Oatmeal and coffee

Another Midwestern morning.  PalKid is exhausted from the ballgame last night and put up a bit of a fight getting up.  But she’s safely off at Sunday school and I’m safely settled into the cafe where I’m enjoying a small bowl of oatmeal with a bit of brown sugar, and some black coffee.  I try to make good nutrition choices but I don’t always succeed.

Did we used to "get it"?

A criticism often leveled at those of us who practice medicine using science and data as our guide is that we don’t know enough about nutrition.  If it were I pointing the finger I would include cancer, heart disease, diabetes, and pretty much all of medicine.  We don’t know everything about everything.  I’d agree, however, that at least when I was in medical school we didn’t have a lot of focused education on human nutrition in and of itself.

Our education on nutrition included the basic biochemistry of human beings and what substances we cannot live without.  Further nutrition education was divided into various pathology topics.  Inborn errors of metabolism where there is a specific defect in a metabolic pathway like phenylketonuria.  This is a disease that can be devastating but can be easily controlled by a specific diet.  Type II diabetes is a complicated disorder affected by both genetics and behavior whose treatment can in part be treated with proper dietary advice.   Medicine textbooks, and university and hospital departments cover what we know about nutrition pretty thoroughly.

At our office, we have a diabetic education nurse who has special training in just this topic, and can work with our diabetics to try to improve their dietary habits, but also helps them monitor their glucose properly, makes sure their relevant preventive care is up to date, etc.  We also have a special pathway to help our patients with high cholesterol make lifestyle choices that will help them lower their cholesterol, and thereby their risk of heart disease.

Not every primary care practice has access to these resources.  One of the failures of our public health system is that we do not provide good education in nutrition to individuals and we create government policies that favor the production and consumption of unhealthy foods.  Most of my patients from Detroit will tell me that they live in a relative food desert.  There are few grocery stores that are easily reached by foot or bus.  Mom and pop “party stores”, which are basically mom-and-pop equivalents of Circle K’s or 7-11’s are much more accessible, but typically provide a choice of inexpensive, unhealthy foods.

Of course, like the rest of medicine, there is lots we don’t know about nutrition as a group and as individuals.  The most common nutritional disorders we see in the US have to do with excessive consumption of low quality foods leading to obesity, but we also have calorie-restriction malnutrition in complicated diseases such as anorexia nervosa, an illness that, like all others, is not simply a matter of proper nutrition.

All this aside the real question is, “What do you mean when you say doctors don’t know enough about nutrition?”  Does it mean that we are expected to have the resources at hand to provide answers to every nutrition question a patient has?  If so, we will always fail.  There is a field devoted to this: dietetics.  But as a society, we don’t have wide-spread access to certified dietitians, nor to we have widespread education on proper nutrition.

My more cynical side suspects the question really means, “Doctors don’t know enough about [fill in non-science based magic food cure] and it must be their inadequate education in nutrition.”

This is not the case.   We know, generally, what dietary interventions can help with the most common diseases, such as heart disease and diabetes, and we at least have an idea how much these factors contribute to the fight.  What we are beginning to learn is the biology of satiety so that we can aid our patients in not feeling horrible while eating properly.

I’m willing to admit that all doctors are not experts on all forms of nutrition science.  But I’m not willing to grant that we should be.

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18 Comments

  1. CanadianChick

     /  September 25, 2011

    Great post, thanks for that.

  2. Did you ride your bike to coffee? I’m copying a comment I left over at Steve Novella’s obesity article on SBM a few days ago. (It’s tangentially related.)

    Sorry for the length, but I need to give the backstory. I’m attending a really great lecture series. The dean of the program, J. John Cohen, MDCM, PhD, spoke about cell biology tonight. During the audience Q&A, someone asked if exercise is good for mitochondria and metabolic efficiency, why does exercise trigger hunger. Dr. Cohen said he actually finds exercise to be appetite-suppressing, and took a quick poll of the audience. The results were about 50-50.

    I was astonished to learn exercise does not trigger hunger in everyone. This seems to me like a potentially productive avenue of obesity research. I will be the first in line when someone figures out how to flip that switch.

  3. As I have a BS in Nutrition I am one of the first to criticize medical doctors for their lack of nutrition knowledge. i accept that you have the basics, but how can you possibly know whether “Medicine textbooks, and university and hospital departments cover what we know about nutrition pretty thoroughly.” when you are lucky to get 30 h of direct nutrition education in medical school.

    I appreciate that physicians cannot know everything, but nutritionists and dieticians are often overlooked when it comes to nutrition research funding. Some how the grant panel(s) at NIH consider research done by physicians ahead of that done by research scientists with a background in nutrition.

    Additionally it is a little frustrating to go to a doctor’s office and be told about the “latest nutrition research” when I was taught the same information as an undergraduate in the mid 1980s.

  4. ginger

     /  September 26, 2011

    Why do you send your kid to Sunday school? I thought you were evidence- and science-based.

  5. Ginger, I wondered the same thing, but was uncomfortable asking. Maybe it was Secular Sunday School.

    Anecdote: My Trophy Husband and I find raising secular kiddos incredibly challenging because it’s so difficult to create safe space for atheist kids in a larger culture that embraces religion. Also, there’s no two-second explanation for anything. “Why am I made of the same stuff as stars?” requires a thoughtful, scientifically-informed answer. It also takes some effort to foster a calm and peaceful family without the threat of god sending uber-adorable little tiny girls to hell for threatening to punch big brothers who are more than twice their size.

    I’m fascinated by how other secular parents navigate these treacherous waters.

  6. I’m not saying this article applies directly to me, but for your edification:
    http://www.huffingtonpost.com/2011/09/23/atheist-jews-judaism-without-god_n_978418.html

  7. Fascinating article. It’s great that Judaism has room for atheists; however, a fair number of commenters disagree with that premise. Still, it seems more welcoming than Christian dogma. Is there more emphasis on the shared cultural history and therefore less bigotry against atheists in your opinion?

    • Yes, many more people identify as “cultural jews” plus/minus a deep faith in a god. That isn’t to say that many, many jews aren’t deeply religious—they are, even in the Reform Judaism movement. The Humanistic movement was founded near where I grew up, and my family was involved a bit, but IMO it was a bit too crunchy, although the lectures by the founder are legendarily good.

      I’d say anecdotally that most reform jews who go to my synagogue would not openly (or otherwise) proclaim themselves atheists (and probably aren’t by many definitions), but at the same time, there may be no constant thought of God and prayer, simply a life led as our tradition teaches us. Many jews I grew up with simply don’t think of god like many christians and muslims do—they simply don’t think about it much at all, but may choose to follow our traditions.

      But as usual, I could be wrong.

  8. What I vaguely recall from a xian childhood is the idea that god is always, always watching you personally. God and dead ancestors. And god can see your thoughts, so make sure they are pure. And don’t drink coffee. Of course people who can’t drink coffee are preoccupied with god and prayer, but this last bit isn’t representative of all of christendom.

  9. Old Geezer

     /  September 26, 2011

    Back on topic, I think what the typical patient is complaining about is that the doctor lacks the education to adequately wave that magic wand for them that erases all those years of improvident living.

  10. I don’t know. I once had an internist prescribe me doritos. (my BP was extra low and I was getting dizzy. He meant it as a joke, I’m pretty sure, but he just meant that salt shouldn’t be hard to get and I should try more of it and see if that helped).

    I’ve never really gotten frustrated at bad nutritional advice from a doctor, but I’ve rarely gotten much of anything. It was frustrating during pregnancy, where I really wanted know know what I *should* be eating, not what I *shouldn’t*.

  11. Beth

     /  September 28, 2011

    I wish medical professionals were more aware of the problems of the underweight aside from those with psychological disease. I’m not talking about not knowing enough, I’m talking about not knowing anything.
    I need to gain weight and the doctors I talked to weren’t of any help but rather the opposite, telling me not to eat this or that when instructions not to eat were the last thing I need. I know there’s an obesity epidemic but not everyone needs to lose weight — some, in fact, need to gain it. Since I’ve gained 5-10 lbs (over a couple years), I have more energy, generally feel better, and mild illness doesn’t hit me as hard as it did before. I ended up looking at information on dealing with starvation because looking up “underweight” doesn’t get you anywhere. I realize that a small percentage of people are underweight and no doubt an even smaller one has enough trouble as to want to get to a more healthy weight. Even so, I wish PCPs recognized that those people exist and have the faintest idea of the broadest brushstrokes of how they could be helped. There’s lots of things about obesity. Unfortunately I haven’t come across a pamphlet or a handout “So, You’re Severely Underweight”. I think there should be something like that and a few of them kept in every primary care physician office just so it’ll be there when they need it.

    • No pamphlet, but a couple of random thoughts, from someone who is not a doctor or other medical professional:

      You might try looking for information targeted at people with cancer or AIDS, both groups that are often underweight for physical reasons.
      Those canned shakes sometimes sold as meal replacements might be useful as supplements to the rest of your diet.
      If you have the time, now that you’ve gained some weight and have more energy, you might try weight-lifting, because that tends to build muscle mass.

  12. Shirah

     /  October 3, 2011

    Disclaimer: Growing up, I attended a Jewish private school for most of my K-12 education. My family is/was conservative. This is just my own experience, growing up in that context.
    I remember a significant part of the take-home-message of the private school I attended and the shuel my family attended was, “This is our heritage, these are our ancestors and our traditions, and we are your people.” There was also of course, “You should follow god’s laws, as given to our ancestors”, but that was *second* to being part of the community and keeping traditions. At least with the community I grew up in “Jewish” meant more of a cultural identity than a religion. Religion as a belief in god was only part of the culture. And if you don’t take that part, some people might have been sad for it, but most didn’t mind either way. (“You do believe in god? Good for you. You don’t believe in god? Good for you. Now will you please pass me the kugel??”)
    To the HuffPo article I’d add that Chabad also played/plays a significant role in outreach and support of Jewish culture/ cultural identity, in addition to Kaplan’s contributions.

    • As you probably know, that whole thing can be incredibly difficult to explain to gentiles.

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