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Registered dietitian Ava Safir and physician advocate Kim Downey discuss their article, “Why patients need a registered dietitian on their health care team.” They highlight the often-overlooked yet crucial role registered dietitians play in improving patient health outcomes and supporting physicians. Drawing from personal experiences and professional insights, Ava, Kim, and Meg explain how dietitians offer specialized, in-depth nutritional counseling that goes beyond the scope of typical medical appointments, addressing everything from chronic conditions to overall well-being. The conversation emphasizes the comprehensive approach of dietitians, who dedicate significant time to understanding patients’ lifestyles, food psychology, and specific needs, thereby fostering sustainable dietary changes and myth-busting misinformation. They argue that integrating registered dietitians more actively into health care teams can lead to reduced medication reliance, better management of conditions like pre-diabetes and GI issues, and enhanced patient empowerment. The key takeaway is: Patients and health care providers alike should recognize registered dietitians as essential team members whose expertise in medical nutrition therapy can be a game-changer for achieving long-term health and quality of life.

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Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Kim Downey. She’s a physician advocate, and she brings us Ava Safir. She’s a registered dietitian. Their KevinMD article is “Why patients need a registered dietician on their health care team.” Kim and Ava, welcome to the show.

Kim Downey: Thanks, Kevin.

Kevin Pho: So Kim, every month, regularly, we have you on and you bring people who are important to medicine, to the cross-section of medicine and various other disciplines. And today you bring us Ava Safir. So tell us about how you found her and what about her and what she has written. How does that resonate with you?

Kim Downey: Sure. So this one is personal, and I think I’ve mentioned to you, Kevin, that I had surgery in December, and after that, I had some lab numbers that were quite concerning, and my primary care doctor thought perhaps he would have to add in another medication. Because of my other cancer surgeries and a complication, I’m on other medications, and I never wanted to be on any. So my goal, I always want to try to reduce them, not add medications.

So I asked him, I said and I think I know a fair amount about healthy eating and a healthy lifestyle. I said, “But maybe there’s something that I’m missing because that’s not my particular area of expertise as a physical therapist.” So I said, “Could you refer me to a dietitian?” And maybe there’s something I don’t know. So he did, and he referred me to Ava.

Within a short period of time, we got to meet. She spent over an hour with me, and she did help me learn some things that I hadn’t been aware of. By the end of the hour, hour and a half, I said, “This is great. Are you inundated with referrals?” And she was like, “Oh, it comes in waves.” And I thought, well, a lot of doctors need to know how valuable this could be for them and their patients. So driving home, I was like, how could I let more doctors know about this? I think by the time I got home, I might have asked her if she wanted to collaborate on an article so we could get the word out.

Kevin Pho: All right. Wonderful. And that story really resonates with me. I’m a primary care physician as well, and there are so many conditions that can be treated without medication and just with dietary interventions. I often send patients to registered dietitians like Ava, but sometimes I actually don’t know what actually happens in a room. So I’m hoping that Ava can shed some light into that. So Ava, you’re a registered dietitian. Tell us first a little bit about yourself and then the article that you wrote on KevinMD.

Ava Safir: Sure. So, I’m a registered dietitian. Sometime in my late twenties, early thirties, I was having some medical issues that I was struggling with, and I came upon a doctor who really took a more lifestyle approach to the condition and she made some significant changes to my diet. I thought I was generally a healthy eater. I exercised regularly. I thought I knew what I was doing. The changes that she made made a significant difference, not only in my lab values, but in how I was feeling. So at that point, I thought, I’m in. I’d like to go back to school. I took all the coursework and became a registered dietitian for the same purpose of why Kim came to my office.

Kevin Pho: So tell us about the KevinMD article that you wrote.

Ava Safir: So, like Kim said, she came in and she asked at the end, “Are you inundated with patients?” And I said, as a small business owner, we often have to pull back the lens and see where our referrals are coming from. How are clients getting through the door? We often find it does actually come in waves. For instance, this month, we seem to be getting quite a few referrals. Last month, not so much. And sometimes it’s hard to really get a handle on why that’s happening. So, when working with Kim, we decided to talk about the benefits of a registered dietitian as being part of the medical team.

Doctors often have 15-minute windows, 20-minute windows, to really spend with their patients. You have a lot to get done in that time period. Whereas we as dietitians, particularly in private practice, have at least an hour. We sit down, we go through people’s entire medical histories, their medications, their supplements, their lifestyle habits, their goals, all of that type of thing. Sometimes just in having conversations with people, things start to pop out—things that you may not have gotten just on an intake form. That really benefits us when we start to work with folks towards their goals, particularly towards their lifestyle habits.

I’m a big proponent of the idea that medicine is great, thank God we have medications. Thank God for Western medicine. There’s a lot we could really do with lifestyle factors, from diabetes to heart disease to gut issues. There are so many things we can do in the food realm, exercise, stress reduction, sleep, all those types of basics that can really improve a person’s quality of life. It’s really important for me as a dietitian to allow doctors to know we’re here for you, we’re here to collaborate with you, we’re here to answer the phone. Go back and forth. I always send my notes to any referring physician, and let’s really try to get these patients the best outcomes that we can by working together.

Kevin Pho: So Ava, what are the most common referral reasons that you get from physicians? What are the most common diagnoses that you see?

Ava Safir: I’d say the biggest ones are weight loss, especially these days, and GI issues. Those seem to be the two big ones.

Kevin Pho: And when you say GI issues, are we talking about things like irritable bowel, what kind of GI issues?

Ava Safir: Yes, IBS and GERD, the ones that may not be life-threatening but certainly affect a person’s day-to-day quality of life.

Kevin Pho: All right. So Kim, when you saw Ava for the first time, everyone says, “Oh, I need to eat better. That’s going to help with a lot of my medical conditions,” but what are some specific things that you learned from Ava that you didn’t know previously?

Kim Downey: Well, one was I was intentional about my protein intake, but I had no idea I was using outdated guidelines, so I should have been getting a lot more protein than I was in my diet. Because of the complexity of my conditions right now, it’s kind of like robbing Peter to pay Paul. My phosphorus runs high, but I don’t have enough calcium and vitamin D. So the things that you might think you could eat to get more calcium might raise your phosphorus. All of that can get really confusing.

Also, I was trying to rely not so much on meat as a source of protein, but it’s hard to get the plant proteins because I think beans have phosphorus. So she helped me walk through some of that, and just adding—and I also don’t like a lot of additives—so even giving me a brand of protein powder to add to my smoothies that had minimal ingredients. That was definitely one.

I also referred one of my friends to Ava, and I just saw her the other night and I said, “What were some of the things that have been helpful so far for you?” And she again said, the amount of time, because she’s a healthy person. She goes to her doctor once a year. They have so many things to talk about that they can’t dive into those nitty-gritty details. She realized that her fat intake was too high, even though she thought she was eating healthy or going with the healthy fats, that it was just too much. So those are a couple of specific things that immediately come to mind.

Kevin Pho: And Kim, how many times did you see Ava over what timeframe before you started noticing a difference?

Kim Downey: Well, I actually have just seen her once, and then she sent me a list of some recommendations and things to do. Since I already thought that I knew some things and knew how to implement them, we just went back and forth via email a couple of times. I will see my doctor next month, and I suspect he’ll order more lab work so we can see if the numbers have changed then.

Kevin Pho: So Ava, when it comes to diet advice, I’m sure that you’re familiar that there’s so much conflicting information that is online in the social media. I talk to my patients all the time in the exam room, and there are various personalities and influencers on TikTok, and they all sell products. They all give their personal advice. So tell us what makes going to a registered dietitian different, and contrast some of the information that you give in your office versus whatever is inundating our patients online.

Ava Safir: Yes, sure. We spend a lot of time myth-busting, I’ll definitely say. One of the differences in seeing a registered dietitian is, for example, in the state of Connecticut, anybody can call themselves a nutritionist. There are no licensing requirements. As a registered dietitian, I had to go through a whole series of coursework. I had to obtain a master’s degree, do an internship, take a certifying exam, and continuing education credits in order to maintain my license.

Registered dietitians, I will tell you as a whole, are fairly type-A people. We tend to be very evidence-based, very research-focused. When folks are bringing in whatever they’re hearing on social media, we often myth-bust through it. We’ll take out the science, we’ll actually explain things even down to a biochemical level of what’s happening in the body in the most simplistic terms, just to try to explain how certain things are and are not making sense.

One of the big things is also there are no quick fixes. A lot of people will come in and just say, “Tell me exactly what to eat, exactly how many calories,” and it’s just not sustainable. Nobody can live their life that way. It’s really about getting the education, the groundwork, the understanding that, A, it’s not just food, first of all. There are a whole host of lifestyle factors, and B, it’s about making it a lifestyle change for yourself that you can live with, that you can still go out to dinner or to a birthday party, but you can also live and eat a healthy, plant-focused, protein-based diet.

Kevin Pho: So Ava, what are some of the most common myths that you have to bust in the office when you first meet a patient?

Ava Safir: One is the quick fix. I think that’s probably the biggest one. The other one is a lot of people think they have to buy a lot of very expensive supplements to be healthy. And you don’t. If you can eat a nourishing, whole-food-based diet, you can get most of what you need just through that.

There are a few supplements that I do generally recommend, things like vitamin D, which are very hard—you said you’re in New Hampshire, we’re in Connecticut—it can be a little hard to get our levels up. But for the most part, if you eat a good whole-foods-based diet, you don’t need to be spending thousands of dollars in supplements.

Kevin Pho: So Kim, one of the things that you mentioned when you met Ava is that she had a lot of time, like Ava was saying, that sometimes the initial consultation can last an hour or more. So contrast that with a typical doctor’s office visit of 15 to 20 minutes. When you first went to meet Ava in person for that initial consultation, what was it like, and then what was going through your mind as she spent all that time with you?

Kim Downey: Well, I love that, and that’s what I thought of going home and why I wanted more doctors to know about it. Because when you go to see a doctor now—and I have different specialists and they do an amazing job in the limited time they have—I’m always so aware of their time constraints. You just know that you have to go in, talk about what you need to talk about, try to exchange a little bit of pleasantries like vacations, try to make something a little personal, and then you know that they have patients waiting for them.

Whereas with Ava, I knew that our time was anywhere from an hour to an hour and a half, so it just felt so relaxed. She had time to really get to know you a little as a person. She does even ask about hobbies like: what do you like to eat? Do you like to cook? All of those kinds of things. So it just had a really good feeling, and you felt like she really got to know you and really tailor a plan specifically to you. And it just felt really good.

Kevin Pho: And Kim, specific outcomes. So once you implemented some of Ava’s changes, tell us how that’s appreciably impacted your lifestyle and maybe impacted perhaps your lab numbers and things like that.

Kim Downey: Well, it hasn’t been all that long, so I don’t know yet about the lab numbers. But one of the things she suggested—well, basically one of the things is my cholesterol had gotten alarmingly high—so she had specifically told me to add, like, psyllium husk. Is that how you pronounce it?

Ava Safir: Psyllium. Psyllium husk. You got it.

Kim Downey: OK. Yes. To my smoothies and that with the protein powder. And then also protein bars. I wasn’t sure what the cleanest brand was, and I had bought a couple, but I thought they were a little sticky, so I was getting some other ones, and she’s like, “Can you kind of stick with the one that only has four ingredients?” So just those things… oh, and then even to add sometimes protein, like the protein shakes, like OWYN, what you need. Oh, WYN, right. So just some specific things with minimal ingredients, it just gave me the confidence. Now, if I’m doing Zooms or something and I barely have time to eat lunch, if I add one of those shakes or a protein bar, I just know that I’m getting the protein and that it’s still real food and healthy. And again, it’s not supplements and I’m not running for the chips or something.

Kevin Pho: So Ava, as a doctor, as we talked about before, sometimes I don’t have an hour to spend with patients, especially for common primary care conditions like obesity. So in my 15 to 20 minutes, what are some high-yield tips that you could share with the other doctors listening to you on this podcast that they could impart on their patients? Short of sending everyone to a registered dietitian, is there anything that we can do in that limited time?

Ava Safir: Yes, I think just getting into lifestyle habits a little bit, if you can. I find often if you pull one thread, the other threads start to come through. So if you talk to somebody about what foods they like to eat, if they know how to cook, who does the food shopping in their home? You can ask questions about exercise, if they get any movement in their day. Sometimes just asking people how they’re feeling, are they sleeping? A lot of times folks will start even from there and let me know that they haven’t been sleeping well. They’re getting up, they’re getting less than six hours of sleep a night, and then that causes them to eat a lot because then they’re hot, tired, and hangry during the course of the day. So sometimes if you can just pull in a couple of those lifestyle strings, people start to open up a little bit more and they’ll start to tell you a little bit more about what’s going on with them. And I think for you as a physician, just having a better understanding of what their day-to-day life is really like would probably benefit you too.

Kevin Pho: So Ava, sometimes when I bring up the recommendation to see a dietitian, patients respond, “Oh, I know what to do. I know how to eat better. I could look it up on the web.” What are some things that I can say, not to sell sending them to a registered dietitian, but maybe to convince them, saying that, hey, a registered dietitian can really offer more than I can give and what they can research on their own? What are some things that I could say to these patients who are initially a little reluctant?

Ava Safir: Yes, sure. First of all, we’re not the diet police. I’ll start there. A lot of people come in thinking they’ll say to me, “You’ve got to tell me to take away everything.” And that’s not true. That’s not what we’re here for. We are really there just to spend time with them, to understand what’s going on, to try to find two to three things, tops, that maybe they could just tweak or work on to really have a big bang on their overall health. We’re there to listen. We’re there to sometimes communicate to their doctors. So sometimes, I know you’re very busy. People go on portals, you’re going back and forth, or what have you. But as a dietitian, I can pick up the phone, call the doctor’s office, and actually end up having a conversation and then communicate back to the patient. So we can also just be that bridge between you and your physician.

Kevin Pho: We’re talking to Kim Downey and Ava Safir. Kim is a physician advocate. Ava is a registered dietitian. Their KevinMD article is “Why patients need a registered dietician on their health care team.” Now, I’m going to end by asking each of you just to share some take-home messages to the KevinMD audience. Kim, why don’t we start with you?

Kim Downey: Sure. So whether you’re a patient or a doctor, you could be asking yourself, how can I feel more supported, personally and professionally? For patients, to know that there are other people out there that could be on your health care team to help, such as sleep specialists and dietitians. And if you’re a doctor, both personally and professionally, because we know that doctors are human and they have the same struggles that other people do.

Doctors have sleep issues and you can see a sleep specialist. Doctors come in all shapes and sizes and are not oftentimes very well-versed in diet as a dietitian, as Ava went to school for. So sometimes a doctor, it could be helpful for them themselves to see a dietitian, and then also knowing that they can refer their patients. It helps the doctor because, as you said on my show, we all want the same outcomes, right? Patients and doctors both just want the best care for the patient. Doctors can feel good about giving that individualized care by referring them to a dietitian, and then, of course, the patients benefit as well. So it’s a win-win.

Kevin Pho: And Ava, we’ll end with you. Your take-home messages.

Ava Safir: I think I would piggyback on what Kim was saying. My message to doctors or just health team members is let’s collaborate. The more we collaborate, the more we all get more out of why we went into health care in the first place, which is to work with our patients and to get positive outcomes. And the more we can support each other and improve our patients’ health, their lifestyle, and their overall wellness.

Kevin Pho: Ava and Kim, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Kim Downey: Thank you.

Ava Safir: Thanks, Kevin.