As many of you will know, I am a qualified medical doctor, and I’m currently doing a one year full-time Masters in Public Health and Nutrition. I spent five years training to become a physician, and I completed 3 years of clinical training (intern and senior house officer years) last July before diving back into full-time education for this year to pursue my passion for public health, health promotion and lifestyle aspects of our health. I actually completed a year of Dietetics before going into Medicine too!
I’ve given you that as an introduction because it tells you that I am a doctor with a passion for improving the health of our population (especially the Irish population) from an upstream, prevention-focused approach. Don’t get me wrong, modern medicine (the acute reactive kind – antibiotics for infections, thrombolysis for acute stroke management, anti-epileptic medications – there are MANY examples) saves lives, and is the bread and butter of what we as doctors use day to day to help our patients. But there is an increasing awareness that lifestyle and health behaviours play a major role in the development of many chronic diseases such as obesity, type 2 diabetes, cardiovascular disease, dementia and cancer. It’s what fascinates me most as a doctor, reflecting on how we can improve these behaviours at a population level to better the health of people of all ages, genders, ethnicities and socio-economic levels.
However, there has been a bit of a social media (and general media) debate gathering traction over the last couple of years on the topic of doctors addressing diet as a health behaviour with patients. One side of this debate says that us doctors don’t know enough about diet and nutrition to deliver healthy eating advice to patients, and that medical schools should be delivering nutritional education to doctors as part of undergraduate training. The other side of the debate says that us doctors shouldn’t be giving individualised nutritional advice to patients, because (and this is true) we are doctors, not dietitians, or nutritionists, and therefore it’s not our role. I think a lot of the movement against doctors discussing diet with patients has been largely fuelled by certain doctors who have been quite prominent in the media particularly in the latter half of the past decade promoting diets of various types (low-carb, plant-based, vegan, vegetarian, high-protein, the list goes on – it might just be whatever diet they have developed for the book they’ve written and want to sell), or cherry-picking nutritional research to share on social media, instead of the whole picture. Finally, the kicker to all of this that I think is often forgotten in this whole debate is the fact that the media (yes, this includes Netflix documentaries – What The Health, I’m looking at you) often grossly misreport or exaggerate nutritional research, which leads to confused patients who, like it or not, trust their doctor, and may well look to their doctor for evidence-based advice amide the scare-mongering.
This post isn’t devised to ‘call out’ any specific doctors in the media, or critique anyone in the nutritional profession calling them out. Instead, it’s a post to tell you my thoughts on this whole debate, because truth be told, it’s got my back up, and I think it’s become heavily over-complicated. I’m going to strip back the noise to share with you the 4 points I’ve been reflecting on – what I think we as doctors should know and do when asked about nutrition by our patients, and why that’s so important. Let’s get into it.
Balance The Basics
Studying my Masters in Public Health and Nutrition this year has meant that I get to cover a whole range of areas relevant to health – non-communicable chronic disease (e.g. obesity, heart disease, type 2 diabetes, cancer, etc), communicable (i.e. infectious) disease, public health policy, health promotion, sociology, and yes, nutrition. Between the many assignments, projects and presentations we have been doing and my own reading outside of college, I have become pretty well-versed in these subjects – but the more I learn, the more I realise there is SO MUCH MORE to learn, and that’s especially true for nutrition. ‘Tip of the iceberg’ doesn’t even cover it! It’s a bit of a running joke among doctors that ‘more you know, the more you don’t know’ and this is because science is constantly evolving. It is challenging enough for doctors to try and keep up to date on the medical literature, let alone the nutritional. And so this is what I mean by ‘the basics.’ With all of the media myths and dietary fads out there, our good old national healthy eating guidelines often get lost in translation. And yet, they’re pretty fricking great, and in Ireland have actually recently been updated (check out the Food Safety Authority of Ireland or Healthy Ireland website, from release in 2016) to reflect the most up to date evidence in nutrition.
So when I say ‘balance the basics’ I mean that doctors should be able to tell a patient (where clinically relevant and appropriate) what these guidelines say. Fruits and vegetables – aiming for 5-7 portions per day. Wholegrains – so important for our digestive and metabolic health by helping us get our fibre in, as well as giving us a range of other micronutrients. Being able to recognise that heavily processed foods should not be the staples of our diet – in fact, these should only be consumed at a maximum once or twice a week (I’m talking about cakes, pastries, biscuits, sweets, etc). The basics do NOT mean that a doctor should be able to tell a patient ‘how to eat’ for specific medical conditions, which is something I often get asked via direct messages on social media. Side note – no doctor should ever give out individualised medical or nutritional advice via social media, as it’s ethically and legally totally wrong. Bottom line for this point gang, is that I do think as doctors we should know what our national evidence-based guidelines say, and be able to discuss that with patients, if asked and if clinically relevant. But it does NOT mean we need to be diet experts.
Bust The Myths
This is where we need to get practical. Unfortunately, the media (and social media especially) misrepresents nutritional research ALL THE TIME. The classic examples of late have been the headlines you’ve probably seen along the lines of ‘Red meat causes cancer’, or the vast media coverage the recent EAT-Lancet publication about ‘planetary diets’ received. In February, I helped deliver a workshop for parents at my college on Healthy Eating for Children, and my section of the workshop was all about ‘Myth-Busting’. I covered meat and my colleague looked at myths around dairy. This was a really important section of the workshop, as the rise in people renouncing or reducing meat and dairy (whatever the motivation may be, whether genuine desire to contribute towards environmental health or just because ‘all the bloggers’ are doing it) means that we may see nutritional deficiencies emerge if people aren’t aware of how to replace the nutrients lost with plant-based alternatives. A classic examples is the better absorbed ‘bio-available’ or ‘haem’ iron found in meat compared to plant-derived alternatives. Another example is the rising trend of young girls cutting out dairy completely from their diet, without really thinking about where that calcium they will now miss is gonna come from.
My point is this – headlines and media frenzies around nutrition, as well as certain healthcare professional ‘influencers’ can lead to a LOT of confusion. Patients trust their doctor, and this is particularly true in Ireland, where historically the general practitioner was a central figure in the community – and still is. I have my own GP and trust him 100%. So if a patient goes to their doctor totally confused about the latest newspaper article claiming ‘X food causes Y cancer’, I believe their doctor should be able to at least give them a reasonable, rational responsible answer, based on the evidence (and where to refer the patient if they don’t have that answer – e.g. to a nutrition professional). For example, the World Cancer Research Fund have a fantastic amount of online resources on how we can optimise lifestyle behaviours to reduce our cancer risk, including dietary behaviours, via their Continuous Update Project. Their ‘Third Expert Report’ details the evidence to date on various food groups that have been studied with regard to their cancer risk, and gives guidelines and recommendations reflecting this. That alone as a simple accessible free resource for doctors is a fantastic start and would help clinicians bust those myths a little.
Question the Context
One thing I have learnt over the past year that I always come back to is the importance of context. What works for me may or may not work for you, and that’s because we are all inherently unique in terms of our genetics and personalities yes, but also our environment, the culture we live in, our socio-economic status, our social networks, our educational and occupational backgrounds, etc. Nutritional advice for one person is not the same as for the other. True, our public health guidelines do apply a generalised approach to recommendations for the population, and I stand by those as mentioned in the first point about the basics. But every patient will come to their doctor with a different set of symptoms and signs for a given medical condition, and the same is true for the queries they may have about their diet. For example, if food affordability is the primary concern of the patient, it’s no good a doctor, dietitian or nutritionist discussing with them the need for healthy fats from avocados (still expensive almost everywhere I’ve seen to date!) or advising a snack of homemade nut butter with sliced apple (though this is delicious). The issue with social media is that a lot of the conversations around food are from those of us lucky enough to come from a middle to upper class background – and chatting about the importance of a ‘plant-based’ diet is not the right conversation for the patient who’s struggling to pay for dinners on the table for their family every week. A great resource example here would be the work Safefood (the public body responsible for raising consumer awareness of issues relating to food safety and healthy eating across both the Republic of Ireland and Northern Ireland) have done with the creation of their 101 Square Meals book available online, designed to help families make healthier meals with the best value for money. It also contains shopping tips, food safety messages, menu planning advice, and even some treats and snacks for special occasions.
Bottom line here in my book is this – the context is key, and any doctor asked about nutrition by their patients should explore that as the first step.
Know the Limits
This is just as important online as offline. We’ve seen quite a few medical professionals sharing their opinion on various dietary approaches, and I’m not gonna call any out here, because it’s not my style to do so, and it’s pretty clear from my content and social media who I’m a fan of! I think one of the most important things doctors can do to promote healthy eating among their patients is to first, just be aware that it plays a role in our overall health and in certain chronic diseases (both from a preventive and management perspective), and second, to know when it’s appropriate to refer the patient (or if the patient wishes) on to a registered dietitian or nutritionist. In the in-patient setting this really isn’t an issue – for example, dietitians are integrated members of the healthcare team for may surgical patients pre and post operatively, and this is also true in the case of managing diabetes as another example (there are many examples, trust me, I loved working with the dietitians at my hospital!). In the community/primary care/out-patient setting where nutrition comes up in conversation, that’s where we can say as doctors, we should know our limits of the advice we can and should give, and when we should refer onwards, and collaborate with dietetic and nutritionist professionals to give the patient the best shot possible at fostering a healthy, balanced, enjoyable relationship with food – for life.
Phew. I’m done, I promise. This post was a jumble of thoughts I had but wanted to make coherent for myself and for you guys, which is where writing always helps me the most. I might even make this topic into a Podcast! I would LOVE to hear your thoughts on this post – leave a comment, drop me line via email, a DM on Instagram, you know where to find me – @theirishbalance on Instagram/Twitter/Facebook!