by Marion Nestle
Sep 5 2010

San Francisco Chronicle column: nutrition advice to doctors

This month’s San Francisco Chronicle column evolved in answer to a question from a former colleague at the UCSF School of Medicine.

Q: What do you think doctors should be telling patients about how best to care for themselves and their families, nutritionally?

A: I had my chance when, long ago, I ran a nutrition education program for medical and other health professions students and practitioners at UCSF.

Then, as now, it was obvious that just about every patient who landed in the hospital needed nutrition intervention. Practically everyone who visited the outpatient clinic either wanted or needed nutrition advice.

Then, as now, few doctors were taught anything about nutrition, let alone the details of what they needed to know to help patients address dietary concerns.

In today’s health care environment, even doctors with advanced nutrition training do not have time to use it. Blame this on how our health care system systematically rewards doctors for treatment of disease, not its prevention.

What doctors need to tell patients about nutrition depends on who the patients are. If people are sick, doctors need to talk to them about how dietary changes and improvements will help them recover and prevent further illness.

But I’m guessing that your question refers to healthy patients who want to stay that way. With these people, what doctors do and say can have profound effects. Doctors are authority figures and their advice is taken seriously.

As a standard part of patient care, doctors routinely ask about drugs, cigarettes and alcohol. Even if they only have a minute, adding one more question about diet can do much good. If nothing else, it conveys that diet matters to health.

Given the reality of time constraints, my wish list for what to do next is necessarily short.

Tell patients that healthy eating simply means three things: variety, minimal processing and moderation.

Variety means choosing many different kinds of foods from the various food groups: meat, dairy, fruits, vegetables, grains. It counts because foods vary in nutrient content. Varying foods within and among food groups takes care of needs for nutrients without having to think about them. People who consume adequate amounts of varied diets rarely exhibit nutrient deficiencies. It’s the most restrictive diets that are likely to be deficient in one or another nutrient.

Minimal processing means that the foods should be as close as possible to how they came from the animal or plant. The greater the level of processing, the less the foods resemble their origins, the less nutritious they may be, and the more salt, sugar and calories get added to disguise the changes.

Minimal processing excludes foods high in salt and sugars and low in fiber, as well as sugary sodas and juice drinks, those popularly known as junk foods.

My definition of minimal processing is only slightly facetious: Don’t eat anything with more than five ingredients or an ingredient you can’t pronounce.

Moderation is about balancing calorie intake with expenditure and maintaining a healthy weight through food choices and physical activity.

These are general principles. Beyond them, nutrition advice must be personalized to the particular individual or family. To do that quickly:

  • Ask patients what they and their children eat. You can start with a waiting-room questionnaire that probes typical intake of foods and supplements.
  • Screen the responses for variety, minimal processing, moderation and excessive or unusual supplement use. Note whether body weights are within healthy ranges.
  • Reassure patients whose diets are varied, minimally balanced and moderate that they are doing wonderful things for their health and should keep doing what they are doing.
  • Refer observations that need further discussion to a nutritionist.

Doctors: You don’t have to do it all. Making it clear that diet matters is often enough to encourage patients to make better dietary choices. Use the services of a nutritionist. Nutritionists are professionally trained to answer patients’ questions about diet and health and to counsel them on dietary interventions.

Patients (meaning everybody): Tell your doctors that you want their advice about diet and health and expect them to know something about it.

  • Great column! As a young medical student at UCSF, I was one of the beneficiaries of your teaching and have never forgotten it. It is truly amazing how little we as medical professionals learn about nutrition during our training. Your advice was wise then and I continue to turn to your writing for reliable and common sense information that is useful to me as an eater and a healer. Thank you!!

  • Do you mean dietician? Because the term is not protected, anyone can call themselves a nutritionist. Based on what I’ve seen, registered dieticians provide far more science-based advice than any “nutritionist”, where advice usually includes unnecessary supplements, worthless detox kits, and often bizarre dietary recommendations.

  • The sad thing is most people, doctors included, believe that “variety” means meat 3 times a day with other animal products for snakes in between. The variety question is beef or chicken.

  • Heather

    I second Scott’s comment. Referrals should be made to an RD, or Registered Dietitian, who is certified by the ADA.

  • Well, an RD has certain types of training. A nutritionist may be equally well trained for the purpose– for example, a community nutritionist may have a focus on education and behavior change rather than clinical training focused on treating illness– but whenever someone is referred to a professional, a review of their education background is wise. A nutritionist may also be diabetes educator without being an RD.

    I, for example, am a nutritionist because I have an MS from a graduate school of nutrition but I have not (yet) completed an RD program because my interests lean toward food system rather than patient/client. An RD is likely in my future, however, not entirely because I need the additional science background but because RD is often written into job descriptions as a standard. But, yes, anyone with a BA in nutrition can call themselves a nutritionist, so buyer beware.

    Now, to weigh in on the actual article: great suggestions for a 60 second clip in an annual physical. I would merely add that a physician should also take that basic risk assessment and consider running relevant nutrient tests like B12 and iron for vegetarians, vitamin D for anyone who wears sunscreen or works indoors, etc. I hope that more doctors take nutrition seriously for their patient’s sakes.

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  • Bobby

    Or they could read your book “what to eat.”

    A book that could easily be converted into a reality TV series (or so we hope).

  • These are great suggestions and it’s about time that more doctors get firm and clear with their “prescriptions” for patients – whether they’re healthy today or not.

    I think for a lot of people who don’t take care of themselves now, it’s difficult for them to really understand the benefits of minimally processed foods. It’s hard to get balance when people might see the “fruit” in a Pop Tart or Crustable as a serving of fruit.

    Moderation is also a challenge when society has become accustomed to super sized servings of food. Throw in the fact that high fructose corn syrup is everywhere you turn in modern convenience food, and there’s no way to seek moderation of HFCS.

    These are critical steps and must be clearly defined. We need education and support of these messages…lots of education.

  • Stuart Katsh

    As an RD in a large outpatient clinic doctors do not have time to do it all. Nor, I have learned, do they have the education to do it all. Medicine is very specialized and, along with limited time per patients health care providers should focus on what is immeadiately on hand with the patient. That is the problems that lie within that practioners area of expertise. Anything beyond that they should refer out whether it be to a specialist but especially to an RD (nutritionist). We are the ones with knowledge on medical nutrition therapy and not other healthcare practioners.

    Oh and I agree a nutritionist is not an RD but all RDs can be called nutritionists. Somone with the appopriate training is whom the patient should see.

  • Anthro

    Interesting discussion of RD vs. Nutritionist. I think this varies by state and corresponding laws for licensing. All sorts of people around here (and other places I’ve lived) call themselves (and conduct professional “practices”) nutritionists. The only training they may have is a dubious mail order “degree”, or some wacky “workshop”. I’ve always looked for the RD myself or at least inquired about credentials when in doubt.

    Doctors’ lack of interest/knowledge on diet leads many a patient into the arms of fringe (or worse) “practitioners” and authors who tell them all sorts of pseudo-scientific things; many of which have been iterated right her in this comment section. One shudders to think what goes on in less science-oriented blog comments.

    The quick answer you suggest for doc’s, Marion, is helpful, but would not go nearly far enough for many people, especially the vague term “moderation”. Most people have no clue about portion sizes, especially younger people who have grown up with current concepts such as a bag of chips is a serving size or whatever the waitress brings on the plate is a serving size. You have to look at really old dishes to see what people used to consider a serving! The tea or coffee “cup” vs. the mug of ever increasing capacity or the little dessert dishes of my childhood for pudding or fruit crumble vs. the current standard. Yes, pudding cups are small, but who eats just one of those little things?–not my kids, anyway!

  • Pete

    Damn Anthro if I didn’t know any better… 😉

    Does anecdotal evidence mean nothing? The advancement of our knowledge through science has to start somewhere. It’s not all about looking backwards vs the present, but looking ahead. Studies continually fail to control consequential variables (for instance the study released today correlating death rate to low carb animal protein based diets which failed to take into consideration the TYPE of meat consumed, which leaves it highly likely that it was processed, grain fed, antibiotic ridden, nitrate-infused convenience meat, as opposed to the grass-fed organic and wild game they should be eating. Just one minor detail!).Link enough of these flawed studies together and you can end up dangerously advising a population on what they should be eating. Suppose we advise people to limit fat intake without smack you in the face, undeniable, indisputable, earth-shattering proof. Acting in what we think is the public’s best interest (or of those with enough political clout or $$) we set the stage for Omega 3 deficiency. That’s just one example. The concentration of Soy protein after “studies” claimed health benefits of soy began to emerge is another. We don’t know the effects those phytoestrogens will have at such high doses.

    But anyone that thinks beyond the existing studies is irresponsible and pseudoscientific?

    I have worked a long time researching nutrition from every angle. I have also tried many nutritional approaches first hand. I was able to figure out what works for my body and not once have I come across a nutritional study that wasn’t flawed in some way. That goes for both studies that support and oppose my way of eating.

    I would very much like to help people wanting to be healthy get there. But unfortunately I don’t think people care enough. Case in point: my brother-in-law. I go out of my way to eat healthy, he eats what he wants, doesn’t care he’s overweight or a diabetic. He just takes his pills (WITH GATORADE MIND YOU) and packs up his insulin kit and its off to enjoy some apple pie.

    With regards to the article: It’s amazing to me that doctors aren’t trained in nutrition. How does that happen? Isn’t that in a 101 class or something? I just don’t get how something so obviously important to health (didn’t Hippocrates write about “food being thy medicine) could be so overlooked. I guess there really is no money in being well.

  • DennisP

    @Pete – “I guess there really is no money in being well.” THAT is the key to all of the discussions on this (and other) blogs. A “well” person doesn’t need to be on life-long drugs (bad for pharmaceuticals) or see their doctor 4 times a year (bad for clinics) or require sugery (bad for hospitals) or eat processed, edible, food-like substances (bad for food processors). Consider the size of the wellness industry (exercise machines, bicycles, wellness consultants, small farmers at farm markets, who else??) vs. the size of the “illness” industries cited a sentence earlier. It’s like your local high school football team playing the Green Bay Packers. They’ve got all the money, the lobbyists, and influence with Congress and the administration. To be well means moderation in eating, in exercise, and in spending money. To be well means NOT spending money on all the goodies society offers to subvert your health. To be well offers no way for others to make big money off of your health (or lack thereof).

  • MA

    @Pete – You said that many people don’t want to get healthy. I agree – they say they do, but won’t do the work required to get there. I know many people who’s health would be greatly improved if they just changed their diet. It’s truly frustrating to see people with children who are on medication for ADD feeding their children processed junk. And how dare anyone question their food choices! It’s sad that they won’t even consider diet as part of the cause or solution. That’s in large part because their doctor didn’t say anything about it, so it must not be important. It’s obvious to most of us who read this blog that diet and health are inextricably linked, but for some reason, that’s not obvious to the general population.

    Why aren’t the doctors, who prescribe the medicine, instead prescribing (or referring to an RD/nutritionist to prescribe) a healthy diet centered on real foods? One would think that all doctors would have to take “food 101,” but, like DennisP says, that’s just not profitable. Very sad.

  • Pete

    @ Dennis – not to mention that 90% of the “wellness” industry is snake oil ta boot! Because there’s more money in selling supplements than actually teaching to fish.

    @MA – It’s really really sad. Especially when I see what parents feed kids at the playground. But here’s the worst part… I am the one chastised for feeding my kid healthy food! It’s like other parents look at you when you tell them “no my kid can’t have a lunchable, nor a cheese doddle, and no they can’t have a sip of your Arizona Iced Tea” it’s like they get defensive… “what are you telling me I don’t know how to raise my kid. You are telling me I’m not a good parent.” And if they every actually come out and say what they are thinking instead of just catching attitude and poking fun I would enthusiastically answer them… “yes, I believe your ignorance is harming your children and our collective future.”

    Time and time again, I am the lunatic for saying my kid can’t have hot dogs. And why is it that whenever you go out to eat they always ask “do you want chicken fingers or hot dogs for the little guy?” Since when did deep fried processed nuggets of what at one time resembled a chicken become the default meal for a developing child? Sorry, I’m just a bit fed up today.

    Plus, there’s no excuse for not knowing “you are what you eat”. I can see misplaced trust in government (meaning the attitude that they wouldn’t sell us something that would kill us) as a quasi-excuse, but if you think that what you eat has no bearing on your health than maybe a Darwin award is in your future.

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  • Sheila

    Interesting discussion! I am a family practice physician, work in a rural health clinic. We serve a remote population, nearest (small) hospital is 30 miles away. They do have RD services, charge $150 for a consultation with the RD. Most of our patients are uninsured, low-income. Most of our patients are obese, many have diabetes/hypertension/heart disease, and smoke. Many of our patients either are illiterate or read at low elementary school level. Many of our patients are not computer literate. Many of our older patients do make a summer vegetable garden to help survive the winter on canned food, but gardening and canning seem to be lost arts among the younger patients. Common food culture in this part of the country is to eat a lot of fried food. Many breakfasts are bacon/sausage/eggs/biscuits and gravy. Fast food is so common here, people even bring their white bags of food with jumbo sodas into the exam room to eat while waiting for the doctor or waiting for lab results, or people bring bags of chips to eat while I am talking to them. (or they did until I made the nurse start telling them they couldn’t bring any food into the exam rooms.) Our clinic is staffed by nurses who themselves are mostly obese, and directors who are mostly obese. For patient appreciation day, our clinic served buttered, salted popcorn and sodas, in spite of my strong verbal and written objections and suggestions for alternatives.
    So, what do I do? I tell every patient about the benefits of a well-chosen diet, the risks of a poorly-chosen diet. I tell them about inexpensive alternatives to get better nutrition. I ask them to commit to making one small change in health habits every week. By the end of the year, they can make ~50 changes in health habits, and that will be huge over time. I ask every patient to start active exercise in some fashion daily, to whatever extent they can given their individual health situation. I advocate regularly for patients to join the exercise classes at our local community center. I speak with every patient about specific foods, portion sizes, content of sugar/fat/sodium, how to read the label (if they can read). I ask them to eat more fresh fruit and vegetables, fewer meals from white paper bags. I ask them to consider starting even just a small garden in the spring, maybe even just a tomato plant and squash or green beans, whatever they like on a small scale to see how easy it can be. I ask them to teach better nutrition to their children by example, and by only having healthier snacks in the house. I ask every diabetic patient to try to attend diabetic education classes, and ask every diabetic patient to meet with the RD to cover individual meal planning issues. I have hand-outs for those who read or have family members who read. I have web addresses for those who do have computer access and skills. I have donated copies of books I consider helpful to the local library. I have posters up in every exam room that show complications of poor control of diabetes and cholesterol. I personally eat an excellent diet, in public, in private, and daily in the staff dining room for all to see a role model. I shop in local grocery stores so patients can readily see what is in my cart. Usually, we laugh as they comment something like, “gosh, doc, you really do eat all that stuff you tell us to eat!”. I have asked for us to use future grant funding for diabetic educator and/or RD for our clinic. I have asked for years to start a community garden on land owned by our clinic.
    In spite of all this, I am sad to report our “numbers” are not dramatically improved over time. I can’t make people do the hard work of changing life-long habits if they are not motivated to do so. In graduate school and medical school, I was sure that all I would have to do is provide good information and the patients would make good use of it. 21 years into practicing medicine, I am no longer sure of that.

  • Marion

    @Sheila: I love hearing about what you are doing and can understand your frustration. But this is why personal responsibility can never be enough to address the obesity problem. You can try to change individual behavior but you are up against a food environment designed to get people to eat more, not less, and to believe that eating a lot of junk food is what they are supposed to be doing. Until the environment makes healthy eating the default, you have an uphill challenge. Courage! And thanks for writing.

  • Cathy Richards

    Family Meals Marion! You forgot about “eating together”. People who eat together eat better and are more likely to progress to making real food vs. processed.

    Regardless of nutrition issues, they are also healthier socially, with a better resiliency to deal with stress, and lower likelihood to practise dangerous behaviours.

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  • FoodGeek

    …or you could just send patients to – a website created by an internist (an M.D.) who grew up in the food and restaurant business. It’s all evidence-based medicine, no fad diets, eat real food that tastes great. I was really surprised to find out that I could cook healthy food that tasted really good.

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