When to Refer to a Dietitian: A Guide for Hunter GPs

Refer to a dietitian when nutrition is part of managing the condition, not only when weight is the concern. In practice that covers type 2 diabetes and prediabetes, raised lipids, PMOS (formerly PCOS), endometriosis, pregnancy and preconception, perimenopause, IBS and coeliac disease, malnutrition risk, eating disorders including ARFID, patients prescribed a GLP-1 receptor agonist, and NDIS participants with nutrition needs. This guide sets out the triggers by condition, the current funding routes, and what a useful referral contains.

Who this guide is for

This page is written for GPs, practice nurses and other clinicians in Newcastle, Lake Macquarie and the wider Hunter. The funding rules are national, so it applies anywhere in Australia. If you already know you want to refer, the refer a patient page covers how to send it. This guide covers when and why.

Clinical triggers for referral, by condition

The table lists common points where dietetic input may change management. The middle column is our clinical framing; the right column is what the cited guideline or source says. It is a prompt, not a protocol. Your clinical judgement and local pathways come first.

Diabetes, prediabetes and insulin resistance

The RACGP handbook says all people with type 2 diabetes should be offered and encouraged to seek medical nutrition therapy from an APD. It describes the APD’s role as helping people build sustainable eating patterns, read labels, adapt recipes and eat out. For people at high risk, the handbook notes that effective programs involve many sessions over months, which may be beyond brief GP care or a handful of care plan visits.

GPCCMP eligibility does not list specific conditions. It depends on whether your patient has a medical condition that has been present, or is likely to be present, for at least 6 months.

Cardiovascular risk and lipids

The 2023 Australian guideline advises healthy lifestyle support at every risk level. It recommends an eating pattern low in saturated and trans fats, and suggests considering a Mediterranean-style or DASH pattern. A dietitian turns that advice into changes your patient can sustain, alongside any medicine you prescribe. Diet works with lipid-lowering therapy, not instead of it.

PMOS (formerly PCOS) and endometriosis

The 2023 international PCOS guideline recommends healthy lifestyle behaviours for all women with the condition. It also asks clinicians to consider eating disorders regardless of weight, and to be aware of weight stigma. It suggests considering referral to suitably trained allied health professionals when women need support with diet. There is no evidence that one diet composition works better than another, so the work is individual.

The RANZCOG endometriosis guideline suggests discussing diet advice, including a low FODMAP approach, with the caveat that evidence of benefit is limited. It also recommends considering multidisciplinary care, especially for ongoing pain after medical or surgical treatment. For patients, our endometriosis care guide explains the local care team.

Pregnancy, preconception and menopause

For gestational diabetes, the RACGP handbook says women should be referred to an APD and a credentialled diabetes educator if the obstetric service does not provide them. Preconception and pregnancy referrals are also worth considering for restrictive diets, hyperemesis, or a history of an eating disorder. In perimenopause, the Australasian Menopause Society notes that fat gain shifts towards central and visceral stores, which is associated with cardiovascular disease and diabetes. It also links healthy bones with adequate calcium and vitamin D, which is another reason to refer.

IBS and coeliac disease

Monash University, which developed the low FODMAP diet, advises that it be followed under the guidance of a dietitian with skills in IBS. Referring before your patient starts means the restriction and reintroduction steps are supervised, which may help avoid unnecessary long-term restriction.

For suspected coeliac disease, Coeliac Australia advises patients to keep eating gluten until testing is complete, because avoiding gluten can make results inaccurate. After diagnosis, it describes a dietitian with coeliac experience as vital for setting up a balanced gluten free diet.

Unintentional weight loss and malnutrition risk

The Malnutrition Screening Tool (MST) asks two questions: recent unintentional weight loss, and poor intake because of reduced appetite. A score of 2 or more means the person is at risk, and the form recommends referral to a dietitian. Malnutrition can occur at any body size.

Eating disorders, disordered eating and ARFID

ANZAED’s practice standards describe dietitians as important members of the multidisciplinary eating disorder team. Dietitians assess and manage the nutrition problems the illness creates. Diagnosis and psychological therapy sit outside dietetic scope and stay with medical and mental health clinicians.

ARFID is more than picky eating. NEDC describes avoidance driven by fear, sensory sensitivity or low interest in food, which can lead to weight loss, nutritional deficiency or faltering growth. NEDC advises against a watch and wait approach. At Ausclin, Tahnia Middleton is an APD and ANZAED Credentialed Eating Disorder Clinician. More on our eating disorder support.

Patients prescribed a GLP-1 receptor agonist

Dietitians Australia has called for every prescription of these medicines to come with a dietitian referral. It cites risks of malnutrition, loss of muscle and bone mass, and disordered eating when appetite is suppressed without nutrition support. It calls for dietitian care before, during and after use of the medicine. This is advocacy and has not changed Medicare funding. Prescribing decisions stay with you. See our GLP-1 medication support page.

NDIS participants

Dietitians Australia notes that the NDIS pricing arrangements have included dietetics under Capacity Building, Improved Health and Wellbeing. Funding depends on the participant’s plan and on the need relating to their disability. Our NDIS dietitian page explains how it works for participants and support coordinators.

Funding pathways: the current rules

GP Chronic Condition Management Plans replaced GP Management Plans and Team Care Arrangements on 1 July 2025. A GP Management Plan and Team Care Arrangements prepared before that date can still support allied health services until the end of 30 June 2027. From 1 July 2027 your patient needs a GPCCMP (or a multidisciplinary care plan) to keep accessing these services.

Aboriginal and Torres Strait Islander patients can claim additional allied health services under MBS Group M11. ARFID is not one of the diagnoses listed in the MBS eating disorder eligibility criteria, so check whether another route applies.

What makes a useful referral

For a GPCCMP referral written on or after 1 July 2025, the MBS requires it to be in writing, signed and dated. It must include your name, your practice address or provider number, and the reasons for referral. It is valid for the period you state, or 18 months from the first service if you state none. It does not need to name a dietitian or a number of services, so your patient can take it to any eligible dietitian. Dietetics does need to be recommended in the patient’s plan for the service to attract a Medicare benefit.

Beyond the minimum, these details save the first session from being spent on history:

• Diagnoses, and which one the referral is mainly for.
• Current medicines, including any recent start or dose change.
• Recent pathology, such as HbA1c, lipids, iron studies, coeliac serology or vitamin D, with dates.
• Relevant history: eating disorder, bariatric surgery, pregnancy, food allergy.
• Your goals for the referral and anything you want avoided, such as weight-focused language.
• Which plan applies (GPCCMP, Eating Disorder Plan, NDIS or DVA), so the patient is billed correctly.
• For eating disorder referrals, who is doing medical monitoring and who the mental health clinician is.

What you get back

For GPCCMP services, the MBS requires the dietitian to send you a written report after the first and last service, and in between if something arises you would reasonably expect to know. For eating disorder dietetics, a report is required after the first service, as clinically needed, and after the final service. At Ausclin, we send a summary to the referring GP.

Local referral guidance in the Hunter

Hunter New England Community HealthPathways is a free online decision support tool for general practice. It covers assessment, management and how to refer to local services. It is a collaboration between local primary care clinicians, the Hunter New England and Central Coast PHN and the Hunter New England and Central Coast Local Health Districts. Access needs a personal account, because the generic logins have ceased. Central Coast has its own HealthPathways site. Check the relevant pathway for public dietetics and eating disorder services in your area.

Ausclin sees patients in person at 18 Wilsons Rd, Mount Hutton, and by telehealth across the Hunter and Australia-wide. Patients do not need a referral to book. We work with GPCCMP and Eating Disorder Plan referrals, NDIS, DVA and referrals from medical consultants.