Brandy W. Root, RD – Medscape Nephrology – Medscape
I started my career in the Deep South of the United States, an area with the highest rate of chronic disease in the country. I moved from Louisiana to Virginia, then to Georgia, Florida, and Alabama. I have served a few urban areas, but the majority of my time has been spent working in rural areas where resources may be limited but preventable, chronic diseases are not.
As Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure”. He was referring to the prevention of town fires. But surely the sentiment fits in the realm of healthcare as well?
Since the passing of the Affordable Care Act (ACA) in 2010, our focus has shifted to the prevention of chronic disease rather than treatment alone. This can leave primary care managers — who probably had little extra time with patients before the ACA was passed — scrambling to both manage existing conditions and prevent the development of future conditions, with few additional resources to address active problems and to predict and prevent future problems.
Of the top 10 most prevalent conditions in the United States, six include nutrition therapy as a significant pillar of care.
Nutrition Education
Nutrition education seems pretty straightforward. For many chronic diseases, the guidelines are similar, with a generic tone of “Eat less processed food and red meat and more fruits and veggies.” That seems easy enough to pass along to a patient in the last few seconds of an appointment. But it can also spark another conversation entirely.
“But doesn’t fruit have a lot of sugar?”
“Are processed foods okay if they’re keto?”
“Coconut oil is natural, isn’t it okay?”
I hear these questions several times a day and they cannot be appropriately answered in the remaining minutes at the end of a medical appointment because there is simply too much education to provide.
Even a brief but well-rounded response to “Doesn’t fruit have a lot of sugar?” would look something like this:
“Fruit has carbohydrates that are broken down into sugars that the cells need for energy. That makes them a great choice for breakfast, lunch, and even a pre-workout snack, but a poor choice for an after-dinner snack when the body’s demand for glucose is likely to decrease. Ideally, we would pair fruit with a protein to prolong the breakdown of carbohydrate into sugar for a most consistent and stable increase in blood sugar.”
Is it realistic for a clinician to tack education onto an already full appointment? Even this brief response doesn’t address the mechanics of glucose metabolism as it relates to other nutrients and to physical activity.
We may believe that such education would overwhelm our patients. But as a dietitian, I believe that my most important skill is the ability to take complex metabolic processes and turn them into digestible concepts for all my patients, regardless of their educational background. I also believe that this skill is the one that makes me a successful educator. When my patients understand how their body works and when and how to fuel it for their intended activity, they can become empowered to care for themselves.
Dietetic intervention has been shown to be a cost-effective way to improve some of our most common chronic diseases and could reduce strain on our overloaded healthcare system. A New Zealand study found significant clinical improvement in obesity, diabetes, cardiovascular disease, and malnutrition in older adults when provided with nutrition education by a registered dietitian. This study also noted that for every NZ$1 spent on dietetic intervention, NZ$5.50 to NZ$99 was saved on patient care.
Dietitians Should Be Down the Hall
I have worked in chronic disease management for my entire care. I keep up to date on developing guidelines and standards of care. I read emerging research. I communicate with my colleagues regarding changes in the field. After nearly 10 years, I find that none of that plays a significant role in my patient’s success. Do my education and experience allow them to trust me more freely? Probably.
But they never succeed at losing weight or managing their blood pressure or their blood sugar because of my continuing education. They succeed because I am given the time and the opportunity to tailor an intervention to suit their lives. There is no one-size-fits all approach to nutrition because everyone has different preferences, restrictions, resources, and needs.
Dietitians should be to the primary care team what physician assistants and nurse practitioners are to the surgical team. We should be in offices working alongside other clinicians. We should be another office just down the hall, not just a business card that collects dust next to a tower of pamphlets on lifestyle changes. Dietitians should be fully integrated into the primary care team, so they are able to discuss concerns with prescribers, request lab work with ease, or recommend changes to supplements quickly and efficiently. This model allows the primary care manager to provide more comprehensive, effective, and efficient care for the patient without increasing their own workload. This model could help to effectively treat chronic disease as well as prevent it by allowing clinicians to easily refer patients for dietetic intervention before they develop a chronic disease diagnosis rather than after.
