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What's Left Out

When Dr. Michael Jon Zackin, N '86, quizzes his patients about what they had for breakfast yesterday, he is not testing their memories. In his pediatric practice in Weston,Mass., he sometimes asks his patients or their parents to do 72-hour nutrition recalls (writing down everything they've eaten for three days) to evaluate their diets. If one of his teenage patients is seriously overweight, Zackin may encourage the youth to meet with him monthly.

"I personally spend an inordinate amount of time talking about nutrition right from the start, at every well-visit," said Zackin, who earned his doctorate from the Friedman School of Nutrition Science and Policy at Tufts before going on to get his medical degree at the University of Massachusetts Medical School. "I try to get families eating well, and talking about eating behaviors."

As a physician, zackin is an exception, and not just because of a lifelong interest in fitness that prompted him to read nutrition books, for fun, at age 12. Studies show that while most physicians are comfortable writing a prescription for a cholesterol-lowering pill or a diabetes drug, telling a patient how many servings of greens to eat or how many minutes of exercise to get is rarely part of doctors' orders. This is despite the bevy of medical literature that says diet and exercise can be just as effective as medication in treating--and especially preventing--illnesses such as cardiovascular disease, diabetes and high blood pressure.

With fitness magazines and even the local news trumpeting the latest nutrition findings, the doctor's pitch may seem redundant. But research suggests that patients need to hear nutrition advice from an authority figure, preferably one who wears a white coat.

"Most consumers say while they get their initial info from the Web and blogs and mainstream media, when it comes to the information they trust, the sources they trust, the physician is number one," said Sylvia Rowe, an adjunct professor at the Friedman School and former president and chief executive of the International Food Information Council (IFIC).

The recent and alarming reports on obesity- related diseases have spurred some doctors to make lifestyle modification part of their exam-room agenda. But while nutrition advocates have long wanted to see physicians act a little more like Zackin, it has been a long, uphill battle, often waged against the American health-care system itself.

Absent in the Exam Room

Why does nutrition get such short shrift? Physicians point to the brevity of the average office visit, which lasts about 18 minutes, according to the New England Journal of Medicine.

"The basic reality is physicians have limited time with patients to convey what they consider to be the critical medical facts. Rarely will they get into lifestyle issues like nutrition and physical activity," Rowe said.

"The exception is if you have an overweight or obese patient, but even that is somewhat ducked unless the patient brings it up." Money is also an issue. Insurance companies don't readily reimburse physicians for preventative nutrition counseling. Then there are physicians' attitudes toward nutrition itself, which they may rank anywhere between alternative and hippy-dippy. Rowe will never forget when the IFIC surveyed physicians about their views on functional foods. One respondent was impressed with the medical research on foods naturally rich in antioxidants. But he wasn't about to tell his patients to go eat nuts and berries. "They will think I'm some sort of quack and go elsewhere," he said.

In general, medical schools do little to dissuade aspiring doctors from the perception of nutrition as a "soft" science. As recently as a decade ago, fewer than 26 percent of medical schools required that students take a nutrition course, while another 25 percent offered no nutrition course at all, even as an elective. Fresh from his studies at the Friedman School, Zackin was unimpressed by the brief nutrition class he and his classmates took in medical school, and wonders how it affected the others' practices. "I think most physicians don't know enough about nutrition, and if you don't know enough, you don't want to talk about it enough," he said.

Margo Woods, an associate professor at Tufts Medical School and the Friedman School, has fought to keep nutrition in the medical school, where it has been a required first-year course since 1991. To integrate even more nutrition into the curriculum, she applied for and won a grant, called the Nutrition Academic Award, from the National Heart, Lung and Blood Institute in 1998. Tufts was one of 10 pilot schools to receive the award, which helped Woods and her colleagues teach diet evaluation and intervention strategies. They developed case studies and brought in trained patient-actors with whom the third- and fourth-year students could practice doing nutrition reviews. This "standardized patient experience" is still part of Tufts' family medicine rotation, which all students go through.

The goal is to know enough to take the right first steps. "You have to be able to evaluate a person's diet by looking at it,"Woods said. "Count up the serving of fruits and vegetables and animal products. Are they having beans and nuts every day? Are half the carbs high in fiber? Even if you refer them to the dietitian, you make the first contact. It's the physician's responsibility to motivate them, to educate them, evaluate what they are currently doing and then negotiate with them about what they think they can change."

That last part can be difficult, because it takes a certain kind of personality to work with patients on lifestyle modification. "Doctors like to tell people what to do, but here, they have to ask, 'What do you think you can do and succeed at?' "Woods said.

The good news is that she has seen medical students become more and more interested in nutrition each year. "What really captures them most is that they have to keep a three-day food record and compare it to some standards," she said. "They click into that because it's personal." This may have an added benefit, because some studies have reported that doctors who have made improvements in their own diets are more likely to give advice to their patients about good eating habits.

This year, the Friedman School and Tufts Medical School have created another nutrition education opportunity for future physicians. Alice Lichtenstein, the Stanley N. Gershoff Professor of Nutrition Science and Policy, and Dr. Edward Saltzman, both scientists at the Jean Mayer USDA Human Nutrition Research Center on Aging (HNRCA), have partnered to teach a nutrition course for the medical school's new M.S. in biomedical sciences degree program, which is designed specifically for students aiming to become stronger applicants to medical school.

Knocking on a Closed Door

Medical school can do only so much.

"We are interested in what doctors know about nutrition, but we are more interested in what doctors use," said Dr. Irwin M. Rosenberg, a University Professor and the Jean Mayer Professor of Nutrition at Tufts.

"The usual rap that doctors don't know about nutrition is not nearly as accurate as the rap that doctors don't use nutrition in their practice."

Rosenberg, a gastroenterologist as well as a nutrition scientist, has spent a good part of his life trying to impress on physicians how nutrition science is relevant to what they do. He likens it to knocking on a closed door that has only barely cracked open: "It's a career-long challenge."

The medical profession has made some strides in adding more nutrition questions to its board exams, and even seen the creation of a certification for Physician Nutrition Specialist. At Tufts, a clinical nutrition postdoctoral program, which is run by Dr. Joel Mason, an assistant professor at the Friedman School, has been active since the mid- 1980s. But these efforts attract the nutrition elite. "They don't get to the bulk of practicing physicians," Rosenberg said.

He has tried to reach out to that audience. For eight years, he was editor-in-chief of Nutrition in Clinical Care, a Tufts-based journal geared toward health-care providers. It reviewed the most pertinent nutrition research and showed how it could be incorporated into daily practice. Doctors could even rip out some of the articles and hand them directly to their patients. It now appears as a regular feature in the journal Nutrition Reviews.

Still, getting physicians to embrace nutrition has been a painfully slow process. Thirty years ago, the head of a major food company complained to Rosenberg: "My dog's vet knows more about nutrition than my doctor does." It was no doubt true, acknowledged Rosenberg, who said the sad part is that most people could say the same today.

"They're not remunerated," he said of physicians. "They don't have time. They've been battered by the pharmaceutical industry to think they can deal with these things with drugs. It's much easier to write a prescription than it is to go over a diet history. The whole medical profession is weak on prevention, which ought to be the proper domain of nutrition."

The Doc and the Dietician

Elizabeth Winthrop, N83, the chief dietitian and internship director for Southcoast Hospitals Group in Massachusetts, has helped teach nutrition classes to medical students during her career, and she admits to having some fun with it. For a nutrition case study, she may offer up a patient with diabetes, gastrointestinal problems and enough complexities to make any resident's head spin.

"We had a couple of messages for them," she said. "Nutrition is important, and you need the dietitian, buddy."

Put another way, doctors need to understand nutrition before they can appreciate the nutritionist. Some physicians get the message more than others. For example, a bariatric surgeon recently asked Winthrop's team of dietitians for their expertise as he expanded his practice. "He didn't feel he could have a high-quality program without us," she said. The dietitians helped design the program, and now help rule people in or out for surgery and provide much of the follow-up.

"There is nothing so wonderful and fulfilling as a hospital dietitian working alongside a doctor who really understands what the dietitian can contribute to the care of the patients," said Winthrop, who trained at the Frances Stern Nutrition Center at Tufts–New England Medical Center.

The working relationship between physicians and dietitians needs to be built over time, she said. Sometimes dietitians find they have to prove the value of nutrition--and of the work they do--to their physician colleagues. "Doctors build their trust in dietitians one patient at a time,"Winthrop said. "If you contribute to good patient outcomes, then you get respect."

Her ideal? A doctor who knows the significance of nutrition and can stress that importance to the patient. "What we need is for a doctor to say to a patient, 'You know, your BMI is 30, and that puts you at a much greater risk for diabetes. I really wish you would sit down with a dietitian.' What we need the doctors to do, for the most part, is tell the patient, 'This is a big problem.' In some cases, we may need them to advocate with insurance companies and say, 'This is an important thing for my patients.' "

Too often, said Margo Woods, the nutrition referral is a "black box."

"There is no communications link between the doctor and the dietitian," she said. Some physicians "definitely refer them to the dietitian, but they don't know what happens."

Without that initial push and follow-up, patients may not stick with the nutritionist for the six to eight weekly sessions that one study found was necessary for a dietary intervention to be successful. One study, in 1994, found that when dietitians get to discuss their dietary recommendations with physicians, they were more likely to be implemented, "indicating how powerful the dietitian-physician interaction can be."

Professional organizations have pushed for the creation of physician/dietitian teams, calling for nutrition experts to be a standard part of every medical office. It is not yet the norm.

"The whole idea of teamwork in medicine is a very important one," said Johanna Dwyer, director of the Frances Stern Nutrition Center and Dietetic Internship. "But I think there is room for improvement there. It hasn't changed as much as I would like."

Lifestyle Medicine

Dr. James Rippe, a cardiologist and associate professor of medicine at Tufts Medical School, is a longtime proponent of preventative medicine in the doctor's office.He edits a textbook, Lifestyle Medicine, which teaches physicians about the impact of lifestyle decisions on wellness, with an emphasis on cardiovascular heath. He knows the barriers that physicians face, but said it is up to the medical community to overcome them.

"If we really want patients to do the best they can for their health, we've got to figure out a way to do this stuff," he said. By not bringing up diet and exercise with patients, he said, "we send them the subtle message that it is not important."

Earlier this year, he launched the American Journal of Lifestyle Medicine, a compendium of prevention-focused, peer-reviewed research that reaches 20,000 physicians every other month.

"Most people go into medicine with the desire to take the best possible care of patients they can," he said. "To deny the existence of this very exuberant,wonderful literature...is a very nihilistic point of view."

In the journal's inaugural editorial, he conceded that change will mean bucking the system: "Our mandate is nothing short of changing the way we practice medicine and provide health care in the United States and the rest of the industrialized world." Others are trying to spark a movement.

Two years ago, a group of doctors formed the American College of Lifestyle Medicine, a nascent organization that wants lifestyle medicine to be incorporated into everything from medical school curricula to a credentialed clinical specialty. It plans to lobby Congress to ensure lifestyle counseling is compensated by Medicare and health insurers.

Maybe all physicians really need are the right tools. Last year, Ann Yelmokas McDermott, N02, and Heather Mernitz, N02, N06, both researchers at the HNRCA, made the case that physicians should provide physical fitness prescriptions to their older patients. In the journal American Family Physician, they detailed how doctors could easily tailor a regimen to the patient, spelling out what type of exercise to do, how often, how hard and for how long. McDermott called the guidelines a "how-to manual for health care providers."

When it comes to exercise guidelines, physicians "don't know what to say," said McDermott, director of the Center for Obesity Prevention and Education at California Polytechnic State University. "As the science community, we need to do a better job of conducting meaningful research for medical practitioners."

Case in point: her own father's doctor, who prescribed blood glucose medications to her dad, but didn't address his complete lack of physical activity."He told him, 'I can't control what you do outside my office, but I can tell you these medicines will make a difference.' " She couldn't help feeling undermined.

"Most individuals look at the physician as the pinnacle of medical knowledge," she said. "Only when the physicians start telling their patients that this is just as powerful as medication will people start hearing it."

Right now, her office is working with the local public health department and local physicians to create a physical activity and nutrition tool kit, including informational handouts, which physicians can employ in their practices. They are also looking at ways for physicians to consistently record Body Mass Index or waist circumference in patients, so their progress can be tracked from visit to visit, even if they change doctors.

Michael Zackin, the pediatrician, is on a task force that is looking at ways to deal with obesity in the office setting. If physicians are going to take up the lifestyle modification banner, the ones who work with children may be standard-bearers.

"Pediatrics is one of the best specialties in which to use nutrition," Zackin said. "We're getting kids from day one, and we can really make a difference in their long-term health

and lifestyles right from the beginning." In fact, that is partly why he went into pediatrics, and may be one reason other physicians find lifestyle modification a lost cause.

"If you have a 40- or 50-year-old person coming in with all these poor habits," Zackin said, "I found it difficult and frustrating to try to change them."

In the end, the call for preventative medicine may come from patients themselves.

"For some time now, but more so recently, patients have been pushing their doctors to know more about nutrition," said Dr. Robert Russell, a physician who directs the HNRCA and is a Friedman School professor."

Many more doctors are contacting me to ask how to counsel patients who come in with questions about specific diets and specific nutrients, or substances such as green tea. Even though the medical schools are falling behind on teaching preventative medicine, including nutrition, I think doctors are becoming more informed on the job. Patients are demanding it."

Julie Flaherty is the editor of Tufts Nutrition, where this story first appeared. She can be reached at julie.flaherty@tufts.edu

  

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