Nutrition Services in Primary Care: Time, Money and Guidelines Stand Between Prevention and Practice

Poor diet is now one of the deadliest risks on the planet. Roughly one in five deaths worldwide is attributable to suboptimal eating, adding up to about 11 million deaths every year, while overweight and obesity contribute another four million deaths annually through the growing burden of non-communicable diseases. Yet a new study from the Republic of Srpska, Bosnia and Herzegovina, reveals just how hard it is for even a well-organized primary healthcare system to turn that knowledge into consistent prevention. The research, published in the International Journal of Public Health, provides one of the most detailed pictures to date of how nutritional services actually function at the front line of medicine, where the battle against chronic disease is supposed to begin.

The study, led by Jelena Niškanović of the University of Banja Luka together with Dragana Stojisavljević and Dijana Manigoda of the Public Health Institute of the Republic of Srpska, set out to assess the provision of nutritional services across primary healthcare facilities, with a particular focus on differences between the Family Medicine, Pediatrics, and Gynecology departments. The team applied a mixed-methods design, combining a cross-sectional quantitative survey with qualitative focus group discussions. The quantitative component covered all public primary healthcare centers in the Republic of Srpska, targeting lead physicians from the three departments, and by the end of data collection in December 2023, 50 facilities had submitted complete questionnaires. Response rates were high across the board: 89.1 percent for Family Medicine, 84.1 percent for Pediatrics, and 88.9 percent for Gynecology. Three focus groups, one for each department, added the voices of doctors and nurses from 12 selected facilities chosen for their size and geographical distribution.

The headline numbers look encouraging at first glance. Services related to the improvement of nutrition and the prevention of non-communicable diseases were provided by 92.4 percent of primary healthcare facilities, while 80.5 percent monitored the nutritional status of the population. But the departmental breakdown tells a very different story. Family Medicine and Pediatrics monitored nutritional status in more than 91 percent of cases, while Gynecology departments did so in only 50 percent, a difference the authors describe as highly significant. The same pattern held for individual services: 75.4 percent of facilities monitored anthropometric parameters such as height, weight, and body mass index, but only 46.6 percent assessed laboratory parameters, 28 percent used dietetic questionnaires, and a mere 20.3 percent assessed clinical parameters related to nutrition.

The provision of counseling services showed equally striking imbalances. Nutritional counseling was significantly more frequent in Family Medicine at 87.8 percent and Pediatrics at 86.5 percent than in Gynecology at 50 percent. Counseling for women of reproductive age, by contrast, was significantly more frequent in Gynecology at 71.9 percent than in the other two departments, where it hovered around 21 to 31 percent. Breastfeeding counseling and the early detection of overweight and obesity were dominated by Pediatrics, while counseling for overweight and obese patients was significantly more frequent in Family Medicine. Overall, nutritional counseling at 77.1 percent, physical activity counseling at 73.7 percent, and counseling for overweight and obese patients at 66.1 percent were provided more often than early detection of overweight and obesity at 51.7 percent, breastfeeding counseling at 46.6 percent, and counseling for women of reproductive age at 39 percent. The authors interpret this as evidence that nutrition services remain largely reactive rather than comprehensive and continuous.

The barriers that healthcare personnel identified are the study’s most sobering contribution. On a five-point Likert scale, the lack of financial compensation for providing nutritional services by the Health Insurance Fund of the Republic of Srpska scored highest at a mean of 4.53, followed by lack of time for counseling at 4.19 and patients’ knowledge of nutrition at 3.92. Analysis of variance revealed significant differences between departments in the reported lack of time, with Family Medicine physicians reporting a mean of 4.47 compared with 3.68 in Gynecology. The statistical signal is precise: the F value of 4.402 with p below 0.05 confirms that the departments genuinely experience the time crunch differently, and the post hoc test pinpointed the gap between Gynecology and Family Medicine.

The focus groups put human faces on those statistics. Family Medicine personnel described nutrition services delivered on an ad hoc basis in the form of brief advice, anthropometric measurements, and basic laboratory parameters, with counseling squeezed into curative examinations of older patients with chronic diseases. One participant admitted that the quality of counseling was essentially random advice and nothing more because of the amount of work, sometimes amounting to handing patients a pre-printed diet plan for a day or two. Pediatric teams described nutrition counseling embedded in the infant counseling center, where healthy children are examined during vaccination visits, but stressed that they lacked separate space and time to devote to nutrition alone, not for lack of desire but for lack of staff. Gynecology teams reported little contact with nutrition services in everyday practice, apart from occasional dietary instructions for specific conditions such as fungal infections or obesity affecting fertility, and referrals to nutritionists at the regional institute level.

The qualitative findings also surfaced a troubling trend that gynecologists are witnessing firsthand. One participant noted that in everyday work they deal not only with pregnant women but also with adolescents and children with obesity, observing that the limit for the first menstrual cycle has moved because of obesity, with girls now presenting with an established menstrual cycle at the age of 10. This observation connects the systemic gaps in service provision to a concrete biological consequence, illustrating how the absence of structured nutritional counseling in one department can ripple into the health of the next generation.

Across all three departments, the most frequently reported obstacles were a shortage of medical doctors and the consequent lack of time with patients, together with the absence of guidelines containing clear dietary recommendations for particular population groups and specific health conditions. Family Medicine and Pediatric personnel added that the existing information system does not support the planning and monitoring of preventive activities, while gynecologists noted insufficient diagnostic equipment and limited biochemical laboratory testing for women at the primary level. The proposals for improvement were remarkably consistent: reorganization of nutritional and preventive services through multidisciplinary teams and counseling centers with dedicated time for nutritional services, development and promotion of new dietary standards and guidelines for both the general population and specific medical conditions, and stronger cooperation with the local community through proactive preventive activities, promotion of proper eating habits via social media focused on children and adolescents, more educational materials, and additional laboratory diagnostics at the primary level.

The study’s context matters. The UNICEF Nutrition Strategy 2020–2030 envisions a world where all children, adolescents, and women realize their right to nutrition, grounded in the Convention on the Rights of the Child, which recognizes adequate nutrition as a fundamental human right. Global initiatives such as the Scaling Up Nutrition Movement, the World Health Assembly nutrition targets, and the United Nations Decade of Action on Nutrition have placed nutrition at the center of development agendas, emphasizing the need for stronger health system responses. Yet the evidence from the Republic of Srpska shows that even where policies exist on paper, practical implementation at the primary healthcare level can lag far behind. Nearly one-fifth of facilities did not offer any form of nutritional monitoring or assessment, and the limited use of dietary assessment tools suggests gaps in knowledge and the absence of standardized protocols, issues that have been reported in other settings as well.

The authors conclude that strengthening nutrition services in primary healthcare requires a comprehensive approach, including capacity building among healthcare professionals, the development and implementation of standardized guidelines, improved financing mechanisms, and enhanced monitoring systems tailored to the specific profile of each department rather than applied uniformly across primary healthcare centers. Greater collaboration with local communities and public health institutions is essential to improve service coverage and effectiveness, and future strategies should prioritize integrating multidisciplinary approaches and enhancing the use of health information systems to promote sustainable improvements in population nutrition and reduce the burden of non-communicable diseases. The study was conducted as part of the Nutrition-Friendly Preschool/School Initiative in the Republic of Srpska, implemented by the Public Health Institute with the support of the UNICEF Office in Bosnia and Herzegovina. The message for health systems everywhere is clear: the will to prevent diet-related disease exists at the front line of medicine, but without time, money, and standardized tools, prevention remains a promise rather than a practice.

Subject of Research: Public Health

Article Title: Nutritional services in primary healthcare in the Republic of Srpska, Bosnia and Herzegovina: strengthening prevention through multidisciplinary approaches

Article References: Nutritional services in primary healthcare in the Republic of Srpska, Bosnia and Herzegovina: strengthening prevention through multidisciplinary approaches. (n.d.). https://doi.org/10.3389/ijph.2026.1609839

Image Credits: AI Generated

DOI: 10.3389/ijph.2026.1609839

Keywords: nutrition, primary healthcare, non-communicable diseases, preventive care, Bosnia and Herzegovina, public health, health policy, Nutritional, services, primary, healthcare, Republic