education and training about the diet and personal interest/experience); organizational culture and resources influence dietary care (MDP not embedded in service culture or current clinic tools and resources, with limited dietary knowledge exchange within and across multidisciplinary teams); and perceived patient-centered barriers to implementation of MDP (socioeconomic challenges in a multicultural setting, and a lack of belief in patient capabilities to improve diet adherence).

Conclusions: Clinician and organizational factors, compounded by perceptions about patient acceptance, influence recommendations of the MDP for patients with coronary heart disease or type 2 diabetes. These factors should be addressed to improve translation of MDP evidence into practice.

Keywords: Coronary artery disease; Diabetes mellitus; Knowledge translation; Mediterranean diet; Qualitative research.