Food is medicine: actions to integrate food and nutrition into healthcare
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2482 (Published 29 June 2020) Cite this as: BMJ 2020;369:m2482Read our Food for Thought 2020 collection
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Dear editor,
In a beautiful and concise review in this journal, Sarah Downer et al. highlight the importance of food as medicine. We agree with their statement that “as healthcare systems continue to evolve to tackle the global crisis of nutrition related disease, food is medicine interventions should be held to rigorous standards when decisions about implementation, coverage, and care are made” [1].
In the cardiology outpatient clinic, we receive daily questions from our patients as how to best prepare for a probable second wave of infection with the SARS-CoV-2 virus. The reason being that patients with underlying cardiac disease have a 5 times increased risk of dying after contracting COVID-19 [2]. Many of our patients developed cardiac problems due to their typical Western diet which is characterized by consumption of too much highly processed foods and a lack of whole foods, such as fruits and vegetables. In order to better advice and motivate our patients to improve their diets we wondered what the best food prescription for our patients could be during the current Covid-19 pandemic and if this diet is also beneficial for their cardiovascular diseases?
It is not exactly known which diet protects patients with cardiovascular disease against COVID-19, but some clues can be found in the literature on diet and influenza. An elegant study in an animal model of Influenza infection showed that the microbiome is an essential factor in the survival of animals [3]. The investigators found out that the level of the Interferon Type I, which has strong anti-viral properties, goes up substantially in response to the microbial conversion of flavonoids to desaminotyrosine (DAT), resulting in better survival. Flavonoids are present in high dose in berries, citrus fruits and green leafy vegetables. Research on the effect of dietary fiber on the immune system showed that the conversion of dietary fibers into short-chain fatty acids (SCFA) increased the survival of Influenza infected animals [4], through dampening of immune-associated pathology in the lung and increased CD8+ T cell effector function, essential to combat viral infection. Finally, recent research showed that low carb and high fat diets protected mice from a lethal dose of Influenza infection [5], through the expansion of protective yδT cells.
But what if these diets do not provide the intended immunoboost to protect against COVID19 in patients with underlying heart disease? The answer is that adopting these diets is still beneficial. A study in more than 50.000 participants in Denmark showed that a sufficient intake of flavonoids was associated with an impressive 30% reduction in both heart disease and cancer [6]. A meta-analysis on the consumption of dietary fibers showed that for every 7 grams of dietary fiber consumed, the risk of cardiovascular disease drops by 9% [7]. Finally, a meta-analysis of the effect of low-carb diets on heart disease, showed a beneficial effect on cardiovascular risk factors [8].
Adopting these diets could potentially help to protect against the deleterious effects of COVID19, but, obviously, clinical studies are still lacking. However, for the sake of the overall cardiovascular health, these diets seem powerful weapons. The current motivation of patients to change their lifestyle in order to protect agains COVID-19 might helpt to sustainably change their diets also in favor of their cardiovascular status.
References:
1. Downer S, Berkowitz SA, Harlan TS, Olstad DL, Mozaffarian D. Food is medicine: actions to integrate food and nutrition into healthcare. BMJ 2020:369:m2482. Doi 10.1136/bmj.m2482.
2. WU Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323(13):1239-1242. Doi:10.1001/jama.2020.2648.
3. Steed AL, Christophi GP, Kaiko GE, et al. The microbial metabolite desaminotyrosine protects from influenza through type I interferon. Science 2017;357(6350):498-502. Doi:10.1126/science.aam5336
4. Trompette A, Gollwitzer ES, Pattaroni C. Dietary fiber confers protection against flu by shaping ly6c patrolling monocyte hematopoiesis and cd8+ cell metabolism. Immunity 2018; 48(5):992-1005.e8. doi: 10.1016/j.immuni.2018.04.022.
5. Goldberg EL, Molony RD, Kudo E, et al. Ketogenic diet activates protective yδT cell responses against influenza virus infection. Science Immunol 2019;4(41): eaav2026. Doi:10.1126/sciimmunol.aav2026.
6. Bondonno NP, Dalgaard F, Kyrø C. Flavonoid intake is associated with lower mortality in the Danish Diet Cancer and Health Cohort. Nature Communications 2019;10:3651. doi:10.1038/s41467-019-11622-x
7. Threapleton DE, Greenwood DC, Evans CEL, et al. Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis. BMJ 2013; 347: f6879. Doi:10.1136/bmj.f6879.
8. Dong T, Guo M, Sun G, et al. The effects of low-carbohydrate diets on cardiovascular risk factors: a meta-analysis. Plos ONE 2020;15(1): e0225348. Doi: 10.1371/journal.pone.0225348.
Competing interests: No competing interests
Food is more than medicine: Access to appropriately nutritious and healthy food is a basic human right, key to disease prevention and so much more than “medicine”
Dear Editor,
We welcome the recent article by Downer et al [1]. As nutrition educators, researchers and clinicians, we absolutely agree with the need to better integrate nutrition into healthcare which requires raising the profile via education, better quality research but crucially more specifics on practical innovations to translate nutrition to the real world making a difference to patient care as well as preventative population health. Adding to the points raised in the article we wanted to highlight the following:
Making Nutrition a universal priority and joining the dots.
We agree that physicians should be encouraged to make more onward referrals to dietitians and appropriately trained nutrition professionals but with only 2.3 trained dietetic/nutrition professionals per 100,000 globally, specialist capacity is woefully inadequate [2]. In our recent paper exploring the views of medical students and doctors, although most agreed nutrition was important only a quarter of those working in clinical practice included nutrition more than once a month and few were confident to discuss nutrition in clinical encounters [3]. Without raising the topic of nutrition and basic nutrition screening it is unlikely that they will be referred on. This responsibility doesn’t stop with doctors and should be integral to standard medical/clinical assessment by all professions, to diagnose nutrition issues where “nutrition-sensitive treatment” requires clear and efficient pathways for community and hospital-based nutrition interventions. Each effective nutrition intervention can also be a “teaching moment” for patients, health care professionals, and even the public. Discussion of vitamin D deficiency as a potential permissive factor in COVID-19 mortality [4,5] has drawn attention to the powerful role of well-balanced nutrition for achieving and maintaining health.
For example, in the UK dietitians have only recently been added to the GP contract in England, allowing primary care teams to directly employ dietitians to be included in primary care multidisciplinary teams [6]. Not only can this ease the pressure on overstretched nurses and doctors but provides staff training and leadership to assist with new innovations to move nutrition from the fringe to the core of health services.
Where available, population nutrition interventions such as community kitchens, are reporting that they are under-utilised as a referral option, suggesting the need to strengthen data on impact to increase awareness amongst health providers. This can improve investment to increase availability, especially in rural areas. Government funding for “meals on wheels” has been cut as foodbank use continues to rise exponentially but unfortunately this does not cater to specific medical nutrition needs. Nutrition interventions need to be more than provision but targeted and appropriate, as well as an opportunity for education and behaviour intervention.
Avoiding the “over medicalisation” of food.
We are concerned about the comparison of food to pharmacological interventions. Prescribing a “diet” oversimplifies the complexity of behaviour change which requires active choice and autonomy in personal decisions as well as wider community and environmental considerations. It is important to position food in line with, not necessarily instead of other medical interventions. A more appropriate paradigm would be to consider the role of food and nutrition in primary, secondary and tertiary prevention of disease alongside treatment of those diseases which are linked with nutrition either aetiologically or where nutrition is part of the management. In tandem, by integrating nutrition trained staff into clinical teams they can educate, negotiate and agree on medically tailored meals and groceries to enhance motivation and confidence. This includes access to cooking skills, workshops and ongoing follow up to sustain impact.
Designing interventions with and not for vulnerable groups.
Lacking in current literature is the voice of the patient and food charities such as food banks. Perceived benefits, realistic and meaningful impact requires co-production to capitalise on lived and clinical experience. Nutrition interventions don’t necessarily need to be centred in healthcare but should consider how we can enhance and build on existing food initiatives to support research and development to aim for the greatest health impact. We also wonder if culinary professionals, many of whose usual employment has been disrupted, could contribute further skills and expertise.
As we are forced to re-examine food and health systems during the COVID-19 pandemic, now seems an opportune time to explore novel ideas and to forge new partnerships and lean innovations to address widespread nutrition inequality and malnutrition in all its forms.
Downer S, Berkowitz SA, Harlan TS, Olstad DL, Mozaffarian D. Food is medicine: actions to integrate food and nutrition into healthcare. bmj. 2020 Jun 29;369.
Global Nutrition Report 2020
Macaninch E, Buckner L, Amin P, Broadley I, Crocombe D, Herath D, Jaffee A, Carter H, Golubric R, Rajput-Ray M, Martyn K. Time for nutrition in medical education. BMJ Nutrition, Prevention & Health. 2020 Apr 16:bmjnph-2019.
Kohlmeier M. Avoidance of vitamin D deficiency to slow the COVID-19 pandemic. BMJ Nutrition, Prevention & Health. 2020 May 20:bmjnph-2020.
Lanham-New SA, Webb AR, Cashman KD, Buttriss JL, Fallowfield JL, Masud T, Hewison M, Mathers JC, Kiely M, Welch AA, Ward KA. Vitamin D and SARS-CoV-2 virus/COVID-19 disease. BMJ Nutrition, Prevention & Health. 2020 May.
British Medical Association. Update to the GP contract agreement 2020/21 -2023/24. February 2020.
Competing interests: No competing interests