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”
We welcome the recent article by Downer et al . 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 . 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 . 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 . 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