1. Introduction
Nutrition is an important factor in the maintenance and the promotion of good health, the prevention of malnutrition and disease, and the treatment of chronic disease throughout life [
1]. Collaboration of an interdisciplinary healthcare team is required, especially in the hospital setting, to ensure high-quality nutritional care [
2,
3]. The new era of quality care requires the involvement of a dietitian in the healthcare team (i.e., nurses, pharmacists, and physicians) to perform a nutritional assessment/diagnosis and develop evidence-based interventions [
3]. Moreover, the healthcare team must have a fundamental level of nutritional knowledge to address critical issues in a more deliberate and holistic approach [
4]. For example, nurses may perform the initial nutrition screening and develop a plan to facilitate patient compliance, pharmacists evaluate drug-nutrient interactions, and physicians oversee the overall care plan and documentation to support reimbursement for services [
3]. Therefore, current research supports the inclusion of nutrition courses in the curriculum of health programs as well as for continuing health education [
5,
6,
7,
8].
As physicians are responsible for the overall care plan and documentation, inadequate nutritional knowledge may affect the medical treatment plan and reduce the quality of patient outcomes. Therefore, physicians are expected to have adequate nutritional knowledge, which needs to be applied in situations such as giving general nutritional advice in response to patient questions during hospital rounds or in the outpatient clinic setting as well as in practical situations such as the management of malnourished patients. Numerous studies have indicated that nutritional knowledge among physicians is insufficient relative to current recommendations [
7,
9,
10,
11]. Research worldwide (i.e., Western studies in the USA [
9], Canada [
5], and Europe [
6,
7]; Asian studies such as in Taiwan [
12], Iran [
13], Turkey [
14]; and the Gulf countries, such as in Kuwait [
15], Saudi Arabia [
16], and Qatar [
17]) have reported nutritional knowledge among physicians as being poor and insufficient. In addition, several studies have evaluated the attitudes of physicians along with their self-perceived proficiency. They found that confidence and knowledge among physicians to effectively provide nutritional advice in their daily practice against malnutrition is lacking [
7,
9,
11].
Malnutrition is a highly prevalent condition in the hospital setting, particularly among the elderly and children [
18,
19]. It is associated with increased morbidity, mortality, prolonged hospital stays, clinical complications, and increased healthcare costs. There are no available statistics of malnutrition in Saudi Arabia; however, a study by Alzahrani et al. in Jeddah reported a high prevalence of malnutrition among geriatric outpatients (33% of total
n = 152) and inpatients (76% of total
n = 248) [
20,
21]. Therefore, including nutrition care as an early identification of malnutrition is considered important in planning for nutritional interventions that could help to reduce or prevent malnutrition-associated poor outcomes. In Saudi Arabia, there is a paucity of data regarding nutritional knowledge and nutritional practice against malnutrition among physicians. Therefore, the aim of this study was to: (1) assess the nutritional knowledge of physicians, and (2) evaluate the self-reported nutritional practice against malnutrition in the hospitals of Jeddah, Saudi Arabia.
4. Discussion
In this study, we investigated the nutritional knowledge and the nutritional practice against malnutrition among Saudi physicians in the hospitals of Jeddah, Saudi Arabia. The findings of this study are relevant as physicians play an increasingly important supporting role alongside qualified dieticians in ensuring patients receive high-quality nutritional care for optimal healthcare management and prevention of disease [
25,
26]. Furthermore, the consistency of our findings with those of other studies from Western [
5,
6,
7], Asian [
12], and Gulf countries [
15,
16,
17] suggests that insufficient nutritional knowledge and practice against malnutrition among physicians may be an international issue. According to Global Advances in Health and Medicine, modern healthcare should embrace the globalization of the healthcare system by providing an opportunity, not for homogenization, but for integration, convergence, and cultures collaboration to learn from our international colleagues [
27]. This increasing body of evidence highlights the need to assess the medical education and training system, not just in Saudi Arabia, but worldwide, to identify factors affecting physicians’ nutritional knowledge, including the current educational system, the confidence, the knowledge, and the attitudes of the physicians toward nutrition care, and to share strategies for improvement. This step is necessary to empower the physician to be able to deliver nutrition care along with the dietitians to prevent and reduce the diet-related diseases globally. The findings and the discussion of different healthcare system are conducive to everyone’s benefit and eventually will advance the health care system internationally [
27].
Overall, we found the study sample to be composed of mainly young physicians, with half of participants aged ≤30 years, 40% having <2 years of experience, and the majority (74%) educated in Saudi Arabia. This may impact the results as the lack of experience could affect their knowledge and practice.
Using the Canadian multiple-choice questionnaire devised by Temple [
5], we observed that, on average, questions were answered correctly by physicians at a rate of only 50%. A similar level of correct responses was reported by Al-Zahrani and Al-Raddadi (52%) in a study conducted in Jeddah in 2009 [
16], Alnumair in Riyadh (50%) in 2004 [
23], and Ozcelik et al. in Turkey in 2007 (48%) [
14] using the same questionnaire. However, the mean percentage for correctly answered questions in the present study was lower than that found in the survey of nutrition knowledge among physicians in Canada (63%), Qatar (64%), and Kuwait (60%). This may be attributed to differences in the studies characteristics, such as age and years of experience. In addition, some of the questions in the Temple questionnaire were changed in some of these studies, which were compared to each other; this could influence the findings. There was a range of 2–4 questions varied between the studies that were made for culture-specific reasons.
There was a high level of variation in the percentage of correct answers between individual questions with scores as low as 6% and as high as 96%, indicating inconsistency in the areas of nutritional knowledge among physicians. The results of the nutrition knowledge questions indicate that Saudi physicians are generally more knowledgeable regarding nutrition directly related to the medical field and highly publicized information. This included the role of omega-3 fatty acids in the prevention of thrombosis, hypertension, and food believed to exert a preventive effect on various types of cancer, antioxidant nutrients, and the prevention of neural tube defects (notably, questions 3, 7, 12, 14, and 15, respectively). This tendency was also reported in studies performed by Allafi in 2012 [
15], Al-Numair in 2004 [
23], and Temple in 1999 [
5]. Relatively few physicians were able to correctly answer questions related to core nutrition topics, such as which nutrient may increase the loss of body calcium loss, which substance raises the level of blood high-density lipoprotein cholesterol, what percentage of the daily total energy should be obtained from fat, and which foods have the lowest glycemic index (questions 2, 10, 17, and 18, respectively).
Considering all the available Saudi studies conducted in the previous 15 years, including those in Jeddah in 2009 by Al-Zahrani and Al-Raddadi [
16], Riyadh in 2004 by Alnumair [
23], and the present study, a consistent and relatively low level of nutritional knowledge (50–52%) is evident among Saudi physicians. Furthermore, we observed that the number of correctly answered questions increased significantly with age and years of employment, which may indicate the influence of experiences and continuing medical education on improving nutritional knowledge. However, in our questionnaire, we did not include a specific question pertaining to continuing medical education or exact nutritional education. This was because the medical schools integrated the nutritional information to their updated curriculum, especially after conforming to national and international standards of the educational accreditation agencies. Although more nutritional material has been integrated into the curricula of medical schools, studies continue to report that physicians received inadequate education and training related to nutrition during their undergraduate studies and residency, respectively [
9,
28]. This situation may affect the interest of medical students toward the importance of nutritional care in the absence of support from their clinical house staff, who also feel that their own nutrition knowledge and counseling skills are inadequate [
10,
29]. In this study, a large majority of Saudi physicians agreed that they found it difficult to perform all areas of nutritional management for malnourished patients, including screening of patients on admission, assessing undernourished patients, and initiating nutritional treatment. This finding is consistent with the research performed by Mowe et al., who reported insufficient knowledge among Scandinavian doctors and nurses [
7]. They and others have suggested that the inadequate nutritional knowledge often observed in hospital settings was the main barrier for performing good nutritional management for malnourished patients [
7,
30]. Moreover, in our study, using a scale from 1 (lowest) to 10 (highest), we observed that the self-reported knowledge of malnutrition treatment among Saudi physicians was modest (6.3) with only a moderate interest in learning more (5.6), as it was not considered highly relevant to their daily clinical practice (6.3). This may be attributed to both inadequate nutritional knowledge and the lack of proper education and training, which led to lower awareness of the importance of nutritional management in healthcare. It has been reported that medical schools do not adequately apply cognitive knowledge, different teaching methods, or the combination of theory and practical knowledge in their education system [
31]. Therefore, the implementation of an integrated nutrition curriculum into the basic education using appropriate teaching methods coupled with continuing medical education after graduation is warranted. For example, some key recommendations have been published by a European Expert group to overcome the inadequate nutritional knowledge and practice in Europe [
32]. They suggested a continuous education program covering general nutrition and techniques of nutritional support for all healthcare staff. In addition, education by lecturing alone might not improve self-efficacy, as it has limited opportunities for practical and clinical experiences [
33]. Carson et al. reported that role modeling [
34], role playing using either simulated or real patients [
35], hands on practice sessions [
36], and viewing videos and web-based cases and discussing them [
34,
36] may develop the self-efficacy of the physicians as well as their attitudes toward the nutrition care. Future work should also focus on the development of practical guidelines relevant to the medical profession, thus standards can be set that all doctors can work to as well as develop and provide resources to support the overhaul of current medical education and practice.
As for most cross-sectional studies, our study was characterized by limitations. First, its cross-sectional nature makes it difficult to establish causality. Second, we were unable to recruit all physicians practicing in Jeddah city; therefore, the small sample size may have affected the statistical power of this study and the ability to detect significant associations. This makes it difficult to generalize our findings. Furthermore, in this study, there was no certain strategy to distribute the questionnaire in terms of number of emails and physicians included in each email; therefore, we were unable to calculate the response rate, and our sample is considered as a convenience sample. Future studies need to consider this point as well as the randomization technique to be able to calculate the response rate and generalize the results. Third, our study included an online questionnaire. Therefore, we shortened the questionnaire to reduce the respondents’ burden and enhance the response rate, which could limit the information that could be obtained. Fourth, the present study was subject to bias, as the self-administered surveys do not always reflect daily clinical practice, and attitudes could be influenced by the daily workload and the physicians’ moods. However, it is generally accepted that the self-report measures of nutrition-related competences could be used as a proxy tool for actual measures of competence [
37].
