Nutritional Medicine , Separating Fact from Fiction
Update on the FODMAP Diet and lack of evidence for its use
Update on the FODMAP Diet and lack of evidence for its use
After reading several “trending nutrition articles” on “hot” topics for this year, one glaring trend stood out . . . the outstanding lack of trust on the part of the public on advice from so-called “experts”, the same experts who are known to disagree with each other on a regular basis despite a commitment on their part to “evidence based practice.” We have lost the public’s trust. It is our fault. We stand guilty as accused.
In some respects, has the public put too much trust in achieving consistency in information? Instead of striving for consistency, perhaps we should be honoring the intuitiveness of the art of practicing any form of medicine. Since all humans are different, studies cannot be consistent and individuals cannot be treated the same while we claim we practice “personalized medicine”.
The truth of the matter is nutritional medicine is an art and a science. Part of the art in nutritional medicine is to see the picture in its entirety and to be able to explore different approaches to fitting the pieces of the puzzle together to optimize outcome. The combination of research, evidence, observation, intuition – all are used in various alternative as well as traditional forms of medicine and used effectively.
The key to making this happen is in the clinician’s knowledge base, experience/foundation in nutritional medicine, critical thinking skills and respect for every patient as an individual, as a unique biochemical entity with a unique microbiome, need for nutrients, potential for supplement-drug interactions, genetic tendency towards chronic disease, etc.. all this while considering the most updated Evidence-Based Guidelines of Care for that particular problem area- be it Cardiovascular or Diabetes.
Defining the Field
What is a “nutritional medicine” approach? In today’s world, it no longer means a rejection of synthetic drugs and treatments, but a more complimentary approach where diet and nutrition, fitness, environment, among other synergistic factors, are used to enhance medical treatment. Most diseases in the mind of the nutritional practitioner are caused by years of unbalanced nutrition and even when genes are involved oftentimes it is a poor lifestyle that enhances the expression of those genes.
Not to confuse the practice of nutritional medicine with the practice of medicine, let’s clearly delineate the differences. The practice of “medicine” is defined in the Merriam-Webster dictionary as “ the science and art dealing with the maintenance of health and the prevention , alleviation or cure of disease; a substance used in treating a disease; the branch of medicine concerned with the nonsurgical treatment of disease.” Taber’s Medical Encyclopedia defines it thusly: 1) A drug or remedy; 2) The act of maintenance of health, and prevention and treatment of disease and illnesses; 3) Treatment of disease by medical as opposed to surgical means. None of these are specific to nutrition. Traditional doctors average one nutritional course in their heavy curriculum.
The definition of “Nutritional Medicine”, on the other hand, explains the field thusly:
1. The use of food and nutrition as a medical approach.
2. Supplementation of diet with nutrients, intermediary metabolic products and probiotics to prevent illness and improve health and disease.
3. The study of the synergistic interactions of a variety of factors such as environment, social health, physical health, fitness, spiritual health, physiology, anatomy are all considered in relation to the nutritional status and needs of the patient. The nutritional medical approach is based on a wide range of disciplines with a focus on application of the knowledge of foods, nutrients, metabolism, counseling, education, medical nutrition therapy and behavior change.
And, finally, in 2005 the definition in Elsevier Jones Mosby’s Dictionary stated that nutritional medicine was 1. Use of food and nutrition as a medical approach and 2. Supplementation of diet with nutrients, intermediary metabolic products and probiotics to prevent illness and improve health and healing.
Medical Nutrition Therapy (MNT) is the term we use for the arm of nutritional medicine that deals specifically with the aspects of nutritional care delegated to Dietitians (a title protected term) who meet practice qualifications as discussed later. To put nutritional medicine back at the forefront of importance in the healing process, doctors can and should make use of Registered Dietitians, the professionals that now specialize in the area of nutritional medicine and are most trained to be the doctor's greatest ally for patient education, behavior change and positive nutritional/lifestyle outcomes.
Regaining the Trust of the Public
The first step in regaining the trust of the public is to talk openly about what nutritional medicine is and provide education on what to look for in a doctor, nutritionist or even in reading material-- especially while cruising the internet highway- to determine credibility.
Next, to regain trust explanations on how this has happened in the first place needs to be identified, explained and rectified. Becoming a savvy nutrition consumer is a necessity these days for everyone. What are some things to look for?
The contradictions in information the public complain about is very real. Here are some of the reasons why:
So, with that said, what types of credentials should you look for in someone practicing as a Nutritionist?
By this point, hopefully, it is understood that even with the guidance of skilled practitioners it is difficult to find one standardized answer to a medical or nutritional question. Practitioners are trained to accept the guidelines that meet the approval of the majority and with the greatest strength of evidence utilized. That is, if they have time to keep up with the changing guidelines while maintaining a busy practice.
Most U.S. and many foreign physicians have one nutrition class and many do not pass graduate level biochemistry classes. Probing to see what type of advanced study a physician has had or what their views are on integrative and functional medicine may give you a clue as to the extent of their skill in nutritional management.
With all due respect to physicians, many are not trained to deliver nutritional services and some cannot even identify the need for such. Others come with a respected background in Alternative and Complementary Healing practices such as Ayurvedic Medicine, a practice centuries old and well respected in many countries. So take care not to be too judgmental, just do your research. Information on complementary medicine may be obtained by the National Center for Complementary and Integrative Medicine , a U.S. Federal website.
With nutritionists, credibility has become more cut and dry in states that have licensure. In most states licensure protects the public by not allowing individuals to practice “Dietetics” or call themselves Dietitians or Nutritionists without meeting the same criteria that all Registered Dietitian Nutritionists (RDNs) have to meet:
1. Obtain a minimum of a Bachelor of Science Degree that includes a core curriculum of classes approved by the Commission on Dietetic Registration. These classes include foods, food management, nutrition, statistics, counseling, professional literature, microbiology, food service management, menu planning, pharmacology, chemistry, biochemistry, physiology, anatomy, to name just a few. In the near future a Master’s Degree will be required to become an RDN and to sit for the National Board Exams.
2. A supervised 900 hour internship;
3. The successful passing of National Board Exams;
4. The maintenance of 75 continuing education credits every 5 years
This qualifies the practitioner to be an Entry Level practitioner as opposed to Competent or Expert. These categories are based on additional education, certification and experience.
Not all licenses are held by RDs, but all licensees must meet the minimum qualifications above, so Dietitians essentially are setting the Gold Standard for minimum criteria for licensure by any other profession than an RD or RDN.
Now, not even all highly qualified RDs agree. It involves their level of specialization, what theory they practice by, their experience in specific areas and how duped they have become by the contradictory nature of published studies and under-researched news stories.
But, if someone were to take the chance on listening to a clerk with a high school education or listening to a skilled practitioner with critical thinking skills and constant competency testing, who do you think you should believe?
Who Does What These Days?
When the dust settles, things will be much different in who practices what. It is in the scope of practice for the "qualified" Dietitian to practice Medical Nutritional Therapy. Medicare now allows Dietitian’s to write diet orders, order supplements, order nutritional labs to follow up on nutritional intervention, perform the nutritional teaching and follow the patient without the doctor’s orders and solely based on the RDs competency level and the admittance to the Medical Staff. RDs are uniquely prepared to handle all aspects of nutritional care.
In some states Dietitians operate private practices similar to Physician’s Offices. Physicians still need to order consultations for many insurances to pay for outpatient visits, but not so in the hospital setting any longer.
So, in a U.S. hospital if a patient has nutritional needs it is the law that they be seen by a “qualified” dietitian, not a diet technician or a physician, but a qualified dietitian. If this does not occur, the hospital is in violation of Joint Commission rules. This is said with emphasis because too many malnourished patients and patients with complications are being readmitted time and time again for the same problems because hospitals have not implemented the new Medicare rulings and patients don’t know when to push for their rights AND nutritional needs are not being met in far too many scenarios.
This is a huge change in the face of nutritional care. What started out as the mainstay of medicine was forgotten with the dominance of the prescription pad and then reborn like a rising Phoenix in Dietitians. What doctors don’t have time to do has now been delegated to RDs, RDNs, and Registered Nutritional Technicians (RNTs) .
So, in summary, what does the changing face of nutritional medicine mean to the public? It means doctors have trained/qualified assets to use to assist them in implementing the nutritional orders they give to patients. . . . to change their diet,to follow a special diet but no instruction or training provided, lose weight, exercise, eat better, lower the blood sugar, decrease the blood pressure, and eat less sodium. It is the RDs that are the ones that help patients figure out how to follow the doctor’s orders, which calcium supplements to take and how much, how to implement public health guidelines, and, in general, to assist the public in questions regarding supplements or drug/supplement interactions.
So, as a result, doctors are more aware of the growing evidence-based importance of nutritional medicine, but just don’t have the time and/or training to work implementing the plethora of nutritional teaching needed. It is the Dietitian’s job to help the Doctor optimize his practice of nutritional medicine by teaching patients and the public on preventive health and nutrition for disease prevention as well as to optimize medical treatment in the treatment of the disease process.
So, in essence, look for doctors that respect the statement by Thomas Edison “The doctor of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with Nutrition.” That time is here. Now. And so are RDNs.
**Caution with State Laws as many are ten years behind actual reality. Maintain malpractice insurance, be friends with attorneys and the healthcare playing field is about to get very different.
Reference: Academy of Nutrition and Dietetic. http://www.eatright.org. Accessed 4/30/16
Davies S. 1991. Scientific and ethical foundations of nutritional medicine. J of Nutr Med 2; 227-247
ACC: American College of Cardiology
AHA: American Heart Association
AACE: American Academy of Clinical Endocrinology
AND: American Academy of Nutrition and Dietetics
NLA: National Lipid Association
ATP: Adult Treatment Panel
CDR: Commission on Dietetic Registration
RDN: Registered Dietitian Nutritionist
Kathryn Shattler, MS,RDN