Hey strangers. I am a month into medical school already and I can’t understand where time went. Some days are gone before I can even catch a full breath! My university has been really good (and unique) in that I have already spent a few days in a hospital, gone on rounds, learned how to take patient histories and vitals, and volunteered at a free clinic. These experiences have stirred up some really strong emotions and lit a few fires under my glutes. This post isn’t directed at anyone in particular, it’s just a reflection of what I think everyone, particularly those in healthcare, should be taught in far more depth.
Now thats its 2016 and America is starting to acknowledge the importance of nutrition, I thought that it would come up a fair amount in medical school. So far, almost zilch. We just finished the embryology section of Anatomy, and the professor did not touch on nutrition at all – except spina bifida and anencephaly (both caused by folate deficiency during pregnancy). What about all the other important nutrients during pregnancy?! I want my peers to know how even a small deficiency in certain vitamins and minerals can lead to really crucial changes in the fetus (decreased IQ potential as the most disturbing example). I want them to know that pregnant mothers must eat fish or take fish oil with DHA in order for their baby to have ideal brain development. Between just my classmates and I, we will see over a million patients. That is one million missed opportunities for nutrition and lifestyle changes if my peers and I don’t learn and disseminate relevant diet/lifestyle information.
Last week, while going on rounds in cardiology and neurology units in the hospital, most patients had conditions that can be prevented with diet and lifestyle or at least modulated once the disease is present. Diet was never discussed and the food served was high carb and sugar-laden. Of course, I understand that diet cannot prevent everything and cannot cure everything. However, if physicians or nurses discussed diet with 10 patients and just 1 had positive outcomes from it, isn’t that worth it?
My gut instinct is that it is. But why? Why change your own diet when you can take medications to deal with disease? Why counsel a patient on diet when they probably won’t do it anyway, or if they do, it might not help much?
We get sick and develop diseases for a variety of reasons. Some are hard and fast – we catch a virus from a person or a dirty doorknob, or a parasite from drinking contaminated water. Some are largely genetic with varying levels of control from the environment and our lifestyle (or none). Some are slow going and cumulative, from the things we eat, to the things we do, where we live, what our jobs are, our stress levels, the chemicals we are exposed to, where we live, etc. Diet is just one fraction of the list of things that affect our health, but it has an exponential impact.
- What you eat affects your health.
- How you live affects your health.
- Your health affects how you live and what you eat.
- And to make it that much more meta, how you live (“the social determinants of health”) affects what you eat.
Sure, you can just take a drug for most of the symptoms and conditions out there. But they are largely just bandaids on an oozing flesh wound. The issue probably isn’t going to go away if the root cause isn’t fixed. In fact, it’s probably going to get worse and possibly bring a few other comorbid conditions along with it. An example of this is Metabolic Syndrome, a cluster of extremely common and preventable risk factors for heart disease, diabetes, stroke and more. The factors are: having a large waistline (preventable with diet/exercise/sleep/stress reduction), a high triglyceride level (preventable with a reduced carb diet), low HDL cholesterol (can increase with exercise), high blood pressure (can improve with weight loss, exercise, smoking cessation, stress/alcohol reduction), and high fasting blood sugar (diet, exercise).
We eat (if we are lucky) 3 or more times a day. That is over 1,000 opportunities to impact our health on a yearly basis. Diseases are heavily tied to inflammation and immune status. A healthy diet will decrease inflammation and improve immunity. A poor diet and/or lifestyle will induce inflammation and shred immunity. These elements matter and it is never too late, and it hurts me to see patients not being given a chance to make that change.
[Side note: I do realize that our healthcare system generally does not allow time for practitioners do this even if they knowledgeable of the lifestyle changes and education to give to patients, but that’s a different post.]
I’m writing this post right now because of what happened at the free clinic this past weekend. I was working with two other more senior med students and an attending physician was supervising us. It was my job to take the history (find out why they are coming in) and ask questions about symptoms, then report back to the physician.
The patient that I saw had a very common profile. She was on a few blood pressure medications and a med for high cholesterol. Her blood test showed she was just on the verge of diabetes, but still in the pre-diabetic range. This is in some ways the last chance for dietary changes to prevent lasting physiologic changes in a patient (though dietary changes for diabetes are always a YES). I asked her as many extra questions about diet and lifestyle as time would allow and then the students and I “presented the case” to the attending MD to make a plan. As the plan was being made, the students and doctor were going to advise that she “lose weight” and not drink juice. [Why is drinking juice the only question practitioners seem to ask?!] I realized that if I didn’t give dietary and exercise recommendations to her, she was going to leave and her blood sugar wouldn’t have much hope of changing. I wrote up a page of diet tweaks in her language that made sense for her situation and gave it (with permission) along with the rest of the plan. She might not make any of the changes, but at least it is possible.
I think that it is important to give patients and clients a physical list of what they need to know and do. No one can remember a laundry list of changes and advice. If we take any responsibility for someone’s success, we have got to make sure we are giving them the tools to do so.
Equally as important as providing the tools is providing an explanation. Most people aren’t going to follow advice if it isn’t logical, and things don’t sound logical without background or reason. In typical healthcare style, there wasn’t adequate time for me to explain why each recommendation was made or explain the general diabetic disease process and how diet can prevent it. I would say that she can look it up online, but a) a lot of the information on the internet is sketch at best b) not everyone has access to the internet and c) the information available in various languages online is super variable! Some healthcare centers have a nutritionist that patients can meet with, which I think is awesome. I hope that patients take full advantage of that, but also pray they aren’t still preaching low fat high carb diets…
As fired up as I am about med students learning about nutrition and providing diet and lifestyle recommendations to patients, I also find it incredibly intimidating. If wish I could teach people, patients, and practitioners everything about nutrition- but I can’t be fully knowledgeable and up to date on everything. It’s going to be a life long process.
Furthermore, we are all different and advice that helps one patient may be detrimental to another. It sometimes feels like opening up a Pandora’s box full of risks and liabilities. My hope is that with common sense and enough research, the risks will be far outweighed by the benefits for patients. I’ll end this with a few ‘safe’ nutritional truths.
Eat whole foods, when you are truly hungry. Fruits and veggies are rich in vitamins and antioxidants (anti-inflammatory). High sugar and processed foods are inflammatory. Fish and pasture raised animal proteins are high in protein and omega 3 fatty acids (anti-inflammatory). High fiber foods are good. Just drink water. Too much of anything is bad. Eat slowly and enjoy. 🙂