Peas Before Pills

Can nutrition replace prescriptions? Medical educators at the UA are planting the seeds.

September 9, 2016

HealthIssue 20: September/October 2016

Think about how your grandmother cooked,” says Dr. Randy Horwitz, the medical director for the Arizona Center for Integrative Medicine. “If you want to start with a good diet, start there. Only cook what you recognize. This is a chicken. This is not a frozen packaged chicken with 15 ingredients.”

Horwitz has evangelized for whole, fresh foods since he completed a fellowship in integrative medicine at the University of Arizona in 2003. Today, he’s the chair of the American Board of Integrative Medicine. Using detailed case studies from evidence-based clinical practice, he trains more than 100 physicians annually through the Arizona Center for Integrative Medicine’s fellowship programs.

He pulls an example from a presentation he used recently in an elective lecture to students in the UA College of Medicine. “I saw a patient in her mid-to-late 50s. She had prediabetes for a few years and her numbers were going up. Her hypertension was controlled with two medications.” The woman’s doctor had recommended a common diabetes drug. “The FDA recommends using the drug as an ‘adjunctive therapy’ for diabetes, along with exercise and diet,” Horwitz says. “She went on an anti-inflammatory diet, which was Mediterranean. She stopped fruit juices, which are just sugar and water. She stopped her bagels that she was eating daily. No diet soda, no fast food, no processed food. She stopped her sugar and salt. So what happened? She dropped to normal levels in three months, and she was able to even stop her blood pressure meds.”

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Horwitz says, “Nutrition often takes a back seat [in medical school] because practicing physicians just don’t give it its due.” Research backs him up. A widely published longitudinal study of nutrition education in U.S. medical schools shows that there is not only too little time dedicated to nutrition in medical school curricula, but also that the amount of time is declining.

Horowitz concurs with a cadre of integrative health leaders who are urging medical schools to substitute nutrition classes for organic chemistry.

The notion is not new. It was first advanced by Dr. Jim Dalen, dean of the UA College of Medicine from 1988 to 2001. It was Dalen who worked with Dr. Andrew Weil to establish the Arizona Center for Integrative Medicine in 1997 and to develop the integrative medicine field in the late ’90s.

The practice of integrative medicine involves a wide range of approaches to helping a patient achieve and sustain good health. Doctors and nurses may practice conventional medical techniques and prescribe medications, but they also work to support patients in making essential changes to their environment, sleep habits, activity level, relationships, resiliency, spirituality, and nutrition. The focus is on healing, and the physician’s role as a coach for a patient’s self-care to prevent illness and maintain health.

The UA established the first residential fellowship in integrative medicine for physicians already in clinical practice in 1997. Its goal was to seed the country with practitioners over a 10-year period. Shorter-term resident and online fellowships are still offered. To date, the UA has trained 1,200 fellows, including MDs, DOs, nurse practitioners, and physicians’ assistants. The UA also offers an Integrative Medicine in Residency program at more than 100 sites around the country, including Banner-University Medical Center.

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As director of Integrative Medicine in Residency for the Arizona Center for Integrative Medicine, Dr. Patricia Lebensohn assures that a thread of nutrition education is sustained throughout the students’ preclinical and clinical years. She also leads nutrition education for residents at Banner.

Lebensohn says she stresses the importance of taking a thorough nutritional history of each patient and analyzing it for insights. “The interest is greatest among students who want to pursue family practice,” she says. “In the Family Medicine Residency here, we do a lot of nutrition education with them [including] food preparation, how to cook healthy foods, preparation of gluten-free and dairy-free diets.”

Arizona Health Sciences Center’s farthest-reaching nutrition education program is its annual Nutrition and Health Conference, now in its ninth year. The four-day conference attracts physicians as well as other professionals concerned with healthy eating. There’s a focus on ways to incorporate nutritional information in a clinical setting and how to evaluate risks and benefits of nutritional recommendations. But panels also cover topics ranging from nutrition and mental health to agricultural practices affecting the nutrition content of produce and the role of microbiomes in heart health.

In 20 years, education in integrative medicine has grown to the extent that the Academic Consortium for Integrative Medicine now has more than 65 members, including some of the most distinguished medical schools in the United States: Scripps, Harvard, Stanford, Yale, Johns Hopkins, and more.

Many of these practices are as old as those of Florence Nightingale, and in clinical practice it is often nurses and nurse practitioners who are the front line in nutrition education. They are usually the only resource for school and community programs and some patients of community clinics.

“Access to clean food, clean water, and fresh air was kind of the cornerstone of how Florence Nightingale thought about nursing,” says Mary Jo Koithan, Ph.D., R.N., and an associate professor in the University of Arizona College of Nursing.

Koithan says that nurses’ frequent interaction with hospitalized patients, and their intake functions in clinics and doctors’ offices, offer them first line opportunities to assess dietary habits and the nutritional condition of a patient. Often, she says, doctors will refer patients to their nurses for information about nutrition.

“The College of Nursing has really adopted an integrated health approach,” says Koithan. “One tenet of integrative care is to believe that the human body knows how to heal itself if you support it properly … It’s a whole-person, whole-systems approach focused on prevention and health promotion. Another tenet has to do with a sustainable community. The health of us … is connected to our space and place.

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“We spend a lot of time on how to intervene with specific symptoms, and we’re looking at nutrition to intervene in a noninvasive … natural way,” she says.

Koithan says the College of Nursing is taking steps to standardize a holistic view of nutrition’s role in both preventive and diagnostic care throughout its own curriculum. In 2016, the college will launch an Integrative Nursing Faculty Fellowship program. “So we’ll be talking about the new way of thinking about nutrition and how it’s connected to the whole of the environment and the whole health of the person,” says Koithan.

The field of community nursing, in clinics and community service centers, offers nurses the best opportunity to educate people about nutrition and dietary changes that can improve their quality of life. Community nurses give classes on preventing and managing diabetes, heart conditions, and celiac disease, and they offer nutrition counseling to expectant mothers. School nurses teach nutrition as part of health classes, and also help families manage students’ diabetes and asthma. Often they pitch in on school gardens to talk about how healthy foods help young bodies to grow and fight disease.

Importantly, community nurses are close enough to their clients’ culture to know what recommendations will actually be sustainable. Koithan describes a program working with the Tohono O’odham to control diabetes with traditional foods, and outreach to home-bound patients to make sure that recommended dietary changes are within the patient’s capabilities.

As more health care providers and their patients become aware of the role of nutrition in good health, insurers and other payers seem to remain oblivious. General nutrition consulting is not covered in a routine office visit. And coverage for food-related disorders, such as diabetes and celiac disease, are generally covered only when referred to specialists.

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The national healthcare business consultant Dr. Eric Justin, also an MBA, has worked as a clinical physician and now consults for healthcare, health insurance, and employee benefits companies.

Asked whether compensation issues constrain opportunities for doctors and nurses to provide preventive nutritional counseling, Justin says, “There is no question that insurance carriers, among others in the larger healthcare space, understand the utility of nutrition education. The dramatic increases in … obesity and diabetes alone have awakened most players.

“Executing on that perceived need is another matter.”

Horwitz highlights the paradox. “There’s no other medication, if you will, that’s taken with such regularity as food. And it really does impact health. Most of our lifestyle diseases can be delayed several years, if not put off forever.”

Here’s his prescription: “There are ample studies that support increasing healthful fats in the diet, and mainly having a plant-based diet is helpful, using meat as a side-dish if you want. If you can tell me what all the ingredients are, you can eat that.” 

Linda Ray has written news and feature stories for as long as she can remember. She wrote press releases for the first national conference on integrative health, held at the Tucson Convention Center in the mid-1970s.

General recommendations for health from Patricia Lebensohn, MD, Director of Integrative Medicine in Residency, University of Arizona College of Medicine.

  • Eat whole foods and limit processed foods.
  • Eat mostly plant-based foods and seasonal/local when possible.
  • When possible, prepare/cook the majority of your meals.
  • Add physical activity/movement daily.
  • Share meals with family and friends.
  • Practice mindful eating.
  • Have three main meals (including breakfast) and a couple of snacks a day.

Recommendations for diet composition:

  • Follow a Mediterranean/anti-inflammatory balanced diet.
  • Have protein, healthy fats, and complex carbohydrates in every meal.
  • Depending on age and health, consume 0.8-1.2 gm/kg of protein (helps with satiety and to maintain lean body mass).
  • Consume healthy fats: avocado, olive oil, nuts (walnuts, almonds, cashews).
  • Avoid consuming refined sugar on a routine basis, especially in the form of sodas and other sweetened beverages.
  • Consume fermented foods: pickles, sauerkraut, kimchi, kombucha, and others.
  • Dink mostly water; some tea and coffee is okay.
  • Alcohol in moderation is okay; consider no more than 7 drinks a week for women and 14 for men.







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