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Prevention and Health Care Reform

The leading causes of death in the United States include heart disease, cancer, stroke, diabetes, and kidney disease (1). These conditions are strongly associated with poor diet, sedentary lifestyle, and excessive weight gain. Currently, 2 out of 3 Americans are either overweight or obese (2). As such, 75% of total healthcare costs are used for the treatment of these chronic conditions (3). Research continues to show that nutrition intervention can drastically improve one’s health and reduce the risk for many of these chronic diseases. Nutrition counseling by a registered dietitian nutritionist (RDN) can make a world of difference for chronic disease management, treatment, and prevention. Nutrition counseling that promotes lifestyle changes to include healthier diets and more physical activity have the potential to reduce incidence of type II diabetes by 34% (4), heart disease by 31%, and stroke by 20% (5). Utilizing these services can make a profound difference in the trajectory of health outcomes and healthcare costs for American’s. However, only 3% of all healthcare expenses are spent on preventive services (3). This is primarily due to a lack of coverage for these services by insurance companies. Medicare covers dietetic services only for patients who have diabetes or kidney disease. As such, patients who are prediabetic, obese, or have cardiovascular disease are not covered by Medicare to see a dietitian. Many people seek nutrition services and choose to pay out of pocket, recognizing the long term benefits these services provide. Yet, many individuals who need these services simply can’t afford to pay for them, costing around $118 an hour (6).

Under the Affordable Care Act (ACA), preventive services are covered more now than ever. The ACA mandated that insurance companies cover preventive services that were identified by the U.S. Preventive Services Task Force (USPSTF) (7). These services include “healthy diet and physical activity counseling” and “obesity screening and counseling (8).” Congress is currently proposing the American Health Care Act which threatens to discontinue the inclusion of these services. Such reform would be a step backwards in reducing the rates of chronic diseases and the rising healthcare costs. According to the Academy of Nutrition and Dietetics President Lucille Beseler, the American Healthcare Act will, “reverse advancements made in disease prevention and chronic care management (9).” With healthcare costs continuously on the rise, investing in prevention is a much-needed solution for our nation’s healthcare costs.

In addition to the inclusion of prevention services, the ACA also includes the Prevention and Public Health Fund. These funds are distributed to the states to be used for community specific programs, including prevention initiatives, surveillance, and research (10). Investing in these types of community programs can reduce healthcare costs. For every $1.00 spent, $6.60 in healthcare costs are saved over a five year period (3). The current healthcare reform proposal will repeal this fund, hurting the communities that have been benefiting from these public programs. The House of Representatives passed the American Health Care Act in May sending it to the Senate for deliberation. In June, the Senate released their revised version of the bill and titled it the Better Care Reconciliation Act. The Senate was unable to repeal the ACA by the September 30th deadline. In October, President Trump passed an Executive Order Promoting Healthcare Choices and Competition, which allows agencies to modify how they implement the ACA. As nutrition professionals, the implications of preventive services is extremely apparent, yet without proper support for these services we risk their exclusion from future healthcare reforms.

  1. FastStats. (2017). Available at: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. (Accessed: 15th December 2017)
  2. Overweight & Obesity Statistics | NIDDK. Available at: https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity. (Accessed: 15th December 2017)
  3. Prevention and Public Health Fund. Available at: https://www.apha.org/topics-and-issues/health-reform/prevention-and-public-health-fund. (Accessed: 15th December 2017)
  4. The data are in: Eat right, reduce your risk of diabetes – Harvard Health Blog – Harvard Health Publishing. Available at: https://www.health.harvard.edu/blog/the-data-are-in-eat-right-avoid-diabetes-2017010510936. (Accessed: 15th December 2017)
  5. Guide to Insurance and Reimbursement – Today’s Dietitian Magazine. Available at: http://www.todaysdietitian.com/newarchives/0217p40.shtml. (Accessed: 15th December 2017)
  6. Preventing Heart Disease | The Nutrition Source | Harvard T.H. Chan School of Public Health. Available at: https://www.hsph.harvard.edu/nutritionsource/disease-prevention/cardiovascular-disease/preventing-cvd/. (Accessed: 15th December 2017)
  7. Health Care Reform and Preventive Services. www.eatrightpro.org Available at: https://www.eatrightpro.org/resource/payment/nutrition-services/health-care-reform/healthcare-reform-and-preventive-services. (Accessed: 15th December 2017)
  8. USPSTF A and B Recommendations – US Preventive Services Task Force. Available at: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/. (Accessed: 15th December 2017)
  9. Academy of Nutrition and Dietetics Announces Opposition to American Health Care Act. www.eatrightpro.org Available at: http://www.eatrightpro.org/resource/media/press-releases/public-policy/academy-announces-opposition-american-health-care-act. (Accessed: 15th December 2017)
  10. Prevention and Public Health Fund | HHS.gov. Available at: https://www.hhs.gov/open/prevention/index.html. (Accessed: 15th December 2017)
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Member Highlight Interview: Sharon Donovan, Ph.D., R.D.

Interview with Sharon Donovan, Ph.D., R.D., Professor and Melissa M. Noel Endowed Chair in Nutrition and Health in the Division of Nutritional Sciences at the University of Illinois and Past President of the American Society for Nutrition.


Dr. Donovan received her Ph.D. in Nutrition from the University of California, Davis and completed a post-doctoral fellowship in Pediatric Endocrinology at Stanford University School of Medicine. She joined the University of Illinois, Urbana in 1991, where she became Professor in 2001 and in 2003 she was named the first recipient of the Melissa M. Noel Endowed Chair in Nutrition and Health. She served as Director of the Division of Nutritional Sciences Interdisciplinary Graduate Program from 1999-2009. Dr. Donovan served as President of the American Society for Nutrition for 2011-2012. She is also President-Elect of the International Society for Research on Human Milk and Lactation (ISRHML) and she continues to provide leadership and guidance in several committees and special initiatives for ASN. In October 2017, she was elected to National Academy of Medicine.

How did you first get involved in nutrition research? What made you interested in the field of nutrition science?

I was an undergraduate student at U.C. Davis majoring in Zoology, with the intention of going to veterinary school. In my junior year, I took a physiological chemistry course (basically nutritional biochemistry) taught by Richard Freedland—and I loved the course! Afterward, I took a nutrition course in the Department of Nutrition, where Bo Lönnerdal was a guest lecturer on the topic of pediatric nutrition—and I was hooked! I switched my major to nutrition science and started doing research in his laboratory and eventually was accepted into his laboratory for my doctoral degree.

When and why did you first join ASN? What convinced you to join the organization?

I joined the former AIN in 1984 as a graduate student in nutrition at U.C. Davis and attended my first FASEB meeting in 1985. I became a Full Member in 1989. I joined because the American Society for Nutrition is the top nutrition society for basic, translational and applied research in nutrition.

What aspects of ASN membership have you found most useful, professionally? What other aspects of your membership do you find useful as your career has progressed?

ASN membership has been instrumental throughout my career. Early on, ASN provided a framework for disseminating my research through annual meetings and publications. Likewise, through ASN I was able to build a broad professional network of colleagues at other institutions in the U.S. and around the world. ASN also provided numerous leadership opportunities through the RIS groups, on the Executive Board as Councilor and Secretary and, eventually, as President of the Society. All of these activities have been very professionally fulfilling for me.

What aspects of your research do you foresee being most important for ASN members?

My laboratory conducts basic and translational research in the area of pediatric nutrition. During this phase of life, proper nutrition is of key importance for growth, development and long-term functional outcomes, such as cognition and immune response. A large focus in my lab is how early life events influence the composition and functional capacity of the gut microbiome. As we learn more about the microbiome and its relationship with many of the same diseases that have long been associated with dietary intake, it is clear that nutrition researchers should know more about this newly appreciated “organ”.

Can you tell us more about your current position and the research activities in which you are involved?

I am a Professor in the Department of Food Science and Human Nutrition and am affiliated with the Division of Nutritional Sciences and the Department of Pediatrics. Currently, my collaborators and I are investigating dietary approaches to improve the structural and functional development of the intestine and the brain, and the development of gut microbiome and the gut-brain-microbiome axis. In addition, I enjoy engaging with researchers in other fields to conduct transdisciplinary research focused on ways to prevent childhood obesity and picky eating behaviors and to reduce the severity of symptoms in children with autism.

What do you feel are the biggest challenges facing nutrition researchers today? Are there any areas where you would like to see more research?

Obviously, research funding continues to be a challenge for researchers in all areas. However, given the importance of nutrition in health and chronic disease prevention, I believe that there are many opportunities for nutrition researchers for interdisciplinary collaborations, which can be very attractive for funding agencies. In my opinion, more research is needed in understanding the contribution of the individual to interactions with diet and other environmental factors. For example, what role are host genetics and epigenetics genetics playing in responses to diet? This has been a hot area of research for a decade, but has not been fully translated to clinical medicine. Similarly, we need to know a lot more about the host aspect of host-microbe interactions, if we are going to tease out the role that the microbiome plays in health and disease.

Is there anything else you’d like to tell ASN members, especially students and postdocs?

I encourage everyone to take the opportunity to get involved in ASN. There are opportunities to “dip your toe” in the water and see how you like it! The RIS’s and other membership engagement groups, such as the Student Interest Group and the Postdoc/Early Career Nutrition Interest Group are great places to get involved. Networking is critical, particularly at earlier stages of your career, and professional contacts made through networking can help open doors that lead to opportunities, including internships, postdocs and jobs. Later in your career, being known by your colleagues can help with getting letters of P&T or learning about new positions in industry.

A Time for Change: Nutrition Education in Medicine

The New England Journal of Medicine recently published an article entitled “Simulation of Growth Trajectories of Childhood Obesity into Adulthood.” The models in the study projected that 57.3% of today’s children will be obese by age 35.1 The bleak predictions of future health trends such as these reaffirm the need for health professionals to be knowledgeable about nutrition.

Patients expect physicians to be sources of information related to nutrition. In fact, 61% of respondents to an American Dietetic Association (now the Academy of Nutrition and Dietetics) survey stated that they believe physicians are a “very credible” source of nutrition information.2 At the same time, though, in a study of internal medicine interns, 86% of respondents admitted to being inadequately trained to provide nutritional counseling. This inadequacy starts early in a physician’s career, with 51.1% of medical school graduates in 2005 reporting that they received insufficient nutrition education during medical school.3

Take the field of cardiology, for example, where a recent study found that, among a cohort of 930 cardiologists, 90% believe their role includes providing patients with basic nutrition information. In the same group of physicians, though, 90% stated that they had received little-to-no training in nutrition during their fellowship, 59% stated that they had received no nutrition during internal medicine training, and 31% reported no nutrition education in medical school.4 Simply put, the perceived role of physicians and the training they are given don’t match up.

This is not a matter of self-reported opinion either, because curricula also lack dedicated nutrition training, and this is not a new phenomenon. In 1962, the American Medical Association (AMA)’s Council on Foods and Nutrition held a conference pertaining to the “inadequate recognition, support and attention” given to nutrition education in medical schools. The council acknowledged that nutrition is intimately involved in the pathogenesis of chronic and degenerative diseases and that the medical curriculum was lagging with respect to advances in nutrition science. 5 The interrelatedness of medicine and nutrition was recognized by the council as more than the just the treatment of isolated nutrient deficiencies.

In 1976, the AMA conducted a mail survey to better understand the status of nutrition education in U.S. medical schools. When 102 medical schools responded to the surveys, fewer than 20% of schools reported requiring a nutrition course.6 The schools cited lack of funds, inadequate number of physicians trained in clinical nutrition, and limited amount of time available in the curriculum as limitations for increased nutrition education. This forty-year-old survey also highlighted the increased interest in nutrition from students and faculty at these institutions.7 We can only assume this interest has since grown.

The scientific conferences and congressional hearings in the decades leading up to the 80s drew attention to the need to improve nutrition education in U.S. medical schools. As a result, the National Research Council Committee on Nutrition in Medical Education published recommendations in 1985 stating that a minimum of 25 to 30 classroom hours during preclinical years should be allotted to covering the topics in nutrition that were underscored by the committee.6 For the past two decades, research spearheaded by University of North Carolina at Chapel Hill has tracked the state of nutrition education in U.S. medical schools every four years. Unfortunately, the data show no sign of changes in the average hours required in nutrition education since 2000. The most recent survey during the 2012-2013 academic year included 121 medical schools, with an average of 19 hours (SD =13.7) of nutrition education in their curriculum. The survey showed that 71% of medical schools failed to meet the minimum recommendation of 25 hours, 36% provided 12 or fewer hours, and 9% provided none.8

Current nutrition education is evidently not translating into practice when only 10% of primary care physicians include weight counseling for patients, and fewer than half of obese and overweight patients are advised to lose weight.9 Primary care practitioners overwhelmingly support requiring additional training so that they will be better informed about the care they provide to their patients with obesity.10

The Association of American Medical Colleges has recently declined to incorporate nutrition into its new blueprint for medical competencies.11 The 2013 American Council for Graduate Medical Education (ACGME) program requirements for Graduate Medical Education in Cardiovascular Disease neglects to mention nutrition. 12 This continues to be the case in the most recent iteration of the ACGME requirements along with the ACGME for Internal Medicine.13,14 These examples show that both medical schools and graduate medical education have yet to legitimize the value of incorporating nutrition training through their competencies.

Three programs that have become recognized for their innovative approach to nutrition curriculum at medical schools include:

  1. The Nutrition in Medicine (NIM) Project – since 1995 this program has aided in the development and distribution of nutrition curriculum for medical students through comprehensive online courses free of charge. The curriculum is a 29-unit curriculum covering basic science content along with clinical applications through cases. About 50% of medical schools actively use the NIM curriculum and the flexibility of the curriculum has allowed for varied implementation at these schools .15 A more recent initiative by the NIM team is the Nutrition Education for Practicing Physicians for residents, fellows, and practicing physicians. These online modules differ from the medical school resources through the greater level of clinical detail and practical applications (http://www.nutritioninmedicine.org/).
  2. Healthy Kitchens, Healthy Lives – The Culinary Institute of America and the Harvard T.H. Chan School of Public Health have collaborated as a strategy to enhance physician ability and motivation for nutrition counseling through interactive cooking experiences. The program uses teaching kitchens to demonstrates how nutrition science can be translated into nutritious meals. This initiative has shown to be successful in changing physicians’ dietary practices and their inclination to offer nutrition counseling at a 3-month follow-up.16 Currently, over 6,000 health professionals have taken the course. This initiative has expanded to 32 organizations located in 16 different states, plus Italy and Japan. The kitchens are active in universities, hospitals, and corporate buildings. (http://www.healthykitchens.org/)
  3. Tulane University School of Medicine’s Goldring Center for Culinary Medicine – this is the first teaching kitchen implemented at a medical school. The center trains medical students and professionals through culinary medicine classes in the form of electives and seminars as well as continuing education. The idea is grounded in the idea that the knowledge to cook nutritious meals encourages patients to buy vegetables and fruits that they previously avoided because they didn’t know how to prepare them. Tulane offers an institutional and away rotation at Johnson & Whales University in Providence Rhode Island where students can participate in hands-on culinary and culinary nutrition classes as well as an academic research project related to medical nutrition therapy. Medical students can also opt to take an 8-class culinary medicine elective during their first or second year of school. (https://culinarymedicine.org/)

The physician is the head of the care team and is responsible for directing care and allocating personnel and resources. Physicians see many patients when they are most in need of nutrition guidance. Therefore, physicians should be able to assess and recognize nutrition-related problems, and appropriately coordinate patient care. Let us hope that these programs are increasingly adopted in medical education so that physicians will be better equipped to address the health of their patients.

 

References:

  1. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-2153. doi:10.1056/NEJMoa1703860.
  2. Nutrition and You: Trends 2008.; 2008. http://www.eatrightpro.org/~/media/eatrightpro files/media/trends and reviews/nutrition and you/trends_2008_are_you_already_doing_it.ashx. Accessed November 30, 2017.
  3. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge. J Am Coll Nutr. 2008;27(2):287-298. http://www.ncbi.nlm.nih.gov/pubmed/18689561. Accessed November 30, 2017.
  4. Devries S, Agatston A, Aggarwal M, et al. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130(11):1298-1305. doi:10.1016/j.amjmed.2017.04.043.
  5. Council on Foods and Nutrition. JAMA. 1963;183(11):955. doi:10.1001/jama.1963.03700110087015.
  6. National Research Council (US) Committee on Nutrition in Medical Education. Nutrition Education in U.S. Medical Schools. Washington, DC; 1985. doi:10.1007/BF02427708.
  7. Cyborski CK. Nutrition content in medical curricula. J Nutr Educ. 1977;9(1):17-18. doi:10.1016/S0022-3182(77)80110-6.
  8. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. J Biomed Educ. 2015;2015:1-7. doi:10.1155/2015/357627.
  9. Kraschnewski JL, Sciamanna CN, Pollak KI, Stuckey HL, Sherwood NE. The epidemiology of weight counseling for adults in the United States: a case of positive deviance. Int J Obes. 2013;37(5):751-753. doi:10.1038/ijo.2012.113.
  10. Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open. 2012;2(6):e001871. doi:10.1136/bmjopen-2012-001871.
  11. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Acad Med. 2013;88(8):1088-1094. doi:10.1097/ACM.0b013e31829a3b2b.
  12. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014;127(9):804-806. doi:10.1016/j.amjmed.2014.04.003.
  13. ACGME Program Requirements for Graduate Medical Education in Cardiovascular Disease (Internal Medicine). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/141_cardiovascular_disease_2017-07-01.pdf. Accessed November 30, 2017.
  14. ACGME Program Requirements for Graduate Medical Education in Internal Medicine.; 2017. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_internal_medicine_2017-07-01.pdf. Accessed November 30, 2017.
  15. Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: nutrition education for medical students and residents. Nutr Clin Pract. 2010;25(5):471-480. doi:10.1177/0884533610379606.
  16. Eisenberg DM, Myrdal Miller A, McManus K, Burgess J, Bernstein AM. Enhancing Medical Education to Address Obesity: “See One. Taste One. Cook One. Teach One.” JAMA Intern Med. 2013;173(6):470. doi:10.1001/jamainternmed.2013.2517.

 

The Art of the Social Media Nutrition Misinformer

I’ve been using Twitter for nutrition science purposes for 8 years now, and so I have observed a lot over this time. I find Twitter a great venue for keeping up with scientific issues specific to nutrition and those broader in science (related to statistics, ethics, new fields/techniques, etc.). For these purposes, you can follow great people and get the collective wisdom and reading list of experts who are doing really great work. At the darker end, like any human social collective, Twitter and other social media platforms can be cesspools to foment misinformation. And in ways, they cultivate and amplify such misinformation over true expertise. To borrow David Nunan’s term, there’s an “epidemic of misinformers”. I’ve maintained a list of such misinformers to observe over the years, and it continues to grow steadily. They are generally much more successful in messaging and motivating followers. These are what I consider the four main characteristics of such misinformers.

First and foremost, misinformers encourage distrust in health professionals. There are constant discussions within health sciences about quality of evidence, how to improve scientific methods, and so on. Such discussions are healthy within the scientific community and serve to increase our confidence in getting to scientific truths. Incrementally, we get better at improving the scientific process itself, which is still infinitely better than trying to get at objective truths through individual experience. Misinformers engage in historical revisionism that often villainizes historical scientists and groups, while promoting an alternative narrative of their heroes victimized by the establishment. Such narratives serve to rile up such communities, and make it difficult to have rational conversations. Those that have negative views against institutions and authoritative figures may find such narratives especially attractive.

Second, there’s always a clear and simple alternative message, and anecdotes are key to showing its truthfulness. Sometimes the message isn’t entirely incorrect. For example, there doesn’t seem to be one diet pattern that is particularly advantageous for weight loss in the general population on average that emerges in research. But people who self-select a particular diet from ideological motivations will likely be more enthusiastic and vocal about it, whether it be low carbohydrate, low fat, vegan, etc. Of course, those trained in critical thinking will understand that the tribalism of social media will make the diet look way more successful than the scientific literature will demonstrate. If you constantly stay up-to-date on the scientific literature in nutrition, you see that usually no single diet pattern clearly rises above the rest for most outcomes, hence a variety of patterns are usually provided as options by science-based practitioners. Yet misinformers will focus on their diet of choice as the one true solution to mitigate disease, suggesting that professional organizations are disregarding evidence when providing other options. Such communities yield many positive anecdotes within their groups, but one must recognize that they will skew the perception of the efficacy of such a diet to the broader population. Of course, how do you explain this to someone enraptured in their preferred narrative?

Third, but the most consistent misinformer characteristic in my opinion: such self-selected communities lack filters to distinguish source credibility. As previously discussed, not all information they share is necessarily incorrect- to the contrary- some may be important, credible, and relevant. But their danger is that mixed within the credible content is that which is not, with followers who are unable to distinguish the black, white, and grey. It is a deep net disservice to share and partner with fringe/pseudoscientific resources that promote dangerous health theories, discourage conventional medicine, and exaggerate or oversimplify information. Such partnerships only legitimize the nonsense to their followers. Often these partnerships are self-serving to amplify the misinformer’s message, sometimes enough to break into the mainstream. But those with respect for the science-based process will only favor credible channels of communication. You can tell when someone’s intentions are not based solely on the truth when they foment distrust in other areas of science as well. They may discount the consensus for vaccines, climate change, or other hot button issues.

Fourth, there’s almost always a book to be sold. I have only my observations, but the more one derides the “establishment” and suggests their own way is better (the further from “convention” the better), it is usually only a matter of time before a book deal is reached. Let me be clear- it is perfectly ok to sell your expertise if one is qualified. But expertise is reached after many years of intensive study with a foundation in the scientific process. The nature of studying nutrition makes it difficult to provide certainty in many areas and misinformers are happy to fill in the gaps. They will not understand that their books are the result of misappropriated respect for their vocality and not their expertise. If not a book, sometimes some other income source supports their continued efforts. Those railing about financial conflicts of interest in science while discounting these and other ideological sources of bias ought to reflect.

Is it our fault that misinformers often “win”? Or is it the nature of nuance that we must maintain when trying to communicate complex scientific issues? The death of the respect for expertise and the complex cognitive biases that social media exposes to our folly? I by no means consider myself any sort of expert, after studying nutrition science for only a decade, which is part of the problem inherent to expertise. I’ll never feel as confident in my social media content than someone who a few months ago latched onto a dietary narrative that perfectly aligns with their worldview. We also hold ourselves to ethical standards within an operating scope that others are not obligated to follow. My cynicism says the misinformers will always win out over good information, and tells me to log off social media and rid the distractions. But I remain hopeful and motivated by the good people I see everyday pushing back in diverse ways, and we must continue pushing.