Embrace food as an 'integral part of medicine' to shift focus from intervention to prevention

LAS VEGAS — Culinary medicine, a new and still-evolving area of medicine, has the potential to reduce the prevalence of various diseases and all-cause mortality, an expert said here in an interview with Healio Internal Medicine at the Cardiometabolic Risk Summit.

A focus on food can also improve preventive care, making patients healthier and minimizing health care costs, said Timothy S. Harlan, MD, the executive director of the Goldring Center for Culinary Medicine and professor at the Tulane University School of Medicine.

"We started by teaching medical students how to cook, and using that metaphor of cooking to help understand how they could have a different discussion with patients about food," Harlan said. "Not about fats or weight loss or carbohydrates or fiber, but about food and changing consumption in a way that will move the needle."

Timothy S. Harlan

By starting with the premise that diet makes us healthier and prevents disease, he said, you can begin to consider the implications.

“The predominant focus is in cardiometabolic risk, is in heart disease, diabetes, hyperlipidemia, hypertension,” Harlan said. “When you consider that you can reduce mortality by 37% by diet, and reduce cardiovascular risk by more using diet than you can by using statins, then you begin to think about that culinary piece as being an integral part of medicine.”

He acknowledged that there is a spectrum of food interactivity with health that goes beyond cardiometabolic disorders, and could benefit individuals such as geriatric patients, pediatric patients, pregnant patients, athletes and patients with conditions like celiac disease, IBS, IBD, GERD, acid reflux, cancer and PCOS.

Harlan said that he has been working for over 4 years to develop a curriculum for students currently in medical school, but there are no specific guidelines for practicing physicians. In the next 5 years, he is hoping to refine the culinary medicine model for practice, which will focus on creating a supporting infrastructure.

"Dietary intervention should become a critical part of every encounter you have with a patient," he said. "You can accomplish a lot in 2 or 3 or 5 minutes... If you ask your patient for a 24-hour dietary recall and you focus on one of those items — breakfast, lunch, dinner, snacks, beverages — you can give them practical solutions for improving their diet. If you do that in a longitudinal manner over and over, making it important, elevating it in the physician-patient relationship, you can help create change in your patients.”

He likened encouraging these changes to encouraging patients to quit smoking.

"When you look at the data on stopping smoking, if we tell our patients to stop smoking, they do at a fairly high rate," Harlan said. "They don't do it on the first time, but you keep at short, simple messages repeated over and over and over."

He said that the supporting infrastructure currently in the works could take a variety of forms.

"In an ideal world, I would like to see that the minute that you walk up to the registration desk that you're confronted with food, all the way through your clinical experience,” Harland detailed. “That a dietary history is being taken as part of your time waiting in the waiting room, there are videos showing cooking and shopping tips, tricks and recipes, the screensavers in your exam room have nutrition- and diet-related content."

He said that world also includes everyone in the office — from the medical office assistant to the nurse practitioner — engaging patients and asking about food.

"Nobody knows how to cook anymore,” Harlan said. “If everybody knew how to cook, including physicians, we could change the course of health care in America."

Harlan explained that they are taking principles of the Mediterranean diet and translating them for American cooks, noting that most doctors fail to understand what the diet means clinically. He said that focusing on elements of the Mediterranean diet can substantially improve health. You can calculate your 9-item Mediterranean diet score based on the following food groups: vegetables, legumes, fruits and nuts, whole grains, fish, oils and fats, dairy, meats and alcohol, he said.

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"If you improve your Mediterranean diet score by two points, it reduces your all-cause mortality by 25% — not just heart disease, stroke and cancer," Harlan said. "Higher Mediterranean diet scores have been shown to reduce risk of Alzheimer's disease, macular degeneration, cancer, etc. So it's all about driving that score up in your patient."

He provided an example of switching a patient’s breakfast from a fast-food egg sandwich and soda to a homemade scrambled egg sandwich on whole grain bread with an apple, which would increase their Mediterranean diet score by two points. Or switching to peanuts or cashews from Cheez-Its, which are made with white flour.

"When you look at this, it's about small, simple, incremental changes," Harlan said. "Nobody has taught us that. And in our defense, as physicians, we have spent two millennia doing interventional care, episodic care — not preventive. We've gotten really good at that. And the problem is we've gotten so good at it, and during that period there's been a concomitant rise in ultra-processed, calorie-dense, nutrient-poor foods that are pretty easily available. We have a crisis of food-related disease."

He said that the U.S. is spending $250 billion a year on diabetes-related care and within the next 10 years, the country will be spending almost a trillion dollars on heart disease-related care, which makes the situation of prevention urgent.

"We're not as good at the intervention as we're going to be, but we're pretty damn good at it," Harlan said. " We need to become really good at the prevention piece and using diet as a treatment."

Harlan incorporates aspects of what he preaches about the Mediterranean diet into his own life, with a fridge and pantry full of fruits, vegetables and items for his "sandwich construction kit."

"I'm a sandwich eater, so I like provolone cheese, hardboiled eggs, and tons of different things to make sandwiches with," he said. "I have a whole bunch of spreads like mustards, chipotle paste and sundried tomato paste."

Harlan said he also buys fresh fish and chicken and often eats rice, because he has celiac disease.

He said that patients looking to improve their diets should be eating more fruits, nuts, whole grains, legumes, vegetables, fish and better quality oils and fats. They should be eating less dairy and meat, especially fatty meat, and be very careful about alcohol.

For physicians looking to incorporate culinary medicine into their practice now, Harlan recommended www.culinarymedicine.org, which has some content and continuing medical education opportunities and will soon feature handouts and recipes.

To physicians who remain skeptical about incorporating another aspect into their brief time with patients, Harlan says: "It's a whole bunch easier than you think. For what it's worth, I practice every day, and I know this works." – by Chelsea Frajerman Pardes

Disclosures: Harlan reports being a publisher for Harlan Brothers Productions, LLC.

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