"Food as Medicine: Integrating the Science of Nutrition into Healthcare" by Leah Harrigan

Food as Medicine: Integrating the Science of Nutrition into Healthcare

Leah Harrigan, Macaulay Honors College CUNY


Abstract: The U.S. Burden of Disease Collaborators found that a poor diet is the leading risk factor for death (2018). About 50% of adults have a cardiovascular disease; over 70% of adults are overweight or have obesity; and about 11% of Americans have diabetes (USDA & HHS, 2020 & Virani et al., 2021). Recently, obesity was identified as a major risk factor for COVID-19 severity and mortality (Demeulemeester et al., 2021). It is evident that diet-related disease is one of the greatest disruptions to the health of Americans.

This epidemic of diet-related disease can be controlled if physicians use nutrition as a form of prevention and treatment. However, physicians are not incorporating nutrition into their healthcare practices as much as they should. This paper will argue that physicians should embrace nutrition as a form of prevention and treatment for diet-related diseases and explore how nutrition can be optimally integrated into healthcare.

This paper will examine the barriers that prevent physicians from using nutrition in healthcare such as the sensitive nature of weight-centered conversations. It will then utilize the scientific literature, medical case studies, and interviews with physicians to support the argument. Moreover, different methods to seamlessly integrate nutrition into healthcare will be investigated. Overall, this project will reveal how uniting nutrition and healthcare can create a new community of physicians who are equipped to mitigate the prevalence of diet-related diseases.


 

The Rise of Diet-Related Diseases

Today, 60% of the adult population in the U.S. has one or more preventable, chronic, diet-related diseases. These diseases include cardiovascular diseases, obesity, type 2 diabetes, liver disease, and some cancers (USDA & HHS, 2020). About 50% of adults have a cardiovascular disease (1); over 70% of adults are overweight or have obesity; and about 11% of Americans have diabetes (2) (USDA & HHS, 2020 & Virani et al., 2021). The U.S. Burden of Disease Collaborators found that a poor diet is the leading risk factor for death (2018). Recently, obesity was identified as a major risk factor for COVID-19 severity and mortality (Demeulemeester et al., 2021). In a study of individuals with obesity living in New York City (NYC), researchers found that those with a BMI between 30 and 34 were about two times more likely to be admitted to critical care after testing positive for COVID-19 compared to those with a BMI less than 30. Those with a BMI greater than 35 were about three and a half times more likely (Satter et al., 2020).


Thesis & Methodology


In a time when most U.S. adults are living with a diet-related chronic disease, it seems intuitive that physicians should be striving to address the primary cause: nutrition (USDA & HHS, 2020). Yet, as physicians continue to focus on solving individual symptoms rather than the root causes of disease, treatments like medication and surgery often overshadow dietary interventions. While physicians acknowledge that nutrition is an essential aspect of health, nutritional advice, or more holistic perspectives on disease intervention, are often neglected. As the epidemic of chronic, diet-related diseases continues to worsen, nutrition must be merged more tightly into healthcare (3). This paper argues that physicians should embrace nutrition as a form of prevention and treatment for diet-related diseases. It will also explore how nutrition can be optimally integrated into healthcare. The scientific literature was reviewed regarding the impact of diet on human health and medical case studies of patients who have been treated with nutrition to manage or reverse their diseases will be analyzed to serve as evidence, and four NYC physicians (4), both MDs and DOs, in different specialties, were interviewed to provide expert opinions on nutrition in healthcare.

Barriers to Using Nutrition in Healthcare


Nutrition is central to all aspects of health and especially interconnected with diet-related diseases. Therefore, it is incredibly important for physicians to understand nutrition and be equipped to educate their patients about it. However, most physicians are not providing nutrition counseling to their patients nor are they using nutrition as a form of prevention and treatment for diseases (Kolasa & Rickett, 2010). Physicians only offer nutrition counseling in 12% of all encounters and 20% of encounters with patients at risk for diet-related diseases (Kahan & Manson, 2019). Accordingly, it may be presumed that physicians are not willing to use nutrition, but that is not always the case. Many physicians support using nutrition and believe that patients would benefit from this form of counseling. After all, more than one-quarter of all visits to primary care physicians (PCPs) are due to nutrition-related concerns (Kolasa & Rickett, 2010). Unfortunately, numerous barriers prevent physicians from using nutrition in their practices at all or to the extent that they would like. Lack of nutrition education in medical training, time pressures imposed by insurance reimbursements, and the sensitive nature of weight-centered conversations all result in the scarce application of nutrition in the practices of physicians.

Lack of Nutrition Education in Medical Training

Research by Adams, Butsch, & Kohlmeier that surveyed 121 U.S. medical schools found that students received an average of 19 hours of nutrition education over their four years of study (2015). When physicians were asked how much nutrition education they received in medical school, the answer was unanimous: “very little.” Dr. Godwin-Gorga denoted that nutrition was often considered in the context of certain diseases or biological processes, but she estimated that her medical school dedicated only one to two hours to the foundations of nutrition science. In a study by Vetter et al., 94% of physicians claimed that it was their obligation to review nutrition with patients, but only 14% of them felt adequately trained to facilitate those discussions (2008). Clearly, the widespread deficiency in nutrition education during medical training has led to low confidence and in turn, increased hesitancy to address nutrition with patients.

Time Pressures Imposed by Insurance Reimbursements

The deficiency in nutrition education is compounded by the fact that physicians face a lack of time to provide comprehensive care. In fact, every physician interviewed reported time as a hindrance to providing nutrition counseling. This comes as no surprise, as the median visit length with a PCP is about 15.7 minutes (Seale et al., 2007). Physicians, particularly in primary care, are restricted to rapid visits because insurance companies do not financially incentivize to meet with patients for longer. Moreover, preventive care services are not reimbursed well. Reimbursement for nutrition counseling, specifically, is not widespread nor consistent among insurance companies, steering physicians away from both offering nutrition counseling and referring patients to dieticians (Kahan & Manson, 2019). Dr. Nestler expressed that she speaks about nutrition with all her patients during annual checkups, but she frequently finds herself in a race against time as she also must cover their existing medical problems, sleep, development, school, screen time, and more. With such a tight schedule, physicians are forced to triage the medical concerns of each patient, addressing the most pressing ones first, often leaving preventive measures, including nutrition, entirely out of the conversation.

Sensitive Nature of Weight-Centered Conversations

Additionally, the sensitive nature of weight-centered conversations is a notable hurdle that prevents physicians from using nutrition in healthcare. If physicians wish to provide guidance about nutrition, the discussion may naturally touch upon weight: a deeply personal topic for many patients. The topic of weight often elicits feelings of guilt, shame, and failure. Patients may not want to bring up their weight and ask for nutritional advice because they fear being judged by their physician or blamed for their weight. “Please Don’t Weigh Me” cards have recently become popular among patients to avoid the anxiety-inducing topic. Dr. Fatima Cody Stanford, an expert obesity medicine physician-scientist, empathizes with patients, but ultimately argues that these cards further perpetuate the reluctance to address weight, which is an important medical data point. Instead, she suggests that the cards should request physicians to forgo derogatory, weight-related comments, thus creating productive and judgment-free discussions about weight (Fallik, 2022).

Sometimes, physicians are the ones who do not want to initiate weight-centered conversations, as they worry about insulting their patients. Dr. Nestler explained that some physicians tend to sugarcoat their concerns or brush over uncomfortable topics to avoid hurting their patients’ feelings. Although a BMI (5) of 25 or higher is classified as overweight, a study found that less than half of patients who are in this BMI range were informed that they are overweight by their physician (Post et al., 2011). This is startling because addressing weight is imperative, particularly if a patient is overweight or has obesity. If physicians attempt to evade delicate discussions about weight, patients may assume that their weight is not a problem, possibly prolonging unhealthy behaviors.

However, this is an approach not shared by all medical providers. Dr. Lerner asserts, “when it comes to informing patients about potentially healthy interventions, I am not shy about [empowering them to know the reality of their health] (2016).” Researchers found that when doctors told patients that they were overweight or had obesity, those patients were more likely to attempt weight loss compared to other patients whose doctors did not inform them (Post et al., 2011). These findings emphasize how crucial it is for physicians to learn how to approach weight-centered conversations in a compassionate manner. The challenges of navigating these conversations, among other barriers, may be holding physicians back from embracing the use of nutrition, ultimately doing a disservice to the health of patients.

Addressing the Efficacy of Nutrition Research

Once these barriers to using nutrition in healthcare are overcome, physicians should aim to incorporate nutrition in their practices because of its myriad of benefits. Yet, before presenting the current body of scientific literature as evidence, criticisms regarding the efficacy of nutrition research must first be confronted. One issue is the shortage of double-blinded randomized controlled trials (6). The lack of blinding is concerning as it can lead to bias, possibly skewing results. In studies of nutrition, blinding is simply not possible because participants must see the food that they are consuming (Weaver & Miller, 2017). Another problem is that many studies are not conducted for time periods long enough to observe the full potential of a food’s effect on health. Unfortunately, study lengths are limited by funding and the challenge of enforcing the consumption of the same foods for an extended time (Weaver & Miller, 2017).

Due to the aforementioned concerns, many physicians opt not to utilize nutrition as modern medicine relies on an evidence-based approach (7) to patient care. However, it is not reasonable to disregard successful nutritional interventions on the basis of weak evidence due to inherent limitations of nutrition research. Dr. Kevin Jubbal, a former surgeon, remarked that in a black and white approach to medicine, nutrition is the gray area. He asserted that although the results of nutrition research are often unclear, by approaching nutrition with nuance and devising individualized treatment plans, nutrition can lead to clinically significant improvements (Jubbal, 2022). After all, evidence-based medicine isn’t strictly confined to what the research suggests, rather it uses the strongest available evidence combined with sensible decision making, risk assessment, and consideration of the patients’ preferences (Johnston et al., 2019).

Benefits of Nutritional Interventions in Clinical Practice

Prevention of Diet-Related Diseases

Despite the difficulty of recording accurate nutrition research, using nutrition in healthcare may play an integral role in preventing, treating, and reversing disease. The ability of nutrition to prevent disease is arguably its greatest strength, as it can eliminate the need for a multitude of medical treatments. Just as vaccines can prevent infectious diseases and the encouragement of smoking cessation can prevent lung cancer, good nutrition can prevent diet-related diseases.


There is convincing nutrition research, both observational and experimental, as well as case studies, which uncover how nutrition is a scientifically and clinically sound method to prevent diet-related diseases. For example, one study that followed over 3,200 individuals at high risk for developing type 2 diabetes gave participants one of three treatments: a placebo; metformin: a drug used to prevent diabetes; or lifestyle modifications including a healthy diet. When the researchers followed up with participants about three years later, those who adhered to lifestyle modifications reduced their incidence of diabetes by 58%, while those given metformin reduced their incidence by 31% compared to those who had the placebo. Researchers concluded that lifestyle modifications were significantly more effective than metformin at preventing the incidence of type 2 diabetes (Diabetes Prevention Program Research Group, 2002). In a follow-up study 10 years later, the researchers found that those in the lifestyle modification group maintained the lowest cumulative incidence of diabetes compared to both the metformin and placebo groups (Diabetes Prevention Program Research Group, 2009). These results have been corroborated by a 2016 study that found consuming a plant-based diet (8) reduced the risk of type 2 diabetes by 20% and consuming a plant-based diet with particularly high-quality plant foods was even more beneficial as it reduced the risk by 34% (Satija et al., 2016). These are just a couple of many studies (9) that validate how nutrition is an effective clinical tool to prevent the onset of diseases, especially diet-related diseases.

Treatment & Reversal of Diet-Related Diseases

Nutritional interventions are unique as they can be used not only to prevent, but also to actively treat and reverse diseases. Dr. Caldwell B. Esselstyn, renowned cardiologist, researcher, and director of the Heart Disease Program at The Cleveland Clinic shared a case study of a 44-year-old man with heart disease and high cholesterol who was treated with a plant-based diet without the use of cholesterol-lowering medication. Before treatment, a fatty material called plaque was built-up in the patient’s coronary artery, inhibiting blood flow to his heart. After adhering to the plant-based diet rather than his typical American diet (10), the amount of plaque regressed, normal blood flow was restored, and thus he reversed his heart disease in just 32 months (Esselstyn, 2001). Scientific literature supports individual case studies like this one, revealing how nutritional interventions both halt disease progression and reverse the state of disease in patients. In 1998, The Lifestyle Heart Trial was the first randomized clinical trial to examine if comprehensive lifestyle changes could reverse the progression of coronary heart disease. The study found that patients with coronary heart disease who went through intensive lifestyle changes, which included a 10% fat, whole-food, vegetarian diet (11) with no medication usage, were able to reverse the state of their disease, while those in the control group, who used lipid-lowering drugs without lifestyle changes, continued to experience disease progression (Ornish et al., 1998). Both the case study and The Lifestyle Heart Trial underscore how dietary changes offer a way to target a primary cause of heart disease: a poor diet, allowing for the reversal of the disease.

Healing the Root Causes of Illness

Though medications and surgeries are often limited to treating one disease at a time, nutritional interventions can ameliorate several diseases at once. Dr. Mark Hyman, family medicine physician and leader in the field of functional medicine (12), discussed an interesting case study to illustrate how dietary changes can tackle the underlying cause of illness, therefore resolving many health conditions in tandem. A 60-year-old woman with obesity, heart failure, type 2 diabetes, coronary artery disease, and early kidney failure was taking numerous medications to mitigate each of her conditions; she even had already endured heart surgery. After only three months of treatment with an anti-inflammatory (13), low-sugar, low-starch, whole-food diet, she lost a significant amount of weight and was able to stop taking all her medications. Her blood sugar, blood pressure, and cholesterol improved. She also reversed her heart failure, fatty liver, and failing kidney. In a year, her diabetes disappeared (Hyman, 2020). It is apparent that nutritional modifications can transform an individual’s overall health by simultaneously treating multiple diet-related diseases.

Improvement of Other Health Conditions

As discussed, nutrition can certainly treat diet-related diseases, but its applications are far-reaching as it can also be used to improve other health issues. For example, Dr. Rosenthal, whose patients present with injuries or disabilities, explained that she prescribes food as medicine to help them manage various pain concerns. By guiding patients through a plant-based diet treatment plan, their pain is controlled, inflammation is reduced, injuries are prevented, and medications are no longer needed. She advocates for lifestyle medicine, which includes using nutrition, as the most responsible and ethical way to treat patients. Dr. Helen Cappuccino, a breast cancer surgeon says, “I don't want my patients to need surgery or medicine. To the extent I can forestall these choices by better eating habits, I want my patients to understand this,” she continues, “I spend a lot of time talking to them about factors that they can control, including diet… maintaining optimal body weight… (DeLuca, 2020 & UB, 2020).” Clearly, Dr. Cappuccino is passionate about using food to help her patients either prevent cancer entirely or manage the severity of existing cancer. Overall, nutritional interventions are versatile, and physicians may consider their use for illnesses beyond diet-related diseases. The overwhelming scientific evidence and clinical success of nutrition as an effective tool to prevent, treat, and reverse disease should motivate physicians to use nutrition in their practices.

Cost-Effectiveness

On top of clinical benefits, nutrition is an incredibly cost-effective treatment. Researchers predicted that if Medicare and Medicaid offered a 30% subsidy on healthy foods (14) to its beneficiaries, over their lifetime, it would increase healthy food consumption, prevent about 3.3 million cardiovascular disease events, prevent over 120,000 cases of diabetes, and save an astonishing $100.2 billion in healthcare costs (Lee et al, 2019). These findings underscore how nutrition can prevent or manage diet-related diseases while also dramatically reducing healthcare costs.

Integrating Nutrition into Healthcare

Improving Medical Education to Include Nutrition

For physicians to embrace the use of nutrition as a form of treatment and prevention, nutrition must first become fully integrated into healthcare. There are several methods by which this can be done; the most immediate way is to improve medical education to sufficiently teach nutrition. The urgency to do so is exposed by the most recent study on the state of nutrition education in U.S. medical schools. Out of 121 surveyed schools, 71% do not meet the recommended minimum of 25 hours of nutrition education and 36% provide fewer than 12.5 hours of nutrition education (Adams, Butsch, & Kohlmeier, 2015).

I will begin by examining how some medical schools have incorporated nutrition into their curriculums to determine if there is an optimal approach to delivering nutrition education. Feinberg School of Medicine at Northwestern is one of few schools that has revised its traditional curriculum to better reflect the importance of diet on health. The updated curriculum now discusses nutrition longitudinally (throughout the four years of medical school), allowing students to merge nutrition with each area of study. Early outcomes of this redesigned curriculum have already reported that students are more confident speaking about sensitive topics with patients (Heiman et al., 2018). This finding conveys that this method of incorporating nutrition into medical education may prepare students to raise delicate, weight-related health concerns that often lead to conversations about proper nutrition.

Rather than establishing longitudinal nutrition education, some schools have introduced separate courses to address nutrition on its own. For example, several years ago, Harvard Medical School had opted to offer a distinct course in nutrition called Preventive Medicine and Nutrition (PMN) in the second-year curriculum. Researchers concluded that the completion of the PMN course significantly increased the confidence of medical students to assess and counsel patients on diet and exercise (Conroy et al, 2004). More recently, Harvard Medical School has transitioned to an integrated nutrition curriculum like that of Feinberg School of Medicine. When researchers compared the attitudes and knowledge about nutrition of medical students that had taken the dedicated PMN course to those that experienced an integrated nutrition curriculum, they found a similar positive impact (Walsh et al., 2011). It is evident that including some form of nutrition education in medical school is imperative to heighten understanding of nutrition concepts and boost confidence in addressing nutrition in practice. However, the comparable outcomes of students who experienced completely different structures of nutrition education indicate that the way nutrition is fused into the curriculum is not a major concern. Instead, schools should focus on delivering high-quality and comprehensive nutrition education, using whichever method of implementation works best for their program. Schools must also recruit more expert nutrition educators, such as registered dieticians, to provide medical students with exceptional lessons on clinical nutrition (Kushner et al., 2014). This is especially important because if the faculty is not proficient in nutrition concepts, students will not grasp the material, regardless of the strength of the curriculum.

Many schools have not yet combined nutrition into their core curriculum, but instead, provide nutrition education as an elective course. In fact, over 55 medical schools in the U.S. now offer culinary medicine electives based on the Health Meets Food curriculum. This science-based curriculum teaches students about the benefits of nutrition and how dietary intervention strategies can be used in the practice of medicine to prevent and manage diseases (Culinarymedicine.org, n.d.). Although offering an elective course is better than having no course at all, not requiring all students to learn nutrition signals to me that these medical schools still don’t value nutrition enough to include it in the core curriculum. Moreover, outsourcing the Health Meets Food curriculum suggests that medical schools are lacking nutrition experts in their faculty to develop their own nutrition education curriculums. As such, all medical schools should begin to implement nutrition education into their core curriculum to better equip the next generation of physicians to address diet, prevent diet-related diseases, and offer nutrition as treatment.

Collaboration between Healthcare Providers and Nutrition Experts

Even if physicians are appropriately trained in nutrition, it does not guarantee that they will always be able to offer dietary counseling. To ensure that nutrition is fully blended into healthcare, there must also be greater collaboration between different healthcare providers and nutrition experts. Physicians, nurses, physician assistants, dieticians, nutritionists, and others should all strive to work together to raise nutrition with patients. Dr. Lerner insisted that physicians need enough nutrition education to at least be able to initiate conversations about the importance of a healthy diet. Nevertheless, he admitted that he is not a nutrition expert and enlists the help of nutritionists if patients need in-depth dietary advice. Dr. Lerner makes a valid point that no matter how detailed and extensive nutrition education is during medical school, physicians will not become experts in the field of nutrition. Physicians must know when to call upon the specialists to take the lead in nutrition-related care for patients.

Likewise, Dr. Nestler said that she and her colleagues often refer patients to nutritionists as well. However, she disclosed that while the intent of referring patients to nutritionists is to ensure that patients receive dietary counseling, she finds that whether her patients follow through with scheduling these visits is unpredictable. Dr. Nestler noted that frequently patients do not end up making appointments with a nutritionist. Dr. Lerner added that referrals to nutritionists are often not covered by insurance, which can impede patients from ultimately receiving pertinent nutrition counseling. It is possible to argue that physicians need to receive a strong enough foundation in nutrition to impart basic counseling at the minimum. Equally important is teaching physicians how to recognize when it is appropriate to refer patients to dieticians or nutritionists who can provide a thorough assessment and an individualized nutrition plan. Dr. Lerner and Dr. Nestler agree that, though collaboration between providers will promote the integration of nutrition into healthcare, patient compliance and insurance coverage remain significant challenges.

Initiatives to Encourage Healthy Eating

Along with increased collaboration between healthcare providers, hospitals and clinics should launch more initiatives that motivate patients to make healthier food choices. In the following section, I will present several examples of such initiatives which may serve as models for other medical centers.

Dr. Nestler mentioned that her hospital, NY-Presbyterian/Weill Cornell Medical Center, has a program called the “Kids and Teens Healthy Weight Program,” which is a series of free group sessions that educate patients about healthy eating through interactive activities such as cooking healthy meals, assembling meal plans, and reading nutritional labels (Weill Cornell Medicine, 2021). I believe that group-based programs like this one should serve as models for other hospitals as they allow physicians and dieticians to efficiently address the nutritional concerns of several patients at once while still giving personalized support in an intimate setting.


University of California San Francisco’s Benioff Children’s Hospital goes even a step further. In addition to providing health education and cooking demonstrations, it offers a Food Farmacy program twice a month, supplying patients and their families with whole grains, fruits, vegetables, eggs, and protein at no cost (UCSF, n.d.). This program is immensely valuable in the community as it helps patients who typically consume an abundance of inexpensive, processed foods to overcome their food insecurity by giving them access to nutritious foods, allowing them to improve their diets and prevent diseases. It is worthwhile to note that both initiatives mentioned so far are targeted toward pediatric populations. Dr. Rosenthal expressed that she believes combating the rise of diet-related diseases starts with the education of young children. I agree that building programs for children should be a high priority because creating awareness around nutrition at a young age will influence these individuals to develop lifelong healthy eating habits, maximizing their likelihood of preventing diet-related diseases.

In 2019, Bellevue Hospital in NYC launched the Plant-Based Lifestyle Medicine Program to treat patients with chronic, diet-related conditions, including heart disease, type 2 diabetes, obesity, high cholesterol, and high blood pressure. The program is guided by physicians and dieticians who create personalized whole-food, plant-based diets to address the root causes of disease. Beyond food, it focuses on increasing physical activity, reducing stress, and improving sleep health (NYC Health + Hospitals, n.d.).

The program is even conscious of patients’ socioeconomic circumstances and cultural traditions (NYC, 2022). Being culturally mindful is also extremely important. Dr. Godwin-Gorga suggested that when physicians recommend specific diets to their patients, they should always stress that aspects of any diet can be adapted to any ethnic cuisine. In this way, patients may feel that eating nutritiously is attainable and will be motivated to actively modify their diet. Another strength of this program is the frequent check-ins and the manageable benchmarks that help patients gradually achieve their health goals (NYC Health + Hospitals, n.d.). In turn, this boosts compliance with dietary recommendations and ensures that these healthy practices are sustainable long-term. Just three years since its initiation, the Plant-Based Lifestyle Medicine Program announced this year that it will expand to six more public NYC healthcare centers throughout the five boroughs (NYC, 2022). The successful health outcomes of this nutrition treatment program and its quick expansion through the NYC Health + Hospitals system are exciting as it demonstrates that physicians and healthcare institutions are starting to embrace nutrition as a legitimate tool to prevent and treat disease. The formation and adoption of more nutrition-focused programs in medical centers across the country will be needed to finally bridge the gap between nutrition and healthcare to promote the well-being of patients.

Conclusion

Overall, many barriers prevent physicians from using nutrition in their practices. However, through the proposed solutions to integrate nutrition into healthcare some of those barriers can be overcome. The scientific literature and medical case studies consistently reveal how nutrition is an effective clinical tool to prevent, treat, and reverse diet-related diseases, emphasizing the need for physicians to embrace nutrition. By uniting nutrition and healthcare, there will be a new community of physicians who are equipped to mitigate the prevalence of diet-related diseases. As more physicians adopt the use of nutrition, the healthcare system can begin to not only value the treatment of disease, but more importantly, the prevention of disease and promotion of health.


Footnotes

(1) Cardiovascular diseases include coronary heart disease, heart failure, stroke, and hypertension.


(2) Over 90% of all diagnosed cases of diabetes are type 2 diabetes (CDC, 2020).


(3) For simplicity, “healthcare” will be referred to as one word throughout this paper. However, I acknowledge that typically, “health care” as two words refers to provider actions while “healthcare” as one word refers to the system. “Healthcare” will be used to refer to both provider actions and the system in this paper.


(4) Physicians were interviewed between December 13th, 2021 and February 2nd, 2022 in NYC. They are Dr. Chloe Godwin-Gorga, MD Family Medicine; Dr. Barron Lerner, MD Internal Medicine; Dr. Jane Nestler, MD Pediatrics; and Dr. Lillie Rosenthal, DO Physical Medicine & Rehabilitation. Two of the four physicians, Dr. Godwin-Gorga and Dr. Rosenthal, practice medicine with an integrative approach that considers the whole patient, including their lifestyle.


(5) BMI is the most commonly used, widely accepted, and practical measure of obesity because of its simplicity, low cost, and high specificity. However, public health scholars recognize that BMI does not differentiate between bone density, muscle mass, and body fat, which can sometimes lead to inaccuracies. To better assess disease risk, other markers of health should be considered along with BMI (Adab, Pallan, & Whincup, 2018 & Olsen, 2018).


(6) Double-blinded randomized controlled trials are the gold standard of clinical research. This research method reduces confounding variables and enables researchers to determine causal relationships (Weaver & Miller, 2017).


(7) An evidence-based approach ensures that patients receive treatments that have been repeatedly tested and have robust results to support their safety and effectiveness (Masic et al., 2008).


(8) A plant-based diet primarily contains foods from plants, including fruits, vegetables, nuts, seeds, whole grains, and legumes with a minimal number of animal-derived foods (Satija et al., 2016).


(9) See (Dahm et al., 2010), (Dehghan et al., 2012), (Estruch et al., 2013), (McGrievy, Mandes, & Crimarco, 2017), and (Micha et al., 2017).


(10) Although not specified in the study, the Standard American Diet (SAD) consists of foods that are high in refined carbohydrates, added sugars, sodium, and saturated fat; and low in fruits, vegetables, whole grains, lean protein, and healthy oils (Grotto & Zied, 2010).


(11) A whole-food, vegetarian diet includes foods that are minimally processed and does not include any meat (McEvoy, Temple, & Woodside, 2012).


(12) Functional medicine is an individualized, patient-centered, science-based approach that seeks to address the root cause of disease. Both a patient’s biology and lifestyle factors are examined to devise optimal treatment plans for long-term wellness (The Institute For Functional Medicine, n.d.).


(13) An anti-inflammatory diet is a style of eating that avoids ultra-processed foods that are high in salt, added sugar, refined grains, and saturated fat; and includes whole foods with no added sugar (Harvard Health Publishing, 2020).


(14) Healthy foods included in this incentive were fruits, vegetables, whole grains, nuts, seeds, seafood, and plant oils.

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