Food for Thought

February 9, 2018

By Hannah Kopinski
Peer Reviewed

Diabetes, hypertension, and hyperlipidemia. One would be hard pressed to find an adult primary care physician in the United States who would not list these three chronic medical conditions as the metaphorical bread and butter of his or her practice. Bread and butter in this case is, however, not just a metaphor. The single most important driver of these conditions and the complications that arise from them (myocardial infarction, stroke, renal failure, just to name a few) is poor diet. The data are unequivocal. The typical American diet, rich in processed meat, dairy, and refined carbohydrates has led to unprecedented rates of disease and death. According to a report compiled by U.S. Burden of Disease Collaborators, poor diet is the single most important risk factor for morbidity and mortality, associated with 26% of deaths and 14% of disability-adjusted life-years (DALYs), a measure of disease burden.1 Through consumption of a typical, unhealthy American diet, our patients are making themselves sick, and our society as a whole is inflicting upon itself suffering and premature death.

As a future healthcare provider, I could easily be disheartened by these statistics, but instead, I choose to find them empowering. If most of the disease in this country is caused by food, then most of the disease in this country is also preventable—even reversible—by changing what we eat. Indeed, there is an abundance of research that shows that lifestyle modification, of diet in particular, is more effective than pharmacologic treatment in preventing and reversing cardiovascular disease[2 ]and diabetes.[3] One such study of note is the Lifestyle Heart Trial, in which patients with coronary artery disease (CAD) were assigned to either an intervention of a low-fat vegetarian diet along with other lifestyle modifications, including stress reduction and exercise but no lipid-lowering drugs, or to a control group in which about 60% of patients received statins and followed their physicians’ conventional lifestyle advice but did not adhere to a strict diet.[ 2] The experimental group showed regression in atherosclerosis while the conventional group saw progression in their CAD along with more than twice as many cardiac events as the intervention group (2.25 vs. 0.89 events per patient). The Lifestyle Heart Trial is just one among many studies supporting the beneficial effects of a whole-food, predominantly plant-based diet on preventing and reversing cardiovascular disease and diabetes. A review summarizing the findings of a number such studies found that plant-based diets are not only associated with lower rates of heart disease, hypertension, obesity, high cholesterol, and diabetes, but were also found to be similarly acceptable to patients compared to other therapeutic diets.[4]

Paradoxically, though the evidence for using diet modification to prevent and treat CAD and diabetes is robust, those of us who are responsible for treating these diseases are given almost no training in how to do so. U.S. medical students receive on average just 19.6 hours of nutrition education during their four years of undergraduate medical training; this amounts to less than 1% of total lecture hours.5 Moreover, the preponderance of these hours focuses on the biochemistry of nutrition and metabolism rather than on teaching students information and skills that are translatable to patient-centered counseling in a clinical setting.[5] In one study surveying 970 medical students from 17 U.S. medical schools, the number of students who believed that nutritional counseling is relevant to medical practice was shown to actually decline over their four years of training from 72% to 46%.[6] What is more stunning is that even in graduate medical training for cardiologists, who are charged with treating more lifestyle disease than perhaps any other subspecialty, nutrition is largely neglected. The Accreditation Council for Graduate Medical Education (ACGME) requires cardiology fellows to demonstrate skill mastery by performing ten cardioversions and 100 cardiac catheterizations, but there is no requirement regarding nutrition knowledge or ability to counsel patients on food,[7] a practice that, if performed well, could help prevent many of these catheterizations and cardioversions from occurring.

There is something very incongruous about this current paradigm within medical education. The medical community understands that a poor diet leads to our most prevalent diseases, and there is abundant evidence that a healthy diet can reverse them like no pharmaceutical on the market can. Yet, due to the lack of nutrition education in our medical training, we feel ill equipped to talk to our patients about food and thus struggle to do so effectively in the brief time we are able to spend with patients during a typical office visit.[5] If medical education put a greater emphasis on training physicians to be both knowledgeable about nutrition and capable of counseling patients on behavior change, doctors would be empowered to make the most use of diet therapy—the most effective means available to both prevent and treat our patients’ diet-related diseases.

Commentary by Dr. McMacken
A wealth of evidence suggests that our food choices are the biggest driver of our health destiny. Drugs have an important role in treating symptoms of chronic disease and in many cases preventing complications, but they do little to address the root cause of illness. Food, on the other hand, actually is medicine; dietary changes can prevent and reverse disease, alter gene expression, and interact in complex synergy with our microbiota to affect health outcomes. We know that we have the ability to prevent about 80% of chronic disease through simple lifestyle habits, including a diet high in fruits, vegetables, and whole grains and low in meat.[8] It’s time that we equip current and future health professionals to leverage the most powerful tool in our arsenal: diet.

Hannah Kopinski is a 3rd year medical student at NYU School of Medicine

Peer reviewed by Michelle McMacken, MD, medicine, NYU Langone Health

Image courtesy of Wikimedia Commons


1. US Burden of Disease Collaborators. The state of US health 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591-608.
2. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998:280(23):2001-2007.
3. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002:346(6):393-403.
4. Ferdowsian HR, Barnard ND. Effects of plant-based diets on plasma lipids. Am J Cardiol. 2009:104(7):947-956.
5. Eisenberg DM, Burgess JD. Nutrition education in an era of global obesity and diabetes: thinking outside the box. Acad Med. 2015:90(7):854-860.
6. Spencer EH, Frank E, Elon LK, Hertzberg VS, Serdula MK, Galuska DA. Predictors of nutrition counseling behaviors and attitudes in US medical students. Am J Clin Nutr. 2006:84(3):655-662.
7. Devries S, Dalen JE, Eisenberg DM, et al. Am J Med. 2014:127(9):804-806.
8. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009;169(15):1355-1362.

2 comments on “Food for Thought

  • Avatar of Erica Lake
  • Avatar of Rosalie Schultz
    Rosalie Schultz on

    While I don’t disagree that health care providers need better education in nutrition and behaviour change, I think this overlooks the reasons why so many people are overweight and obese.

    The problem is that food of low nutritional value is too readily available and too cheap. Also few people have the need and many do not have the capacity to exercise in their day to day lives.

    To address obesity we need changes in food production, processing and marketing; and in our working lives, and transport and leisure systems.

    Suggesting that doctors don’t know enough may be no more useful that making judgements about people who are overweight. We are small players in the a big system that needs to change.

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