Put nutrition counseling in primary care

The United Nations designated 2016 to 2025 the “Decade of Action on Nutrition” in recognition of the growing importance of food and diet as it relates to all aspects of human health. We’re almost halfway through, and we’re not making the progress we need to.

A comprehensive study of scientific evidence for global diet goals and sustainability, the EAT-Lancet Commission Summary Report, stated, “Unhealthy diets now pose a greater risk to morbidity and mortality than unsafe sex, alcohol, drug and tobacco use combined.”  Further, only one-quarter of Americans today meet the recommended daily intake of healthy, unprocessed foods. A significant majority of people don’t have diets that support health and wellbeing.

There are a couple of reasons for this, but the fact that nutrition isn’t incorporated into general medicine leads the way. It’s no wonder; there’s virtually no time spent on Nutrition in medical school or residency. A study from Case Western Reserve University in 2016 reported only 20 hours of nutrition education in U.S. medical school curriculums, which reflects the fact that general medical curricula were largely created in the 1920s before there was an awareness of lifestyle-related chronic disease.

Giving short shrift to nutrition education prevents providers from recognizing food and diet as fundamental in disease development and control which leaves a focus on medication as the only means of altering pathophysiology.

When doctors aren’t formally educated about nutrition, it shouldn’t surprise us that it’s rarely addressed in clinical visits.  Studies have shown that nutrition counseling occurs in only 20 to 30 percent of non-acute primary care visits, and the length of counseling per visit averages one minute. 

It’s not something that can easily be inserted into an office visit. Visits are already very busy and burdened by tasks required by the electronic health record that compete for time against the patient’s needs.

Putting nutrition into the medical conversation is worth the time and effort though. Nutrition education, when coupled with other interventions, works. Studies have demonstrated positive change and health benefits when dietary habits in low-income neighborhoods are prioritized in medical care as a result of it.

Expecting patients to recognize the role nutrition plays on their health and seek out nutrition education on their own, or referring them to a nutritionist, is not sufficient. Inequities persist in access and means to consult a Nutritionist, with many insurances not covering this service, or only covering it if the patient already has a significant chronic disease like diabetes, but not before.  Primary care is usually more accessible, and more importantly, by addressing nutrition in primary care practice, the divide between diet and health or disease can be properly addressed and managed.

It’s crucial that we do this in order to protect the entire health care system.  For years, the World Health Organization has asserted that non -communicable diseases are on the rise, and there is an association with increased consumption of processed foods in modern diets, specifically fats, sugars, and salt.  The WHO projects that by 2025, the end of the “Decade of Action on Nutrition,” the economic cost of food-related non-communicable disease and obesity alone will account for over seven trillion dollars across the globe.

The United States is contributing to this economic burden significantly.   For example, in 2018, U.S. health care spending was reported at nearly double that of Sweden or Canada, and despite this, the U.S. suffers lower life expectancy.  Food and diet is one way to confront the cost of chronic illness in our country.

Including nutrition in primary care isn’t impossible. When we’ve incorporated other preventive screenings and counseling into primary care,  they’ve caused seismic shifts in population health. As a prime example, vaccination programs cause synergistic effects on health. Data from 2015 showed that vaccinations in the U.S. resulted in 3 million lives saved annually.  This figure represents deaths avoided, and doesn’t even include the gains in health that come from the avoidance of debility and disability.

Other evidence-based screening practices have been implemented in primary care with great success. Screening and counseling for alcohol and tobacco exposure, high-risk behaviors, and depression are just a few examples.  Screening for food insecurity does happen in some practices, but this needs to be made universal and expanded to incorporate screening for nutritional content, harmful (ultra-processed) foods, and excess calories.

The effects of this lack of integration of nutrition into medical care became exceedingly clear when the COVID-19 pandemic struck.  Obesity, hypertension, and diabetes are all linked with poor diet and were all identified as risk factors for hospitalization and even death from COVID.  COVID-19 is a striking example of the serious consequences of poor nutrition, but there are many others like cognitive decline and dementia, osteoporosis, cancer, and immune system impairment.

The benefits of including nutrition in primary care outweigh its costs. If nutrition were prominent on the agenda of primary care, PCP’s would also identify more people who may be eligible for SNAP (Supplemental Nutrition Assistance Program) and WIC (Special Supplemental Nutrition Program for Women, Infants, and Children). SNAP and WIC are two federally funded programs proven to improve food security and provide patients the ability to higher quality, healthier foods by incentivizing healthy food purchases.

One of the best solutions to rising obesity and non-communicable disease rates lie in primary care.  Medical professionals can influence the U.S. food system indirectly through demand and collective purchasing power by educating their patients to choose and purchase healthier options. Merely improving nutrition education succeeds in shifting people’s thinking about food.

Simultaneous with the WHO’s declaration of the Decade of Action on Nutrition is the “food is medicine” movement that has been growing in response to mounting evidence that a nutritionally-sound diet and access to quality foods improve health outcomes.  The theory behind food is medicine is that food is a preventative public health system.

This movement includes prescription meals to people with multiple chronic conditions and low income, food delivery services, and community food quality assessment. So far, the food is medicine solution has proven cost-effective, and one study reported a 16 percent reduction in health care costs in meal recipients.

We know that widening health disparities are partially diet-dependent. Integrating nutrition into primary care is really a social necessity. Just as everyone should have access to medical care, all Americans should have equal access to proper nutritional guidance and nutritious food.

Melinda Mesmer is an internal medicine physician and a public voices fellow, The OpEd Project.

Image credit: Shutterstock.com

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