Blog | Monday, October 17, 2011

Oatmeal and coffee

Another Midwestern morning. My child 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.

coffee + oatmeal by emmadiscovery via Flickr and a Creative Commons licenseA 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 Ks or 7-Elevens are much more accessible, but typically provide a choice of inexpensive, unhealthy foods.

Of course, like the rest of medicine, there is a lot we don't know about nutrition as a group and as individuals. The most common nutritional disorders we see in the U.S. 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 do 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.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.