In the era of new cholesterol guidelines that significantly increase the number of statin-eligible patients, published in a country where the obesity epidemic continues unabated, it may be time to rethink our approach to disease management and prevention.
According to the American Heart Association, cardiovascular disease (CVD) affects 80 million Americans and prediabetes (PD) affects 67 million. These diseases are food related and largely preventable, yet nutrition is rarely used as a cornerstone of therapeutic intervention. Instead, most current disease management approaches, such as prescribing statins, paradoxically enable poor dietary patterns, perpetuating the underlying stimulus and creating a vicious cycle. This approach is like trying to put smokers on inhalers rather than trying to help them quit smoking.
This is fundamentally nonsensical – and clearly unsustainable.
The costs of cardiovascular disease care are exploding. The AHA projects that by 2030 we will be spending over $800 billion annually on heart disease care. Put in context, that’s equivalent to the economic stimulus used to save the entire U.S. economy after the Great Recession. Spent every year, year after year, treating just one – largely preventable – disease. We simply cannot afford these statistics.
So why is food the forgotten stepchild of care? Some reasons are readily identifiable and addressable, while others are more systemic.
1. Don’t ask. Don’t tell.
How many times have you taken a thorough dietary history? If you are like most physicians, it’s not something you do routinely. Our patients eat at least 3 times per day – every day. Yet most of us know very little about that activity and how it could be playing into our patients’ health and their treatment plans.
Lack of time is often cited as the main impediment to undertaking dietary surveys. But it can frequently be accomplished within a 1-2 minute exchange. “So what’s a typical breakfast for you? Lunch? Dinner?” That information can be gleaned in under 30 seconds. But you have to dig a little further. It’s not enough to have your patient report that they eat cereal for breakfast. You need to find out which one, and how much of it they eat. You also need to ask specifically about beverages, desserts and snacks – since patients don’t readily offer up that they eat a bowl of ice cream every night before bed or that they drink 8 cans of Mountain Dew each day because “water is for bathing”.
You will be amazed at what you learn when you start doing this. You will encounter people, as I have, who eat 4 bowls of Fruit Loops for breakfast; who think drinking 3 quarts of orange juice a day is good for them; or who buy most of their food at the gas station convenience store. You will come to quickly understand why they have hypertension, or dyslipidemia, or a bulging waistline. We assume people with diabetes or obesity or heart disease don’t have the best diets. But until you ask, you can’t possibly know the depths of your patients’ nutritional dysfunction.
2. Impractical solutions.
Nutrition interventions in the doctor’s office are usually limited to rudimentary pamphlets. These materials generally counsel home cooking – even though Americans are cooking less than they used to. People have reduced their time in the kitchen by half in the last 20 years, relying instead on processed convenience foods and restaurants. This type of advice is largely meaningless because it ignores life realities.
Prescription medications, on the other hand, are presented in a pre-dosed format, and come with precise instructions, ensuring ease of use and minimal impact on daily routines. In other words, drugs are easy, food is hard.
What if food advice was as easy to follow – and dispense – as medication advice and pharmaceuticals? If you start to consider food as therapy, it all becomes far more logical – and easier to implement. We know patients can generally follow concrete advice. So why not “prescribe” drinking 8 oz of water with each meal and eating 1 handful of raw almonds QD, if that’s appropriate for your patient. You can even write it out on a prescription pad as a formal instruction. No, this won’t solve everything, but no drug solves everything either. However it is certainly more health promoting than the alternative – 3 sodas and a bag of M&Ms.
3. Inadequate training.
Physicians, the front line in disease management, are not trained in nutrition. We are trained to prescribe medications, despite guidelines instructing us to champion dietary interventions. It makes little sense that we are tasked with treating nutrition-based diseases and expected to oversee the advice of dieticians and nutritionists without any meaningful education or experience in this field. It behooves us to know more.
As a medical community we should lobby our training programs and our professional societies to offer nutrition education with a focus around disease management and prevention. No student currently in medical school should be allowed to graduate without exposure to core nutrition instruction.
4. Food is more confusing.
The supermarket has morphed from a trusted resource into a veritable minefield. Patients who try to make “healthier” food choices by purchasing “better for you” foods, are often duped by products with limited nutritional value making sanctioned, but meaningless, health claims. Most health claims are focused around reduced content of putative ingredients (“low salt”, “low cholesterol”, “low fat”) rather than actual health benefits. Taken to the extreme, a cup of high fructose corn syrup (HFCS) would qualify as a heart-healthy product – HFCS contains no salt or cholesterol and is completely fat free.
Well-intentioned efforts to educate consumers about relative food quality have become a conduit through which to simply manipulate a purchase. If anything, patients are more confused than ever about which foods are actually good for them.
Health claims should probably be banned completely from all food products, with the FDA focusing instead on ensuring transparency in ingredient lists. “Ingredient splitting” (where multiple ingredients are used for the same purpose but each is used in smaller amounts so as to fall lower on an ingredient list) is an especially egregious practice and should also be banned – especially when it comes to sweeteners.
5. Treatment inequality.
It is accepted that prescribing a medication indicates a more complex clinical encounter deserving of a commensurately higher billing code. Instructing a patient in dietary adjustments may be just as cognitively challenging and equally clinically impactful but does not qualify for higher reimbursement. To top it off, medication costs are often insurer subsidized, whereas food almost never is.
The perversity of this situation is shocking.
In essence, insurance companies agree to pay physicians more to manage the symptoms of a disease rather than to treat its cause – and apparently prefer to bear the brunt of pharmaceutical costs even though the brunt of paying for treating the cause (changing the food) would actually fall on the patient.
Changing insurance reimbursement models would go a long way to modifying treatment patterns. But until that happens, we should still address the cause, even as we manage the symptoms. Empowering patients to help themselves heal is foundational to medical care.