Sunday, November 18, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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Stand Up for Healthy, Sustainable Food

Tara Scott, MD

A few years back, I met “Anne” during an ER shift. She was on her way to being admitted to the hospital with uncontrolled hyperglycemia and cellulitis. Serendipitously, she was able to follow up with me in clinic after her brief stay. The hospital team had started her on insulin, and her sugars were still regularly in the 300s. One day, puzzling over the challenges of her new diagnosis, she said to me, “Doc, I know there’s stuff I need to learn about eating right, but I don’t know how.”


You may be surprised to learn that the next thing I said to Anne was, “Would you consider letting me join you at the supermarket where you shop?” A few weeks later, as we wandered through the aisles of Food Max, I showed her how to read labels. We substituted products she typically bought with similar products that contained more whole grains, less sugar, or shorter ingredient lists--all while trying to stay at the same price point.


By now, you may be rolling your eyes and thinking that my going to the market with every patient who needs to change their diet is not sustainable. You might also be thinking that it’s not really part of my job description. You are right on both counts, but I felt completely unprepared by my training to face the incredible rising tide of overweight and diet-related disease. Somewhere amid the Krebs and urea cycles in a biochemistry course in medical school, I was taught about glucose, proteins and fats, and in what percentages they should be eaten and how, if you eat too much, you become overweight. Period.


If you are like me, this distant set of biochemical reactions never translated into anything useful when trying to educate patients about how to eat. So, I did something radical: I went to the supermarket. When Anne came back to the office a few weeks later, she proudly reported that she had been reading labels. Within six months, she was on a single oral medication and no insulin with a hemoglobin A1c of 6.2, where she remains today.


In the years since I graduated from family medicine residency, a fair amount of journalism has shed light on why I felt confused and ineffective when talking to patients about food. Writers like Marion Nestle and Michael Pollan have exposed how the food industry controls the nutrition advice created by the USDA, the country’s main source of information about nutrition.[1,2] Evidence does play a role at times, but it is often obscured by industry concerns. In the 1990s, for example, USDA scientists wanted to say “Eat less meat” because of compelling evidence that a plant-based diet led to better health. The livestock industry subsequently pressured the USDA into changing the message to “Choose food that is lower in saturated fat.” This wording wasn’t just confusing to the public; doctors got confused too.


Unfortunately, that’s not the end of it. The dominant food production systems in the United States constantly employ new chemical and biological inputs that may impact health. Arsenic is just one of many additives that have been pushed by the industry to increase yields, ward off pests and prevent infections caused by overcrowded animals. A 2006 report by the Institute for Agriculture found that arsenic, a known carcinogen, enters the food supply in feed given to factory farmed chickens.[3] Not only do unacceptably high levels of arsenic remain in the chicken, but the chemical is also found on produce grown with manure from chickens who receive the arsenic-enhanced feed.


In the last few years, my colleagues and I at the Santa Rosa Family Medicine Residency have set out to unravel the complexity of food, the food environment and the food system. The role of the physician in mastering this broad new array of topics pertaining to food has yet to be determined. Our belief, though, is that doctors, armed with science and invested with public trust, are actually the perfect people to stand up and become highly visible advocates for healthy food. No matter how much you know about food right now, you can become an agent of change for healthy food.


Below are a few steps that can help you begin advocating for healthy and sustainable food.


Educate yourself. Regardless of when you graduated from medical school, it’s likely that you need to learn more about food than you currently know. Being able to make good choices for yourself (and guide patients in making food choices) will mean seeking out lectures, articles and books, and attending conferences on food and nutrition. The Omnivore’s Dilemma and Food Politics are two excellent primers.[1,2]


Be a role model. As you read and learn more, reflect on your personal or family eating and purchasing practices. Do not underestimate your impact as a role model for healthful eating among your family, friends and community. Consider the power of your dollar when you choose where and what kind of food you buy. If you want to see healthy food become more available to everyone, create demand for it by shopping in places that promote the healthiest food with the most positive impact on the community and the least impact on the environment. If you are eating and enjoying a healthy diet, you will also be a more convincing advocate for healthy eating with your patients.


Be an advocate for healthy food in your children’s schools, your workplace and your community. If you would like to see frozen fried tater tots taken off your child’s lunch menu, your publicly expressed opinion as a doctor may have a powerful impact and could help mobilize other parents with less credibility. If your workplace offers nutrient-poor, calorically dense foods to employees, engage your coworkers in a discussion about how your office, clinic or hospital can support the health of the workers and patients who come there. On a community level, find out when the board of supervisors is discussing topics pertaining to issues like accepting food stamp benefits at your local farmer’s market.


Talk to patients about food. Asking patients about what they eat will send them a powerful message that food is important and that you care about what they eat. In this age of hurried office visits and electronic prescribing, it is easy to forget the primary importance that diet plays in most of the chronic conditions we see. Develop a short “review of systems” that allows you to quickly assess a patient’s eating habits and identify areas that can be improved. For example, ask “How many sugar-sweetened beverages do you drink in a day?” or “How many days a week do you eat breakfast?” These two simple questions can be easy springboards into talking about healthy eating habits.


Meet patients where they are. Like physicians, patients have varying levels of resources and knowledge about food. While some patients have ample budgets and knowledge, others do not. No matter how great you are at talking about food in simple terms, if you are not aware of your patients’ literacy level and economic resources, they may not be able to put your advice into action. One way to get at this is to ask, “How knowledgeable do you feel about what food is healthy? or “Are your food choices limited by your budget?” When you give advice, try to put it into specific terms and talk about foods as whole foods. Use phrases like “Try using olive oil for salads” instead of talking about mono- and polyunsaturated fats. Maintain a set of handouts about food and diet that patients can take away from the visit.


Join an advocacy group. Food advocacy groups can keep you in touch with emerging food issues electronically and give you easy steps to take for action. If you are busy, like most physicians, a simple monthly email or following a Twitter feed is a great way to start getting educated and involved. It’s not too late to pressure your representatives for initiatives that promote healthy, local food in the 2012 Farm Bill, scheduled for a vote in Congress later this year.


Be an advocate within your profession. Find out about your professional group’s food policies. Encourage your professional group to take a clear stand on policies that impact the way we eat in the United States. If your organization has not yet taken a stand on soda in schools, for instance, put forth a resolution to help the organization take a clearer stand.


As physicians, we may find it difficult to accept that much of what we learned about food and nutrition was not actually science--but the cover has been blown off that secret. Now we are free to dive into the truth about food and to decide how involved we want to be in making change.


Dr. Scott is a faculty physician at the Santa Rosa Family Medicine Residency.




For a list of movies, books, articles and advocacy organizations pertaining to food, food systems and human health, visit




1. Pollan M, The Omnivore’s Dilemma, Penguin (2006).


2. Nestle M, Food Politics, U California Press (2007).


3. Wallinga D, Playing Chicken: Avoiding Arsenic in Your Meat, Institute for Agriculture and Trade Policy (2006).



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