Put nutrition counseling in primary care [PODCAST]

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“One of the best solutions to rising obesity and non-communicable disease rates lie in primary care. Medical professionals can influence the U.S. food system indirectly through demand and collective purchasing power by educating their patients to choose and purchase healthier options. Merely improving nutrition education succeeds in shifting people’s thinking about food.

Simultaneous with the WHO’s declaration of the Decade of Action on Nutrition is the “food is medicine” movement that has been growing in response to mounting evidence that a nutritionally-sound diet and access to quality foods improve health outcomes. The theory behind food is medicine is that food is a preventative public health system.

This movement includes prescription meals to people with multiple chronic conditions and low income, food delivery services, and community food quality assessment. So far, the food is medicine solution has proven cost-effective, and one study reported a 16 percent reduction in health care costs in meal recipients.

We know that widening health disparities are partially diet-dependent. Integrating nutrition into primary care is really a social necessity. Just as everyone should have access to medical care, all Americans should have equal access to proper nutritional guidance and nutritious food.”

Melinda Mesmer is an internal medicine physician.

She shares her story and discusses her KevinMD article, “Put nutrition counseling in primary care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Melinda Mesmer. She is an internal medicine physician, and she wrote the KevinMD article “Put nutrition counseling in primary care.” Melinda, welcome to the show.

Melinda Mesmer: Hi, Kevin. Nice to be with you today.

Kevin Pho: So we’ll get into the article a little bit, but first off, can you share your story and your journey to where you are today?

Melinda Mesmer: I’m a primary care physician. I’m at Mass General in primary care right now, and I’ve been in primary care six and a half years. Before that, I worked as a hospitalist for about 12 years, which I enjoyed very much. But one of the main things that I wanted to make a shift for was that I was really interested in working in more preventative care.

Also, I saw as a hospitalist, over time, really the power of the longitudinal relationship with your patients. I would see that all the time with patients that we admitted and discharged, and how important a PCP could be in the outcomes for the patient and, overall, how they coped with medical illness and disease. So I switched over to primary care. One of the things that has been a real focus for me, or a real interest, has been nutrition and diet.

Kevin Pho: So tell me some of the biggest challenges you face when switching from the inpatient side to the outpatient side.

Melinda Mesmer: So I think initially there were a couple. One of them, of course, is you see different types of problems. You’re managing very different types of conditions. I was very comfortable managing pneumonia, heart failure, acute MI, assess, stroke coming in, doing ER assessments and admissions, medicine consults, and pre-op. And then when you move to the outpatient setting, your shift is very different, and you’re titrating medications. You’re doing the initial diagnosis, starting from scratch, trying to figure out where this is all going when someone first comes in presenting with initial symptoms of a disease. You’re also working really as a coordinator among specialists and an advocate for your patient. But I think that the types of medical problems that you see and what you manage are different.

I also think it’s very different in terms of, as a hospitalist, you’re spending a lot more of your time working with other physicians, be it your co-hospitalist, because the patient requires 24-hour care, so you’re constantly talking with the night team or the weekend team, and, of course, working closely with the specialists involved in the case. Whereas as a primary care physician, the pace is usually slower, but there’s a lot more independent time, and it’s really just more focused on the physician with the patient.

Kevin Pho: Now, after being a hospitalist for so long, how long did it take for you to become comfortable in a primary care setting?

Melinda Mesmer: Oh, it took a while. There were a lot of things I hadn’t done in a long time, office gynecology, things like that, and getting more familiar with a lot of the oral medications. But it took a while. Luckily, I had good colleagues. And with the electronic medical record, for all the things that sometimes make life hard for us, everything is available right there, and you’re easily able to see what they’ve been on. But it did take some time to transition.

Kevin Pho: And after being in primary care for a few years now, is it what you expected?

Melinda Mesmer: I think so, yeah, pretty much. I think that it definitely takes a while to establish a long-term relationship with your patients, or to feel like you really know them well or they know you. But I think that after you have that, after a certain amount of time, and it’s usually, for most people, after two or three years, they’re coming to you, and a lot of times, fortunately, you get to see their family members, their spouses, sometimes their children, brothers, and sisters. You have a real sense of them as a person and their preferences about treatment, or what they would be willing to do diagnostically, or what works for them with their lifestyle. And I think that’s really rewarding.

Kevin Pho: All right, so let’s transition into your KevinMD article. It’s titled “Put nutrition counseling in primary care.” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Melinda Mesmer: Well, I guess I’ll start with the why, or how I got really interested. So I’ve always been interested in nutrition, but I clearly remember one case I can think of in particular. It was a man in his early 40s who came in with his wife, and he had obesity, type 2 diabetes, hypertension, and depression. We were discussing his most recent A1C, which was now well above 10, and talking about increasing, yet again, his long-acting insulin. He was on several oral agents.

And we started talking about, well, what are you eating? It was revealed that he’s eating Frosted Flakes every day and a Coke. He doesn’t like coffee; he likes Coke in the morning. Lunch is usually nachos. He’ll get nachos and then have a hot dog or deli meat, and sometimes he likes to have a Snickers bar when he picks up his son from school. We were talking, and we hadn’t even gotten to dinner. This was just such a crystallizing case to show that we’re going to add more and more insulin just to cover breakfast, basically. We’re not even treating the underlying condition; we’re basically treating the diet.

And it got me really interested in reading more about sugar and the diet and how it affects multiple medical morbidities. Then reading about sugar led to reading about ultra-processed foods, and I came across an article that talked about how the United Nations decided that there was going to be a Decade of Action on Nutrition from 2016 to 2025. And I thought, “We’re in the middle of the Decade of Action on Nutrition, and I personally hadn’t heard of it.” And I thought, “If this is happening on a global scale, how is this infiltrating medical practice and working with patients, and what are we doing to get on board with that?” I started reading more about that, and basically the whole purpose of this working group through the U.N. was to talk about the effect of diet and nutrition on all of human health.

I then found a commission report from the EAT-Lancet Commission, which put out a big summary article where they talked about looking, on a global scale, at diet and nutrition and how that impacted chronic non-communicable diseases. They found that nutrition, or lack of nutritious diets, was actually more harmful on a global scale, just based on the percent of people affected, and drug use, alcohol, tobacco, and unsafe sex practices. And I thought that was also obviously very impactful and profound when you think that everybody eats; not everybody smokes.

So that kind of started me reading more and getting more and more interested in what we can do as medical providers, because I think there is a rather large disconnect in medicine, especially in primary care. We have a patient with diabetes, and we refer them to the nutritionist, and I think in doing so, we’re almost outsourcing the importance of nutrition. If we were to take that on ourselves, I think it sends a big message to the patient: “Hey, this is important. This is as important as your medication.” Also, being the source for them to come to with questions and guidance.

I was also researching how much nutrition education people get in medical school, which is not much. There was a study in 2016 out of Case Western that showed only about 20 hours out of the entire four years of medical school are devoted to nutrition education, on average. I think that’s something that’s still lacking and falling behind if we don’t get doctors educated about nutrition. Of course, we get a lot of education about heart disease and heart failure and feel very comfortable, but I think feeling as comfortable about nutrition education and counseling is something that needs to happen more.

Kevin Pho: So what are some nutrition pearls that you learned over the course of your research that you didn’t know before?

Melinda Mesmer: Well, I think one of the biggest things was the importance of getting actual nutrients in the food, and that it isn’t just about calories. One study did show that only about 25 percent of Americans actually get adequate nutrients in their diet. So they’re getting plenty of calories, and with the obesity rates being what they are, people are getting enough food calories in general, but not necessarily getting the vitamins, trace minerals, protein, and healthy fats. I think that was something that was shocking, that only 25 percent of the country is getting nutrition.

And I think also there’s the importance of being aware of ultra-processed foods and all of the harms that they can have. Ultra-processed foods often replace calories that would come from healthful foods. They’re usually much more calorie-dense per unit weight than if you were to eat fresh or unprocessed foods. And oftentimes, in processing them, making them palatable, and adding these flavors and colors and whatnot, they also do have chemicals that are known to be unhelpful.

So I think just seeing how much of our food supply, and what the general population, all of us, eat, it’s actually very difficult to avoid all processed foods. Our cereals and crackers, not that all cereals and crackers are bad, but my point is they are all processed, and thinking more about that is something that’s important.

Kevin Pho: So I’m a primary care internal medicine physician myself, and like many primary care doctors, we have limited time with patients. As you know, we have 15 to 20 minutes with each patient, and there’s more and more asked of us per visit. Now, how do you incorporate nutrition into a typical patient visit when there’s already so much for us to do in that 15- to 20-minute time span?

Melinda Mesmer: So that’s a huge problem, right? We have so many demands on us, based on the quality measures and the EMR, things we have to click off. But I think it’s about sending the message that you’re interested, number one, and also that you’re willing to talk about it and you’re willing to provide resources.

So on every single new patient visit and every annual physical exam, I make sure that we address diet. So, “Tell me what you’re eating. If an eight-ounce cup is a serving of fruit or vegetable, how many servings a day do you get, combined? What about your dairy? What about meat? On average, what are your snacks?” And we review all of that. I mean, I have people that come in for their annual physical, and I haven’t seen them in a whole year or more than a year, and they say, “Oh, I knew you were going to ask me about my diet today.” And I think it sends a message that it’s important, and oftentimes it’s a real opportunity to talk to the patient about their health and about risk factors for osteoporosis or diabetes.

And I think it’s important that primary care takes that on, because I’m sure, as you know, most insurances won’t pay for a nutrition consultation, even if you were to choose to refer your patient, unless the patient does carry a diagnosis of diabetes, heart disease. Whereas if they have just hyperlipidemia, or they have prediabetes, or they’re just overweight but not morbidly obese, they can’t access nutrition. So if you don’t make it a priority, I think that’s important.

So I think it’s about trying to build it into the visit and trying to make handouts that are very simple that you can give to your patient, or websites. I think it’s important to try to incorporate that, at least at the yearly visit.

Kevin Pho: We’re talking to Melinda Mesmer. She is an internal medicine physician, and she wrote the KevinMD article “Put nutrition counseling in primary care.” Melinda, what would you say are your highest-yield tips that you give the patients in the exam room when you’re talking about improving their diet?

Melinda Mesmer: Trying to eat more plant-based, and telling them to think of each meal and what percent of that meal is going to be made up of vegetables or fruits or protein, and saying, “OK, if that’s your starting point, then you can add on from there.”

And think about it over the course of the day. People say, “Well, I grabbed a pastry and a coffee for breakfast,” or they skip lunch. And I tell people, “You can’t wait until dinner, when you’re home and you’re relaxed, or you’ve got through the day.” It’s also a very big missed opportunity, because that means all day you haven’t had good, nutritious food to be operating on. So I tell people, “You really have to think of it over the course of the day. This isn’t just one big meal where you’re going to go home and cook something or eat four servings of vegetables.”

But think about the patient’s lifestyle, and have them tell you, “Well, what are your challenges?” “OK, let’s think about that.” And the more you talk to patients, a lot of times, and I’m sure you know this in primary care, your patients will tell you, “Well, this really works for me,” or “I food prep,” or “I get this food from here,” or “I joined a CSA.” And getting ideas of what resources are available in the community is really helpful.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Melinda Mesmer: I think my take-home message is that primary care in particular, but all of medicine, I think, we have to get really interested in nutrition now. I think that this is a disconnect right now: We’re seeing that the field of nutrition is growing. There’s also, which we haven’t touched on, the whole “food is medicine” movement, which I think is very exciting. I think there’s a lot of opportunity there.

And I really think that internal medicine especially could take ownership of this and make a huge difference in the medical care of our patients by trying to address things both preventatively but also as secondary prevention, around diet counseling and helping our patients access healthier foods in our communities.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Melinda Mesmer: Thank you so much, Kevin.

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