35. A Prescription of Nutrition

Contagious Conversations  /  Episode 35: A Prescription of Nutrition





Dr. Judy Monroe: Hello, and welcome to Contagious Conversations. I'm Dr. Judy Monroe, President and CEO of the CDC Foundation and host of today's conversation. Every episode we hear from inspiring leaders and innovators who make the world healthier and safer for all of us. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

Joining me today are Drs. Thea James and Elizabeth Petelin. Dr. James is associate professor of emergency medicine at Boston Medical Center, vice president of mission, associate chief medical officer, and co-executive director of the Health Equity Accelerator. Dr. James also serves on the Board of Community Servings, an organization with the mission to actively engage the community to provide scratch-made, medically-tailored meals to individuals and their families experiencing critical or chronic illness and nutrition insecurity. Dr. Petelin is in her third year of residency in the Family Medicine Residency program at MercyOne in Des Moines, Iowa. In this episode, we'll bring together medicine and public health, starting with a mystery clinical case.

Welcome, Dr. James and Dr. Petelin.

Dr. Thea James: Thank you so much.

Dr. Elizabeth Petelin: Thanks for having us.

Dr. Judy Monroe: So, Dr. Petelin, I'm going to start with you. You recently presented a case report that had stumped several specialists and clinicians. Tell us a little bit about how the patient presented and why was it a mystery case, why was it a difficult diagnosis and a little of how you and your team cracked the case?

Dr. Elizabeth Petelin: Yeah, so the patient presented to my outpatient residency clinic for ER follow-up. She was a female in her 60s who had been, for the last two months, having worsening pain and bruising in her left lower leg after she had just bumped it on a car door. She said it was so minor, she barely even remembered that it had happened. It just never got better. And so she'd been seen in the ER and they had tried antibiotics that hadn't helped. She'd finished several courses. She'd also seen a dermatologist who said, ‘I don't know what this is, but it's not your skin,’ and an orthopedic doctor who said, ‘Well, maybe the pain is from osteoarthritis,’ and had sent her on her way. So now she was seeing me two months after the symptoms had started.

I knew this wasn't cellulitis looking at it, but I wasn't quite sure what it was. I hadn't seen anything like it, nor had the preceptor or the supervising physician in my outpatient clinic. So I knew that her leg was swollen. It was from her knee to her toes was all bruised as well. So I sent her to the ER because I knew I couldn't do the work-up in my outpatient clinic that she needed. And since she was continuing to get worse, I knew she needed treatment fast. So she went to the ER and my inpatient family medicine resident colleagues admitted her to our service. They had a wide list of what this could be when they first started. They got a lot of lab work and most of it was all normal, other than some things that maybe pointed towards malnutrition.

But they did notice that she was having these signs of malnutrition and talked to her and found out that she'd lost her job, and that was why she was having these signs of malnutrition. A medical student that worked with our team was actually the one who suggested the diagnosis first. They'd noticed some additional signs and said, ‘Hey, what about scurvy?’ And so, scurvy is actually relatively easy to diagnose once you think of it. The reason it's such a mystery is we don't see it anymore. It's so rare, or at least we think it's so rare. And so we don't think about it as a diagnosis. So we got a vitamin C level and it was zero. So she did in fact have scurvy that was causing all of her symptoms. Thankfully, it was pretty easy to treat. We just started her on vitamin C and she quickly got better.

Dr. Judy Monroe: Wow. Well, so first of all, congratulations on the diagnosis. In all of my years of practicing family medicine in a variety of settings, I never saw a case of scurvy and really thought of it as a diagnosis of long time ago. I mean, that was the pirates' disease and it was on ships back when, and yet here you are having diagnosed a case of scurvy in Iowa. Obviously vitamin C is in fruits and vegetables. It's common in foods. Here we are in the 21st century. How did this happen for this particular person?

Dr. Elizabeth Petelin: Yeah, so first of all, all the credit goes to the residents that were actually on the inpatient service. While I saw her first and have been presenting on it, they were the ones that actually made the diagnosis, them and our medical student. So I want to give them a shout out for actually thinking of this. What had happened for her was, she found that it was cheapest to eat white bread and turkey sandwiches every day. That was the cheapest way that she could think to get enough calories in. And we actually saw it in another patient in the year since we've seen that patient, that was eating fast food burgers for their entire diet.

You think that everybody has access to fresh fruits and vegetables, but when I was doing my research for my presentation earlier this month, I found out that actually 7% of the US is estimated to be deficient in vitamin C. So it's actually more common than we think. It's just hard to diagnose scurvy because the symptoms can vary so much. But usually we see this in patients with a lack of access to food, like our elderly, our homeless or our financially disadvantaged patients. But we can also see it in people who have GI problems that don't allow them to absorb vitamin C, or those who are restricting for either psychiatric reasons or things like autism.

Dr. Judy Monroe: So Dr. James, I want to bring you into the conversation. You're an emergency medical physician, but obviously the health impacts of diet and proper nutrition impact health very broadly. So in your experience, how big a role have you seen proper diet and nutrition play in the overall health of the patients you see? And have you seen scurvy?

Dr. Thea James: I have not seen scurvy, and I'm not so sure I would've been as sharp as Dr. Petelin and picked it up. I'm not so sure. In emergency medicine, as you say, I'm an ER doctor, but you see everything coming through the door and you have to apply some sort of differential diagnosis. But one of the things I want to highlight that is very particular about our patient population is, I've worked in a safety net hospital for 30 years. You cannot apply things that you learn in medical school without being cognizant of nuances. You can't just focus on disease and the treatment of disease. You really have to focus on the whole person.

In our hospital, at least 50% of our patients live at or below the federal poverty level, and so they have extreme difficulty prioritizing health. They're prioritizing survival. And some people don't understand that when a person's disease doesn't get better, or if they come in over and over again with the exact same issue. And when you can't prioritize health because of economic issues, it's a recipe for repeat ED visits or repeat hospital admissions. And what we do is reset them to baseline. For example, if their disease is always out of control, but then we're discharging them right back to what's causing it.

So one of the things we've learned over time, and I would say the CDC was a leader in this when they first started talking about the health pyramid, and it basically is turned upside down from the way we were taught in medical school in terms of what are the things that contribute to it. So we have to consider all those social things that are contributing to whatever it is we see coming in the door. So we definitely see people who are lacking proper nutrition, because you need it for everything. You need it to grow, develop, brain function, even to recover from surgery.

Dr. Judy Monroe: So tell me about some of the ways you work with your colleagues and patients to address nutrition issues.

Dr. Thea James: One of the things we've done is, the way that we approach patients, is we screen all of our patients for determinants of health, number one. So if there is an issue or a problem with food insecurity, we're going to know about it right then and there and we immediately connect people to resources for that. Some of the resources we have internally. For example, we have the first hospital-based prescription food pantry in the country, and the doctors actually write prescriptions for patients to get food in our food pantry, which is supplied by the Greater Boston Food Bank.

And so it is disease specific. And we also have a teaching kitchen that goes along with that to introduce people to various different ways of preparing different types of foods in healthier ways to address the particular issues they have. We also have a rooftop garden. We're about to start two other ones. But the rooftop garden is used for cafeteria food. It's used for inpatient food. We also have a farmer's market pre-COVID that we have not opened back up again. And we also have beehives up there, so we make honey.

Dr. Judy Monroe: Dr. Petelin, I want to come back to you in a minute, too. First of all, thank you for calling out your team and giving credit to the team for the diagnosis, because so much of what we're talking about is team-oriented and it needs to be the team within the ecosystem that I think Dr. James is talking about. These are big issues that need to be overcome. And when we think about this case of scurvy that we started with, that seems to me it's the tip of the iceberg for the nutritional deficiencies and the issues that we have.

So Dr. Petelin, you're currently a resident. What exposure, when you were a medical student, what type of exposure did you have about the proper role of diet and nutrition and the overall patient health? And how much exposure to social determinants of health–the issues that Dr. James is talking about, how practicing physicians can connect with and get their patients those fundamental things that are needed?

Dr. Thea James: Yeah. I actually got more exposure in my undergraduate because I was a kinesiology major, which is exercise physiology, and a lot of exercise physiology is nutrition. But we talked about it in medical school in a lot of our classes about how nutrition plays a role in everything. We especially talked about it in GI, our gastrointestinal system, but we talked about it in every system. We also at our school had a course that was offered on healthy diets and encouraging nutrition, which was wonderful. It was offered by the dean to help us understand a little bit better what exactly we could be telling our patients, not just learning it in the context of textbook knowledge. As far as social determinants of health, I feel like my school did a really good job.

We didn't just learn it in the classroom where we were exposed to a lot of these things, but we learned it by going out into our community as well. Our school had a free clinic that we staffed with our attending or supervising physicians as well as medical students being scribes. But then we also had a program where every Friday in the fall, we would go do free physicals for low-income elementary school children. And many of these children, this was the only doctor exposure that they had, was seeing medical students and our supervising physicians. And so I got to see directly how these social determinants of health were impacted before I even finished my preclinical years. And so that was a wonderful experience. I got to see a lot of pathology that I never thought I would see, and find out from children how this was affecting their lives.

Dr. Judy Monroe: We'll be right back with Dr. Thea James and Dr. Elizabeth Petelin.

Millions of Americans struggle with hunger. Millions more struggle with diet-related diseases like heart disease and diabetes. While the effects of hunger impact all Americans, that toll disproportionately impacts underserved communities, communities of color, low-income families and rural Americans. The CDC Foundation is proud to be working with the White House and partners to end hunger and increase healthy eating and physical activity by 2030. Learn more at cdcfoundation.org/hungerandhealth.

And now back to our conversation with Dr. James and Dr. Petelin. [Dr. Petelin], how much exposure to public health, the governmental public health system did you have? Talk to me about that a bit, and do you see ways that there could be better support from governmental public health to medicine or vice versa?

Dr. Elizabeth Petelin: Yeah, we didn't have a whole lot of exposure in medical school, but I have a lot more exposure now because of working in a residency clinic where a lot of our programs are publicly funded. We're a federally qualified health center, so our patients, the amount they pay is based off of their income rather than their insurance status, which is a great benefit to our patients and allows us to get them prescriptions at low cost and access to specialists as well. But I think a big way that public health can be a little more supportive is in the encouragement of preventative care.

Like Dr. James was saying, we have screening tools in place for these social determinants of health, so if the patients can just get to us, we can catch a lot of these cases because we will find out, in our clinic, that the patient has food insecurity and connect them with our family support worker that works full-time in our clinic. But if we don't know that these problems exist, it's hard for us to address them and get them connected to the resources that they need. We're fortunate in our residency clinic to have a lot more resources, and so we just need the patients to get connected with them.

Dr. Judy Monroe: Well, thank you for that. One of the things during COVID that the CDC Foundation did, we supported health departments across the nation. We hired staff, we supported them with a number of needs, but we also supported community-based organizations and then connected the CBOs to the health departments. And in turn, we were supporting some medicine, some clinical trials, and then there were a variety of things that we helped support.

Dr. James, coming back to you, thinking about community-based organizations, as you serve on the board of the non-profit called Community Servings, and I think some of this you might have touched on in your earlier answer, but is there more you want to say about that particular nonprofit and how they go about their work?

Dr. Thea James: Oh, absolutely. I mean, Community Servings started a long time ago and back during the early days of HIV, and it was getting medically-tailored meals to people who were suffering from HIV at home, and people really just malnourished, terribly so. The way it works is, I mean, I think you already know how it works, but it has a kitchen. It hires people on its staff to prepare meals, but it also educates and teaches people. I might also add that it's not just anybody in their kitchen. They have actually hired people who are considered reentries into a system, for example, who may have been incarcerated at some point. But at any rate, they bring people in, they teach people the food business, everything around nutrition, food preparation and everything.

Those people also have the opportunity to rise through the ranks in the place within the organization. But, they prepare these special meals for people with specific types of diseases and they transport these meals to people's houses. But I will also say that it has actually evolved with everything else. It is a CBO, it's a community based organization, but it has particularly, I would say since 2018, they've sort of integrated into the mainstream of health care. I'm talking about Medicaid, for example, Medicare for example, in terms of they now have contracts with hospitals. Medicaid changed this reimbursement model where hospitals are accountable for their patients thriving and doing well.

And that was a great entry point for Community Servings. They can do this. They can provide the meals that patients actually need to stay healthy and be able to stay home and not have to have their diseases out of control. And so it has really grown and evolved, and it's a win-win. The government is better, patients are better, the community servant is better. And I think it will continue to do so as everything else evolves. And it has scaled tremendously I will say in the last three years or so, I mean three or four years. It has really, really, really scaled. It has a new building now, has a brand new kitchen. I mean, it just continues to grow and it is of great benefit to everyone. I'm really proud to be on that board.

Dr. Judy Monroe: It sounds tremendous, and I didn't realize that they took individuals that have been incarcerated, and having that training and that opportunity is just fantastic. So we know that obesity rates are continuing to rise in the United States. They're linked to heart disease, stroke, type 2 diabetes, a number of different cancers. And we also have this phenomenon of people being undernourished even though they're getting a lot of calories. So we've got this really mixed challenge before us.

Dr. James, thoughts on better preparing our medical students to face the health implications of diet and nutrition. I'm intrigued by your background, Dr. Petelin, with what you did in your undergrad that gave you such a strong foundation. But not every medical student has that background. So thoughts on how we do a better job supporting our medical students when it comes to nutrition?

Dr. Thea James: Well, I think teaching them to engage with patients. I just had a coffee this morning with a pre-med student, and I was saying this to him, I was saying, ‘When you start school, they're going to teach you about disease and they're going to teach you about how to treat the disease. But what will be important is that you broaden that because there's a human being connected to that disease, and you're going to need to understand all of the nuances of the human experience. You're can't make assumptions about whether people have things or not have things.’

You just can't give people directions or instructions without understanding their relationship to that. Whether or not they have the resources, do they understand it, even culturally, does it matter to them? And so you're going to have to understand what matters to them and you can only do that by engaging with them on that level. You have to talk to people. It's the easiest opportunity to get the best outcome that's possible. You ask patients, they will tell you, but you have to ask them.

Dr. Judy Monroe: But you have to have time to listen, right?

Dr. Thea James: Exactly. Absolutely.

Dr. Judy Monroe: You have to take that time. Absolutely. Well, we clearly, y'all have made the case here that food and nutrition are really fundamental to good health. Let me offer both of you an opportunity for any closing remarks or closing advice that you'd like to give. Dr. Petelin.

Dr. Elizabeth Petelin: Yeah, I think it's important to always ask about nutrition. It's really easy to get caught up and just say, ‘Oh, everybody knows they're supposed to eat healthy,’ or just tell people to eat healthy. But actually explaining what that means and how the patient can fit that into the context of their life is important as well.

Dr. Judy Monroe: That's beautiful. Dr. James, anything, any last words?

Dr. Thea James: Yeah. I would say, similar to what Dr. Petelin said, and again, using time to engage with people no matter who they are, and set high bars because where you set the bar becomes a self-fulfilling prophecy. So don't listen to things like you can't boil the ocean and all these other things, because what happens when you think like that is nothing ever changes. You look at the data 10 years, 20 years, 30 years later, nothing ever changed because you never did anything different. So you have to really set high bars to not just fill gaps and things people have, but also eliminate gaps. So I ask my patients one question, no matter what it is, before I begin to think of any treatment at all. I ask them, ‘What would it take for whatever this thing is you're here with to not happen again?’ And they will tell you. And they will tell you. It's an easy question.

Dr. Judy Monroe: That sounds like the question that we can wrap up our podcast, because that's fantastic. What a great question to ask family members as well, right? I mean, not just patients, but friends, family, others that might have had a hard time or had something happen. So I love that. I want to thank both of you for joining us today. And for our listeners, if you're not aware, our nation now has a national strategy to end hunger, nutritional deficiencies, that was released on September 28th at the first White House Conference in the last 50 years. It had been almost 50 years since there had been a conference nationally looking at these issues of hunger, nutrition and health.

And so there's room for everyone within the strategy to take action. So I love what you said about this. It's not boiling the ocean. Don't be dismayed by that because every individual can take small actions both individually and within their family. You can help your community. Philanthropy can step up and help. If we do this systematically, we can have a better education, stronger education, but it doesn't have to be overly complex either, as you both have really, really outlined today. So, thanks so much for joining me today.

Dr. Thea James: Thank you so much for having us.

Dr. Elizabeth Petelin: Thanks for having me.

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