Nutrition talks with patients: option or obligation?
■ What should a doctor’s role be in promoting healthy eating?
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to email@example.com, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted June 4, 2012.
Nutrition is a major factor in an increasingly complex equation that determines overweight and obesity in the United States. Are physicians prepared to help patients improve this aspect of obesity prevention?
Reply: Being overweight or obese increases the risk for many chronic health conditions. Even in the absence of excess weight, unhealthy food choices and physical inactivity are associated with major causes of morbidity and mortality, including cardiovascular disease, hypertension, type 2 diabetes, osteoporosis and some types of cancer. The high prevalence of these diseases begs that counseling in nutrition be offered as a part of good medical care. In many cases, such counseling becomes a necessity.
Recently, the Centers for Medicare & Medicaid Services announced that Medicare will pay for obesity counseling if it is coordinated by a primary care physician. CMS determined that “the evidence is adequate to conclude that intensive behavioral therapyfor obesity, defined as a body mass index 30 kg/m2, is reasonable and necessary for the prevention or early detection of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is recommended with a grade of A or B by the [U.S. Preventive Services Task Force].”
More people seek medical care services from a primary care physician than from any other source. Hence, the primary care physician should be the one to initiate discussions about nutrition. Perhaps the best time to do it is when explaining the management of the many chronic conditions that diet can affect, such as hypertension, hyperlipidemia and overweight.
Some points that physicians should share with patients:
- Being overweight or obese significantly increases health risks, and lasting lifestyle changes are required to protect health. Even small changes, sustained over time, can improve health.
- Reducing calorie intake and increasing energy expenditure are essential to losing excess weight or preventing additional weight gain.
- A healthy diet can reduce health risks even without weight loss. A healthy diet emphasizes vegetables, fruits, whole grains and low-fat dairy products; includes fish, poultry, beans, nuts and seeds; and limits saturated and trans fats, cholesterol, sodium and sugar-sweetened foods and beverages.
The role of dietary counseling
The U.S. Dept. of Health and Human Services has developed evidence-based guidelines for nutrition and physical activity to promote health and reduce chronic disease risk. The recommendations of the Dietary Guidelines for Americans are exemplified by the Dietary Approach to Stop Hypertension (DASH) eating plan, which, in clinical trials, demonstrated health benefits, including lowering blood pressure, improving blood lipids and reducing cardiovascular disease risk and mortality. The Physical Activity Guidelines for Americans also contain recommendations for reducing chronic disease risk and managing weight.
The U.S. Preventive Services Task Force has determined that intensive behavioral dietary counseling is beneficial for adult patients with certain risk factors for cardiovascular disease or other diet-related chronic conditions (a grade B recommendation), but also that there is insufficient evidence to support routine counseling in unselected patients (grade I statement — insufficient evidence available). A grade B recommendation also was given to screening adults for obesity and offering intensive counseling and behavioral interventions for obese adults. An “I” statement was given for counseling and screening overweight adults.
Whether physicians should be the ones to provide intensive counseling, however, is a little less clear. Because nutrition education is severely limited in most medical schools, the primary care physician may not be the person most qualified for the task. On average, medical students receive less than 20 contact hours of nutrition instruction during their medical school training. Hence, many do not feel equipped to give sound nutritional advice. In a recent survey of primarycare physicians, 78% said they had no prior training on weight-related issues; and 72% of those said no one in their office had weight-loss training.
Studies indicate that first-year medical students are more likely to find nutrition education relevant compared with those at the end of their medical school training. Not surprisingly, many medical students who receive nutrition education feel more confident about diet and exercise counseling. This nutrition education has been shown to translate into their personal habits with a decrease in unhealthy food choices and an increase in physical activity noted upon course completion. Studies also have shown that physicians and medical students who practice healthy behaviors are more likely to encourage their patient population to adopt healthy behaviors.
There is a critical need for physicians with solid nutrition education, yet too many physicians are ill-prepared to be on the front lines of the nutrition crisis. To improve nutrition education among medical students and residents, there should be a unified curriculum and nutrition physician mentors. For this to happen, accrediting organizations such as the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education must make nutrition education a priority in their standards for accreditation.
Because primary care physicians are the clinicians most likely to encounter patients who need nutritional counseling, it might be advantageous for primary care governing bodies such as the American Academy of Pediatrics, the American College of Physicians and the American Academy of Family Physicians to develop core competencies to ensure that residency program graduates are able to address nutrition and assist patients in achieving a healthy relationship with food. For those physicians who have completed residency training, more efforts should be made to ensure that continuing medical education and virtual courses are easily accessible and affordable.
As emphasis on nutrition in medical schools evolves, registered dietitians can be valuable partners in providing comprehensive nutrition and weight-loss services. Individuals with a variety of conditions and illnesses can improve their health and quality of life by receiving medical nutrition therapy. During such an intervention, registered dietitians counsel clients on behavioral and lifestyle changes required to impact long-term eating habits and health.
We believe that nutrition conversations with patients are essential for prevention; physicians can and should initiate the discussion.
Joylene John-Sowah, MD, MPH, medical officer, National Heart, Lung and Blood Institute, Washington
Fatima Cody Stanford, MD, MPH, incoming fellow, Obesity Medicine and Nutrition, Harvard Medical School/Massachusetts General Hospital
Kathryn McMurry, nutrition coordinator, National Heart, Lung, and Blood Institute
The views expressed by the authors do not necessarily reflect the views of the National Heart, Lung and Blood Institute.
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to firstname.lastname@example.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.