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Doctored up

(article, Linda Shiue)

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The activist chef Jamie Oliver, the muckraking journalist Michael Pollan, and the food writer Mark Bittman all advocate cooking at home not just for its pleasures and rituals, but for its health benefits. 

Sure, it's great to see these celebrities extolling the virtues of everyday cooking. But they're cooks and writers, not medically trained health experts. And as a practicing physician myself, I'd like to see more doctors speaking up about the health importance of home cooking.

Of course, a few celebrity doctors — notably Dr. Mehmet Oz and Dr. Andrew Weil — are well known for their ability to reach the masses on the topic of better eating. Still, they're the odd men out, the exception to the general rule that doctors don't generally discuss healthy eating with their patients.

We're used to doctors checking our weight and assessing our cholesterol. So why don't doctors prescribe recipes, or cooking lessons, or grocery-shopping suggestions?

[%image veg float=right width=400 caption="'Just as patients are advised to increase their consumption of fruits, vegetables, and whole grains, it's time to incorporate this advice into meals served in health-care settings.'"]Because when it comes to nutrition, we physicians often fail to practice what we preach. Short on time, we frequently dine on junk-food snacks from hospital vending machines. And the food we provide our support staff is no better; their hard work might be rewarded with a cake or, worse, takeout fast food, as was the case in my office recently.

We don't eat any better than our patients, so it's no surprise that we lack credibility when it comes to doling out nutritional advice. Dr. Lenard Lesser, a colleague of mine at the Palo Alto Medical Foundation, says it’s time for health-care professionals to be better role models. 

“Food served at medical meetings does not seem to adhere to any nutritional guidelines," he says. "Just as patients are advised to increase their consumption of fruits, vegetables, and whole grains, it's time to incorporate this advice into meals served in health-care settings.”  

There are signs, however, that nutritional awareness is shifting in health care. Medical schools are starting to require nutrition courses. Cooking classes geared to doctors are popping up. And hospitals are overhauling their dreaded institutional fare, improving the eating experience for patients and staff alike.
h3. Educating medical students and doctors

Traditionally, nutrition has not been covered in medical school. While the National Academy of Sciences has recommended 25 hours of nutrition coursework since 1985, most medical schools fail to meet that minimum. In fact, a survey conducted by the University of North Carolina in 2010 showed that only 27 percent of U.S. medical schools did so, which was actually a decrease from 38 percent in 2004.

Nevertheless, some medical schools have tried to improve nutrition education. For the past two decades, the University of North Carolina has offered a free online curriculum called Nutrition in Medicine, which provides nutrition instruction for medical trainees at various levels of training and for practicing physicians as well.
More teaching hours, however, doesn't address a basic problem: the emphasis on the molecular study of nutrition instead of patient-focused practicalities. A 2012 literature review in the journal Teaching and Learning in Medicine revealed a profound lack of effort by medical schools to train students in such everyday skills as the specifics of what to eat, how to shop for food, and how to cook it at home. 
A few medical-school programs, however, have begun to leap this hurdle. New York University’s Langone Medical Center, for example, recently introduced a course for medical students called Cook Healthy, Eat Fresh. (The acronym, of course, is CHEF.) Graduate students from NYU's Department of Nutrition, Food Studies, and Public Health lead classroom sessions that give medical students an overview of the science and theory behind current dietary recommendations, and cooking classes are held at the department’s teaching kitchen. 
In Texas, Baylor University medical students Amy Cobb and Jasdeep Mangat co-founded the similarly named Choosing Healthy, Eating Fresh, a six-month elective for second-year medical students featuring monthly cooking classes from a local chef. 
And Tulane University in New Orleans recently established the Center for Culinary Medicine, a collaboration between Tulane's medical school and the culinary program at Johnson and Wales University. The center, which will include the nation's first teaching kitchen affiliated with a medical school, lists "hands-on, evidence-based education to medical students and community members on healthy, affordable cooking" as its chief goal.
Dennis Ren, a rising second-year Tulane medical student and the president of the teaching kitchen's medical-student club, thinks the culinary-medicine experience will make him a better doctor. “By participating in hands-on cooking classes, I'm able to give more specific and concrete dietary counseling to patients," he says. "For example, instead of advising a patient just to lower the amount of sodium in her diet, I can say, ‘Rather than using a lot of salt in your food, you can still bring out the flavor you want by using some acid like lemon juice, or by replacing some of the salt with Worcestershire sauce.’”

At New York’s Lenox Hill Hospital, newly minted doctors in the internal-medicine residency program can take a six-week course in nutrition, weight management, and exercise, including cooking classes. The program focuses on healthy and affordable food, mainly seasonal, plant-based whole foods. “Residents are the front line," says program founder Dr. Robert Graham. "They’re the ones seeing patients in clinic and taking care of patients in the hospital.”
As for physicians who've completed their training, there are programs for them, too, including at the University of Massachusetts and through Harvard University, where nearly a decade ago Dr. David Eisenberg created a continuing-education course titled '"Healthy During Eisenberg's four-day course, which meets each spring, doctors swap scalpels for chef’s knives and white coats for aprons as they attend cooking demonstrations and get hands-on experience in the kitchens of the Culinary Institute of America in California. 

Eisenberg isn't stopping with doctors; as he told the New York Times in a 2012 profile of his program, he's working on a prototype to replicate teaching kitchens in "the places that need them most: medical schools, hospitals, universities, public schools, and military bases."
h3. Improving hospital food
While some medical students and doctors are becoming more savvy about nutrition, health, and cooking, the options for patients can still be generally summed up with the dismissive phrase "hospital food." It's not just the unpalatable Jell-O cups; nutrition is often ignored, too. 

At the well-regarded academic medical center where I trained, my postpartum lunch tray included a plastic-wrapped, highly processed PB&J sandwich. And this type of offering is the norm. Vending machines in hospitals sell soda and candy, just as they do anywhere else, while hospitals that ban fast-food chains make headlines. 
Over the past few years, however, a few hospitals have overhauled their food services to address both nutrition and taste. One of those is New Milford Hospital in Connecticut, which adopted a seasonal, plant-based menu (think portobello burgers and quinoa as entrées). The hospital also developed a program called Plow to Plate, connecting local farmers and fishermen with hospitals, physicians, chefs, and community members.
Marydale DeBor, New Milford Hospital’s former VP of external relations, has launched a New Haven-based consulting firm called Fresh Advantage. With the slogan “Food is Primary Care,” the firm aims to guide other hospitals in transforming their “ancillary institutional food service to health-promoting food care — without increasing costs.”

The Affordable Care Act, DeBor says, has tightened requirements for not-for-profit hospitals to justify their tax status via community benefit. Promoting healthier eating and providing healthier food to patients, she feels, is a highly appropriate way to serve the community.
Meanwhile, other programs are tackling the hospital-food problem. Health Care Without Harm, for example, is an international coalition of hospitals, health-care systems, medical professionals, and community and environmental groups. The coalition, which began in 1996 after the Environmental Protection Agency identified the incineration of medical waste as the leading source of dioxin, now includes 480 organizations and lists reforming the food system as one of its goals. 

In 2005, Health Care Without Harm began its Health Food in Health Care Initiative to inspire the health-care industry to “become leaders in shaping a food system that supports prevention-based health care.” This includes coordinating the Healthier Food Challenge of the Healthier Hospitals Initiative, whose pledge to “provide local, nutritious and sustainable food” has been signed by more than 500 hospitals around the country. A 2012 downloadable report on the latter initiative showed that participating hospitals were serving 10 percent less meat, that hospital spending on healthier beverage choices had increased from 10 percent to over 60 percent, and that hospitals were obtaining 4 percent of their food from local and/or sustainable sources.

[%image reference-image float=right width=400 caption="Sometimes doctors can prescribe a diet re-do, rather than medicine."]A similar program was launched in 2012 by the Partnership for a Healthier America, of which First Lady Michelle Obama is the honorary chairwoman. Hospitals participating in the PHA’s Hospital Healthy Food Initiative program pledge to offer lower-calorie meals with an emphasis on plant-based foods.  Hospitals in the program need to meet specific food and nutrition standards. They also can no longer offer deep-fried food and must offer only healthy foods near cash registers, which means no more candy bars and chips. Sixteen private-sector health systems, which include more than 150 hospitals, have signed onto the program.

That's a lot of hospitals, and a lot of pledges to focus on prevention through applied nutrition education at every level. But will all these good intentions bear fruit — such as fresh sandwiches instead of processed PB&J on hospital trays? 

Next time you see your physician, ask what she's cooking for dinner. You might get her recipe for a favorite kale salad instead of a prescription for cholesterol-lowering medication. Or you might just send her home with something new to chew over: the back-to-basics concept of food education. 

p(bio). Dr. Linda Shiue is an internal-medicine physician at the Palo Alto Medical Foundation in the San Francisco Bay Area. She teaches healthy-cooking classes to patients and community groups and writes about food on her blog, Spicebox Travels. Follow her on Twitter: @spiceboxtravels.

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