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The White Coat Hanging Next to the Skeleton in the Closet: Medically supervised starvation is NOT good medicine

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An op-ed piece recently appeared on the New York Times website that brought to attention the ingredient list in medical food supplements being offered in hospitals to sick patients who are having trouble eating. The piece was written by a second-year internal medicine resident at the Hospital of the University of Pennsylvania. I love it when physicians express their concern surrounding the nutritional quality of the food their patients are eating (and I happen to work with a LOT of them). We are living in an era where people are demanding more than ever to know what is in their food and how it affects their health and well-being. But this piece has some serious and dangerous implications.

Take a minute to read it.

The piece laments the “sugary shakes” provided to patients who are suffering from malnutrition in the hospital. The products (think Ensure and Boost) are medical foods formulated to help patients meet nutritional needs by packing in complete nutrition (protein, carbohydrate, fat, and vitamins and minerals) in a small, tasty, easy to drink shake.  They are usually given to patients who aren’t tolerating or don’t want to eat regular food due to a severe decrease in appetite or medication side effects (eg., mouth sores from chemo).

In a well-intentioned (but misguided) attempt at promoting a whole-foods approach to healthy eating, this physician’s op-ed appears to be muddling together two totally different problems in the field of nutrition: protein-calorie malnutrition (or simply “malnutrition”) in the hospitalized patient and the nutritionally inadequate diet of the patient in the community (where we assume they are well or at least medically stable despite having some chronic conditions). No doubt, hospital food could be improved upon, as could the standard American diet. But I wonder – is the malnourished patient in the ICU the appropriate example to use to spark this discussion?

More concerning, the piece is also completely overlooking the entire field of clinicians with expertise in treating both of these nutrition problems: registered dietitian nutritionists (RDNs). An RDN is the one clinician whose primary role is to address problems with eating and nutritional quality and effectively treat malnutrition.  Physicians should be consulting the nutrition experts that the Joint Commission mandates be on staff in hospitals for this very reason. Most physicians just don’t have the knowledge base in clinical nutrition to address it adequately in their hospitalized patients, nor the time to make a big impact on a patient’s eating habits during a clinic visit. This is not to say they aren’t extremely well-trained, intelligent, and dedicated providers. They just aren’t trained in nutrition. An alarming 75% of physicians received no nutrition education in medical school, and those who did get the education took a single course in the field3,4. The knowledge of nutritional characteristics of food, human physiology in health and illness, digestion and absorption, and counseling strategies for supporting patients in implementing lasting behavior change set up dietitians to be food and nutrition experts –  the first line of support physicians should be leaning on when faced with a nutrition problem like malnutrition.

I imagine every dietitian reading the piece started pulling out their hair when they read that “with each passing day, [the physician] watched [the ICU patient’s] legs grow thinner and thinner, his energy wane.”

That’s because malnutrition is a very real and very dangerous problem in our healthcare system, and has been for decades. It occurs when a patient’s overall calorie intake is reduced to the point where the body is forced to break down its own muscle to provide adequate energy to sustain life. This can be due to a loss of appetite or inability to eat because of some physical, cognitive, or emotional problem (difficulty chewing or swallowing, chronic nausea, memory problems, loneliness). Acute and chronic illness (like cancer or heart failure) can also lead to malnutrition. Malnutrition can worsen a chronic or acute illness, prolonging hospital stays, and impairing healing and recovery after illness or surgery. Also important to note, the patient doesn’t always look the part – a patient with obesity may be malnourished when severely reduced calorie and protein intake lead to the depletion in lean mass that is associated with the adverse effects listed above.

Are a few boxes of Ensure at the bedside going reverse malnutrition (a condition that 20-50% of hospitalized patients are admitted with or develop during their hospital stay1)? Of course not. But oral nutrition supplements are just one component of the nutrition therapy provided by RDNs to malnourished patients. An RDN consult would result in a full assessment of the patient’s food intake, dietary restrictions and preferences, any recent or chronic changes in weight, the patient’s ability to adequately chew food and safely swallow food and liquids, and gastrointestinal problems such as nausea, vomiting, constipation, or diarrhea. RDNs review medication lists, bloodwork, and anthropometric measurements, and perform nutrition-focused physical exams to assess for muscle wasting and nutrient deficiencies. A nutrition diagnosis of malnutrition could be made when the patient meets specific criteria related to weight loss, quantity and quality of food intake, and the physical appearance of muscle and/or fat loss. The RDN would then intervene with behavioral, dietary, and supplemental treatments designed to get the calories in while addressing the barriers to eating (for example, some patients won’t touch their food unless a certain family member is sitting next to them). In severe cases of malnutrition, an alternative to eating by mouth is needed and a feeding tube would be recommended and managed by the RDN (the life-saving formulas for which are provided by the “food giants” Nestle and Abbott).

An oral nutrition supplement like Boost or Ensure (of which, by the way, there are higher protein versions, as well as specially formulated versions for people with diabetes, kidney disease, and gastrointestinal disorders) provides us the confidence to know that our patients are actually getting the calories, protein, and other nutrients they need to prevent or treat malnutrition.

Oral nutrition supplements are heavily researched and their effectiveness in preserving lean mass in hospitalized malnourished patients is well documented in the medical literature. To deny that is to turn one’s back on evidence-based medicine, the foundation of modern day medicine.

These products are literally life-saving.

Any call for more attention to be paid to the food we serve sick people in hospitals is welcomed with open arms by most RDNs in the clinical realm. RDNs practice and preach “food first” whenever possible. The op-ed’s author suggests smoothies, yogurt, and almond milk for patients who need more protein. We can usually make a smoothie happen for hospitalized patients on a case by case basis, even in large facilities. But providing fresh smoothies for every hospitalized patient is not feasible. Problems that make this prohibitive include the cost of the food and the labor, food safety concerns (cross contamination), and the potential for recipe noncompliance by food service staff. Imagine the sheer amount of time it would take to make 500 smoothies at lunchtime. Almond milk is a terrible source of protein (1 gram per 8-ounce serving) and can have as little as 30 calories per serving, making it a subpar food choice for treating malnutrition.  Yogurt, while being higher in protein than almond milk, still doesn’t qualify as an acceptable alternative to a complete meal replacement shake (although it’s a great snack and available at pretty much any hospital). Probiotics are wonderful, but many oral nutrition supplements have prebiotics. Prebiotics may support the growth of beneficial gut bacteria even more effectively than certain probiotics strains2.

We need more physicians who truly care about the food their patients are eating. But these doctors don’t have to re-invent the wheel! RDNs share the passion for nutrition education and are a physician’s great untapped resource for evidence-based nutrition information for patients in the hospital and in the clinic.

I worry that the physician-approved bashing of a medical food supplement whose effectiveness in treating a life-threatening condition is supported by a lot of scientific evidence was a huge missed opportunity to address the very real problem of adequate nutrition provision and education in our healthcare system and the community.

 

Courtney

 

 

1Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. (2013). Nutrition in the hospitalized patient. J of Hosp Med. 8(1): 52-58.

2Schrezenmeir, J, and de Vrese, M. (2001). Probiotics, prebiotics, and synbiotics – approaching a definition. Am J Clin Nutr.  73(2): 361s-364s

3Kahan, S. Manson, JE. (2017). Nutrition Counseling in Clinical Practice: How Clinicians Can Do Better. JAMA. 318(12):1101-1102

4Plush, C, Delgado, V, Lin, E. (2017). Registered dietitians as physician extenders in nutrition counseling. Bariatr Surg Pract Patient Care. 12 (4): 143-144

 

 

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