We need our clinicians to buy in to the concept that “thy food is thy medicine, and thy medicine is thy food”. Instead of arguing over what Hippocrates meant by this, exactly – or whether he even said it – why not encourage his medical descendants to take up this mantle?
Arguably, most doctors are more equipped to write a prescription or make a referral than to discuss nutrition and lifestyle interventions. Without question, pharmaceuticals have their place, but so does food as medicine, and our brilliant doctors – in whom we trust – must take greater steps towards preventative care and lifestyle interventions that will address the growing burden of type 2 diabetes, obesity and malnutrition in this country.
An estimated 60 per cent of adults and one in four children in Ireland are either overweight or obese. The direct and indirect costs to the exchequer which are associated with obesity are estimated to exceed €1 billion per annum.
The Healthy Ireland Framework 2013-2025 states that the “health and wellbeing of everyone living in Ireland . . . is the most valuable asset that we possess as a nation”. The report goes further to say that health in Ireland will be unsustainable in the future due to lifestyle diseases and ageing populations. It makes a strong argument for greater emphasis on illness prevention.
Therefore, I ask our politicians, the HSE and the Department of Health: if our health and wellbeing is such a prized asset, why isn't more being done to protect it?
Both hospitals and the food service sector are considered key areas for public policy interventions in this regard. Yet many doctors have no nutrition training. In the US, this has resulted in changes to curriculums whereby culinary medicine is being incorporated into doctor training in Harvard and Tulane universities, and even in some US hospitals. Nutrition knowledge and cookery education, like prescribed exercise, should become another tool in a clinician’s toolkit. Ironically, the one place that we go to to get help when chronically unwell is a hospital. Yet doctors working there are ill-equipped to intervene – or even get involved – in this critical area.
Hospital food
In the UK, £50 million has been spent on failed bids to improve hospital food. Reports suggest 17 separate government initiatives since 2000 have resulted in no discernible improvement in the quality of meals served to patients. Albert Roux, James Martin and Loyd Grossman have all tried. Prue Leith has now taken up the baton.
But remaking hospital menus isn’t easy.
Hospitals have to operate on strict budgets and food supply is frequently outsourced to companies that specialise in high volumes of food at a low cost – often resulting in packaged and processed foods. Research shows us that 30-40 per cent of hospitalised patients are considered to be at risk of malnutrition. However, hospitals are a place where "nutritionism" rules.
"Nutritionism" is a term coined by the Australian sociologist Gyorgy Scrinis, and popularised by food writer Michael Pollan. It means reducing the value of a food to specific nutrients it contains. It's a little like the food pyramid – which forms the basis of diet recommendations in Ireland.
A cereal advertisement I viewed recently is a perfect illustration of how nutritionism works. It talks about superfoods (health halo, anyone?) and we KNOW superfoods are healthy, right? By eating these cereal products, we get more zinc, more fibre and folic acid than . . . what? Not eating these processed cereals?
So how do we get zinc, iron, vitamin C, B6, fibre and folic acid if we don’t eat the cereal?
Well, for starters we could eat meat, shellfish, legumes, nuts, dairy and eggs and even some dark chocolate for the zinc and iron. But the ad implies that eating more chocolatey cereal will serve you better than half a cup of black beans. As Marion Nestle, professor of nutrition at NYU, points out, such ads are not saying whether the iron from the fortified cereal is going to be absorbed as well as from the black beans, or what additional benefits you'll get from eating the black beans and how much sugar is in the cereal versus the black beans. (For the record, 78 per cent of the cereal will turn to glucose once you eat it).
Central to health
What we eat is central to human health, enabling the cells in our bodies to perform their functions via the nutrients, vitamins and energy consumed, but food also goes beyond calories and macronutrients. Anthropologists often declare “You are what you eat”, and certainly, by examining a person’s diet, much can be gleaned about their background, financial status, religious beliefs and education level.
Since the 1970s, nutrition and public health experts have translated reductive principles – Eat less fat! Eat less salt! Avoid processed foods! – into dietary guidelines for the general public, telling us what to eat more of (fibre, vitamins, calcium, iron, Omega 3s, for example) and to avoid foods considered bad for health, such as saturated fats and refined foods high in sugar, salt and fat. Arguably, this abstract dietary advice is an oversimplification of something much more nuanced and complex. There are so many reasons as to why we eat the food that we do: for pleasure, convenience, and the cost of food, or due to food knowledge and our culture. Therefore, thinking about food in terms of calories-in and calories-out is reductive – a "mechanical approach [that] plays right into the hands of the food industry", as food writer Joanna Blythman says in her book What to Eat.
Food in hospitals is a budgetary nuisance. Improving the quality of hospital food service is complicated – it has to deal with procurement, production, distribution/service, and safety/sanitation – all of which are interrelated. Therefore, quality improvement strategies should be developed from a holistic point of view with engineering expertise: food service professionals in hospitals need to continuously research, plan and manage production processes to improve quality of products and efficiency of processes.
More chefs must be trained in culinary nutrition (thankfully happening out in IT Tallaght) and empowered as valued team members in hospital food service quality management who can communicate with patients.
Potential impact
If we could radically improve the food environment within hospitals, what impact would that have on both staff and patients?
Hospital food is often hardly recognisable as nourishing food, but rather as a source of “safe” calories. Food safety dominates our food production and is prioritised at all costs – often at the expense of pleasure, culture and consumption. In addition, patients face a myriad of problems: inappropriate eating positions, food left out of reach, sounds, smells and cold temperatures that negatively affect food intake. Research shows that energy intake is improved among patients eating at a table rather than in bed – ideally patients should eat communally unless they are completely bed-ridden, which would inevitably help with access, palatability and food waste. All of these principles should form part of a culinary medicine philosophy.
We should take the “ounce of prevention” approach. I think we can all agree that the rising cost of healthcare is unsustainable and that the economic burden of diet-related noncommunicable health risks and diseases is growing. Yet, while there is an obvious lack of healthy food procurement and promotion policies in institutions, worksites, schools and Government, it seems blindingly obvious to many of us that prevention is better than cure. For many patients, nutritious food is medicine.
But what about detractors who say food is not medicine? That it doesn’t matter if you get the iron and folate from cereals or whole foods – what’s important is just to get the nutrients. And this is where the arguments start to fall down: we know that iron is a mineral that serves several important functions such as carrying oxygen throughout your body and making red blood cells. However, although synthetic nutrients are almost chemically identical to those found in whole foods, the production process is very different to the ones found naturally in plants and animals. So despite the similar structures, your body may react differently to synthetic nutrients, especially when it comes to absorption.
When you eat whole foods, you’re not consuming single synthetic nutrients, but rather a whole range of vitamins, minerals and enzymes that work synergistically to improve absorption: synthetic nutrients are unlikely to be used by the body in the same way. Take vitamin E, for example: studies show that natural vitamin E is absorbed twice as efficiently as synthetic vitamin E.
National wellbeing
If clinicians better understood food and its importance to health and wellbeing, and made that understanding available to patients, families and healthcare systems for high-impact, low-cost, high-value care, then what effect would that have on the health of our nation?
And before you think I am suggesting that chewing parsley could replace a surgery, consider the following: is it wrong to think of food as medicine? Does it do a disservice to both food and medicine? Possibly – because in reality, food is so much more than medicine: it’s social, it’s cultural and it’s a huge part of our lives. It is not just fuel and it is much more than nutrients – but overemphasising the immediate impact of eating a “superfood” whilst ignoring long-term eating habits misses the mark. Eating “junk” food – occasionally – is very different to the impact on health when repeated regularly and combined with other unhealthy lifestyle habits (lack of sleep, insufficient exercise, smoking, drinking, stress).
Food is a significant human exposure and those of us fortunate enough to have food to eat every day can use it to impact our general health and wellness, including the prevention (or promotion) of chronic illness, and the management of virtually all diseases.
Food can definitely be medicine.
Too frequently though, the power of healthful eating is underrecognised or underapplied. Guidance related to food is not often part of a physician’s armamentarium. This needs to change.
We need food education for our children and the best food environments for our hospitals.