Rocky Vista University: Integrative Medical Nutrition Study Notes

Session Overview and Objectives

• The session focuses on describing the importance of integrating nutrition into clinical practice and learning strategies from physicians who have successfully implemented these practices.

• It explores how diverse healthcare practitioners, including MDs, NDs, and DOs, can collaborate to provide nutrition-services.

• The order of discussion includes:

  • Joan Eggert, MD, MPH, RD (Retired): Integrating Nutrition Into Clinical Practice or "How to do more in less time."

  • Lena Kian, ND: Integrative Medical Nutrition.

  • Keith Bodrero, DO, PhD: Using Nutrition in an Integrative Medicine Practice.

  • Ryan M. Greene, DO, MS: Utilizing Nutrition-Related Technologies.

  • Open Question and Answer Session.

Integrating Nutrition into Clinical Practice (Dr. Joan Eggert)

• Importance of Integration:

  • Nutrition-related disorders account for the majority of morbidity and mortality in the United States.

  • Age-adjusted death rates for leading causes of death related to nutrition ($2020$ statistics per $100,000$ population):

    • #1: Heart Disease: $166$

    • #2: Cancer: $146.2$ (Diet specifically influences breast and colon cancer).

    • #5: Stroke: $38.8$

    • #8: Diabetes: $24.8$

    • #10: Kidney Disease: $12.7$ (Frequently a complication of diabetes).

  • Mortality following amputation in diabetic patients:

    • $5$-year mortality for Below-Knee (BK) amputation exceeds $40\%$.

    • $5$-year mortality for Above-Knee (AK) amputation exceeds $60\%$.

• Clinical Conversation Strategies:

  • Assess the patient's "numbers."

  • Discuss the leading causes of mortality.

  • Compare the patient’s specific numbers to the "normal range."

  • Provide a one-page handout containing the patient's data.

  • Respect the patient’s background and listen to their priorities.

  • Ask what is realistic for the patient.

  • Implement "Baby Steps": Start with painless changes. For example, a diabetic who eats toast with butter and jam might not switch immediately to oatmeal and eggs, but they might agree to use melted cheese in place of butter and jam.

• Woman’s Preventive Health Report Card Checklist:

  • Safety reminders: Seat belts and bike helmets.

  • Immunizations: Annual Flu and Covid; Prevnar PCV20 and Pneumovax (once); Shingles (once); Tdap every $10$ years.

  • Cardiovascular (CV) Goals:

    • Total Cholesterol (TC): < 200

    • LDL: < 100

    • HDL: > 45

    • Triglycerides: < 180

    • Glucose: < 100

    • FT4: $0.5$ to $1.5$

    • Blood Pressure (BP): < 130/80\,\text{mmHg}

  • Weight and Exercise:

    • Exercise: $45\,\text{min/day}$.

    • Ideal Weight: < 130\%.

    • Ideal Body Weight (IBW) Formula for Women: $100\,\text{lbs}$ at $5\,'$ plus $5\,\text{lbs}$ for each additional inch in height.

  • Recommended Diet: Fish, chicken, beans, whole grains, fruits, and vegetables.

  • Screenings:

    • Breast Cancer: Monthly Self-Breast Exam (SBE) and yearly mammogram.

    • Colon Cancer: Colonoscopy every $10$ years starting at age $50$ ($5$ years if positive family history or polyps).

    • Osteoporosis: $1200$ to $1500\,\text{mg}$ Calcium per day ($300\,\text{mg}$ = $1$ cup milk/yogurt, $1/2$ cup cottage cheese/ice cream, or $1\,\text{oz}$ cheese).

    • Bone Mineral Density (BMD): Age $65$ or $1$ year after menopause (if not on estrogen), then every $2$ years.

  • Falls Prevention: Lighting, grab-bars, secure rugs, clear paths. Weights or walking $45\,\text{min/day}$.

• Men’s Preventive Health Report Card Checklist:

  • Immunizations: Same as women (Flu, Covid, Prevnar PCV20, Pneumovax, Shingles, Tdap).

  • CV Goals: Same as women (TC, LDL, HDL, Triglycerides, Glucose, FT4, BP).

  • Weight and Exercise:

    • Ideal Weight: < 130\%.

    • IBW Formula for Men: $110\,\text{lbs}$ at $5\,'$ plus $5\,\text{lbs}$ for each additional inch in height.

  • Screenings:

    • Prostate Cancer: PSA at age $50$; repeat every $2$ to $4$ years if < 4 on prior test. High-risk patients start at age $40$ to $45$.

    • Colon Cancer: Colonoscopy every $10$ years starting at age $50$ (every $5$ years for positive history).

    • COPD/Asthma: Smokers must stop. Yearly CT for those > 55 years old with a $30$ pack-year history.

  • Accidents and Falls: Bike helmets, seat belts, ATV safety, gun safety, and home environment hazards.

• ‘Health at Every Size’ Principles:

  • If a patient refuses weight control discussions, the provider should accept this without judgment.

  • Factors like physical/sexual abuse history, bullying, or low self-esteem from failed dieting may be barriers.

  • Focus on other health improvements:

    • Increase physical activity.

    • Increase consumption of fruits, vegetables, fish, chicken, whole grains, and beans.

    • Practice yoga or stress reduction.

    • Ensure sleep of at least $6$ hours per night.

Resources and Office Education Strategies

• Reliable Information Sources:

  • Registered Dietitians (RD) and Certified Diabetic Educators.

  • UpToDate Patient Handouts.

  • NIH (PubMed).

  • Professional Associations: ACOG (Obstetrics/Gynecology), AAP (Pediatrics), AAFP (Family Physicians).

  • American Diabetes Association and American Heart Association.

  • Mayo Clinic and WebMD online.

  • Weight Watchers.

  • WIC or SNAP (supplemental nutrition program) dietitians.

  • County Extension Nutritionists (USU & USDA).

• Office-Based Opportunities:

  • Handouts in waiting rooms, nurses' stations, and patient rooms.

  • Monthly "current topic" emails with healthy recipes.

  • Bulletin boards in waiting areas.

  • Magazine subscriptions promoting healthy food.

  • Displaying maps of local hikes and information on gyms/trainers.

• Nutrition Topics by Milestone:

  • Pregnancy: Handouts for each month of pregnancy, prenatal vitamins, folate.

  • Infants: "Breast-feeding is best" discussions and milestones for solid foods.

  • Teens: Sports nutrition and avoiding unhealthy behaviors like anorexia, bulimia, and alcohol.

  • General: Weight-neutral strategies for slowing metabolism, pre-diabetes diets, heart-healthy diets, and yearly report cards.

• Community Visibility Strategies:

  • Lead "Walk With A Doc" events.

  • Volunteer for blood pressure/sugar checks at senior centers or soup kitchens.

  • Present safety and healthy menu ideas to outdoor, rockbound, or ATV groups.

  • Provide medical support for marathons, Senior Games, Special Olympics, or disease-specific walks (Alzheimer's, Diabetes).

Integrative Medical Nutrition Perspectives (Dr. Lena Kian)

• Framework for Food Choices:

  • Personal preference: Enjoyment, nourishment, and age.

  • Social, emotional, and cognitive influences: Habits, comfort foods, advertising/promotion, eating away from home, and current trends.

  • External factors: Availability/economics, cultural background, family, religion, and specific health concerns.

• Social Ecological Framework: A mapping of the diverse environmental, societal, and individual levels of influence on nutrition and physical activity decisions.

Osteopathic and Integrative Practice (Dr. Keith Bodrero)

• Background: Dr. Bodrero holds a PhD in organic chemistry and worked as a research scientist at the Food Science Department at Michigan State University.

• Clinical Focus: Integrative medicine with interests in osteopathic manipulation and treating chronic conditions such as fibromyalgia and chronic fatigue syndrome.

Nutrition-Related Technologies (Dr. Ryan M. Greene)

• Continuous Glucose Monitors (CGM):

  • Available Platforms: Levels, Supersapiens, Nutrisense, Stelo (DEXCOM).

  • Benefits: Real-time glucose response to diet, exercise, and lifestyle; understanding sensitivities to movement and food.

  • Pros: Easy iPhone/Android interface, developing API integration (Whoop, Oura, Apple Health), global blood sugar understanding.

  • Cons: High cost ( >\$300/\text{mo} without insurance), not approved for Type $1$ diabetics, requires practitioner knowledge for longitudinal application.

• Metabolic Breath Testing (Lumen):

  • Function: Measures CO2 concentration in breath to determine metabolic rate. Higher CO2 indicates carb burning, as carb metabolism produces more CO2 than fat metabolism.

  • Pros: Helps optimize nutrition for weight loss; strong app support.

  • Cons: Handheld device is cumbersome to use multiple times daily; requires a large volume breath.

  • Pricing Tiers:

    • Metabolism Booster ($6$-month track): $\$249$.

    • Advanced Fat Burn ($12$-month track): $\$299$ (Black Friday sale $\$259$).

    • Optimal Health ($18$-month track): $\$349$.

    • Renewal rates: $\$13/\text{mo}$ or annual renewals after the initial track.

• Food Sensitivity and Microbiome Testing:

  • Common Brands: Genova, Spectracell, VIOME (Gut Health).

  • Criticisms/Cons:

    • IgG Testing Reliability: IgG antibodies do not reliably identify food allergies or sensitivities. Most people produce IgG after eating; levels may reflect frequent exposure rather than specific sensitivity.

    • Cost: Generally exceeds $\$300$ per test with no insurance coverage.

    • Volatility: The microbiome changes weekly; VIOME reports take $4$ to $6$ weeks to return, affecting real-time utility.

Future Trends in Wellness Technology

• AI-Powered Wellness: Synergy between Thrive Global and Function Health.

• Digital Clinics: Services like Superpower aiming for disease prevention and longevity.

• Wearable Integration: Oura Rings partnering with Dexcom to connect activity and sleep data with blood sugar levels.

Questions & Discussion

• The session concluded with an Open Question and Answer Session for students and practitioners to discuss the application of these nutrition strategies and technologies.