We need more nutrition education in medical schools

By Dr. Margaret Rundle

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Dr Margaret Rundle is a Family Physician practicing at Malvern Medical in Scarborough. She completed her BSc in Nutritional Sciences, (UofT’85), Undergraduate in Medicine (UofT’89), followed by Family Practice Residency(UofT’91). Dr. Rundle founded the Rundle-Lister Lectureship in Transformative Nutritional Medical Education, which is a part of the Food as Medicine series at the University of Toronto. She, her husband and two boys, ages 27&24, enjoy very active, healthy lives.

 

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As physicians, we share a basic understanding about diet, but food remains under-appreciated as an intervention point to empower patients about the treatment and prevention of disease.

There is little dispute among care providers that a person’s dietary habits influence preventative and treatment outcomes. Every year, there is more cutting edge research validating the role of food and therapeutic diets for chronic disease management and prevention. However, basic education on the role of nutrition and lifestyle has been a blind spot in the Canadian medical school system for a long time.

I have spent the past 27 years as a Family Physician, and I make it part of my clinical work to motivate and educate my patients around the role of nutrition in their health and well-being. My interest stems from my early school years when I participated in a variety of athletics and wanted good nutrition to support my involvement.  I completed a four-year undergraduate degree in Nutritional Sciences with the intention to go into Medicine afterwards. In my four years of medical school, I was surprised to find that we were exposed to only about 20 hours of nutrition education. I recall it being primarily about knowing what are vitamins, minerals, carbs, fats, with nothing about the role of dietary interventions.

When I first started practice, I still cared a lot about the role of physical activity and nutrition but it was easy to get caught up in the day-to-day handling acute problems, making diagnoses, and writing prescriptions. What had happened to my passion in preventative medicine? It was after I attended a series of conferences that focused on advances in scientific research around food and nutrition that my passion was renewed. I literally got tingles as I sat in the audience. I was back! Since then, I’ve changed my practice to spend at least 15 minutes of a 45-minute physical talking to, and enquiring about, nutrition, exercise and lifestyle.

However, from the treatment point of view, many physicians still do not look into what we can do with nutrition. We share a basic understanding about diet, but food remains under-appreciated as an intervention point to empower patients about the treatment and prevention of disease.

 

Weaving food and nutrition into medical education

One problem is that in most medical schools, physicians are not being taught the latest concepts in nutrition science. Research shows that doctors currently don’t feel confident enough to counsel their patients about their diets; in fact, more than half of graduating medical students rate their nutrition knowledge as “inadequate”. Nutrition education simply isn’t prioritized enough in the medical curriculum in North America. Another study in Academic Medicine shows that only 27% of 105 medical schools in America met the minimum requirement of 25 hours in nutrition education.

In fact, 87.2% of the Canadian students surveyed in a study said their undergraduate medical program should dedicate more time to nutrition education.

There is demand from Canadian medical students for more nutrition education.  In fact, 87.2% of the Canadian students surveyed in a study said their undergraduate medical program should dedicate more time to nutrition education. While a lot of these students said they were somewhat comfortable in their knowledge about the role that nutrition plays in disease prevention, they felt ill-equipped to counsel patients on dietary requirements across all stages of the patients’ lives.  They also said they have trouble identifying credible sources of nutrition information.

Medical school faculties need more staff who are qualified to teach nutrition. I believe that understanding the role of food as treatment should not be relegated to a few more hours or as a separate course, but woven into the entire medical curriculum. We should talk about nutrition when students study pre-natal health, pediatrics, ophthalmology, oncology, or orthopedics. Fortunately, this has already begun at the University of Toronto thanks to the guidance of a team of physicians including Dr. John Sievenpiper, and to the very generous donation from Johanna & Brian Lawson for the creation of the Centre for Child Nutrition at the university.

 

A trusted and reliable education resource for physicians and patients in nutrition

What about the physicians who are already practicing? I’m currently working with the University of Toronto on accredited nutrition education for practicing MDs and have founded the Rundle-Lister Lectureship in Transformative Nutritional Medical Education. This lectureship is part of the Food as Medicine Series and provides an annual award to a clinician recognized for providing an outstanding contribution to the role of nutrition in patient care. The conferences help to address the knowledge gap in continuing medical education in nutrition; for example, our first Food as Medicine conference focused on the impact of gut microbiome in health and disease. There is a saying that “we are what we eat”. While there is truth to that, I also believe that as more research is tackled, we will further understand how the foods we eat affect our microbiome and consequently, the impact of those changes on our health.

Patients and physicians alike also look to the internet for educational assistance. For doctors who do not have the time for nutrition counseling, or wish to refer patients to reliable and trusted websites, I envision a day when we can refer to a University-affiliated “go-to” web hub.  The University of Toronto is one of the few Faculties of Medicine that has a Department of Nutrition under its umbrella. By developing such a website, the University of Toronto would be in an excellent position to become known as the place for physicians to update their knowledge and for patients to get safe, reliable information about nutrition.

I’m not asking doctors to become dieticians. But physicians are in a unique and powerful position because they can provide advice to patients during annual check-ups or at times of acute illness when it is most likely to resonate.

I’m not asking doctors to become dieticians. But physicians are in a unique and powerful position because they can provide advice to patients during annual check-ups or at times of acute illness when it is most likely to resonate. For long-term change to really happen, the opportunity sits with redesigning medical education for future physicians. They can be taught about the value of nutrition in their clinical practices, and to position dietary approaches as a complement to traditional medicine for the maintenance of health and prevention of chronic diseases.

 

Transforming the hospital meal for sustainability

By Allison Gacad, Loran Scholar and Nourish Researcher and Annie Marquez, Nourish Innovator

 

A meal at a healthcare system is a juggling act of numerous priorities: is it nutritionally adequate for the patient? Does it fit within the allocated budget? Are there a variety of colours and textures on the plate? Among these questions, a new priority is beginning to emerge: how sustainable is this meal?

The most powerful path to being sustainable as a healthcare institution isn’t through turning off the lights or unplugging electronics – it’s in changing the way that patients eat.

The most powerful path to being sustainable as a healthcare institution isn’t through turning off the lights or unplugging electronics – it’s in changing the way that patients eat. From the production of the ingredients to the processing at a factory, to the transportation required to bring the food to the plate, the creation of a meal radiates social, economic, and environmental effects well beyond the person who is eating it. When we amplify this by the thousands of meals prepared, served, and consumed daily in healthcare institutions across Canada, the impact is monumental.

The choices that food service managers make about what is served on the plate ultimately influence global systemic issues of climate change and public health. Despite this immense opportunity for proactive change, not all food service managers are equipped with the knowledge and tools to act in the interest of environmental sustainability.

Nourish Healthcare’s Sustainable Menus collaborative working group is a team of healthcare leaders looking to address this knowledge gap and transition food in healthcare towards sustainability. Through the creation of a practical and user-friendly sustainable menu guide for food service managers, the group is looking  to mobilize sustainable food choices in healthcare and the reduction of greenhouse gas emissions. Below are some of the pathways towards sustainability presented in the guide:

 

Moving towards plant-based proteins

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Agriculture — the system that powers the production of our food — accounts for nearly 24% of global greenhouse gas emissions. However, the production of certain types of foods are more resource intensive than others. Livestock — including red meats, pork, and poultry — contribute to 18% of global greenhouse gas emissions. Large volumes of water are needed for livestock to drink and maintain hygiene. Vast amounts of land are used to produce their feed and even their natural digestive processes directly contribute to the greenhouse gases in our atmosphere.

In contrast, plant-based proteins such as legumes benefit soil ecosystems rather than impair them. Legumes are recognized as “soil building crops” thanks to their properties which improve soil structure, reduce erosion, and increase organic content.

For most healthcare facilities, traditional protein is animal-based and is usually in the form of beef or pork. Transitioning into plant-based proteins can be challenging, but even small efforts can have massive impacts. According to Healthcare Without Harm, “Eliminating meat for one day per week, for example, could reduce emissions by an estimated 1.0 gigatons (Gt) to 1.3 Gt. per year, the equivalent to taking 273 million cars off the road.” Plant-based proteins are also substantially cheaper than their animal protein equivalents, in fact being approximately 4 times less expensive per gram of protein.

 

Less processing, more whole foods

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Chicken nuggets, bags of chips, and microwavable meals: ultra-processed foods have little resemblance to whole foods. They are better described as formulations of industrial ingredients and other substances derived from foods and additives. Not only are these foods full of calories and have limited nutritional value, but the energy and water required for their production is extensive. Processed foods are also a source of ample plastic waste due to the packaging of the products to optimize transportability.

The convenience of ultra-processed foods is attractive in healthcare settings. Pre-packaged portions make it easy to serve clients – but at a cost to nutrition, sustainability, and sometimes even budgets. Instead, looking to whole foods or minimally processed foods such as raw fruits and vegetables or simple baked goods can be beneficial for patients and the planet.

 

Local food, local economies

Prioritizing the procurement of local foods is path that can help meet priorities around creating delicious, sustainable and cost-efficient meals.

In a recent article in Food Service and Nutrition Magazine, Jennifer Reynolds of Food Secure Canada describes the following 5 reasons for buying local food:

  1. Reducing food miles: The smaller the distance food needs to travel, the smaller the environmental impact.

  2. Fresher, more flavourful food: Local food is often harvested only hours before being sold – the freshness results in better taste.

  3. Seasonal eating: When fruits and vegetables are in season, they are at peak flavour and ripeness.

  4. Supporting local economies: Producers directly receive profits and consumers learn how their food is grown.

  5. Transparency: Consumers gain a better awareness of what they’re buying.

 

Reducing waste

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Food waste leads to lost calories, money, and energy. In 2010, the annual value of food wasted in Canadian hospitals was about $45 million. This was the result of either kitchen food waste, where food may be overproduced or prepared inefficiently, or patient food waste, where food is left uneaten and remains on the plate.  Hospital kitchens can use simple methods of reducing waste such as freezing leftover bread or pureeing proteins into soup in order to maximize use of the ingredients purchased.

Reducing food waste is a sustainable action that also meets needs around enhancing patient health and satisfaction. Observing how much and what foods are left on the patient plate can empower care providers to identify signs of malnourishment and support food service managers in identifying recipes that need to be improved.

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Moving forward, it is vital that we see healthy food as synonymous with sustainable food, for the health of the patient, population and planet.

There is no doubt that making sustainable food choices can nourish both patients and the wider environment. Health care facilities which elect to prioritize sustainability in their kitchens will emerge as leaders in public health. As climate change continues to aggravate existing global problems such as food security, infectious diseases and extreme weather patterns, making sustainable food choices is part of the public responsibility of hospitals to reduce the impact of a warming climate. Moving forward, it is vital that we see healthy food as synonymous with sustainable food, for the health of the patient, population and planet.

 

Toward a New Era of Values-Based Purchasing: Welcome to Fasken Law & Buy Social Canada

We are building an ever-stronger team to bring values-based procurement  to Canadian health care. Today we are delighted to officially welcome Fasken Law and Buy Social Canada as project partners to one of our five Nourish collaborative projects.

The values-based procurement team's scan of best-in-class social procurement language is currently underway. Under the leadership of Buy Social Canada's David Le Page and Maija FIorante, the scan will cover provincial, domestic, and international examples of language that harnesses a public buyer's purchasing power to procure foods that support the health of patients, communities, and planet.

With the legal expertise of award-winning firm Fasken Law, led by Kathryn Beck, Vanessa Mui, and Daniel Fabiano, we will bring this research to life by developing and open-sourcing tested language for adoption by health care food purchasers.

We will develop, test, and open-source two sustainable procurement tools: one to support organizations with self-operated food services and one for organizations with outsourced food services. Creation and testing of two procurement tools aims to support the sector to break out of the current cost-driven process that defines healthcare food purchasing. Our goal is to advance more responsible procurement of healthy, sustainable and tasty meals for health care. Similar to our peers in the Nourish Sustainable Menus project, we are interested in the social, economic, and environmental dimensions of sustainability.

Over the next months, we will be recruiting health care sites to test the contract language developed by our team. Please send us a note through the Get in touch form if you are interested in being a beta-test site or would like to become otherwise involved.

With the growing circle of engagement around this project, so too is our confidence growing that we urgently need to bridge the gap between our desire and our capacity to bring our values more fully to life in our public institutions. 

We will develop, test, and open-source two sustainable procurement tools: one to support organizations with self-operated food services and one for organizations with outsourced food services... We urgently need to bridge the gap between our desire and our capacity to bring our values more fully to life in our public institutions. 

We couldn't be happier to be joined by Fasken and Buy Social as we continue on this journey. 

Travis Celebrates Indigenous Peoples Day at Grove Park with a Traditional Menu

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June 21 marked National Indigenous Peoples Day, and to celebrate and honour the day, Travis brought Huron-Wendat and Anishinabek dishes to the Grove Park Home menu. We interviewed Travis to learn how it all came about and to hear his takeaways from the day.
 

What got you thinking about Indigenous food in care?
I never really considered Indigenous food in healthcare prior to becoming a member of the Nourish cohort. After learning more about traditional foods from other cohort members, I realized that there is a lot that needs to be done to promote Indigenous foods in Canada and to educate the public.

Why does it matter to you?
It was important to recognize Huron-Wendat and Anishinabek people. The area is rich in their history, and I believe it was an opportunity to share their culture and cuisine with our residents, families and employees.
 

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I did some research on the Huron-Wendat and Anishinabek foods, and spoke with a family member who is actively engaged in sharing Indigenous traditions.


Tell us about your process to create a new menu for this day.
Initially, I reached out to Kathy Loon and Kelly Gordon, as well as Hayley Lapalme who provided me with some feedback on menu creation. That gave me a good baseline to develop the menu. Then I did some research on the Huron-Wendat and Anishinabek foods, and spoke with a family member who is actively engaged in sharing Indigenous traditions.

What's on the menu and how did you develop it? Where did you source the food?
The menu consisted of Three Sisters Soup, we used a recipe sourced online. We were originally going to serve a maple glazed trout but had difficulty sourcing a suitable cost-effective product, so we went with salmon. From there it was accompanied with blueberry bannock (which was a commercially sourced tea biscuit), maize (corn) and for dessert was fresh strawberries, sourced locally.
 

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How was the menu received?
The menu was received quite well, and the promotion of Indigenous Peoples day engaged our staff to discuss further. We had the adult day program staff even prepare a First Nations treat consisting of warm apple slices, cranberry and berries.

What reactions did residents give? What about staff?
We have a small contingent of Indigenous residents, but the most popular menu item was the Three Sisters Soup. We had numerous staff thank us for doing something to recognize the Indigenous population. It was well received.

Will you do it again? Same or different?
I would absolutely do it again. I didn't give myself enough time to source product. In the future, I would get in touch with a local Native Friendship Centre or one of the many reservations close by to source better recipes and menu item options. It can be difficult to develop a menu in long-term care that is appropriate for an ailing population that we serve.

 
I would absolutely do it again. A few suggestions for others: connect with your local Native Friendship Centre, traditional food specialists, and even the clientele that you serve.
 

What advice do you have for others who are thinking of bringing traditional foods into their own menu?
A few suggestions for others, as said above: connect with your local Native Friendship Centre, traditional food specialists, and even clientele that you serve. Do research on the items you are serving so that you can educate the people you're serving. Have fun sharing and learning!

Thank you Travis! 

Patients and staff enjoy traditional foods at Saskatchewan Health Authority Regina on National Indigenous Peoples Day

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To celebrate National Indigenous Peoples Day on June 21, Stephanie and her food and nutrition staff at Saskatchewan Health Authority facilities in Regina served up delicious traditional dishes to both staff and patients. We interviewed Stephanie to learn about how she and her team planned this menu and what inspired her.
 

What got you thinking about Indigenous food in care?  
Nourish! It was the collective knowledge and the passion of my Nourish colleagues that inspired me to start thinking about how I could incorporate more traditional foods into the menus where I work. I had a moment around the Colton Boushie trial where I thought to myself, ‘If everyone did one small thing to move this forward, we could change things.’ And then I realized, ‘Well, what am I doing?’ So I decided to dedicate a large portion of our new Wellness Garden to Truth and Reconciliation, where we will grow traditional medicinal plants in partnership with local First Nations communities and Elders. Doing this menu was another step we could take to put our learning into practice.

Why does it matter to you?
It matters because many of the people in our care have Indigenous roots and sadly this has been largely overlooked in our menu planning. I believe that every person has the capacity to contribute in a positive way to truth and reconciliation.
 

Nutrition and Food Services employee, Lee Bannister, dishing up the bison stew for patients at the Regina General Hospital in celebration of National Indigenous Peoples Day!

Nutrition and Food Services employee, Lee Bannister, dishing up the bison stew for patients at the Regina General Hospital in celebration of National Indigenous Peoples Day!


What's on the menu and how did you develop it? Where did you source the food? 
At our Nourish retreat in April, my group had the good fortune to visit the Squamish Lil'wat Cultural Centre in Whistler as a part of our learning journeys, and have lunch from their café. I had the most amazing salmon sandwich on bannock and wondered if it was something we could do in our cafeterias here in Regina. I described it to one of my Food Services Managers (Garnet Roberts), who is also an amazing chef, who said “no problem.” Garnet used Traditional Foods and Recipes from the Wild Side, a publication by the Native Women’s Association of Canada as a resource for recipes.

Our Food Services Manager used ‘Traditional Foods and Recipes from the Wild Side,’ a publication by the Native Women’s Association of Canada as a resource for recipes.

 

With National Indigenous Peoples Day on the horizon, we selected this day for its debut and learned to create a recipe for salmon on bannock sandwich with arugula and a juniper dill aioli. Using bison sourced locally from Saskatchewan, Garnet also prepared a dish of bison stew, served with corn and bannock to honour the day while also celebrating local ingredients. The stew was perfect as it could work with nearly all diet types (although we did have to relax our restrictions for sodium and fat). We served this meal across our four Regina sites to nearly all patients and residents and featured this item in the cafeteria as well. We lost count after 1000 servings! It was a big hit.
 

Joyce Wong serving up the salmon on bannock sandwich in the hospital cafeteria

Joyce Wong serving up the salmon on bannock sandwich in the hospital cafeteria


What reactions did the residents give? What about staff?  
There was a real buzz in our kitchens. Staff was excited about serving something new and different and we had never really done anything in celebration of National Indigenous Peoples Day before. Many of the staff tried the stew before we served it and they felt proud – proud of our department for making the day special for the people in our care and proud of themselves for being a part of it.

Will you do it again? Same or different?  
We will absolutely do it again, but we will have to find a different recipe for next year.  The bison stew and bannock was such a hit we are planning to add it into our regular menu rotation. As for the salmon sandwich, I’m pretty sure we will see it in our cafeterias again soon – it sold out too!
 

The bison stew and bannock was such a hit we are planning to add it into our regular menu rotation.
 
Paul Neiman, a cook at the Wascana Rehabilitation Centre (Regina) , proudly displays the salmon on bannock sandwich prepared in honour of National Indigenous Peoples Day. Wascana joined the Pasqua Hospital, the Regina General Hospital and Regin…

Paul Neiman, a cook at the Wascana Rehabilitation Centre (Regina) , proudly displays the salmon on bannock sandwich prepared in honour of National Indigenous Peoples Day. Wascana joined the Pasqua Hospital, the Regina General Hospital and Regina Pioneer Village in this celebration, serving more than 2000 servings of bison stew and salmon sandwiches to our patients, staff, and visitors.


What advice do you have for others who are thinking of bringing traditional foods into their own menu? 
My advice to others is, especially if this is for a special occasion like National Indigenous Peoples Day, would be set aside your dietitian hat (or work with your dietitians) and relax your nutrient goals for the day. We decided we wanted something special for everyone, including our patients on more restrictive diets (like cardiac and renal), so they too could experience the meal as close to the ‘real thing’ as possible. We made a version with ground bison and veggies so even our folks on soft and minced diets could enjoy the same meal. We were so pleased to hear we got it right, with colleagues from Native Health Services sharing… “that was some top quality bannock today”.

Thank you Stephanie!