David Eisenberg 00:00:00 Most Americans believe that physicians are trained to do this, that somebody is testing them in these competencies. The fact, though, is they're not.

Austin the Trail 00:00:20 Welcome to Off the Chart: A Business of Medicine Podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Littrell, I'm the assistant editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, we're talking about nutrition and specifically what physicians are taught about nutrition and med school. Medical Economics Senior Editor Richard Payerchin is joined by Dr. David Eisenberg, a board certified internal medicine physician, director of culinary nutrition at the Harvard T.H. Chan School of Public Health, founding co-director of the Healthy Kitchens, Healthy Lives Conference, and founder and former executive director of the Teaching Kitchen Collaborative. Dr. Eisenberg was also part of the team to publish proposed nutrition competencies for medical students and physician trainees, a consensus statement in JAMA Network Open recommending nutrition competencies in medical education specific to specialization to improve patient and population health.

Austin the Trail 00:01:13 If you're interested in reading more, you can find that article linked in the show notes down below. With that, Dr. Eisenberg, thank you again for joining us. And now let's get into the episode.

Richard Peyton 00:01:34 I'm Richard Payerchin reporting for Medical Economics. With me today is Dr. David Eisenberg, director of culinary nutrition and adjunct associate professor of nutrition at the Harvard T.H. Chan School of Public Health. Dr. Eisenberg, thank you for joining us today.

David Eisenberg 00:01:50 It's my pleasure, Richard. Thank you for having me.

Richard Peyton 00:01:54 And you have an extensive background in medicine just for the sake of maybe some of our readers and viewers who are not familiar with your background. Can you briefly introduce yourself and your training experience and research?

David Eisenberg 00:02:08 On paper, I'm a Harvard academic, researcher, clinician, educator, went to Harvard College, Harvard Medical School, did research fellowship at Harvard. but I'm actually the son of bakers from Brooklyn. And that's how I got into this curious field of bringing together people who make food cooks, bakers, etc., and medical educators, clinicians and nutrition experts.

David Eisenberg 00:02:41 so much of my life has been about connecting the two of them to see what they could learn from each other, teach each other, and hopefully help the larger community take better care of itself.

Richard Peyton 00:02:53 And I think that's a great introduction, both to your background and some of the concepts that I wanted to talk to you a little bit about. Hopefully today and to begin at the beginning, so to speak. Can you introduce the concepts behind lifestyle medicine? What is it and how does it fit into the contemporary US health system?

David Eisenberg 00:03:13 Well, lifestyle medicine is a very large umbrella. I prefer to focus more on teaching kitchens and culinary medicine if I can. Teaching kitchens are more than kitchens. The origins of teaching kitchens come exactly from the Yellow Emperor's classic of Internal medicine. How can we teach modern Americans our patients how to eat, cook, move, think smarter. Better? That's what a teaching kitchen is. The kitchen is the attractant. People are fascinated by pots, pans, fire techniques they don't have.

David Eisenberg 00:03:51 They'll come into the kitchen. But in addition to teaching people which foods they should eat more or less of and why and how to cook them, we also remind them that movement and exercise is important. We remind them that mindfulness is critical to understanding how to plan a meal, enjoy a meal, live mindfully. We also have to bring or borrow from our colleagues who are registered dietitians and psychologists. The skills of behavior change. How do you help somebody who is utterly stuck and would like to live differently? Change behaviors? And how do we learn the skills of motivational interviewing and apply them to patients, particularly in a primary care setting? To help people who are ready to change. That's a big part of that conference. But teaching kitchens are all of those things. They're not just kitchens. And what has happened over the last decade is when I started Healthy Kitchens, Healthy Lives more than 20 years ago, the first request of the audience was, do you think someday any of you might build a kitchen in a hospital to teach your patients what they need to learn about food, which foods, how to cook them, how to incorporate them in their lives to either prevent illness or modify the natural course of their illness.

David Eisenberg 00:05:23 And over the years, in 2014, ten years into the conference life's lifespan, I said, I've been asking this question rhetorically at the beginning of Healthy Kitchens Healthy Lives for a decade. Have any of you built a hospital teaching kitchen and a hundred hands? Well, that was ten years ago. So I pivoted from a focus on complementary and integrative medicine, which had been my life's work until then. To the creation of something called the Teaching Kitchen Collaborative so I could. Bring together clinicians, researchers, educators who had used teaching kitchens to teach people how to eat, cook, move and think better, and share their strategies so that we could co-create curricula and ways of educating patients. That worked. And, you know, bringing people up to speed. There's now an ongoing multi-site trial to test the hypothesis that if you can use one curriculum at four university hospitals with teaching kitchens, perhaps we can demonstrate you can teach people with obesity, diabetes or pre-diabetes other metabolic derangements. If you could teach them to make better food choices, to prepare the foods at home with their loved ones to move more to change their behaviors over the course of 16 weeks, one session a week for four months, and then meet once a month for eight months and then follow these people for 18 months.

David Eisenberg 00:07:04 Can we demonstrate that they will change behaviors, that their biomarkers will shift in a positive direction? That those changes really imply reductions in health care costs over a lifetime. These are some of the examples of the Teaching Kitchen collaboratives work. There are now 74 members. If anybody listening to this wants to learn more, go to Teaching kitchens.org. But this will bring us to some of the questions. And are you going to ask me how is this relevant to a primary care doctor. You know, could you imagine if primary care doctors all had access to a local teaching kitchen, that they could all experience some of these classes themselves, so they could make referrals of their patients who were ready to learn the skills of changing how they eat, cook, move and think. Could you imagine? Observational studies or randomized trials to test whether an introduction to these, you know, content driven classes plus experiential classes change their patients in a positive way. Then we would be in a different place because people could change the things we know they want to change, but don't appreciate how to change.

Multiple Speakers 00:08:28 Say, Keith, this is all well and good, but what if someone is looking for more clinical information?

Multiple Speakers 00:08:34 Oh, then they want to check out our sister site, Patient Care Online. The leading clinical resource for primary care physicians. Again, that's patient care online. Com.

Richard Peyton 00:08:47 I did have some questions about teaching kitchens. I had some questions about the consensus statement on, nutritional competencies in medical education. Where should we go next?

David Eisenberg 00:08:58 So in 2020. In 2017, I had a meeting with my Harvard colleagues and a representative from Congress, Jim McGovern, who was the chair of the Rules Committee of Congress. And we had been meeting really for decades, raising the question of when might it be possible to either incentivize or mandate that doctors learn something about nutrition? And when we told Congressman McGovern, who also had oversight in some ways over Medicare, Medicaid and agricultural budgets, when we told him that doctors in the United States are not required to demonstrate competencies in nutrition or their ability to give advice to patients about food.

David Eisenberg 00:09:53 He was flabbergasted. He said, that's impossible. We said no. That's a fact. Endocrinologists, pediatricians, cardiologists are not required on any of their licensing exams or board certifications to demonstrate their competence to advise patients about nutrition or food choices. And he said, we have to change that. It took him five years, but in 2022, he co-authored a resolution in Congress that was bipartisan and said, basically, we Congress understand that the American public is experiencing increasing rates of obesity, diabetes, other health food related chronic illnesses. Increasing in its costs. And we've learned that you are not doing an adequate job in demonstrating that physicians have competencies in nutrition. Therefore, the resolution said, you need to change that and enhance nutrition education for medical students and graduate medical trainees, meaning residents. It also went on to say, as a reminder, we Congress, spend then $13 billion a year on your training. We reserve the right to stop that funding if you do not move in this direction. That was throwing down the gauntlet.

David Eisenberg 00:11:38 So the Association of Medical Colleges. The Accreditation Council for Graduate Medical Education and the American Association of Colleges of Osteopathic Medicine held a nutrition summit in 2023 to respond to this, because it was an existential threat to all the funding for medical training in all specialty at all levels, and I was invited to speak there. And two of the main points that I shared were first, trying to educate physicians and also trying to educate patients about improved nutrition in the absence of any experiential learning in the kitchen. It's kind of like talking to people about the benefits of swimming in the absence of a swimming pool. How do you do it? We can't just talk Talked about nutritional deficiencies and biochemistry. How do we talk in practical terms to people that they will understand about how to make better food choices, how to prepare their food wisely, how to eat it with their families, etc.? Second, I said, and this is in 2023, based on what I had seen from the formation of the Teaching Kitchen Collaborative. I said there are probably close to 50 medical schools using teaching kitchens today, teaching medical students and residents a different relationship to food, using kitchens and going to groceries, and employ employing experiential learning.

David Eisenberg 00:13:22 But they're all using different curriculum. So I made a proposition, and this was based on advice I got from some very senior medical educators. They said instead of trying to advocate for any one curriculum. Why don't you, David, invite all the heads of all the residency programs and all the deans of education to join you in performing a modified Delphi survey to identify competencies that they would want every medical student and every resident to know when it comes to nutrition and advising patients about food. So with the Acgme, we identified experts in nutrition education from across the country who have different backgrounds. And we identified directors of residency programs in all the major specialties. We brought them together in about 37 of them. We reviewed the literature on what was known about competencies in nutrition. And we went through four rounds of voting. Which of these competencies would you want every medical student to be able to demonstrate before they graduate. And which ones would you demand that residents know? With the caveat that there will be unique competencies for different specialties.

David Eisenberg 00:14:48 We created a list of competencies where there was at least 70% agreement that these had to be learned and demonstrated, and we published them in September in Jama Network Open. It also asked the question should these be optional, recommended or required? And 97% of the voters, regardless of whether they taught nutrition or whether residency director said these have to be required on licensure and certifications. Second, we asked, do you think doctors should also learn about and be able to talk to patients about The impact of food choices on climate change and the survivability of the cloud, and more than three quarters of those involved in the voting said that is also something that should be mandatory. We also realized when we wrote up the competencies, which include things like doctors need to know nutrition facts, doctors need to identify food, and nutritional insecurity. Doctors need to be able to talk to patients where they are in a non-judgmental way, about whether they want to change their relationship to food, and to do that without shaming them. These are not insignificant educational obstacles.

David Eisenberg 00:16:17 How do you train the next generation to have a conversation with a patient about food, and their relationship to food that doesn't have its basis on how tall are you? How much do you weigh and what foods do you eat? Which is ridiculous. And how does a doctor do that with a patient who's neither their body habitus in size or age, or their race? It is difficult, but we must learn to do this. Given the fact that three quarters of Americans are overweight or obese and diabetes rates are exploding not only in the United States, but around the world. I could go on with what the other competencies are, but you get the gist. I think most Americans believe or believed that physicians are trained to do this, that somebody is testing them in these competencies. The fact, though, is they're not. We were never tested on it. We were never brought into a teaching kitchen to translate it. We were never expected to role play with a patient who was seeking advice. Now that their blood pressure is up, their cholesterol is up, their weight is up, their liver functions are up and they don't know what to do because in the social determinants of health, they live in a food desert and they don't make enough money to just eat fresh vegetables.

David Eisenberg 00:17:39 We have to do better.

Richard Peyton 00:17:41 This has been a fascinating. One of the things I had mentioned at the beginning of our conversation was just, you know, obviously learning about the US health care system writ large, some of the different trends and issues, and sort of like realizing that we're in a time of evolving medicine. again, it's just like another element within healthcare that I find to be fascinating. And it sounds like we're in that right now for medical education, you know, regarding nutrition and diet.

David Eisenberg 00:18:10 I think we are in that moment. And I think, you know, there's an increasing interest among the public and the current Trump administration in looking at nutrition and diet and nutrition education for physicians. So I think the momentum is there. But thinking back just to my primary care world and my colleagues who are still practicing primary care, and the conference that I direct, which is predominantly attended by primary care clinicians. If all primary care doctors could learn more about these tools and know how to apply them, and also experience being in the teaching kitchen, which is so much fun, helping others learn these skills and helping them realize that they can do it themselves is such a joy that they could also envision a different path forward in their own clinical and professional lives.

David Eisenberg 00:19:09 So for your primary care doctors, there are now primary care practices and groups of physicians that have teaching kitchens because they realize the patients love it. They change their behaviors. It enables the clinicians to feel as though they're really making substantive change above and beyond diagnosis and prescription. So I think we're in the middle of a transformational moment.

Multiple Speakers 00:19:43 Hey there, Keith Reynolds here. And welcome to the P2 Management Minute. In just 60s, we deliver proven real world tactics you can plug in to your practice today, whether that means speeding up check in, lifting staff morale, or nudging patient satisfaction. North. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow hack and employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at Kay reynolds@lifesciences.com with your topic, quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers and nationwide.

Multiple Speakers 00:20:23 Let's make every minute count together. Thanks for watching and I'll see you in the next P2 management minute.

Richard Peyton 00:20:33 Your paper standard patient History can be augmented using ethnographic food. Life questions noted that there have been successful interventions based on asking patients about food insecurity to go beyond just food insecurity. Can you explain maybe some of those concepts around interviewing patients about food life and that communication that you talked about just a few moments ago?

David Eisenberg 00:20:58 You know, one of the top ten competencies that we'd love every physician to have is to enable them in an empathic and informed way to meet people where they are when asking them about their relationship to food. And it's not sufficient any longer to just measure their height, weight, calculate their BMI and ask them about their diet. That doesn't work any more than telling people who smoked that smoking can cause cancer. Didn't change their behaviors. It's a ineffective way of meeting patients. So the article you mentioned published in nutrients was written with anthropologist with whom I shared the puzzle. How do we talk to patients in a non-judgmental way? In the spirit of working with them, regardless of how ready they are to change.

David Eisenberg 00:21:59 But in an effort to gain their trust so we can help refer them to the right people if they want to change their relationship to food. So there are three questions that doctors could be asking patients that are talked about in that paper. I'll just repeat them to you just so the audience can get a sense and maybe want to look at the paper, which again is written by an anthropologist who is expert in asking questions non-judgemental in an effort to solicit information without judgment. So imagine asking a patient in the history of the present illness after saying, you know what's bothering you, and tell me about your family history and tell me about your medications. And tell me about your exercise. What have we said to people? What food or flavors take you right back home? That's a wide open, open ended question. A follow up question might be what are your food rules? Not what do you eat and not eat? Not what should you eat? And don't not how guilty you feel about the fact that your BMI is now 35, whereas it was 32 years ago.

David Eisenberg 00:23:18 The third question we ask is how are you learning to care more about food in your life? These are examples and gifts from the anthropology community. To begin a conversation and see who actually would value the help of their doctor in navigating a different course, because they know that they've gained weight and their blood pressure is up and their blood sugar is up and the meds aren't working, and the food that is junk, and they're not able to teach their kids to do it any better. But this is an opening which to me is so refreshing because if the clinician, particularly primary care doc, establishes trust with a new or established patient in the area of do you want me to help you navigate a different path regarding your relationship to food and cooking? And the patient says, yes, you don't have to fix that in that visit. You could schedule another visit to just discuss that and then figure out would it be appropriate to refer them to a registered dietitian? Is there a teaching kitchen in my community? Is this a psychological issue where they really need some mental health expertise in addition to those things? But again, this comes back to the competency.

David Eisenberg 00:24:46 How do we talk to people in a way that improves their outcome? I'll give you another historical example that comes to mind. I remember saying this to the anthropologist. Medical doctors are trained in medical school to ask patients who are severely depressed if they have had suicidal thoughts, Suicidal ideation. It's called. They actually have to go further and say, have you developed a plan? Now, there was a controversy 50 years ago that said, well, if you ask somebody that and they tell you they have a plan, you will precipitate suicidal behavior. It's actually the opposite. So the analogy here is how do we touch somebody in that most personal, intimate, sensitive place who is lost with regards to their relationship to food in an effort to gain their trust and help them before they perpetuate this cardiovascular disaster through eating horrible food for the rest of their life. And I think the medical profession, I think from a scientific as well as ethical, moral and clinical standpoint, sees the value proposition. If we could train one another to do that better, or have somebody in our practice who could do that.

David Eisenberg 00:26:21 Whether it's the D or the MD or the physician assistant. But how do we help people navigate a different relationship between them and food? That's what a lot of this is about.

Richard Peyton 00:26:34 In in your papers, you had noted about, you know, how much money Americans are spending on both health care and food. And I'm just kind of curious from both the physician standpoint as well as a patient standpoint. How strong is the case for broader reimbursement from Medicaid, Medicare and private insurers when it comes to nutritional interventions?

David Eisenberg 00:26:56 Well, I think the best example is a diabetes prevention project, the DPP, which is covered under Obamacare. So if people have diabetes or pre-diabetes, they should say they are covered. To see a nutritionist, to learn a different relationship to food. That's existing law. That's after years and years of research. The diabetes prevention project led to this regulatory and financial relationship that was, legally incorporated into Obamacare. So let's use that as an example building on that. I think it's time for DPP 2.0.

David Eisenberg 00:27:45 How do you bring up how do you improve the science? How do you improve the interaction with the patient? How do you add cooking to that? So you don't just prevent diabetes for people who are pre-diabetic, but you actually go further and help them have enhanced competence in picking foods, cooking foods, eating foods, exercising more. So that's that's an example that exists. Let's think of a new and unbelievable opportunity with regards to GLP one weight loss drugs, these miraculous inventions of the last decade that transform bodies predictably to lose up to 20 or 25% of bodyweight, which will increasingly become more available as there's more competition and or the government starts telling drug companies we can't pay that much for these medications. Put that aside for a second. One of the consequences of a GLP one drug and its. Impact in terms of weight loss is the body almost always preferentially loses muscle mass unless somebody works out and lifts weights while they're on top one drugs. It's also a case that bone mass decreases unless they get enough calcium and have a good diet.

David Eisenberg 00:29:18 And I could make the scientific argument today that we should be doing studies to look at the combination of GLP ones, plus teaching kitchen curriculum as opposed to either a law. And the future may be some combination of those two, either for people that already have obesity and diabetes, or people who have overweight and prediabetes, or even people who are just modestly overweight. If we could bring them back to a healthy weight, but give them the life skills to eat, cook, move and think smarter in their 20s and 30s? Imagine how much money we would save. Imagine how much disease burden we would alleviate from the entire Higher public. So these are all future experiments to be done. But I think there's a role for teaching kitchens as really classrooms of life skills, to combine miraculous new drugs and external interventions with time tested truths that how we eat, move, think really matters. So I hope these provoke you to think about it. And the financial implications are massive. What if people that learn to take better care of themselves can then come off the drugs? What if giving a whiff of the drug to people who are not yet fully obese and diabetic, but just are overweight? What if that stops them from ever needing the drugs long term? Not to say takes them off the rosters of people with obesity, diabetes, and hypertension down the road.

David Eisenberg 00:31:01 And how about the quality of life? If we could teach people at a younger age to prevent overweight and obesity and stress. Think of how much we would diminish the burden of illness. I think these are all things that a lot of primary care doctors think about. There are a lot of primary care doctors coming to healthy kitchens, healthy lives who are, you know, for lack of a better term, burnt out in just prescribing drugs. And they realize they want to help people take better care of themselves, in addition to using the wonderful drugs and surgical interventions that we have in our tool chests. So I think there's a place for both.

Richard Peyton 00:31:46 You know what, doctor? I was going to say, we've covered a heck of a lot of ground in a short amount of time. And with, I think any of these topics, we could, we could, we could go on for hours and hours on some of these. I am really grateful for you taking the time. One question, if I may.

Richard Peyton 00:32:01 I'll keep you on for two more minutes. It's but one question I do like to add. We did cover a heck of a lot, and our main audience is primary care physicians. What did we not talk about that you would like them to know? Or what would you like to say to them?

David Eisenberg 00:32:16 I touched upon it very briefly, but it is so much fun to learn this yourself in a teaching kitchen or in healthy kitchens, healthy lives. And it's more fun to watch your patients learn this. It's infectious. And I would argue it's an anti burnout experience because you get back to why many of us went into medicine in the first place, which is to help people and help them either modify their disease that they unfortunately have now or prevent it at the very start. And I think the more primary care doctors learn about this field of teaching kitchens, food as medicine, Lifestyle medicine, the more they will realize that it's not one or the other. But I think in the future, clinicians must be trained in both lifestyle teaching kitchens and the technologies of the modern era, because together we can do a much better job in taking care of our patients, reducing the burden of disease and suffering, and probably reduce costs enormously.

Richard Peyton 00:33:27 Doctor, it's been a great conversation and I really do appreciate you taking the time. Hopefully we'll get a chance to connect again in the future. And I'm just super excited to see what what developments are going to come forth and certainly wish you the best on your own research as well.

David Eisenberg 00:33:40 Thank you. And if there were questions that come through based on this interview, please share them with them.

Richard Peyton 00:33:46 Absolutely, absolutely.

David Eisenberg 00:33:47 Thank you so much, Richard. It's been a pleasure talking to you.

Richard Peyton 00:33:50 I've really enjoyed it. And again, just wish you the best going forward. Thank you so much.

Multiple Speakers 00:33:54 Thank you. Sure. Bye.

Austin the Trail 00:34:06 Once again, that was a conversation between medical economics senior editor Richard Payerchin and Dr. David Eisenberg, director of culinary nutrition at the Harvard T.H. Chan School of Public Health. My name is Austin Littrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode.

Austin the Trail 00:34:24 You can find us by searching off the chart wherever you get your podcasts. Also, if you like the best stories that Medical Economics and Physicians Practice published delivered straight to your email six days of the week, subscribe to our newsletter so that medical economics and physicians practice off the chart. Business and Medicine Podcast is executive produced by Chris Maslin and Keith Reynolds and produced by Austin Littrell medical Economics, Physicians Practice, and Patient Care Online are all members of the MJH Life Sciences family. Thank you.