Attitudes and knowledge of dietitian practice among a representative sample of Israeli adults

Highlights

• •Israeli adults identify dietitians as the healthcare professionals with the most knowledge of nutrition.
• •Most Israelis would turn to a dietitian if their goal was to lose weight or improve dietary habits.
• •Most Israelis would not turn to a dietitian if they believed they had a food sensitivity.
• •Israelis previously treated by a dietitian had better knowledge of what dietitians do.
• •Israelis often thought dietitians provided alternative healthcare rather than medical nutrition therapy.

Abstract

Background

There is confusion among members of the general public regarding the role of dietitians in healthcare. Little is known about public attitudes towards dietitians among the general public in Israel.

Objectives

The present study aims to identify beliefs and attitudes about dietitians in clinical practice held by a representative sample of Israeli adults.

Methods

The present cross-sectional survey was conducted online.

Results

A total of 402 Israeli adults participated. The majority of respondents indicated that dietitians perform nutrition consultations and weight loss counselling. More than half of respondents knew that dietitians have at least a bachelor’s degree, but more than one third thought the degree was in alternative medicine. The majority of respondents ranked dietitians as the healthcare professionals with the greatest knowledge of human nutrition. Approximately have of respondents had been previously treated by a dietitian, and these people were more likely indicate the importance of nutrition care in treating chronic disease; further, they stated that dietitians utilize biochemical, anthropometric and other data in order to personalize nutrition care. In logistic regression analyses of specific dietitian roles, prior treatment by a dietitian emerged as a robust predictor of the role of the dietitian in healthcare.

Discussion

Respondents identified dietitians as the professionals with the most knowledge of nutrition and the clinicians with whom they would most likely consult if they desired to change their eating habits.

1. Background

Professional organizations, such as the Academy of Nutrition and Dietetics in the US, stress the professional training and expertise of registered dietitians (RDN, 2023). Nevertheless, it appears that there is confusion among members of the general public regarding the role of dietitians in healthcare. For example, a qualitative study found that Australian adults with or at risk for lifestyle-associated chronic disease rated general physicians as the preferred source of nutrition information and care, ranking dietitians only second (Ball et al., 2014).

The Pew Research Center conducted a representative survey of US adults aged 18 or older regarding their attitudes and beliefs about dietitians. Overall, 60% of those surveyed reported a “mostly positive” attitude towards dietitians. Trust towards dietitians was greater among older survey participants and those who reported familiarity with dietitians’ work. The level of public trust in dietitians was almost twice that afforded nutrition scientists discussing their research findings (PEW, 2024, PEW RC, 2024). A recently published systematic review focused on healthcare professional and patient opinions on dietitians and dietetic services highlights gaps in treatment expectations and the need to better engage patients in the treatment to achieve treatment goals (Ball et al., 2014).

Little is known about public attitudes towards dietitians among the general public in Israel. The present study aims to identify beliefs and attitudes about dietitians in clinical practice held by a representative sample of the general Israeli adult population. Specifically, the present study was designed to describe the attitudes of the general Israeli public towards dietitians, including their work characteristics, areas of expertise, and public experience with these professionals.

2. Methods

2.1. Study Design

The present cross-sectional survey was conducted on a representative sample of Israeli adults residing in Israel at the time of the survey.

2.2. Ethics

This study received ethics approval from Ariel University. Participants were contacted by telephone and gave verbal informed consent to participate. All data were anonymous.

2.3. Study population

Included in the present survey were Israeli adults aged 18 or older, men and women, who provided verbal informed consent to participate. Individuals younger than 18 years of age or who did not provide verbal informed consent were excluded.

2.4. Development of the study instrument

The survey instrument was developed in the framework of Nutrition Week in Israel. Registered dietitians from the Israel Ministry of Health, the Israel Dietitians Association (ATID) and dietitians from academia formed a focus group to address issues and concepts for the survey. An initial set of questions was developed and piloted among university administrative personnel and students. The pilot permitted estimation of readability, comprehension, and ease of use. Based on these findings, repetitive questions were removed, and unclear questions were re-worded for clarification. This process was repeated again among different participants. This version was reviewed and agreed upon by the focus group dietitians, and was then submitted to another group of respondents, once and again after two weeks to estimate reliability. The final version was also submitted to a different group of registered dietitians from the Ministry of Health, ATID and academia to attain expert validity and face validity.

2.5. Study procedures

Interviewers from Sekernet, an Israeli company specializing in survey management. Sekernet developed the representative random sample list, and contacted potential participants by phone. The identity of the respondent was verified to ensure the representativeness of the sample. Study objectives were described, and verbal informed consent was requested. If obtained, the interviewer read each study question to the participant, and answers were recorded. At the end of the survey, participants were thanked. The survey, translated into English, is available in Appendix 1.

2.6. Statistical analysis

Data were stored on an Excel spreadsheet (Microsoft, USA) and transferred to SPSS v28 (IBM, USA) for analysis. Descriptive data were calculated for each variable. Categorical variables are presented as n (%), while continuous variables are presented as mean ± standard deviation. Data were compared by prior exposure to dietitian treatment using the t-test for independent samples for continuous data and the chi-square test for categorical data. Due to between-group differences in age and ethnicity, logistic and general linear models were created as appropriate for all survey questions that differed by group, controlling for these covariates, to determine whether the difference could be associated with prior dietitian treatment or whether it was confounded by age and/or ethnicity. All tests were two-sided and considered significant at p < 0.05.

2.7. Sample size and study power

With a sample size of 402 participants, the present study had a 5 % margin of error and a 95 % confidence level, assuming a response distribution of 50 %.

3. Results

3.1. Total study population

Characteristics of the total study population are presented in Supplemental Table 1. The sample was a representative random sample, and the table findings are consistent with published characteristics of the Israeli population (Elliott and Gibson, 2023).

Shown in Supplemental Table 2 are impressions of dietitians’ work and the education required to become a dietitian in the total study population. In response to the question, “What best describes what dietitians do?” Participants could mark all responses they felt were applicable. The majority of respondents indicated that dietitians perform nutrition consultations and weight loss counselling. Additionally, medical nutrition therapy and improved eating patterns are part of the perceived professional activities of dietitians. A minority of respondents identified kitchen management, food industry or research as activities typical of dietitians’ work. Regarding academic training for the profession, more than half of the survey participants knew that dietitians have at least a university degree (BA, BS); nevertheless, more than 35 % thought that dietitians have an alternative medicine license or completed some courses in nutrition.

Supplemental Table 3 shows the degree of respondent agreement with statements characterizing dietitian practice/knowledge in the total study population. The most frequently agreed-with statements included: “Dietitians change eating behaviors”; “Dietitians conduct health promotion”; and “If I had an obese child I would consult with a clinical dietitian because s/he is the most appropriate professional”. Interestingly, while few respondents identified research as the purview of dietitians, more than 70 % agreed with the statement, “Dietitians conduct research on the association between food and disease.” More than 60 % of respondents agreed with the statement, “I will have less trust for an overweight dietitian,” and almost half agreed that nutrition and dietetics are forms of alternative medicine.

Displayed in Supplemental Fig.1 are statements regarding dietitian professional conduct. The majority of survey respondents disagreed with statements indicating that private dietitians were more professional than those employed by health maintenance organizations or hospitals; that male dietitians were more professional than female dietitians; and that dietitians give less professional consultations than other allied healthcare professionals.

In Supplemental Table 4, survey participants in the total study population indicated which professional they would consult in specific situations and to rank healthcare professionals in terms of their nutrition knowledge. If faced with food sensitivity, almost 80 % of respondents indicated they would turn to a physician, while fewer than 12 % said a dietitian. Nevertheless, respondents ranked dietitians as the profession with the greatest nutrition knowledge, perhaps suggesting that study participants perceived food sensitivity as a problem not associated with nutrition. Consistent with this, respondents selected dietitians as the professionals with whom they would consult if they wished to change eating behaviors.

As shown in Table 1, fewer than half of the survey respondents had ever consulted with a dietitian. Of the 192 individuals who had seen a dietitian, the majority had done so through their health maintenance organization. The majority of respondents who had consulted with a dietitian had been referred by a physician, while approximately one-third had self-referred to dietitian care. More than half of the dietitian visits were attributed to weight loss, while approximately a quarter of visits were attributed to dyslipidemia and a desire to acquire healthy eating habits. Most respondents (75 %) had seen a dietitian at least twice, and most (87.5 %) were at least somewhat satisfied with their treatment experience.

Table 1.

History of consults with a dietitian (more than one response permitted) in the total study population (a representative sample of Israeli adults, n = 402) May 1-May 31, 2022.

Description	% individuals answering “yes”
Ever consulted a dietitian	47.8
Among those who answered “yes” above, n = 192:
Consulted a dietitian through the HMO	82.3
Hospital	12.5
Private clinic	13.5
Gym	7.3
Other	3.6
Professional referring to dietitian (among those who answered “yes” above, n = 192) – more than one response permitted
Family physician	62.0
Pediatrician	3.1
Nurse	2.6
Self-referral	30.2
Hospital	10.9
Gym or personal trainer	3.6
Media	4.2
Reason for referral (among those who answered “yes” above, n = 192) – more than one response permitted
Weight loss	57.8
Hyperlipidemia	23.4
Hyperglycemia/gestational diabetes	19.8
Eating disorder	7.3
Learn healthy eating habits	23.9
Vegetarianism/veganism	4.2
Inflammatory bowel disease	4.7
Childhood obesity	1.0
Post-surgery	7.8
Other	14.1
Number of visits at dietitian (among those who answered “yes” above, n = 192)
Once	25.0
2–4 times	44.3
5–7 times	14.1
More than 7 times	16.6
Satisfaction with visit (among those who answered “yes” above, n = 192)
Not at all	12.5
Somewhat	34.9
Much	40.1
Very much	12.5

3.2. Comparisons between respondents who had vs. Those who had not ever consulted with a dietitian

Table 2 compares study population characteristics by prior dietitian treatment. Participants who had previously consulted with a dietitian were significantly older than those who had not; additionally, Jewish respondents were significantly more likely to have previously consulted with a dietitian than members of other ethnicities. Thus, all differences between those who had and those who had not previously consulted with a dietitian were further assessed using logistic regression or general linear modeling as appropriate for the question to determine whether differences were, in fact, attributable to differences between groups or were confounded by age and/or ethnicity.

Table 2.

Demographic characteristics by prior treatment by a dietitian in a representative sample of Israeli adults, n = 402 May 1-May 31, 2022.

Characteristic	Prior dietitian treatment (n = 192)	No prior dietitian treatment (n = 210)	p-value
Age (years)	45.1 ± 15.8	38.4 ± 14.9	<0.001
Sex (% female)	52.2	47.8	0.07
Education level (%)			0.35
Fewer than 12 years	5.2	6.2
High school matriculation	19.8	27.6
Trade license	27.1	22.4
BA/BSc	35.4	30.5
MA/MSc or greater	12.5	13.3
Region of residence (%)			0.15
North (Galil, Golan, Tzfat, Acco)	10.9	18.6
Haifa (Haifa, Hadera and suburbs)	11.5	16.2
Tel Aviv/Yaffo	20.3	15.7
Yehuda/Shomron	5.7	4.3
Center (Sharon, Shfela)	24.5	25.2
South (Ashkelon, Be’er Sheva and suburbs)	13.5	11.0
Jerusalem	13.5	9.0
Type of community			0.07
Large city (Tel Aviv, Jerusalem, Haifa, Be’er Sheva)	39.6	28.6
Small-Medium city	45.8	53.8
Moshav/kibbutz/village	14.6	17.6
Ethnicity/religion			0.008
Jewish	87.0	73.8
Arab	8.3	19.5
Christian	3.1	4.3
Other	1.6	2.4

As shown in Fig. 1, more respondents who had been seen by a dietitian identified nutrition consultation and medical nutrition therapy as part of a dietitian’s work. In logistic regression analysis into which age and ethnicity were added, differences remained significant by prior dietitian consultation.

Fig. 1.

Perceptions of dietitians’ work by prior dietitian consult in a representative sample of Israeli adults (n = 402) May 1-May 31, 2022.

Table 3 displays agreement with statements about dietitian practice and knowledge. Significantly more participants who had prior treatment by a dietitian agreed that these professionals are essential in the treatment of chronic diseases. This difference was again assessed using general linear modeling, and remained robust after controlling for age and ethnicity.

Table 3.

Agreement (yes/no) with statements characterizing dietitian practice/knowledge by prior treatment by prior treatment in a representative sample of Israeli adults (n = 402) May 1-May 31, 2022.

Description	% individuals answering “yes” among individuals with prior dietitian treatment (n = 192)	% individuals answering “yes” among individuals without prior dietitian treatment (n = 210)	p-value
Dietitians know how to cook well	18.2	17.1	0.78
Dietitians learn a great deal of chemistry	45.3	41.9	0.49
Dietitians mainly work in hospitals	9.4	6.7	0.32
Dietitians earn above-average wages	31.8	40.5	0.07
Dietitians are essential in the treatment of chronic diseases	72.4	54.3	<0.001
Dietitians conduct health promotion	88.0	83.9	0.23
The best professionals to consult for treating eating disorders such as anorexia or bulimia are dietitians	45.8	42.4	0.47
Dietitian and food technologist are synonymous terms	18.8	19.0	0.94
Dietetics and nutrition are forms of alternative medicine	45.8	50.5	0.35
Dietitians give everyone the same menu	12.0	11.0	0.75
Dietitians change eating behaviors	89.6	91.0	0.64
If I had an obese child, I would consult with a clinical dietitian because s/he is the most appropriate professional	80.7	74.8	0.15
If I go to a dietitian, I will receive a menu that will provide me with nothing to eat	19.3	16.7	0.49
I will have less trust in an overweight dietitian	56.3	64.3	0.10
Dietitians research the association between food and disease	70.8	70.5	0.94

Displayed in Table 4 is the degree of agreement with statements about dietitians by prior dietitian consultation. Individuals who had prior dietitian consultation experience more strongly agreed with the statement, “Dietitians individualize diet therapy to reflect comorbidities, biochemistry, and personal preferences” than individuals without such experience. This finding persisted in a general linear model controlling for sex, type of community, age and ethnicity.

Table 4.

The degree of agreement with statements about dietitians by prior dietitian treatments in a representative sample of Israeli adults (n = 402) May 1-May 31, 2022.

	% individuals indicating the stated degree of agreement among individuals with prior dietitian treatment (n = 192)				% individuals indicating the stated degree of agreement among individuals without prior dietitian treatment (n = 210)
Description	Not at all	Somewhat	Much	Very much	Not at all	Somewhat	Much	Very much	p-value
A private dietitian is more professional than an HMO dietitian	53.6	26.0	13.0	7.3	48.6	28.1	19.5	3.8	0.14
A private dietitian is more professional than a hospital dietitian	52.6	29.2	12.0	6.3	52.9	29.0	14.8	3.3	0.49
Male dietitians are more professional than female dietitians	84.4	11.5	3.6	0.5	81.9	10.0	6.2	1.9	0.37
Dietitians individualize diet therapy to reflect comorbidities, biochemistry, and personal preferences	4.2	12.5	46.9	36.5	3.7	21.4	50.0	22.9	0.009
Dietitians give fewer professional consultations than other allied healthcare personnel	63.0	30.2	3.6	3.1	57.1	31.9	9.5	1.4	0.07

Analyses were repeated using general linear modeling, adjusting for age, ethnicity, type of community and sex, which differed or marginally differed by prior treatment by a dietitian. Findings were unchanged by adjustment (data not shown).

In Table 5, participants were asked to identify the professional with whom they would consult under certain circumstances and to rank healthcare professionals by nutrition knowledge. Regarding the professional to whom respondents would turn if they suspected a food sensitivity, significant differences were not detected by prior consultation with a dietitian, and respondents in both groups indicated that they were most likely to seek out a physician for treatment. Similarly, no differences were observed between individuals who had vs. had not previously consulted with a dietitian; however, members of both groups ranked dietitians as most knowledgeable about nutrition. Respondents ranked dietitians as the professionals with whom they would most likely consult if they desired to change their eating habits. These rankings did not differ by prior consultation with a dietitian.

Table 5.

Ranking of healthcare professionals on clinical proficiencies by prior dietitian treatment in a representative sample of Israeli adults (n = 402) May 1-May 31, 2022.

Description	% individuals answering “yes” from among individuals with prior dietitian treatment (n = 192)	% individuals answering “yes” from among individuals without prior dietitian treatment (n = 210)	p-value
With which professional would you consult first if you suspected you had a food sensitivity?
Dietitian	14.1	9.5	0.84
Nurse	0.5	0.5
Doctor	75.5	82.9
Occupational therapist	0.5	0.5
Speech pathologist	0.5	0.5
Naturopath	7.8	5.2
Physical therapist	0.0	0.0
Psychologist	0.5	0.5
Personal trainer	0.5	0.5
Please rank the following professionals in terms of their knowledge of nutrition
Dietitian	61.5	58.6	0.90
Nurse	0.5	0.0
Doctor	21.8	26.7
Occupational therapist	0.5	1.4
Speech pathologist	1.0	0.5
Naturopath	10.4	8.1
Physical therapist	1.0	1.4
Psychologist	1.0	1.0
Personal trainer	3.1	3.8
If you wanted to change your eating behavior, which professional would you prefer to consult?
Dietitian	68.2	67.6	0.19
Nurse	0.5	1.0
Doctor	9.9	16.7
Occupational therapist	0.5	0.5
Speech pathologist	0.0	0.0
Naturopath	9.9	4.3
Physical therapist	0.5	0.0
Psychologist	4.2	2.9
Personal trainer	6.3	7.1

Totals of some columns may be slightly more than or slightly less than 100% due to rounding.

4. Discussion

The present study was conducted in a representative random sample of Israeli adults who were asked to provide responses to questions about their beliefs and attitudes regarding dietitians. Of the 402 respondents, 192 (47.8 %) had previously been treated by a registered dietitian. Overall, respondents identified dietitians as the professionals with the most knowledge of nutrition and the clinicians with whom they would most likely consult if they desired to change their eating habits. These responses did not differ by prior consultation with a dietitian.

Knowledge, attitudes, and beliefs regarding dietitians can inform how the public interacts with dietitians. In Japan, for example, a survey of pharmacists and pharmacy dietitians indicated that dietitians performed significantly more consultations than pharmacists regarding obesity, hypertension, and diabetes (Demographics, 2024). These findings are consistent with the 62.9 % of participants in the present study who agreed with the statement, “Dietitians are essential in the treatment of chronic diseases.” This percentage was significantly greater among individuals who had previously been treated by a dietitian compared to those who had not (72.4 % vs. 54.3 %, p < 0.001). Further, more than half of the 192 respondents who had consulted with a dietitian had done so for reasons that could be classified as chronic disease, including weight management, dyslipidemia and/or hyperglycemia.

According to the US Bureau of Labor Statistics, dietitians and nutritionists “plan and conduct food service or nutritional programs to help people lead healthy lives.” (Kizaki et al., 2021) Similarly, the Association of UK Dietitians describes the professional activities of dietitians as interpreting nutrition science “to improve health and treat diseases/conditions by educating and giving practical, personalised advice to clients, patients, carers and colleagues.” (US Bureau of Labor Statistics. Dietitians and Nutritionists. Avail[cited, 2023). More than 90 % of respondents to the present survey indicated that dietitians primarily provided nutrition consultations, though the percentage was slightly greater among those who had vs. had not previously been treated by a dietitian (95.3 % vs. 90.0 %, p = 0.04). Almost 17 % more individuals with prior dietitian consultation experience indicated that dietitians performed medical nutrition therapy: 78.3 % vs. 58.6 %, p = 0.01. It would appear that prior experience with dietitian services sharpens respondent understanding of the professional activities of dietitians.

In the US, approximately 60 % of adults indicated they hold a mainly positive opinion of dietitians, and 60 % indicated that dietitians care about their patients’ best interests some or all of the time; conversely, only 47 % believed that dietitians provide fair and accurate information all or most of the time, and fewer than 20 % felt that dietitians were transparent or took responsibility for their mistakes all or most of the time (PDW, 2024). In that survey, older Americans and those more familiar with dietitians’ work viewed dietitians more positively. Greater trust was expressed towards dietitians in a survey conducted in the UK, in which 82 % of respondents indicated they would trust the nutrition advice they received from a dietitian (British Dietetic Association. What do dietitians do, 2017, British, 2024).

While identical questions were not asked in the present survey, it can be inferred from the degree of disagreement with the statement, “Dietitians give less professional consultations than other allied healthcare personnel” that these clinicians are not less-well thought of than other healthcare professionals. Specifically, 93.2 % of respondents who had vs. 89.0 % of those who had not previously consulted with a dietitian somewhat or strongly disagreed with that statement, an opinion that did not differ by prior consultation with a dietitian.

A survey of dietitians in France, Brazil, and Spain revealed that dietitians viewed their profession as essential to society, through which they promote health and educate the public to prevent primarily non-communicable diseases; nevertheless, dietitians from all three countries felt their profession was undervalued (British Dietetic Association. Survey finds that almost 60% of people trust nutrition advice from underqualified professionals, 2017). Interestingly, Israeli participants in the present survey most strongly associated dietitians with health promotion and changing eating behavior, The perceived clinical value of dietitians could be extracted from the question about who respondents would consult for a suspected food sensitivity. While twice as many would consult a dietitian as a naturopath, respondents overwhelmingly selected physicians as the health care practitioner of choice in this situation. This may represent an undervaluation of dietitian services and expertise; conversely, it may reflect the belief on the part of respondents that food sensitivities necessarily require medical intervention.

The present survey has a number of important advantages. It was conducted in an adequately powered, representative sample of Israeli adults, so it likely provides an accurate estimate of public opinion, beliefs, and knowledge. Further, the questionnaire was validated by a group of leading dietitians from academics, the food industry, and various clinical backgrounds, providing it with expert validity. Finally, the survey was conducted by trained, professional survey administrators, ensuring uniform survey presentation.

4.1. Study limitations

Like all studies, the present survey also has limitations, the most important of which is its cross-sectional design. This design precludes the assignment of causality, making it impossible to determine if responses that differed significantly by prior dietitian consultation differed as a result of the prior exposure or whether the attitude/belief/knowledge predisposed the individual to seek nutrition advice from a dietitian. The difference is salient in that if pre-existing attitudes predispose one to seek dietitian consultation, dietitian professional organizations could focus on promoting information about dietitians, increasing public awareness and the likelihood of seeking care. If, however, prior treatment at a dietitian precedes the attitude/belief/knowledge, the goal would be to expose as many citizens as possible to nutrition care, thus improving their knowledge of dietitian work and attitudes towards dietitians.

Responses that differed by prior dietitian consultation included 1) knowing that dietitians performed nutrition consultations; 2) knowing that dietitians practiced medical nutrition therapy; 3) knowing the educational requirements for becoming a registered dietitian; 4) identifying that dietitians are essential in the treatment of chronic disease; and 5) knowing that dietitians consider biochemical tests, comorbidities, and personal preferences when creating a diet prescription. Each of these differences was assessed again in a logistic or general linear model as appropriate for the outcome variable, and in each case, prior dietitian consultation remained a robust and significant predictor.

4.2. Conclusions

In conclusion, the present survey revealed that Israeli adults hold generally positive attitudes towards dietitians and that there appear to be associations between prior dietitian consultation and some attitudes/beliefs/knowledge about the profession, though the direction of the association is unknowable given the research design. Respondents who had previously received nutrition consultation from a dietitian were older and more likely to be Jewish. This may imply a need to encourage more utilization of dietitian consultation among Israeli ethnic minorities and younger adults.

CRediT authorship contribution statement

Mona Boaz: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Conceptualization. Vered Kaufman-Shriqui: Writing – review & editing, Project administration, Methodology, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Data availability

Data will be made available on request.