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Time is tight. Insurance coverage is tricky. But still, doctors should be doing more to help their patients eat better, argues a new editorial in the journal JAMA.
I spoke with co-author Dr. JoAnn E. Manson of Brigham and Women's Hospital and Harvard Medical School. Our conversation, lightly edited, follows.
Why call for more food counseling now?
There's overwhelming and mounting evidence that nutrition plays a major role in the development of chronic diseases. Poor nutrition is a key contributor to most chronic diseases in the United States, including diabetes, hypertension, obesity, cardiovascular disease and cancer. But nutrition is rarely being discussed by clinicians with their patients in clinical practice. Only 12 percent of visits include a discussion of nutrition.
So we thought it was really time for a call to action to encourage the discussion of nutrition by clinicians using a team approach. It doesn't have to be time consuming, but it would demonstrate to patients that this is a priority, this is important, and it would help to ensure that patients are receiving evidence-based information about nutrition, as opposed to just hearing what could be misinformation through other outlets.
So it's a call to action — but to whom and to do what, exactly?
We are recommending that clinicians bring up the subject of nutrition and do a brief assessment.
We include in the article a brief instrument, a screening tool, to identify problems in terms of very high intake of fast foods, sugar-sweetened beverages, low intake of fruits and vegetables. Hand-outs can be given to patients. Using a team approach in terms of highlighting some of the key nutritional principles about the importance of increasing fruits, vegetables, whole grains, avoiding really high intake of sugar and sugar-sweetened beverages and fast foods, and providing very specific recommendations about substitutions that can be made that would not require a dramatic change in the dietary pattern of the patient, but could tremendously impact their health.
I would imagine, though, that there are many clinical visits where discussion of nutrition would not make sense.
Discussion of nutrition may not be appropriate for all clinical visits. For example, a patient who has an ankle sprain or has an asthma attack. You want to address the acute problem.
However, the vast majority of office visits and clinical practice visits are related to these chronic diseases — hypertension, diabetes, cardiovascular disease, obesity — and this is where our discussion of nutritional principles, some advice about substitutions in the diet, and also some assessment of the patient's quality of diet could be extremely helpful in terms of their long-term health and prevention. It would go a long way in leading to fewer of these chronic diseases long-term.
What about the eternal time crunch of the office visit?
We believe that this approach could take very little of the clinician's time. We fully understand the time pressures in clinical practice, and this can be done as a team approach.
The questionnaire that's used for assessing diet could be given to the patient in the waiting room, and there could be a clinical assistant or a health care coach who's involved with group practices.
Also, materials could be given to the patient, such as what we what we propose in the report: an instrument that suggests some specific substitutions that could be made, such as replacing sugar-sweetened beverages with water, flavored water, coffee, tea; replacing sweets, such as desserts, or a snack such as potato chips, with a handful of nuts.
Some of these changes, even small steps, could go a long way in improving a patient's health. For example, just increasing fruit intake by one serving of fruit per day has been linked to a reduction in tens of thousands of deaths per year in the United States.
You compare this approach to how doctors address smoking. How is that?
We are proposing an approach that is quite similar to addressing smoking, where a key step is just starting the conversation and assessing the patient's willingness and interest in making behavior change; focusing on very small steps; ensuring that there is adequate support; and a follow-up for the patient, trying not to do it all at once.
You know it can't be done in a single visit, where you totally overhaul the patient's diet, but you do it more in the long term. And also, don't try to do it alone. It will often take a team approach.
Readers, should your doctor talk with you more about your diet?