Abstract
Background: Plant-based diets (PBDs) have gained popularity in recent years due to their co-benefits for human and planetary health. Although clinical guidelines now recommend well-balanced PBDs, it remains unclear how dietitians in the United Kingdom (UK) and Republic of Ireland (ROI) view such diets and their implementation in practice. This study aimed to evaluate the perspectives of registered dietitians (RDs) on the role of a whole food plant-based diet (WFPBD) in clinical practice. Methods: A cross-sectional online survey was conducted amongst RDs in the UK and ROI between September and November 2023. Results: A total of 335 RDs participated in the survey. Most RDs (76%) agree that a well-planned WFPBD is suitable for all stages of life, with some (48%) expressing concerns over the risk of malnutrition and micronutrient deficiencies. Three-quarters of RDs (75%) incorrectly thought that plant protein is incomplete, necessitating protein combining. A WFPBD was on average ranked fourth out of 14 dietary strategies for managing some of the leading non-communicable diseases. Excluding dairy and eggs was the primary reason preventing RDs from personally adopting a WFPBD, whereas meal preparation and cost were the main barriers for their clients. The majority of RDs (79%) feel they did not receive sufficient education on WFPBDs, with 58% agreeing there are insufficient evidence-based resources available in their field. Only 33% feel supported when advocating for a WFPBD in their workplace. Conclusions: Although many RDs view WFPBDs as viable and clinically relevant, significant barriers to their implementation exist, underscoring the need for enhanced education and support.
Generated Summary
This cross-sectional online survey, conducted between September and November 2023, aimed to evaluate the perspectives of registered dietitians (RDs) in the United Kingdom (UK) and Republic of Ireland (ROI) on whole food plant-based diets (WFPBDs). The research explored their knowledge, beliefs, and perceived barriers to implementing WFPBDs in clinical practice. A 35-question survey was distributed to RDs through email, social media, and MyNutriWeb (MNW), a UK web-based nutritional and education organization for HCPs, and the Irish Nutrition and Dietetic Institute (INDI). Data from 335 RDs were analyzed, focusing on their understanding of WFPBDs, the perceived benefits, and the challenges they anticipate or encounter in their practical application of WFPBDs. The study also assessed the RDs’ awareness of current clinical evidence, their confidence in counselling patients, and the resources available to support WFPBD implementation. The findings were analyzed using descriptive and inferential statistics, with regression models used to evaluate differences between subgroups of RDs. The study’s aim was to understand how dietitians perceive and implement WFPBDs in clinical settings, with the ultimate goal of identifying areas for enhanced education and support.
Key Findings & Statistics
- A total of 335 RDs participated in the survey.
- Most RDs (76%) agreed that a well-planned WFPBD is suitable for all stages of life, with some (48%) expressing concerns over the risk of malnutrition and micronutrient deficiencies.
- Three-quarters of RDs (75%) incorrectly thought that plant protein is incomplete, necessitating protein combining.
- The survey defined a WFPBD within the framework of the EAT-Lancet planetary health diet, where 287% of total energy is derived from minimally processed whole plant foods, and meat and dairy foods are minimized.
- Knowledge of WFPBDs was evaluated based on three core knowledge domains: the suitability of WFPBDs throughout the lifecycle, micronutrients of concern, and current evidence of WFPBDs in managing or reducing the risk of certain chronic disease conditions.
- Approximately 38% of RDs scored 75% or more with knowledge related to WFPBDs in the life cycle, 12% scored above 75% regarding micronutrients of concern, 64% scored above 75% for nutrients of less or no concern and 22% of RDs achieved a score of 75% and greater for knowledge related to WFPBDs’ role in managing certain chronic diseases.
- Linear regression analysis revealed respondents that tended to score the highest across all domains were RD’s specialising in weight management and paediatrics, whereas those working in oncology had overall lower knowledge scores.
- RDs were asked to identify what conditions a WFPB dietary pattern has been shown to reduce the risk of. Heart disease (94%), elevated cholesterol (91%), hypertension (82%).
- The majority of RDs (63%) considered a vegan diet to most resemble a PBD pattern.
- When assessing RDs’ overall dietary patterns, 65% said that they had personally tried transitioning to a WFPBD, as defined as the EAT-Lancet dietary pattern.
- Three-quarters of dietitians (75%) across all specialties thought plant-derived proteins were incomplete and should be carefully paired with other plant-based protein foods for optimum protein requirements.
- A Mediterranean dietary pattern was ranked as the primary intervention for managing T2DM and CVD as two areas of chronic disease, as well as for weight loss management as an additional dimension.
- A WFPBD ranked four out of 14 as the preferred dietary intervention for T2DM and weight loss and fifth for CVD, with 22%, 24% and 22% of RDs viewing a WFPBD as a viable and clinically relevant dietary pattern for managing T2DM, CVD and weight loss, respectively.
- 67% of RDs believed a WFPB dietary pattern to be sustainable long-term, whereas only 16% agreed that their clients with co-morbidities would adhere long-term to a WFPBD.
- Excluding dairy (42%) and eggs (38%), concerns over micronutrient intake (33%) and protein inadequacy (31%) were the primary reasons preventing RDs from fully adopting a WFPBD.
- Concerns related to meal preparation (46%) and financial cost (39%) were revealed as the commonest perceived barriers for their clients.
- Approximately 50% of RDs felt they were confident in counselling patients to switch to a WFPBD. However, only 20% of RDs felt they received adequate training in plant-based nutrition during their undergraduate dietetic degree, whereas 20% of all respondents declared that they received no training within the university.
- 58% of RDs felt there were not enough evidence-based educational resources for them and their patients to implement a WFPBD in practice.
- Only 33% of RDs feel supported if and when advocating for a WFPBD for their patients in their respective places of work.
Other Important Findings
- The majority of RDs from the UK and Republic of Ireland in this study hold a positive view of whole food plant-based diets (WFPBDs) and are willing to recommend them to their patients.
- Considerable knowledge deficits related to current clinical evidence of WFPBDs exist amongst RDs, particularly, in the area of oncology. Additionally, three-quarters of dietitians falsely believed that plant proteins are an incomplete source of protein.
- A WFPBD was on average ranked fourth out of 14 dietary strategies for managing some of the leading non-communicable diseases.
- Excluding dairy and eggs was the primary reason preventing RDs from personally adopting a WFPBD, whereas meal preparation and cost were the main barriers for their clients.
- The majority of RDs (79%) feel they did not receive sufficient education on WFPBDs, with 58% agreeing there are insufficient evidence-based resources available in their field.
- Only 33% feel supported when advocating for a WFPBD in their workplace.
- The commonest micronutrients of concern that RDs reported when following a WFPBD were vitamin B12(90%), iron (82%) and calcium (70%).
- RD subgroups that significantly deviated from this overall knowledge pattern were RDs working in the fields of (i) oncology, of whom only 61% viewed plant-based protein as incomplete and (ii) gastroenterology, of whom 86% viewed plant-based protein as incomplete.
- There appeared to be a trend in oncology RDs, who were less likely to recommend WFPBDs for chronic disease management, including T2DM, CVD and weight loss management, although this did not reach statistical significance.
- Regarding education, RDs with a postgraduate qualification were more likely to recommend WFPBDs in clinical practice for T2DM and CVD.
- RDs were asked to rate their preferred dietary approach in the management of some of the leading chronic, lifestyle-related diseases.
- A WFPBD ranked four out of 14 as the preferred dietary intervention for T2DM and weight loss and fifth for CVD, with 22%, 24% and 22% of RDs viewing a WFPBD as a viable and clinically relevant dietary pattern for managing T2DM, CVD and weight loss, respectively.
- The commonest perceived barriers for the RDs’ patients were meal preparation and financial cost.
- When exploring the perceived motivations of their clients for transitioning to a WFPBD, most RDs said it was related to the environment (62%) and improving their overall health (58%).
Limitations Noted in the Document
- Gender discrepancies existed with participant demographics, with a higher proportion of female respondents and less representation of dietitians in the UK.
- Selection bias could not be completely ruled out among respondents.
- The scoring system used to assess RDs’ knowledge was not formally validated.
- Personal dietary factors were not controlled for in the regression analyses due to a lack of information on the personal motivation for respondents’ dietary patterns.
- The study was a pooled analysis between the United Kingdom and Irish dietitians, which may impact findings.
- RDs participating in this study may not be representative of RDs in the workforce as a whole.
Conclusion
The study highlights that while many RDs in the UK and ROI view WFPBDs positively and recognize their health benefits, significant knowledge gaps and barriers hinder their full integration into clinical practice. “Although many RDs view WFPBDs as viable and clinically relevant, significant barriers to their implementation exist, underscoring the need for enhanced education and support.” The study emphasizes the need for targeted educational initiatives and access to further evidence-based resources to enhance RDs’ overall knowledge of WFPBDs. The lack of sufficient education and training in plant-based nutrition, both during their undergraduate studies and in continuing professional development, is a major barrier. Furthermore, the study shows a disconnect between the RDs’ positive views and the challenges they face in practice, especially those in oncology. The lack of workplace support and evidence-based resources compounds these difficulties. Addressing these issues is crucial for dietitians to effectively counsel and support patients in adopting WFPBDs. The study’s findings call for action from public health agencies and universities to provide better education and support, fostering a more conducive environment for RDs to implement PBDs. “These findings suggest a call to action amongst public health agencies and universities in providing further education and support to help RDs appropriately implement PBDs into their practice.” The study also notes that the belief that plant proteins are incomplete and require careful pairing remains a widespread misconception, indicating the need for continuing education to clarify this area. Moreover, the study’s findings suggest a need to refine approaches to address perceived patient barriers, such as meal preparation and cost, which are critical for supporting WFPBD adoption. The study concludes that by enhancing the knowledge, support, and resources available to RDs, the integration of WFPBDs into clinical practice can be improved. This will enable dietitians to more effectively guide patients towards healthier, more sustainable dietary patterns. “Although the evidence and updated clinical guidance have become clear regarding the positive impact of PBDs on human and planetary health, it is apparent that there remains a significant need for further education, training and support within university settings, and amongst graduates and experienced RDs across clinical specialties.”