0:00
Hippocrates said, Let food be thy medicine, and medicine be thy food. If that was said so long ago, how did we miss that in the treatment of our patients?

0:20
Welcome to off the Charter 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 Latrell. I'm the assistant editor in medical economics, and I'd like to thank you for joining us today. In today's episode medical economics, senior editor Richard Pearson spoke with Dr Jennifer troke, professor of biomedical sciences and director of lifestyle medicine programs at the University of South Carolina School of Medicine Greenville. Dr troke is a national leader in Lifestyle Medicine and a driving force behind efforts to integrate nutrition, physical activity, behavior change and self care into medical education. She explains how the Greenville program was built from the ground up, with lifestyle medicine as a core focus, how it's shaping a new generation of physicians and why prevention deserves the same priority as treatment in US healthcare, they also discuss the future of medical training, from culinary and teaching kitchens to the policy conversations in Washington and why she believes that every medical student should graduate prepared to help patients make healthier choices. Dr choke, thank you so much for joining us, and now let's get into the episode.

1:30
Thank you for joining us today.

1:32
Thank you, Richard for having me. I'm very blessed and honored to be able to speak with medical economics and with you today and be able to bring to your readers the importance of nutrition and lifestyle, medicine in medical education, and how truly important it is that our future doctors are trained in this, to have the competencies to work with our patients and our population in the United States, one of the

1:55
things I was kind of curious about is sort of overarching in the Big Picture of the US healthcare system. You know, there's there's there's physicians, there are other clinicians, health systems, independent practice, pharmaceuticals and medicines. Of course, we can't ignore the effects of those. Can you talk a little bit about sort of big picture with lifestyle medicine? Where exactly does it fit into the contemporary US healthcare system?

2:23
That is such a fantastic question. Richard, and that's again, something that I teach the students. What is the difference with conventional medical education and conventional medicine, with lifestyle medicine and conventional medicine is very much the root of it is, you know, starting at the disease, and what are the ways to treat and manage the symptoms of chronic disease? Let's say, you know, type two diabetes. For example, if a patient is diagnosed with type two diabetes, what from a from a medication perspective, keeps their blood glucose regulated, you know, and keeps that down, and then also helps reduce risk of cardiovascular disease and cancers, because we know that type two diabetes is a very inflammatory process in the body, and it sets up very high risk for our other chronic conditions. We know that cancer and cardiovascular disease are primarily the two top diseases that cause mortality in the United States, and type two diabetes is a high risk factor for that where the where the conventional medicine starts at the disease, lifestyle medicine starts at the root cause of disease, so starts further upstream and says, What exactly are the lifestyle behaviors, the dietary related patterns that cause this chronic condition? And the students learn that there's another way. Another way is looking at, you know, the conventional medicine is, it's really the doctor's responsibility to treat and manage this patient lifestyle medicine is it's a shared decision making process between the doctor being that patient's biggest advocate, you know, their biggest cheerleader, and taking the time to talk with the patient and utilizing behavioral you know, theories like motivational interviewing to see where the Patient is and their steadiness and their readiness to change, to see if they're if they're wanting to change, to see what aspects of their change, what aspects of their lifestyle that they'd want to change. They may not want to walk into a gym, but we may be able to reduce sodium content in their meals, you know, so really meeting that patient where they are, and having that shared decision making process so that it's a team effort, rather than the doctor's responsibility. And there was a paper that came out in 2023 demonstrating that that physicians who practice lifestyle medicine have less, far less burnout than physicians that do not practice lifestyle medicine and are in that, you know, in that conventional area of like. Treatment, you know that health care system, the other one is, you know, I always say to the medical students, it's not an either, or it's not either you put a patient on medication or you utilize lifestyle that they go very much hand in hand. So we don't want to demonize, you know, one or the other. You really want to use them as, as partners, as adjunct. You know, if a patient comes in and has uncontrolled hypertension, you need to utilize the pharmaceuticals and the medications to bring that, you know, high blood pressure down, so that the high blood pressure doesn't cause a stroke or a myocardial infarction, which is called a heart attack, and yes, absolutely, utilize those medications to help the patient and then over time, because we know that lifestyle behaviors take time. Over time, use the lifestyle modifications with the patient talking with them, so that they can eventually reduce the dosage of the medication, or maybe even reduce medication altogether. So we want to make sure that we utilize those hand in hand. But if a patient is newly diagnosed with type two diabetes, and, you know, has a has an A 1c that's maybe in that 6.5 to 7.5 range to where they just have started that we highly recommend. Hey, let's talk with your patient about the the changes that they may be able to make to not need to get on medication in the first place and put type two diabetes in remission. Because that has now been, you know, there's evidence around that type two diabetes absolutely can go into remission without medications if proper lifestyle is managed. So, you know, when we look at there's, there's definitely a place for both. The one thing I say with this, you know, with our students and our future doctors, is, if you're going to utilize a medication, be a very responsible physician, and don't just send out a medication or prescribe a medication with your with your patient, without talking to them about their lifestyle and how they got that disease in the first place. That is being a responsible doctor, so utilizing both and making sure you're being responsible in your you know, the management of your patient.

7:13
This is something that may go back here into years, decades, even generations, of medical education and training. But it seems as though, up until recent times, doctors received relatively little instruction about diet and nutrition in medical schools. Can you explain why that is?

7:34
Richard, that's a great question. I we've talked about that for years, like, Why aren't doctors trained in nutrition in order to have the competencies to speak with their patients about nutrition, because we now have the term diet related diseases, as opposed to chronic diseases. And I will mention the medical students again, right as I meet them, Hippocrates said, Let food be thy medicine, and medicine be thy food. If that was said so long ago, how did we miss that in the treatment of our patients? And now we, you know, really talk more about chronic diseases being diet related diseases. I mean, that's now a new terminology, because we know that the evidence is there that most of our chronic conditions are related to a poor diet, and, you know, and patients aren't taught that. You know, none of us were really, really taught that, but patients are taught that by their physicians because physicians are trained in medical education. In the 90s, the nutrition academic award came out, and there were certain medical schools that were chosen for the nutrition academic award and given funding, federal funding, to implement 25 hours of nutrition into medical education. And unfortunately, as you know, is what happens with funding and with grants, is as that funding was completed and expired, those medical schools, you know, lost our, you know, our hours of nutrition. So they weren't required anymore to have that, that 25 hours of nutrition. So you know, these days, especially in traditional medical schools, you won't see nutrition in medical education. And I've had this conversation with other doctors across other health care systems, and you know, wonderful debates, of them saying, we did learn nutrition, but they learned biochemical nutrition that's very, very different. They learned the electron transport chain. They learned the Krebs cycle, or the TCA cycle, whichever way you want to describe it. They learned the aspect of where, you know, our vitamin B's come from, our vitamin DS they you know, they learned which ones are water soluble. Which ones are fat soluble? They did not learn what we call Applied Nutrition. Where, you know, what is the primary source of vitamin D? What is the primary source of vitamin D? Vitamin you know, vitamin B. Pardon me, you know, where are the ways in which you get that? How do you take a T. A patient what to buy at the grocery store in order to maximize a whole food, plant based food pattern and a, you know, a food that really a pattern that really treats the microbiome. There's a lot of evidence now coming up on making sure we have a healthy microbiome, because the gut itself is responsible somewhere between 70 and 80% of of our immune function in our body. So if we don't have a healthy gut, we don't have a healthy immune system, we have chronic inflammation. We saw this in covid. We saw that those who already had a chronic inflammatory response in their bodies had a much larger response to the virus, you know. So those you know, so we really are, you know, hasn't, haven't been taught that, but now we're seeing more and more of nutrition really coming in front and center role as it should have been for so many years.

11:02
Hey, there. Keith Reynolds here, and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into 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, an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at kreynolds, at mjh, lifesciences.com with your topic, a quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute.

11:55
In terms of in this is something that that I will see, if I can clarify here, because also from sort of a layman's and patients perspective, patient's perspective, you know, even you, you open up your phone, you see the different feed. And there's, there's a news article that talks about coffee is drinking coffee is good for you. Drinking coffee is bad for you. One glass of wine a day is good for you. One glass of wine a day not so good. Yeah. And there's, there's a lot of information out there, I guess. Can you talk a little bit about sort of the the research foundations of lifestyle medicine, and what has been proven to work, and maybe what is, sure, more questionable science,

12:35
sure, sure, when we look at the evidence around nutrition and lifestyle medicine, so the scientific, peer reviewed evidence, there's strong, significant associations between whole food, plant based food patterns and an improvement in chronic disease. There are, there are randomized, controlled trial evidence. You know, out there good research groups and research programs that look at more of a longitudinal comparison between a high processed food and a whole food, you know, plant based food pattern that demonstrate that there's an improved improvement in most indices in health, a one, CS, hyper, you know, blood pressures, lipid profiles, etc, with, you know, more of a whole food pattern, the most scientifically evidenced food pattern. So if you think about the Mediterranean diet, the South Beach diet, the keto diet, the you know, all of these different diets that come up the most evidence based one is the Mediterranean diet. The Mediterranean diet is really looking at our, you know, whole fresh foods, non processed foods. It does not rule out animal based proteins. It certainly rules out processed foods. So, you know, there through the years, as we, as we kind of navigate ourselves through the evidence of what is the healthiest food pattern? Is it being 100% whole food, plant based and not getting animal products? Is it, you know? Is it something that is at having some animal products in there, it really is much more dependent upon the processed foods, the high sugar foods, the low nutrient dense foods are the are the research program or the research evidence that comes out and says those are the healthiest for chronic conditions. So I would encourage our doctors, our readers, to say you don't necessarily need to be dogmatic of one particular food pattern or one particular diet, the very first thing you need to do is meet their patient where they are. You need to dispel the misinformation that you see all over, all over Google and Tiktok and you know, and Instagram and and you know influencers that say that they lost 20 pounds in five days by using a particular diet. We know that. Those are things that are, that are attention seekers, and they're not founded in evidence. The most important thing is to take a look at, again, reducing the processed foods. All of the evidence is there for reducing a processed foods, reducing of the sugars, you know, reducing of some of the saturated fats. You know, this is more recently, dietary cholesterol has not been as demonized as it has in the past in terms of raising blood blood cholesterol levels, because it used to be, well, you can't have as much cholesterol because it raises dietary cholesterol levels. It does in individuals who are sensitized to cholesterols. But if an individual takes in too much saturated fat that also can be converted to cholesterol. So they're all of these just just ways that you know, our doctors are needing to navigate what is out there in the community, and again, to dispel that misinformation, and that in itself, is why we published the the competencies paper, led by a wonderful doctor, David Eisenberg, on really looking at what are the what are the information that the doctors need to know, and what are the competencies that they need to be able to have as they graduate their medical school and get into working with their patients. And a lot of that is really understanding that Applied Nutrition base, which is far less than, you know, understanding everything about a micronutrient that goes through the Kreb cycle. It's much more about, really, that Applied Nutrition and and meeting the patient, and understanding, you know, to talk about a patient about their food pattern, and teaching kitchens, getting it, I would say the most important thing about nutrition and having the competencies for nutrition is getting the patient into the kitchen with the doctors and having the patient have that experiential learning of how To cook their favorite meal and maintain the taste and the texture and the joy and the community about their favorite meal and how to make that healthier without losing all of those that that is one of the most important things that we could do.

17:14
And you know what you you teed me up on a couple of a couple of points, like I said, I want to make sure that we get to and but if I may, let me take a step back, because earlier in our conversation, you did mention some of that economic and financial elements of healthcare and our physician audience members provide great services to their patients, and of course, deserve to be compensated for those treatments. Can you talk a little bit about how strong is the case for broader reimbursement from Medicaid, Medicare and private insurers for nutritional interventions?

17:49
I am very hopeful that this current administration is going to work with each other, you know, so that Department of CMS and the department for health and human services are going to work together to understand that it is absolutely essential that if we want our doctors being trained in competencies for nutrition and other lifestyle behaviors and talking and having the time to take to talk with their patients about this, that they absolutely deserve to be reimbursed for these conversations, so the coding and the billing needs to be put into place through CMS and through HHS on the incentivization of having these conversations With the patients. So if a patient is a patient who has complex care, you know may not have only one chronic condition, and many of our patients, CDC reports that four in 10 patients have at least, I'm sorry, six in 10 patients of the population have at least one chronic condition. Four and 10 have two or more. So we don't just have patients who have type two diabetes. We'll have patients who have type two diabetes and hypertension. We have patients that have, you know, individual that have other chronic conditions, that are that are working with cardiovascular disease, family histories, you know. So it's really important that our current administration take the time to develop those codes and allow for a billing infrastructure that allows for that we talked about the very beginning of the interview, that quality of care that the doctor can have with the patient, rather than episodic care payment models. So if we're wanting to improve the health of our nation, we need to incentivize to have that prevention of chronic diseases, rather than management of chronic diseases. So I'm very, very hopeful that this is a direction that with the new administration, that we go so that. Doctors can adequately and very deservedly, you know, be compensated for their time and their expertise in nutrition and lifestyle medicine,

20:12
you know, what? If I may, I want to go back to something you mentioned a few moments ago, because this, this also caught my ear about the notion of not just necessarily talk with a physician, talking with a patient about some of their lifestyle choices and and nutritional requirements, but actually instructing them in the kitchen. And I was wondering if you could talk, maybe anecdotally, or if there's been like, sort of the nature of research on teaching kitchens, sort of, what is a How would you describe those settings? And maybe what's an example of how it works?

20:43
Oh, such a I love. What a favorite question. What a favorite question. For the last eight years, USC, School of Medicine, Greenville has had a teaching kitchen by partnering with our community partner, which is Greenville Technical College, at their truest center for Culinary and Hospitality innovation, and it is an industrial teaching kitchen. It's beautiful. It is in the community. It's actually in a in a in a community area that is lower socioeconomic status in Greenville. And it's in a beautiful location that allows for us to bring in community members and have the community members go through the cooking process and go through the the ingredients, go through the actual recipe, and talk with the students who are, you know, doctors shortly after that, on how to prepare a healthier option that you know, again, with their chronic conditions. So we choose a meal based on their chronic conditions. The easiest example is if a patient has hypertension, we choose a meal that lowers the sodium content in that meal and uses other spices in order to maintain the taste while reducing the sodium content. And this is something that is integral, that needs to be in, needs to be implemented across the United States, to have teaching kitchens that are connected to medical schools and that are connected to healthcare delivery systems. And nobody does that better than David Eisenberg, with the Harvard teaching kitchen collaborative of really understanding what does it take to upfit a kitchen to be connected to, you know, either a delivery system or a medical school, so that the doctors can learn it while they're in training, and then doctors can apply it and bring student and bring patients into the kitchen. If you watched any of our videos that that Roger sent over to you, the patients love it. They love it. It's not it's something that brings joy to them. It is not intimidating. They you know, whereas starting an exercise program might be a little bit intimidating for some, you know, but coming into the kitchen and learning how to cook their favorite meal, that is, you know, also really important again, bring in that whole foods is something that we've just seen success after success. We've had patients come into our kitchen who have lost 39 pounds, gone off of blood pressure medication, type two diabetes medication, you know. So we've got success story after success story. The other thing from a school and a student perspective, I'm going to share with you, just got it this morning at 9:37am from a medical student who's now in her third year, and she's in her family medicine rotation. She says, Hi, Doctor chok, just wanted to send a message in family medicine, I'm doing so many nutrition discussions and exercise prescriptions with patients feeling so grateful and passionate for all the lifestyle medicine education you've taught me, the students are loving the aspect of the lifestyle medicine nutrition, and they will take this on into their Practice no matter where they are in the country. So having teaching kitchens connected to medical schools and healthcare delivery systems is key. The final thing I'll say is, again, we've been operating for eight years. We are now going beyond the four walls of our teaching kitchen, and we are implementing a mobile teaching kitchen unit that is going to be something that we can take to churches. We can take it to fairs, health fairs, and the students are going to go out into the community and meet the community where they are in their different neighborhoods, utilize the kitchen to train the patients out in their neighborhoods and provide ways in which they can improve their nutrition through our our mobile teaching kitchen. So we call that the MTK, and we're really excited to get that up and we're to get that up and running. We're very we're it'll be up and running by this coming year.

24:57
It sounds like, you know, we talk a lot about. Finance and science of medicine. It sounds like there can be some fun elements to to that as well.

25:06
Oh, I, you know, I'm it is incredibly fun. The doctors love it. We have a doctor who is getting certified as a culinary medicine specialist through the American Academy of Nutrition. And he is actually in with the students, and he is cooking with the students right now, literally right now. And he as a practicing gi physician, has fallen in love and has asked how, if he can come back and be faculty at our school after he finishes his certification. And you know, that's a resounding yes every doctor. We've had fellows come in that were not trained in our medical school. We've had residents come in. We've had we now have an attending that's coming in and learning how to cook in the kitchen, and we have plans to make this a CME continuing medical education. Credit for, credit for attendings that can come in and cook in the kitchen and learn as well, so that we can retrofit, you know, like we can retrofit the that's the right word, you know, train them, because they really, really do enjoy it there. There's such a stress reduction when you're when you're in the kitchen and learning, you know, learning how to cook and cooking with people who care.

26:22
And, you know, again, another great segue here, because this goes back to the, you know, the concept of teaching kitchens and medical education. You did talk about in our conversation the proposed nutrition competencies for medical students and physician trainees. Can you elaborate a little bit more about what that consensus statement is and how it came about,

26:42
absolutely, and I will defer to Dr Eisenberg on the details of that, but it was a very well thought out Delphi process where content experts across the United States came together, I believe, a minimum of four times to look at existing competencies. And there were hundreds, hundreds of them, what should doctors know by the time they graduate? You know, so, so creating like, what should they now? And what is the consensus of that we had a number of conversations around that. We had lots of homework assignments around that. And really bringing together, what are the top tier competencies that doctors should know upon graduation, you know? And understanding again, what are our do they need to know their macronutrients, their micronutrients. Do that, you know, yes, that's incredibly important. Do they need to know how to counsel their patients through using, you know, behavioral, behavioral theories and models? Do they need to understand that there's a difference on, you know, based on demographics, based on population, based on, you know, so, so, really, we we really got together and utilize that Delphi process to come to that consensus of what a doctor can learn in four years, four years of a medical school, of course, again, learning everything else to become a doctor and what were the most important ones. We were able to take duplicatives and merge them into a more coherent competency, you know. So there were many of those that we did. And I'm very, I'm very proud of, you know, Dr Eisenberg's team and the entire team of pulling that together, because I do believe from there, you know, medical schools can take those competencies and start creating curriculum around their those competencies for their medical schools. One thing that not you know, not many individuals, at least in you know, the US population, know, is when you see one medical school curriculum, you only you see one medical school curriculum. Medical school is not a cookie cutter curriculum. It's not something that we download and implement into our schools. It is what's considered from the licensing body. So the LCME, the accrediting organization that accredits medical schools to be medical schools. It is a faculty owned curriculum. So that is a good thing, because the way that we train our doctors may be different than the way that another medical school trains our doctors, but we all have the same graduating goals, right? So there may be multiple ways in which nutrition can be implemented into their medical schools because they have a different system than we do, all with the same graduate, you know, with very similar graduating goals. But that is a plus, because then the faculty can choose how those competencies are met through the through the education of the medical school, so it doesn't. Doesn't need to be a hard and fast rule. It can be adaptive, like adaptive and flexible, in order to get those trainings in, to increase the competencies for those graduating medical students

30:09
with the Make America healthy again initiative, what other policies and directives would you like to see come to the table that could really make a difference in that initiative and campaign?

30:20
Sure, sure. So colleagues of mine and I, we, we worked with the Commission with the Make America healthy again commission to really help them understand what lifestyle medicine is, what nutrition and lifestyle medicine is, and how important it is to get it into medical education, how important it is to get in into population health. I adored the first report that came out of looking at childhood, chronic diseases and reducing, again, a lot of the processed foods, the food dyes, the colorings, you know, and everything. But really, to increase lifestyle medicine, education and practice, you know, the current practitioners for Make America healthy again, we're I'm hopeful, because the report that came out, I believe it was May, May 15, item number seven was to implement lifestyle medicine training and lifestyle medicine research. So I'm hopeful. I would love to see much more of that in their their future iterations of really bringing the forefront of not just nutrition, but physical activity, sleep hygiene, stress reduction, reduce it. You know, reduction of risky substance use. And, you know, in social and social capital, or, you know, increasing social connectivity, because the evidence is there that every single one of those pillars are promoted of health, so not just to focus in on nutrition, I guess is my answer is, nutrition is a fabulous place to start, but we are holistic beings. And if we say to the medical students, if you have to choose between exercise and sleep tonight, you choose sleep so that you can really reconcile what you learn today, so that your body is able to increase its melatonin, which is a very high antioxidant in our body. So you know, understanding how the six pillars all work together, nutrition is a fantastic place to start. I would love for those who are leading the MaHA you know, the MaHA commission, to really understand more the evidence around that and to really bolster all six pillars of lifestyle medicine.

32:34
Our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know?

32:40
Thank you, Richard for that question. I would love to say to your main audience, or primary care physicians, a huge thank you and gratitude toward their practice as primary care physicians. We all know. You know there are many specialties and sub specialties of practice of medicine, surgery, anesthesia. You know, dermatology, primary care physicians are the foundation of patient wellness and population health and the our primary care physicians are our biggest champions, our biggest cheerleaders for our patients and our population. And we know that they have a lot on their shoulders. We know they have a lot to cover with their patients. And just want to be very, very thankful, and hopefully, you know by them being able to learn to practice lifestyle medicine, as the paper in 2023 reported that the joy and the and the joy and the the satisfaction that they receive by having a patient who is being really impacted positively, and seeing benefits of reduction of a one CS and blood pressures and, you know, and seeing that satisfaction really helps with any sort of burnout that they may be experiencing. So I would, you know, I would hope to suggest that they try lifestyle medicine practice with their patients and see what they think, and then maybe find a little local teaching kitchen to where they could learn how to cook and bring their patients into into a teaching Kitchen to help them learn how to eat healthier. You B once again,

34:29
that was a conversation between medical economics senior editor Richard pearton and Dr Jennifer trilke from the University of South Carolina School of Medicine Greenville. My name is Austin Latrell, 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 you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. 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 the. Restrict your email six days of the week. Subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine. Podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Latrell. Medical economics and physicians practice are both members of the MGH Life Sciences family. Thank you.