How Far Will MDs Need To Go on Population Health? Nutritional Advisement as a Barometer

Nov. 19, 2015
The recently published recommendations of the American Academy of Pediatrics around counseling parents about nutrition reflect a far broader reality, as U.S. healthcare shifts inevitably towards bigger-picture approaches to population health

An article this summer in the online publication MedPage Today alerted me to the fact that the American Academy of Pediatrics (AAP) had taken the formal position that pediatricians should take advantage of patient visits to advise their patients’ parents to encourage healthy eating in their children.

As the June 29 MedPage Today report by Jeff Minerd noted, “Pediatricians should advise families to replace the cookie jar with a fruit bowl and trade in soda for tap water or low-fat milk, according to new recommendations from the American Academy of Pediatrics (AAP) for preventing childhood obesity. The recommendations, published in the journal Pediatrics, lay out how pediatricians can be more proactive in helping families nip excess weight gain in the bud. ‘Because of the numerous medical and psychosocial complications of childhood obesity and the burden of pediatric obesity on current and future health care costs, this condition is now recognized as a public health priority by many groups and experts,’ wrote the authors, led by Stephen Daniels, MD, of the University of Colorado and chair of the AAP Committee on Nutrition.

And the report quoted Dr. Daniels’ statement in AAP’s press release, in which he said, "Even when families have knowledge of healthy behaviors, they may need help from pediatricians to motivate them to implement behavior changes. Pediatricians can and should play an important role in obesity prevention because they are in a unique position to partner with families and patients and to influence key components of the broader strategy of developing community support.”

Among the recommendations from the AAP were the following: parents should entirely remove sugar-sweetened beverages such as soda and iced tea from their children’s diets, substituting them with water and low-fat milk, with sparkling water, unsweetened flavored waters, and artificially sweetened drinks used as transitional beverages; parents should replace high-calorie foods in their children’s diets with low-carliorie foods such as vegetables, fruits, whole grains, low-fat dairy, lean meat and fish; they should encourage their children towards more physical activity, and less television and electronic game time; and so on.

Now, those recommendations are obviously nutritionally sound, and totally non-controversial. But what’s interesting to me about this development is several things. Let me unpack some of those elements here.

First, most physicians still aren’t getting much nutrition education in medical school, and those who do get nutrition education usually get it in the context of general pre-clinical education.  According to an article published earlier this year in the Journal of Biomedical Education, researchers did a survey of medical school leaders and found, among other things, that “The responding medical schools reported that they provide on average 19.0 hours of nutrition education... Over a third of the responding medical schools reported requiring 12 or fewer hours of nutrition instruction; twelve of those institution, 9 percent, required none. Less than a third (35 of 121, 29 percent) of the responding medical schools reported that they provide at least 25 hours of nutrition education across the four-year curriculum. In terms of enrollment, this means that 24.6 percent of all medical students get the minimum of 25 hours, while 16.1 percent of all US medical students (those enrolled at 24 schools) get 30 hours or more. Eight of these schools reported that they provide between 40 and 75 hours of nutrition education.”

Significantly, the authors of the article—Kelly M. Adams, W. Scott Butsch, and Martin Kohlmeier—noted that “Most reported nutrition education takes place during preclinical training, adding up to an average of 14.3 (SD 10.5) hours of instruction. The instructional hours of nutrition education are lower during clinical training with an average number of 4.7 (SD 6.2) required hours. This number of hours does not include various electives, seminars with voluntary attendance, or student-organized activities.”

What’s more, these statistics reflect what’s happening only now in medical school education. The reality is that the vast, vast majority of practicing physicians in the U.S. who graduated from medical school more than 10 or 15 years ago likely received almost no education on nutrition, apart from what they learned as individuals, apart from their medical training. And allopathic medicine in the U.S. remains strongly biased against honoring disciplines that fall outside allopathic medicine.

But here’s the interesting part: with healthcare costs continuing to rise in the U.S., and with rates of chronic illness, including among children, absolutely exploding, these days, physicians are going to have to get involved in nutritional counseling, at a high level (and of course then turn their patients, and patients’ parents, in the case of pediatricians, over to professional nutritionists in their practices and hospitals), moving forward.

What’s particularly interesting is the population health/accountable care angle. Because of these broader trends, we’re moving towards a situation in U.S. healthcare in which physicians are inexorably being pulled into broader discussions and broader efforts now. Simply writing prescriptions for medications and referring their patients for surgery, as has been typical in a fee-for-service-driven system, is no longer sufficient or satisfactory. Instead, as the healthcare system moves gradually but inevitably towards some version (or almost certainly, may different versions) of capitated payment, what physicians will need to do in their practices is also shifting.

That is particularly true as modified capitation-based payment contracts push doctors forward into areas that they have either not felt the need to be involved in, or even felt comfortable navigating. But if we say that population health-based care delivery is going to be patient-centric—or even better yet, “person-centric”—then hadn’t we best ensure that everything done in interactions with patients—with people—be done in a way that works to enhance the health of patients/people?

If the answer is yes, then physicians advising their patients on nutrition, or in the case of pediatricians, advising their patients’ parents on nutrition—becomes not only logical but really, imperative. To be clear, no one is going to expect the pediatrician to deliver a lecture in childhood nutrition. Instead, that physician will need to ensure that s/he initiates a conversation with the parent that can then be followed up by her/his staff, including nurses, dieticians/nutritionists, and others, as timely and appropriate.

Moreover, all these actions will inevitably become documented and calculated in some way. It’s interesting to look back on the arliest disease management programs, and to look at how far things are starting to move under some care management paradigms under population health and accountable care umbrellas.

So healthcare IT leaders will need to make sure that the population health, clinical decision support, data analytics (including both report-writing and physician dashboard elements), and other aspects of all the solutions intended to support this work, be as agile, interoperable, and easily modified as possible, because the parameters of all this work will continue to change over the next several years, sometimes quite rapidly.

 In the end, the American Academy of Pediatrics’ new guidelines represent a recognition of the emerging new reality in healthcare—a reality that stands in stark contrast to the siloed, very limited approaches of the past (and present still, in many care and operational environments). But change is coming, and coming fast. And everyone—including healthcare IT leaders—needs to prepare now, for the emerging new world.

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