Check out the short video above! Great info from Dr. Greger about how to get kids to eat healthier!
Check out the short video above! Great info from Dr. Greger about how to get kids to eat healthier!
The National Academies of Science recommend a minimum of 25 hours of nutrition education for medical students, but a 2015 study showed that 71 percent of medical schools failed to meet that goal. Despite this lack of formal nutrition education, doctors remain a trusted source of nutrition information for patients. But just 14 percent of physicians say they feel adequately trained in nutrition counseling.
“Food touches our patients in so many conditions — diabetes, celiac disease, food allergies, high blood pressure — we need more education about food and nutrition so we can be better physicians,” says Timothy Harlan, a practicing internist and associate dean for clinical services at Tulane University School of Medicine.
Harlan is part of the groundswell toward educating physicians about nutrition. He’s also executive director of Tulane’s Goldring Center for Culinary Medicine, the first dedicated teaching kitchen implemented at a medical school. Yes, you read that right: It’s an actual kitchen where medical students learn to cook and provide nutrition advice to patients.
The inclusion of nutrition education in medical schools is a growing trend. The Goldring Center has already licensed its culinary nutrition program to 25 other medical schools and six residency programs, and Harlan says he talks to a few medical schools or residency programs every week about what Tulane is doing.
There’s even a bill before Congress to try to enforce nutrition education for physicians. The Enrich Act hopes to use grants to encourage the development and expansion of nutrition and physical activity curriculums.
For doctors who missed the culinary curriculum in medical school, there are now opportunities for nutrition-based residencies, fellowships, conferences and online continuing medical education (CME) courses.
“The few hours of nutrition that are taught in medical school are often nutritional biochemistry, which has nothing to do with food. Those scientific teachings can’t help doctors answer practical patient questions, like ‘Which fat is best — butter, margarine or oil?’ ” says Victoria Maizes, executive director of the University of Arizona Center for Integrative Medicine, which offers nutrition courses both in medical school and as post-graduate education.
The center’s most popular CME course focuses on the “anti-inflammatory diet,” Maizes says. Culinary-minded physicians can also attend the center’s Nutrition & Health Conference, a combination of lectures and tastings that focus on everything from gluten-free diets to sustainable food systems.
“When a doctor learns about a healthy lifestyle, they are more successful at motivating their patients to be healthier, too,” Maizes says.
Seventy percent of Americans say registered dietitians are their most trusted source for nutrition information. So why do doctors need to know more about nutrition?
“We’re not trying to turn physicians into dietitians,” Harlan says. “But many people don’t get to see a dietitian as easily as a doctor. So the physician should have some basic nutrition knowledge.”
He and others in the field have said that when doctors learn more about nutrition, they are better at integrating dietitians into the health-care team and are more likely to refer patients to a dietitian as readily as they would to a cardiologist or endocrinologist. It creates a more effective medical plan, they say, where patients are taught about using food as prevention or treatment before turning to medications or surgical intervention.
Robert Graham,co-founder of Fare Wellness in New York, is one of a small but growing number of doctors who have embraced the concept of a “farmacy.” He provides patients with nutritional prescriptions — such as “fruits and vegetables 5-9x/day” — that they can take to the farmers market or grocery store.
“People are looking for a prescription from their doctor, so why not make it have some impact?” Graham says. “My prescription depends on their condition, but the aim is to get people towards a whole-food, plant-based diet, because the more plants you eat, the longer you live.”
Graham says patients are more likely to fill a prescription than to follow spoken advice. And his success rate? “One-third of my patients contemplate the advice; one-third take action and make steady dietary changes; the final third want deeper details and are referred to a dietitian for nutrition counseling.”
With better eating habits, Graham says, his patients see measurable changes in their health, such as lower blood pressure and reduced cholesterol. He wrote in an email: “Doctors need to take off the lab coats and put on chef jackets; put down prescription pads and pick up recipe books; slow down and learn how to cook so that we can prescribe cooking and eating real food to our patients.”
Registered dietitian Cara Rosenbloom is president of Words to Eat By, a nutrition communications company specializing in writing, nutrition education and recipe development. She is the co-author of “Nourish: Whole Food Recipes featuring Seeds, Nuts and Beans.”
Any illness that can be treated by diet alone should be treated by no other means.
During his career at Duke, Dr. Walter Kempner treated more than 18,000 patients with his rice diet. The diet was originally designed as a treatment for kidney failure and out-of-control high blood pressure at a time when these diagnoses were essentially a death sentence. Patients who would have died in all other hospitals had a reasonable chance for survival if they came under Kempner’s care.
Kempner was criticized for his lack of controls, meaning that when patients came to him he didn’t randomly allocate half to his rice treatment and put the other half on conventional therapy. Kempner argued that the patients each acted as their own controls. For example, one patient, after the medical profession threw everything they had at him, still had blood pressure as high as 220 over 160. A normal blood pressure is considered to be around 120 over 80—which is where Kempner’s rice diet took him. Had the patient not been given the rice diet, his pressures might have been even lower, though: zero over zero, because he’d likely be dead. The “control group” in Kempner’s day had a survival expectancy estimated at six months. To randomize patients to conventional care would be to randomize them to their deaths.
Beginning in the late 1950s, drugs became available that effectively reduced blood pressure and hypertension, leading to a decreased demand for the rice diet. What conclusions can we draw from this all-but-forgotten therapy for hypertension? Not only was it the first effective therapy for high blood pressure, it may be equal to or more effective than our current multi-drug treatments.
This causes one to speculate on the current practice of placing patients on one drug, then another, and perhaps a third until the blood pressure is controlled, with lip-service advocacy of a moderate reduction in dietary sodium, fat, and protein intake. At the same time, the impressive effectiveness of the rice-fruit diet, which is able to quickly stop the leakage from our arteries, lower increased intracranial pressure, reduce heart size, reverse the ECG changes, reverse heart failure, reduce weight, and markedly improve diabetes, is ignored.
Today many people follow a plant-based diet as a choice, which is similar to what Kempner was often able to transition people to. After their high blood pressure was cured by the rice diet, patients were often able to gradually transition to a less strenuous dietary regime without adding medications and with no return of the elevated blood pressure.
If the Kempner sequence of a strictest of strict plant-based diets to a saner plant-based type diet offers the quickest and best approach to effective therapy, why isn’t it still in greater use? The powerful role of the pharmaceutical industry in steering medical care away from dietary treatment to medications should be noted. Who profits from dietary treatment? Who provides the support for investigation and the funds for clinical trials? There is more to overcome than just the patient’s reluctance to change their diet.
What Kempner wrote to a patient in 1954 is as true then as it is now 60 years later:
“[D]rugs can be very useful if properly employed and used in conjunction with intensive dietary treatment. However, the real difficulty is that Hypertensive Vascular Disease with all its possible complications—heart disease, kidney disease, stroke, blindness—is still treated very casually, a striking contrast to the attitude toward cancer. Since patients, physicians, and the chemical industry prefer the taking, prescribing, and selling of drugs to a treatment inconvenient to patient and physician and of no benefit to the pharmaceutical industry, the mortality figures for these diseases are still rather appalling.”
Despite hundreds of drugs on the market now, high blood pressure remains the #1 cause of death and disability in the world, killing off nine million people a year. A whole food, plant-based diet treats the underlying cause. As Dr. Kempner explained to a patient, “If you should find a heap of manure on your living room floor, I do not recommend that you go buy some Air-Wick [an air freshener] and perfume. I recommend that you get a bucket and shovel and a strong scrubbing brush. Then, when your living room floor is clean again, why, you may certainly apply some Air-Wick if you wish.”
Michael Greger, M.D.
PS: If you haven’t yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able: Combating Disabling Diseases with Food, and Food as Medicine: Preventing and Treating the Most Dreaded Diseases with Diet.
In a letter to JAMA, the preventive-medicine expert addresses the failure of the newest USDA Dietary Guidelines to articulate the health and climate benefits of a low-meat diet.
Plant-based sources of protein, like lentils and nuts, are alternatives to meat.
Studies show that vegetarians and vegans have lower rates of heart disease and cancer, and that nearly 15 percent of all planet-warming greenhouse gases comes from raising cattle, pigs, poultry and other animals. The upshot is that the estimated greenhouse gas emissions of a vegetarian diet are half those of a meat-based diet. To improve public health and combat climate change, China recently released national dietary guidelines whose goal is to cut national meat consumption in half by 2030.
Yet, here in the United States, where we eat 80 percent more meat than do people in China, guidelines recently released by the federal Department of Agriculture don’t recommend that we eat less meat. For good sources of protein, the new guidelines list meat, eggs and dairy first, with no suggestion that nuts, seeds and legumes could be a better choice.
Disappointed by this aspect of the USDA Dietary Guidelines for Americans 2015-2020, Stafford wrote a letter to the editor of JAMA that was published July 12. “The health benefits of specific components of plants have been documented, as have the harms associated with constituents largely unique to meat,” he wrote. “Vegetarian diets have been associated with a reduction in cardiovascular disease mortality by as much as 29 percent and cancer incidence by 18 percent.”
Q: What initially prompted you to write your letter?
Stafford: These guidelines have been long-awaited and there are many aspects that are improvements, but I was very disappointed by the way the guidelines dealt with recommendations about the consumption of meat.
People who consume meat generally have worse health outcomes, particularly in terms of heart disease, stroke and cancer. On the flip side, clinical trials show that people who eat mostly plants have better health outcomes. And the evidence goes further than just suggesting an association — it shows that plant-based diets directly cause better health.
The USDA guidelines clearly state that saturated fats should be reduced. We know most of the saturated fat in our diets comes from animal sources, and yet the guidelines don’t take that next logical step and tell consumers to eat less meat. I am bothered by the lack of an explicit message around meat.
Q: What would you say to people who think that eating meat is essential to health and a more natural part of a “paleo” diet?
Stafford: The first way to answer that is to think about protein requirements. The average amount of protein people consume in the United States is far more than we need. A plant-based diet can provide all the protein anyone needs — 40 or 50 grams. Two cups of lentils, two cups of yogurt or a single 4-ounce steak would cover a whole day’s protein requirement. People are generally misinformed about the amount of protein they need, some believing they need four or five times as much protein as they actually do.
Second, the only real deficit in a vegetarian or a vegan diet is a lack of vitamin B12. That’s something that all people who are eating a predominantly plant-based diet should be aware of. The recommended daily requirement for B12 is 2.4 micrograms and even that tiny amount is higher than most people need because it accounts for those people who absorb B12 poorly. On a vegan diet, you could get that much B12 from a vitamin supplement or a tablespoon of nutritional yeast or a serving of fortified tofu. Even if you eat meat, you would need only about 1.5 ounces of beef per day or two forkfuls of fish.
The idea of eating unprocessed or minimally processed foods has value — which the paleo diet emphasizes — particularly when it comes to plants. But some anthropologists think the actual meat consumption of our ancestors was quite low, which would undermine the story that justifies lots of meat in the paleo diet. But regardless of what our ancestors ate, we now live in a very different food environment and we need to be very careful about how we interact with that environment.
Q: From a global environmental perspective, would it be better if people ate mostly plants?
Stafford: Yes, for a couple of reasons. One is that the process of producing meat generates more greenhouse gases per calorie than does growing plants of the same nutritional value. In essence, we can eat the corn and soy we grow or we can feed these plants to livestock and then eat the livestock. For a lot of reasons, it’s energetically much more efficient to eat the plants ourselves.
Food production also relies on other scarce environmental resources. Water is the big one, as is arable land. Both the water and land required for a calorie from meat is far greater than the amount required for plant-based foods.
Q: Do you think there’s support for your point of view generally?
Stafford: I think there is general agreement among scientists interested in nutrition that a plant-based diet provides better outcomes and that this evidence should be more explicitly reflected in the guidelines. What’s so striking about the new guidelines is that they are based on that same information, the same data. Clearly, the recommendation that we reduce our intake of saturated fat comes from that same pool of evidence. But the guidelines don’t say which foods contribute to our consumption of saturated fats. Instead, they leave it up to the consumer to figure out that saturated fats mostly come from animals. Essentially, they’re only telling part of the story, and leaving out the most practical advice.
Q: What do you think it would take for the USDA to change their guidelines?
Stafford: I think it requires a reframing of how we think about dietary guidelines. Dietary guidelines are often focused on the idea that we break foods down into particular components — micronutrients and macronutrients — and that we can define a healthy diet in terms of the proportions of these different categories of nutrients.
But the fact is people eat food; they don’t eat protein or saturated fats or carbohydrates alone. So in some sense the very process of creating guidelines that are based on these categories of nutrients misses the fact that people eat foods, not these categories.
It’s not enough to just tell people what nutrients they should be consuming. I think it really has to come down to telling people what types of foods they should eat less of and what types of food they should be eating more of.
I think the guidelines have moved in the right direction. For instance, the guidelines have moved away from a recommendation to reduce total fat intake and are now focused solely on saturated fat, for which there’s more evidence of harm. And the guidelines’ emphasis on fibrous vegetables and whole grains are more forthright.
But the whole regulatory and guideline process really needs to become more practical and actionable by consumers. It would be much more direct to simply tell consumers to eat less meat. And that would be the most effective way to reduce the consumption of saturated fats.
Despite the tendency of consumers to be attracted to fad diets, I think Americans are more ready than ever to hear a simple recommendation to eat less meat. The dietary evidence is stronger today than it’s ever been. And I think consumers are also uncomfortable with both the environmental impact of their diets and the issues surrounding the ethical treatment of animals. The time is right for the USDA to be more direct in their recommendations, even if it means making a recommendation that is contrary to the interests of some entrenched food manufacturers.
I certainly think more pressure from scientists to have the USDA state the obvious consequences of the data would help. I also think it’s important that consumers complain to the USDA that the guidance is not nearly as clear as it could have been.
Previous research showed that a fiber called inulin can stimulate the gut bacteria to produce a short-chain fatty acid called propionate, which can in turn signal to the brain to reduce one’s appetite. In 2013, another study also showed that inulin-propionate ester, which induces the gut bacteria to produce even more propionate, can help volunteers prevent weight gain even more than inulin. To determine where propionate is acting in the brain to curb food cravings in humans, researchers from the Imperial College London, the University of Glasgow, and University of West Scotland administered a milkshake to 20 volunteers containing either inulin or inulin-propionate ester. Then they monitored the volunteers by MRI imaging while they were being shown pictures of food. They found that, compared to people to drank inulin, people who drank the inulin-propionate ester have less activity in the reward center of the brain called the caudate and the nucleus accumbens when they were shown high-calorie but not low-calorie foods. This latter group also rated the high-calorie foods less appealing and ate less food per meal. This study clearly illustrates how feeding high-fiber foods (e.g., beans, fruits, and vegetables) to gut bacteria can influence eating habits and health.
Areas of the brain associated with food cravings. The areas marked in blue and yellow – called the caudate and the nucleus accumbens – showed reduced activation to high-calorie foods when the volunteers took the propionate food supplement.
Credit: Image courtesy of Imperial College London
Byrne CS, Chambers ES, Alhabeeb H, et al. Increased colonic propionate reduces anticipatory reward responses in the human striatum to high-energy foods. Am J Clin Nutr. 2016;104:5-14. DOI: 10.3945/ajcn.115
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