Despite a wide variety of dietary options available, a prolonged controversy still exists about optimal nutritional plans for cardiometabolic patients, which contributes to the challenges faced by clinicians while caring for these patients. A poor diet is a major contributor in exacerbating the impacts of the cardiometabolic disease; as well as a leading contributor to morbidity and mortality worldwide.1,2 Thus, proper nutrition for cardiometabolic health is paramount, a view emphasized in several clinical practice guidelines.3-5 However, defining proper nutrition for cardiometabolic disease is challenging and can be very controversial. Clinicians may not be aware of appropriate healthy eating patterns or the evidence for different dietary approaches on cardiometabolic health outcomes; this is more apparent by the fact that many clinicians do not receive adequate training on nutrition and are less likely to address nutrition as a topic during a clinical visit. To gain more insight in this area, we had an opportunity to talk with Stephen Devries, MD, FACC, a preventive cardiologist, and Executive Director of the Gaples Institute for Integrative Cardiology, a nonprofit dedicated to advancing the role of nutrition and lifestyle in medicine.
Because of all the diet and nutrition advice available, most people are puzzled with the concept of “the ideal diet.” Recently, the EAT-Lancet commission report, a largescale nutrition initiative by The Lancet, emphasized the consumption of plant-based diets over meat-based diets6, an approach that also is supported in the diabetes, hypertension, cholesterol, and primary cardiovascular disease (CVD) prevention guidelines.4,5,7,8 Dr. Devries echoed this approach: “the diet that would be most helpful for the vast majority of people would be one that is predominantly plant-sourced, a diet rich in vegetables, fruit, beans, whole grains. Although frequently overlooked, it’s best that these items be consumed in as close to their original state as possible–not ground into flour or extracted into juice.” – he told Cardiometabolic Chronicle.
Often while talking about diets, people are focused on how much protein, carbohydrate, and fat they should consume. “For protein, the evidence is clear that a decisive shift to more plant-sourced protein is ideal. Rich plant sources of protein include beans, whole grains, nuts, and tofu. Most people consume more protein than needed and can easily obtain more required from plant sources.” Dr. Devries added - “with regards to fat and carbs, rather than focusing on amounts, it is most helpful look at the quality rather than quantity.“
“With fats, cutting down on saturated fat is an important step, but the replacement is equally important and ideally includes foods with healthier fats like Omega-3s (like fish, walnuts, and flax) and monounsaturated fats (such as extra-virgin olive oil, avocado, and almonds). In contrast, replacing saturated fat with refined carbs–a historically common swap–yields no net benefit.“
“Similarly, for carbs, rather than focusing on quantity, a good strategy is to improve the quality of carbs with an emphasis on whole grains, and fruits and vegetables-again, served whole rather than ground into flour or extracted into juice.“
We can also help our patients by encouraging them to gradually transition towards more plant-sourced foods. And if there is one thing that the science is very clear on, it is the need to remove processed meats from our diets, like bacon or sausage; the World Health Organization has deemed processed meats as carcinogenic to humans9, and there is clearly decreased risk for CVD or diabetes after eliminating processed meats from the diet10.”
Paradoxically, several studies have shown that most physicians and other healthcare professionals receive exceedingly limited education in nutrition as part of their formal clinical training.11 Only 25% of medical schools in the United States offer a dedicated nutrition course, and few medical schools achieve the 30 hours of nutrition education recommended by the National Academy of Sciences.12 Furthermore, lack of nutrition persists even after formal training, as studies have shown that most clinicians that specialize in cardiometabolic care do not keep up to date with continuing education in nutrition.1 Dr. Devries was in full agreement with these facts as he pointed out that “unfortunately the state of nutrition education in medical training is dire, recently a study that we published in The American Journal of Medicine, which was a survey of over 600 cardiologists, showed that 90% of cardiologists reported receiving no or minimal nutrition education during their training. Interestingly, in the same survey, 95% of cardiologists reported that they felt it was their duty to at least begin the nutrition conversation with their patients”.1 At the same time, he underscored the fact that nutrition counseling needs to be a team effort rather than the sole responsibility of the physician. Participation of experts, such as registered dietitians and other nutrition professionals is of the utmost importance.
Nevertheless, clinicians may not adequately address nutrition with their patients, not only due to a lack of knowledge and training, but also due to the limited time they have to spend with each patient. Dr. Devries shared some practical pearls on how to circumvent this barrier: “given the time constraints, there are some efficient ways to make a meaningful difference with nutrition in your practice, including a quick dietary assessment that could be distributed to patients while they’re waiting in the waiting room. Physicians can then choose one nutrition topic identified by the survey to discuss for a minute or two during each clinic visit.
Moreover, a critical nutritional intervention that takes even less time is for clinicians to make a simple statement to patients that emphasizes nutrition as a priority; and that makes clear that as essential as it is for them to carefully take their prescribed medication, that optimal health also requires attention to nutrition and lifestyle. From there, patients should be directed to appropriate nutrition resources, which could include appropriately trained dietitian/nutritionists, nurses, health-coaches, and chefs.
On being asked about the common questions raised by patients about the nutrition, Dr. Devries said, “many of the questions that patients have are specifically related to what sort of diet they should be on, e.g. a low-fat, a low-carb, or should it be a vegetarian, vegan or gluten-free diet”. Physicians should, at minimum, have a solid foundation of nutrition knowledge that will allow them to begin the nutrition conversation with their patient and to make appropriate referrals.
Thus, it imperative that clinicians receive additional education on the benefits of nutrition and comprehensive nutritional approaches aimed at better managing patients with cardiometabolic risk or cardiometabolic disease. Dr. Devries and the nonprofit Gaples Institute have taken a leading role in tackling the nutrition education vacuum among healthcare professionals, offering a nutrition course and several other resources for the busy clinician across their platforms (more information on the nutrition course can be found on their website, https://www.gaplesinstitute. org/e-learning-physicians/).