Journal of Functional Foods 105 (2023) 105558

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Journal of Functional Foods

journal homepage: www.elsevier.com/locate/jff

The advising behaviour of healthcare professionals; considerations of

dieticians and general practitioners regarding dairy and
probiotic interventions
A.M. van der Geest a, *, J.J. Feddema a, L.H.M. van de Burgwal a, O.F.A. Larsen a
a
Vrije Universiteit Amsterdam, Athena Institute, De Boelelaan 1085, 1081 HV Amsterdam, the Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: Dairy and probiotics are examples of products that contain ingredients that provide health benefits beyond the
Dieticians basic nutritional components of the food itself. However, strong evidence based on randomised controlled trials
General practitioners is generally lacking, which in turn leads to weak guidelines and recommendations for clinical practice. Inter­
Considerations
estingly, despite the limited regulation of probiotics, for example, a significant proportion of healthcare pro­
Probiotics
Dairy
fessionals still recommend these products. We set out studying the advising behaviour of general practitioners
Advising behaviour (GPs) and dieticians and their underlying motivations whether to advise probiotics, a relatively new intervention,
and dairy, an older intervention by conducting interviews and setting out a questionnaire. This study found that
the vast majority of GPs and dieticians recommended dairy and probiotics. The proportion of dieticians that do
not advise both dairy and probiotics was too small for statistical analysis, therefore, the results are mainly
focused on GPs. Considerations that appeared to be associated with GP advising behaviour were related to
compliance with protocols and guidelines in regard to both dairy and probiotics. For probiotics in particular,
GPs’ knowledge and patients’ interest in using probiotics was related to advising behaviour of GPs. Consider­
ations solely related to recommending dairy were related to GPs’ perceptions about the amount of evidence of
dairy efficacy and the recommendation of dairy in scientific journals. The study highlights the influence of
authority-driven, expertise-driven and patient-driven considerations on whether or not to proceed with recom­
mending an intervention. Insights into the drivers of GPs to advise, gives input to stakeholders in the nutrition
innovation system to understand and allow to use appropriate tools to support GPs in making an informed de­
cision to increase the quality of care provided.

1. Introduction
Although plants, herbs and other natural products have been used as
medical substances since ancient times, nutrition and pharmacology
research developed predominantly separately in the western world.
Pharmaceuticals were generally produced to treat, cure or prevent dis­
ease, and the primary goal of nutrition was to provide essential nutrients
to maintain or improve health. Over the last decades, the strict
distinction between pharma and nutrition has become increasingly
smaller as growing scientific evidence indicate a relation between nat­
ural products and risk factors for disease, such as the association be­
tween low-fat fermented dairy and a risk reduction of type 2 diabetes
(Georgiou et al., 2011; O’Connor et al., 2014; van Daal et al., 2021).
With the increased recognition of the potential of nutrition to treat or
prevent disease, new markets and product categories such as functional
foods, medical nutrition, and nutraceuticals positioned at the interface
between traditional foods and pharmaceuticals emerged.
Examples of products that offer health benefits beyond basic nutri­
tion are probiotics. Probiotics are defined as “live microorganisms
which, when administered in adequate amounts, confer a health benefit
on the host” (Hill et al., 2014). Examples of functionalities are reduced
pain and symptom severity in Irritable Bowel Syndrome (IBS); Antibiotic
Associated Diarrhoea (ADD) and lower risk of food allergy (D’souza
et al., 2002; Didari et al., 2015; Hempel et al., 2012; Sang et al., 2010;
Tang et al., 2010; Van der Geest et al., 2022). Surprisingly, probiotics
have remained largely unregulated, despite the growing interests and
consensus on their health benefits. Due to inadequate regulation many
products without proven “functionality” are available on the market,

* Corresponding author.
E-mail address: A.m.vander.geest@vu.nl (A.M. van der Geest).

https://doi.org/10.1016/j.jff.2023.105558
Received 21 December 2022; Received in revised form 3 April 2023; Accepted 19 April 2023
Available online 2 May 2023
1756-4646/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
A.M. van der Geest et al.
posing challenges for the knowledge and understanding of consumers
about nutrition and the resulting implications to health benefits (van de
Burgwal et al., 2018; Van den Nieuwboer et al., 2016). In addition, as
most of these products are available as over-the-counter products, reg­
ulatory agencies cannot provide the same level of clinical guidance that
they do for pharmaceuticals that are only accessible by prescription.
To eliminate ambiguity and confusion, and prevent mistrust in
nutrition among potential end users, the need and demand for nutri­
tional advice, including nutrition with specific health benefits, has
increased. Hence, HealthCare Professional (HCPs) are called upon to
integrate nutritional advise in their daily practices. However, nutritional
interventions generally lack a strong evidence from large and high-
quality trials as confounding factors such as background diet, intra-
and interindividual variation, hamper measuring physiologically rele­
vant change after nutritional interventions (Larsen et al., 2020; Weaver
and Miller, 2017). This often results in weak guideline recommendations
(which are driven by RCTs) and could result in insufficient imple­
mentation in clinical practice. Interestingly, despite limited published
evidence and guidelines for nutritional interventions, previous studies
show that already in 2016, 99% of Dutch GP gave nutritional advise and
53% gave probiotic advise in their practice; and in 2019, 86% of Eu­
ropean GP gave nutrition advice and 81% gave probiotic advise in their
practices (Flach et al., 2017; Van der Geest et al., 2020). This suggests
HCPs have considerations beyond a lack of limited evidence that weigh
more heavily when making the clinical decision to advise nutritional or
probiotic interventions. However, HCPs not adhering to guidelines or
not being driven by evidence might be a point of concern as these tools
are generally used to improve health outcomes and discourages the use
of ineffective interventions, which have the potential to increase
morbidity and mortality (Woolf et al., 1999).
Although the advising behaviour of HCPs has implications for the
adoption of beneficial treatments because they are the lynchpin between
beneficial interventions and patients, little is known about what con­
siderations support their decision to (not) advise an intervention. Hence,
this paper seeks to address this gap by using both qualitative and
quantitative methods to analyse the considerations related to HCPs
advising behaviour regarding nutritional interventions. To examine
whether considerations to advise nutritional interventions substantially
differ between different types of nutritional interventions, this study
used probiotics as a relatively new type of nutritional interventions and
dairy as a established nutritional intervention. If we gain understanding
on what considerations determine HCPs advising behaviour, comple­
mentary information can be provided or extended services can be
developed, to support informed decision making of HCPs.
2. Materials and methods
2.1. Study design
This study takes qualitative and quantitative approaches to identify
and analyse dieticians’ GPs considerations for recommending probiotic
and dairy interventions in their practices. To this end, interviews were
performed with Dutch dieticians and GPs and a questionnaire was
developed to collect quantitative data on the relation between the
identified considerations and their actual advising behaviour. Study
participants must be licensed HCPs such as registered GPs and dieticians
to be included in this study. Therefore, GPs in training were excluded as
well as (vitality) coaches.
2.2. Semi-structured interviews
The selection of GPs and dieticians was based on the network of the
authors of this paper and the snowballing method was used to recruit
additional study subjects among respondents’ networks to ensure rep­
resentatives in the study population (Noy, 2008). Semi-structured in­
terviews were conducted with 8 dieticians and 10 GPs employed in The
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Journal of Functional Foods 105 (2023) 105558
Netherlands. During the (telephone) interviews, oral informed consent
was obtained from all participants, and permission was asked and ob­
tained to record the interviews. Active asked informed consent is
registered in the interviews’ recordings and transcripts. A topic list was
used in the interviews to assess: 1) knowledge regarding probiotic or
dairy interventions 2) considerations for recommending probiotic or
dairy 3) any additional comment. The semi-structured design allowed
for probing on the considerations behind their advising behaviour. With
permission of the respondent the interviews were fully transcribed and
independently coded by two researchers. Codes were created induc­
tively to capture the meaning and content of each sentence and were
consensually harmonised to compile a list of 23 considerations. New
codes were created to capture the meaning of groups of initial codes.
This process resulted in a three structure with three layers to organise a
total of 3 themes: knowledge, attitude and external factors. Knowledge
is defined, by the Oxford Dictionary of English, as the state of knowing
about a particular fact or situation. Attitude is defined, as the way that
you think and feel about something; the way that you behave towards
something that shows how you think and feel. External factors refer to
elements or influences that exist outside an individual and affect deci­
sion-making.
2.3. Questionnaire
Based upon the interviews, a questionnaire was developed to quan­
titatively collect data on the considerations. The voluntary question­
naire with both open- and closed-ended questions was created through
the online questionnaire program Qualtrics. Respondents were
randomly assigned to answer questions either for probiotics or diary.
The anonymous questionnaire started with information about the
essential elements of the research, including how we handle the ob­
tained data and a time indication of 5–10 min to complete the ques­
tionnaire. Participants consented to participate by submitting the
completed survey. Respondents were asked to fill out demographics data
and questions on their knowledge regarding dairy and probiotics and
advising related questions. Furthermore, respondents were asked
whether they agreed upon the 23 considerations proposed in the ques­
tionnaire. Using google maps, we mapped all 212 dietician practices in
the Netherlands and approached them by mail with an invitation to
participate in the study. A total of 108 responses had been collected,
indicating a response rate of 51%, which is well within the norm for
surveys (53+/- 20%) (Baruch and Holtom, 2008). To approach GPs, a
mailing list of 130 respondents was collected on a Dutch College of GPs
congress. In addition, the questionnaire was enclosed with a Dutch
journal named GPs & Science. This journal has a circulation of 14.400 of
which a total of 320 HCPs consisting of dieticians and GPs filled in the
dairy questionnaire and a total of 343 respondents filled in the probiotic
questionnaire, indicating a response rate of 4,6%. Respondents’ IP ad­
dresses were used to identify potential duplicate entries. Duplicates were
eliminated before analysis.
2.4. Statistical methodology
After the data was explored by analysing the ratio of dietitians that
do and do not advise dairy and probiotics, dieticians were excluded from
the quantitative analysis as the proportion of dieticians that do not
advise both dairy and probiotics was too small for statistical analysis.
Hence, only the subset of GPs was quantitatively analysed. The statis­
tical analyses were carried out using, Excel, SPSS 25.0 software and
Rstudio (Team, 2015). Before further analyses were done, a Shapiro-
Wilk test was performed to test for the normality of the sample data.
In order to compare two independent groups that consist of one ordinal
and one categorical variable, a Mann-Whitney U test was performed. To
test whether there are non-random associations between two categorical
variables, the two-tailed Fisher’s exact test was used. To study the
variability in the large data set a Principal Component Analyses (PCA)
A.M. van der Geest et al.
was conducted. A p-value of < 0.05 was considered as statistically
significant.
3. Results
3.1. Qualitative analysis
A total of 10 GPs and 8 dieticians participated in an interview. The
characteristics of the interview participants are presented in Table S1. I.
Fig. 1 illustrates the three overarching themes and subthemes derived
from the data after inductive coding that are presented here: knowledge
(information, familiarity and interest), attitude (belief, risks, evidence,
responsibility, trust, need and rational thoughts) and external factors
(patient factors and recommendations authorities). These themes have
emerged through an inductive process; statements were grouped as
associated with knowledge, attitude and external factors.
HCPs state that a sufficient amount of knowledge or some familiarity
with the effects of an intervention on health is a crucial driver for HCPs
to advise a particular intervention. However, some HCPs argue that the
information on the efficacy is inconsistent, hindering HCPs from gaining
knowledge and therefore preventing HCPs from advising. HCPs also
mentioned their interest in the potential effects of an intervention as an
important determinant for recommending an intervention.
HCPs mentioned that some interventions were simply part of a
healthy diet without supporting this with arguments, indicating belief is
an important determinant of HCPs advising behaviour. Contrarily some
HCPs were more sceptical as they did not trust the industry behind an
intervention. In addition, some HCPs questioned the validity and
amount of evidence regarding the efficacy and risks of an intervention
and indicated this as a driver to advise or not advise probiotics and
dairy. Other HCPs questioned whether it’s their responsibility to advise
Fig. 1. Considerations to advise probiotic or dairy. 23 considerations can be categorized in three main themes: knowledge, attitude and external factors.
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Journal of Functional Foods 105 (2023) 105558
patients of certain interventions or were convinced that certain in­
terventions are not necessary to use. Lastly, we identified two consid­
erations that were related to logical reasoning, and clustered under
‘rational thought’.
The external factors theme could be subdivided into 2 sub categories:
patient factors and authorities’ recommendations. There were three
considerations related to patient factors as they all indicate patients can
influence the advising behaviour of HCPs. For example, a HCP may
decide not to recommend an intervention when a patient cannot afford
it. In contrast, the demand from the patient for an intervention seems to
nudge HCPs towards recommending an intervention. Furthermore,
when HCPs see in their own practices that patients benefit from a spe­
cific intervention, chances become greater that they will advise the
intervention for other patients too. The considerations that are grouped
under the sub-theme of authorities’ recommendations were all related to
the recommendation of a treatment by authorities such as colleagues,
protocols, guidelines, scientific journals and teachers.
3.2. Quantitative results
The quantitative analysis consisted of three parts. First, the data
regarding GPs and dieticians advising behaviour was explored in more
detail. In the second part of the quantitative analysis we determined
which considerations are statistically related to GPs advising behaviour.
Finally, in the third part of this quantitative analysis, a principal
component analysis was conducted in order to visualize the most
dominant considerations that characterize a specific subgroup, GPs who
advise dairy or probiotics versus GPs who do not advise dairy or
probiotics.
A.M. van der Geest et al. Journal of Functional Foods 105 (2023) 105558

3.2.1. Specifications advising behaviour in comparison with probiotic advisors (p < 0.001). Fig. 3D shows that
A total of 664 HCPs fully completed the questionnaire between there were no statistically significant differences found between dairy
March and August 2020. 187 respondents did not meet the inclusion advisors and dairy non-advisors.
criteria as they did not complete the questionnaire (n = 132) or were As shown in Fig. 4A, different types of probiotic products such as
from other specializations than the intended study population (n = 55). supplements, fermented dairy or a combination of probiotic product
The characteristics of the questionnaire participants are presented in types are advised about equally. As shown in Fig. 4B the vast majority of
Table 1. As presented in Fig. 2, the majority of HCPs advise dairy and HCPs, 80%, advised a combination of milk, yoghurt and cheese. The sub-
probiotics in their practices (respectively, 83% and 68%). HCPs that analysis found statistical differences between which product types are
advise the use of probiotics or dairy in their practices are referred to as advised by the different HCPs, GPs versus dieticians. In comparison to
“advisors” from here on out and HCPs that do not advise probiotic or GPs, probiotic supplements were statistically more often advised by
dairy are referred to as “non-advisors”. dieticians (respectively 15% vs 56%, p < 0.001), whereas GPs signifi­
Not only the vast majority of HCPs advise dairy and probiotics in cantly more often advised fermented dairy (respectively 51% vs 7%, p <
their practices, but there also is a discrepancy in these HCPs’ certainty 0.001). In the dairy category, yoghurt was statistically more often
regarding their decision to advise or not. Fig. 3A shows that in com­ advised by dieticians than GPs (respectively 29% vs 10%, p < 0.01),
parison with dairy non-advisors, probiotic advisors and probiotic non- whereas GPs statistically more often advised a combination of yoghurt,
advisors, dairy advisers were more often sure regarding their decision milk and cheese in their practices (84% vs 69%, p < 0.01). A complete
to (not) advise. Moreover, this study explored to what extent HCPs are overview of which product types of probiotics and dairy being advised
sure regarding which dairy or probiotic product to advise. Fig. 3B shows by dieticians and GPs is presented in Figure S1.
that in comparison with dairy advisors, probiotic advisors are less sure Probiotics and dairy are advised for a variety of diseases, as shown in
regarding which probiotic product to advise in their practices. Fig. 5A&B. GPs most often advised probiotics for Antibiotic Associated
Furthermore, the perceived level of knowledge regarding dairy and Diarrhoea (AAD) (respectively 89% vs 99%, p < 0.01), whereas di­
probiotics was assessed. As shown in Fig. 3C probiotic non-advisors eticians advised probiotics more often for IBS (respectively 73% vs 98%,
perceive themselves to have statistically significantly less knowledge p < 0.001), abdominal pain (respectively 54% vs 83%, p < 0.001),
constipation (respectively 38% vs 85%, p < 0.001), Irritable Bowel
Table 1 Disease (IBD) (respectively 21% vs 75%, p < 0.001), and others
Questionnaire participants characteristics respectively probiotic questionnaire (respectively 6% vs 28%, p < 0.001). In comparison to dieticians, GPs
and dairy questionnaire. significantly more often advised dairy products for bone problems
Probiotics Dairy
(respectively 92% vs 100%, p < 0.001). In contrast, dieticians in com­
parison with GPs statistically more often advised dairy products for
Advising behaviour N (%) N (%)
malnutrition (respectively 100% vs 87%, p < 0.001) and vitamin defi­
Advisors 156 (67%) 203 (84%) ciency (respectively 94% vs 78%, p < 0.001). For specifications of other
Non-advisors 78 (33%) 40 (16%)
indications mentioned by dieticians and GPs see Table S2.
Profession N (%) N (%)
GP 175 (74%) 194 (78%)
Dietician 59 (26%) 49 (22%) 3.2.2. A multitude of considerations are related to GPs (not) advising dairy
Age N % N % or probiotics
GPs (N = 369) Dieticians In Fig. 6, the 23 considerations that were derived from the interviews
were used to explore whether these considerations can be correlated to
(N = 108)
< 30 years 16 (33%) 36 (4%) GPs’ actual advising behaviour. Dieticians are excluded as the percent­
31–40 years 120 (31%) 33 (33%) age of dieticians that do not advise probiotics and dairy is too small for
41–50 years 106 (13%) 14 (29%) further analysis. The Man Whitney U test determined whether signifi­
51–60 years 73 (22%) 24 (20%)
cant differences could be found between GPs who advise dairy or pro­
60 < years 52 (1%) 1 (14%)
I’d rather not say 2 (0%) 0 (1%)
biotics and GPs who do not advise dairy or probiotics.
Sex N % N % In the knowledge theme, the perceived amount of knowledge as well
Male 132 (36%) 1 (1%) as the interest and familiarity with the possible effects of probiotics were
Female 225 (61%) 107 (99%) significant determinants for GPs to (not) advise probiotics (respectively,
I’d rather not say 12 (3%) 0 (0%)
p < 0.01, p < 0.001, p < 0.001). Interestingly, for dairy, only one small
statistically significant difference was found between GPs who do and do
not advise dairy in regard to consistency of information on dairy (p <
0.05), indicating knowledge and the related considerations determine to
a large extent the advising behaviour of GP in regard to probiotics but
barely influence advising behaviour for dairy.
In the attitude theme, there was much overlap regarding statistically
significant considerations that were related to GPs (not) advising dairy
or probiotics. Some considerations stood out as they had a high degree of
significance for dairy and not for probiotics. The first consideration that
determined the advising behaviour of GPs in regard to dairy to a great
extent was related to GPs belief that dairy belongs in a healthy diet (p <
0.001). The second consideration that was only statistically significant
for dairy was related to GPs attitude regarding the amount of evidence
(p < 0.001).
Again, in the external factors theme, overlap in statistically signifi­
cant considerations was observed. This included GPs’ conviction they
should advise probiotics and dairy if it is recommended in guidelines
and protocols (p < 0.001) as well as GPs’ own observation regarding
patients benefitting from the use of probiotics and dairy (p < 0.001).
Fig. 2. The majority of HCPs advise dairy and probiotic in their practices. Lastly, mainly in the probiotic group, the advisory behaviour of GPs

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A.M. van der Geest et al. Journal of Functional Foods 105 (2023) 105558

Fig. 3. A, B, C & D: HCPs were asked whether they were sure regarding their decision to (not) advise and regarding their product choice. Moreover, HCPs were asked
to assess their perceived level of knowledge regarding dairy and probiotics. In addition to the 5 individual data points of the likert scale, we have added distribution
lines to the figures to highlight the overall pattern of the data. A) Probiotic non-advisors were in comparison with dairy (non–)advisors and probiotic advisors less
sure regarding their decision to (not) advise (Kruskal Wallis test, p < 0.001). B) Probiotic advisors were in comparison with dairy advisors more often not sure
regarding their product choice (The Man Whitney U (MWU) test, p < 0.001). C) Probiotic non-adviser significantly more often perceived to have less knowledge
(MWU test, p < 0.001). (D) The perceived amount of knowledge did not statistically significantly differed between dairy non-adviser dairy advisors. (* p ≤ 0.05, ** p
≤ 0.01, *** p ≤ 0.001).

Fig. 4. A&B: Different types of probiotic (A) and dairy (B) products are being advised. (A) Fermented dairy, supplements, and a combination of the foregoing
are advised about equally. (B) With a majority of 80%, HCPs mainly advised a combination of yoghurt, milk and cheese in their practices.

could be related to their patient population asking for probiotics (p <
0.001).
3.2.3. Principal component analysis to determine the contribution of the
different considerations
As shown in Fig. 7, a Principal Component Analysis (PCA) was used
to visualise our high-dimensional dataset. The PCA analysis plot shows
clusters labelled by their advising behaviour, a cluster in red represents
GPs who do not advise dairy or probiotics and a cluster in blue repre­
sents GPs who do advise dairy or probiotics. Fig. 7A shows that GPs who
advise dairy and probiotics are mainly distributed in the right quadrants
while GPs who do not advise are distributed in the left quadrants. Thus,
advisors and non-advisors differ primarily on dimension 2, the
horizontal line. Fig. 7B shows which considerations strongly influence
dimension 2 and are likely responsible for the differences between ad­
visors and non-advisors. As shown in Fig. 7B, the largest contributors to
dimension 2 are, for both probiotics and dairy, the considerations
related to adherence of guidelines and protocols (10 & 11). Thus, these
results suggest non-advising GPs might be driven to a large extent by
interventions being included in guidelines and protocols. In contrast,
GPs’ considerations to advise seems to differ between dairy and pro­
biotic interventions. In regard to probiotic innovation GPs’ advising
behaviour seems to be driven by considerations related to GPs’ knowl­
edge and interest in probiotics (1 & 4). In case of dairy, GPs’ advising
behaviour seems to be driven by considerations related to their
conviction diary belongs in a healthy diet and their perception regarding

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A.M. van der Geest et al. Journal of Functional Foods 105 (2023) 105558

Fig. 5. A&B Dieticians and GPs were asked to list the medical indications for which they advise (A) probiotics or (B) dairy. Multiple answers were
allowed. (A) Significant differences were found between dieticians and GPs for almost all indications. AAD is significantly more often advised by GPs in comparison
with dieticians. All other indications are more often advised by dieticians in comparison with GPs. (B) Significant differences were found between dieticians and GPs
for all indications. (* p ≤ 0.05, ** p ≤ 0.01, *** p ≤ 0.001).

Fig. 6. A multitude of considerations were answered statistically differently between GP who advise dairy or probiotics and GPs who do not advise dairy
or probiotics; the “x” in the considerations stands for probiotics or dairy. Figure S2 (probiotics) and S3 (dairy) show the likert scale, mean and standard
deviation per question. (* p ≤ 0.05, ** p ≤ 0.01, *** p ≤ 0.001).

the amount of evidence regarding dairies efficacy (3 & 7).
4. Discussion and conclusion
This study found 23 different considerations for dieticians and GPs
when it comes to advising probiotics and dairy. While adherence to
protocols and guidelines is a significant determining factor for Health­
Care Professionals (HCPs) advising probiotics and dairy or not, a range
of other factors influence decision making for HCPs. With the majority of
HCPs advising dairy and probiotics in their practices, a major contrib­
uting factor for GPs to advise probiotics and dairy are their own ob­
servations that patients benefit from the use of it. Some drivers for

6
A.M. van der Geest et al.
Fig. 7. (A) The PCA plot shows GPs who advise probiotic or dairy are differently distributed in comparison to GP who do not advise probiotics or dairy. (B)
Considerations 10 and 11 contribute to a greater extent to the advising behaviour of both GP who do not advise dairy and probiotics. Moreover, consideration 3
determines the advising behaviour of GP who advise dairy to a great extent and considerations 1 and 4 determine the advising behaviour of GP regarding probiotics.
further recommendations were intervention-specific, as only the
following factors were determinants of recommendation behaviour
regarding probiotics: the amount of knowledge GPs themselves
perceived; interest in the effects of the intervention; and patients
themselves requesting a specific intervention. Considerations that were
found to be solely associated with dairy advice behaviour were GPs’
perceptions of the amount of evidence on the efficacy of dairy; GPs’
belief that dairy belongs in a healthy diet; and dairy recommendation in
scientific journals.
Although the majority of healthcare providers advise dairy and
probiotics in their practice, clear differences were found in the level of
knowledge they thought they had. In line with previous studies, this
study found that HCPs who advised probiotics themselves reported
having more knowledge on the subject than non-advisers (Van der Geest
et al., 2020). In contrast, there were no statistically significant differ­
ences in self-reported knowledge between advisers and non-advisers of
dairy interventions Fig. 3A,B. This implies that GPs adopt a more
expertise-driven decision-making approach where the possession of
domain-specific knowledge forms the deciding factor when advising on
probiotics. This study also found considerations which seemed to belong
to a more authoritative driven decision-making such as the inclusion of
an intervention in guidelines and protocols. This consideration corre­
lates with GPs’ advising behaviour towards both dairy and probiotics,
implying that the inclusion of interventions in guidelines and protocols
could potentially determine the advising behaviour towards a variety of
interventions. Guideline recommendations are frequently derived from
systematic reviews and meta-analyses of Randomized Controlled Trials
(RCTs). However, studies on the relation between health and nutrition
are often inconclusive, which raised concerns in the scientific
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Journal of Functional Foods 105 (2023) 105558
community about the validity of outcomes obtained by RCTs in the
nutritional context (Van der Geest et al., 2022; Zeilstra et al., 2018).
After all, the homogeneous patient groups used in RCTs do not accu­
rately reflect treatment effectiveness for the majority of the population,
which in reality is varies in age, types and severity of symptoms, and
usually has comorbidities (Bensing, 2000). Despite these objections,
RCTs are still considered the gold standard method for examining the
effectiveness of a therapeutic intervention (Desai et al., 2019). On the
one hand, this indicates the need to reconsider the existing methodical
structures in the context of nutritional interventions. On the other hand,
HCPs should not directly link the lack of nutritional interventions in
guidelines to the ineffectiveness of an intervention.
Clear differences were found in how GPs scored the level of evidence
for efficacy of the interventions. GPs who advised dairy themselves re­
ported that there was plenty of evidence regarding its efficacy, and GPs
who didn’t advise dairy reported that there was little evidence regarding
its efficacy. In contrast, GPs who advised probiotics did not significantly
differ in their perception on the amount of evidence regarding probiotics
efficacy. This is in line with recent evidence that also found a consid­
erable proportion of GPs recommend probiotics despite their disbelief in
its efficacy (Van der Geest et al., 2020). Interestingly, as mentioned
earlier, GPs’ advising behaviour in relation to dairy did not appear to be
correlated with their knowledge, implying that their judgements on
effectiveness were not formed by reflection on GPs’ knowledge of
effectiveness, but, for example, by authoritative sources that told them
about the efficacy of dairy which GPs assumed to be true. Moreover,
theories of behaviour focus mainly on deliberative processes, however,
the role that implicit processes such as habit have on advising behaviour
is mostly underreported (Potthoff et al., 2019). Thus, GPs may also
A.M. van der Geest et al.
assume that there is sufficient evidence because they have been rec­
ommending it for years and the intervention is embedded in their cur­
rent advising routines, a phenomena named habitual clinical behaviour
(Potthoff et al., 2018). Wierenga and colleagues distinguished between
reasoned decision-making in which information is actively sought and
alternatives are considered; and routine decision-making in which a
decision is made without further exploration of alternatives. It has been
found that HCPs apply routine decision-making in about 70% of cases,
indicating HCPs choose from a limited number of treatment options that
comes to mind given the patients’ health problem (Wierenga, 1989).
This clinical habitual behaviour not only hampers the adoption of novel
beneficial interventions, but may also be detrimental to the quality of
care, as HCPs are not triggered to reconsider their previous decisions in
light of current insights. Hence, GPs should be encouraged to use active
problem solving where the doctor carefully weighs the advantages and
disadvantages.
Although a substantial group of GPs perceived there is insufficient
evidence regarding the efficacy of probiotics, they still recommend
probiotics, indicating that other factors count more heavily than the
amount of evidence for a substantial part of GPs (van der Geest et al.,
2020; Flach et al., 2017). For probiotics, for instance, patients’ treat­
ment preference seemed to determine GPs’ advising behaviour, sug­
gesting that patients’ conviction potentially outweigh those of GPs. Of
course, this is also related to the nature of probiotics, which are available
as over-the-counter-product, which empowers patients to decide for
themselves whether to use it or not. This also changed the role of the GP
from a gatekeeper role to an advisory role. In addition, changing social
cues, such as patients demanding a specific treatment, can contribute to
breaking clinical behaviour of HCPs (Aarts et al., 1998; Potthoff et al.,
2018; Sweeney et al., 1998). In this regard, patients are valuable change
agents, to break advising habits of GPs and enhance the adoption of
alternative or novel treatments. Moreover, patients’ user experiences
could represent valuable outcomes not only for the GP and clinical
practice but also for clinical research as these outcomes can contribute
to the external validity of studies evaluating clinical effects (Van Der
Geest et al., 2021; van der Waal et al., 2019).
The present study has several limitations that must be taken into
account when interpreting the results. One of the limitations is the
geographical bias of the study, as all HCP included in this study were
Dutch, which is a culture with a strong dairy-eating tradition. This may
limit the generalizability of the results to other populations. Addition­
ally, the results were collected on a voluntary basis, which may intro­
duce self-selection bias, where HCP who are more interested or
knowledgeable about nutrition may have been more likely to participate
(Heckman, 1990). This may lead to an overestimation of the prevalence
of certain attitudes or behaviors in the sample. Nonetheless, the GPs
group exhibited a balanced proportion of advisers and non-advisers,
suggesting that the sample was heterogeneous. Due to limited previ­
ous research in the field, we were hampered to make realistic assump­
tions about key parameters needed for a power analysis, therefore, no
power analysis was conducted, which may have affected the statistical
power of the study. To enhance the validity of this study, various other
strategies were employed. A mixed method approach was used to in­
crease internal validity, and consistency of findings was ensured by
involving multiple researchers with diverse backgrounds in various
stages of the research process, from design to data collection and anal­
ysis. The use of multiple researchers also reduced the impact of subjects
and circumstances on the findings, increasing both the reliability and
applicability of the results (Riege, 2003). To achieve external validity,
this research involved different actors, such as GPs and dieticians from
different regions in the Netherlands. Results were compared with recent
literature and presented at a conference, allowing for feedback and
improving the validity, interpretation, contextualization, and presenta­
tion of the results.
8
Journal of Functional Foods 105 (2023) 105558
5. Conclusion
This study has been one of the first attempts to examine the advising
behaviour of HCPs regarding dairy and probiotics by gaining a better
understanding of considerations that are at the root of their decision to
advise or not advise. Overall, the study highlights the influence of
authority-drive, expertise-drive and patient-driven considerations on
whether to (not) advise probiotics. Despite, the current study is limited
to the context of dairy and probiotic interventions, the insights into the
drivers of GPs to (not) advise, gives input to stakeholders in the nutrition
innovation system to understand and allow to use appropriate tools to
support GPs in making informed decisions.
Ethical statement
No animal or human experimentation was conducted in this
manuscript.
CRediT authorship contribution statement
A.M. van der Geest: Conceptualization, Formal analysis, Resources,
Data curation, Writing – original draft, Project administration, Visuali­
zation, Funding acquisition. J.J. Feddema: Validation, Formal analysis,
Writing – review & editing. L.H.M. van de Burgwal: Writing – review &
editing, Visualization, Supervision. O.F.A. Larsen: Conceptualization,
Formal analysis, Writing – review & editing, Visualization, Supervision,
Funding acquisition.
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.
Data availability
Data will be made available on request.
Acknowledgements
The author greatly acknowledges all dieticians and GPs who partic­
ipated in this study. In addition, the author would like to thank Cato
Wiegers for carefully reviewing the paper.
Funding sources
This work was financially supported by Nederlandse Zuivel Organ­
isatie (NZO). This work is independent of the funder and does not
necessarily represent its views.
O.F.A Larsen is also Senior Manager Science at Yakult Nederland B.V.
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