by Lisa O’Hearn, Munich International Women’s Club
“An apple a day keeps the doctor away…”* While a 2015 study by researchers from Dartmouth College and the University of Michigan found no evidence that this old Welsh proverb was true – adult consumers of one small apple per day had the same number of physician visits as those who did not eat apples – better nutrition can be the key to better health, particularly in the area of non-communicable diseases. Food can often play a role in both disease prevention and disease treatment.
What is the role of food in our lives? From a purely health and well-being standpoint, food is used to maintain our health, prevent disease, allow our bodies to function and provide our cells with information. We all know that a healthy diet is recommended – but most of us don’t always follow that recommendation. Why not? Researchers at the University of Minnesota suggest two possible reasons: 1) we focus on what to avoid, not what to eat; and 2) we know what to do, but choose not to act.
Eating the wrong diet has made us sick – sicker than many even realize. Poor diet causes more than half a million deaths per year in the US; it is the leading cause of mortality. However, it’s not just the US that has a problem. Cardiovascular and respiratory diseases, cancers, and diabetes are responsible for 71% of global deaths (41 million) each year (World Health Organization, World Health Statistics 2018). Malnutrition is considered a major risk factor in the development of non-communicable diseases (NCDs) such as these. While malnutrition can be defined by a lack of sufficient energy or nutrients, it can also be characterized by excessive and imbalanced intake of nutrients. Nearly one in three people worldwide are currently considered malnourished. This number is expected to rise to two out of three by 2025 if current trends continue. Children affected by either form of malnutrition are at a greater risk of developing NCDs as adults.
What happened to our diets and health? We used to worry about all of those starving children around the world – do we now need to worry that they might also be eating too much? Over the last 50 years or so, the food and farming industry focus has been on efficiency: to increase the amount of available, inexpensive and high calorie foods to feed the hungry. Unfortunately, this has often decreased the diversity of foods available, as well as displacing the typically healthier local diet. Foods high in salt, sugars, saturated fats and trans fats have become more widely available, while the availability of fresh produce, legumes, nuts and pulses has not always improved as much.
According to researchers at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University, nearly half of all deaths in the US each year from heart disease, stroke and type 2 diabetes can be attributed to 10 foods – whether by eating too little or too much of them.
(Chart based on infographic at https://nutrition.tufts.edu/sites/default/files/documents/FIM%20Infographic-Web.pdf)
Could changing our diet really make that much of a difference? We’ve seen taxes installed on sugar-sweetened beverages, with some modest decrease in consumption. Unfortunately, sugar-sweetened beverages are just a fraction of the obesity problem and its related NCD issues. Maybe we need to also concentrate more on what we should eat, rather than what we shouldn’t be eating. Just as weight loss programs that restrict certain foods never seem to work out in the end, could implementing a diet full of foods that are good for us on a more consistent basis be better than simply removing certain items that we shouldn’t be eating? In addition, could this diet really stave off NCDs and lower health care costs? We know health care is expensive – and the US spends more per person on health than comparable countries. If “prescribing” fruits, vegetables, nuts and fish could lower insurance premiums and keep people healthy, shouldn’t we give it a try?
The use of “food as medicine” has already been used successfully with certain populations. Take for example, the Fresh Food Farmacy for type 2 diabetes patients in Pennsylvania. This program included adults whose type 2 diabetes was not well controlled and who also had food security issues. The patients enrolled in the program receive enough fresh produce, whole grains and lean proteins to feed themselves and their entire households two healthy meals for five days per week. They were also given menus and recipes to help them use the “prescribed” ingredients. In addition to the food provided, they were required to attend 15 hours of group classes to help them learn more about their disease. They had access to a care team of medical professionals to provide coaching and case management. Results as of March 2018 include the servicing of 112 patients. After 18 months in the program, patients saw an average drop in HbA1c (blood glucose) levels of 2.1 percentage points. Conversely, those patients taking two to three medications to treat their diabetes typically see a drop in HbA1c of 0.5 to 1.2 percentage points. The drop in HbA1c levels using this program corresponds to a more than 40% decrease in risk of death or serious complications from diabetes. Additionally, the costs for pilot patients dropped by 80% – from an average of $240,000 to $48,000 per member per year. Much of the food (60%) is purchased through the local food bank, so the cost of the free healthy food averaged about $6 per person per week. The program receives a portion of funding via grants and private donations and uses in-kind support and rent-free space for the food pantry, so costs would likely increase as the project scales. But in any event, this non-traditional approach to diabetes treatment using fresh healthy food is something to consider.
“When diet is wrong, medicine is of no use. When diet is correct, medicine is of no need.”—Ayurvedic proverb
An innovative “Shop with your Doc” program in Southern California’s St. Joseph Hoag Health Alliance features doctors meeting at the grocery store with patients. As they shop the aisles, the physician provides suggestions for healthier choices and the reasons behind those choices. The organization believes programs such as this can prevent, limit or even reverse disease by changing patients’ diets. Medical institutions such as St. Joseph Hoag Health are making a philosophical switch to becoming health organizations rather than health care organizations. Elsewhere in Southern California, the Loma Linda University School of Medicine offers training for residents in “Lifestyle Medicine,” a formal subspecialty in using food to treat disease. While diet alone is not always the solution to treating a disease, research continues to accumulate that shows the power of food to treat, reverse or prevent many.
Taking things even further, a new branch of scientific research is developing around nutrigenomics, or the study of the interaction between nutrition and genetics. Scientists now understand that genes set the baseline for how your body can function, but nutrition modifies how your genetic makeup is expressed. High-tech farmers are entering the conversation, using precision agriculture to produce nutrient-rich and genetically beneficial food. As geneticists and nutritionists continue to work together to see how diet can most impact genetics, the future could see individualized nutrition for a patient’s profile that would be used to prevent and treat disease – a dietary “prescription” tailored to your own DNA. Exciting stuff for sure!
But now, let’s reconsider that apple once again. Researchers at Tufts University recently compared people who took vitamin supplements with others who consumed the same nutrients via food. They tracked intake of vitamins A and K, magnesium, and zinc. When these nutrients occurred naturally in people’s diets, they were less likely to die of heart attacks and other diseases. While vitamin supplements are synthesized to be the exact replica of what you’d get naturally in certain foods, they are missing out on a variety of other benefits of these foods. Minimally processed foods often deliver more fiber, which slows the absorption of sugar and feeds our microbes. In addition, these fruits and vegetables are healthier than supplements thanks not only to the nutrients and fiber they provide, but also thanks to the microbes they contain themselves. Maintaining a healthy and diverse biome is vital to digestion, metabolic health and the functioning of our immune systems. A July 2019 study from Frontiers in Microbiology found that the average apple contained about 100 million bacteria – a more diverse range than any supplement. These bacteria were rarely dangerous; most are innocuous or even beneficial. Researchers suggest that they interact with the microbes already in our guts and are helpful in maintaining the diversity in our gut biomes. When considering the apple, it turns out that most – 90% – of these bacteria are contained in the core. So maybe the old saying just needs to be updated a bit…a whole apple a day, may keep the doctor away!
*The aphorism “An apple a day keeps the doctor away” originated in Wales, first appearing in a publication in 1866 in a different rhyming format: “Eat an apple on going to bed and you’ll keep the doctor from earning his bread.”1 The saying reappeared in 1913 in its current form. Medical practice in the 19th and 20th centuries was crude, and the public sensibly sought to keep physicians (and other health practitioners) away—a sentiment that may not be out of place in the 21st century. Through the ages, the apple has come to symbolize health and healthy habits, and has been used by government and private health organizations to symbolize lifestyle choices that lead to health and wellness.(1.)
Sources:
- Davis, Matthew A.; Bynum, Julie P. W.; Sirovich, Brenda E. (May 1, 2015). "Association between apple consumption and physician visits". JAMA Internal (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420713/)
- https://www.takingcharge.csh.umn.edu/food-medicine
- Mozaffarian, Dariush and Glickman, Dan, (August 26, 2019). “Our Food is Killing Too Many of Us,” The New York Times.
- Andrea T. Feinberg, Andrea T.; Hess, Allison; Passaretti, Michelle; Coolbaugh, Stacy; Lee, Thomas H. (April 10, 2018) “Prescribing Food as a Specialty Drug”. NEJM Catalyst. (https://catalyst.nejm.org/prescribing-fresh-food-farmacy/)
- Branca, Francesco; Lartey, Anna; Oenema, Stineke; Aguayo, Victor; Stordalen, Gunhild A.; Richardson, Ruth; Arvelo, Mario; Afshin, (January 28, 2019) “Transforming the food system to fight non-communicable diseases,” The BMJ. (https://www.bmj.com/content/364/bmj.l296)
- Gorn, David (January 17, 2017) “Food as Medicine: It’s Not Just a Fringe Idea Anymore.” (https://www.npr.org/sections/thesalt/2017/01/17/509520895/food-as-medicine-it-s-not-just-a-fringe-idea-anymore)
- Hamblin, James (August 7, 2019) “The Best Probiotics,” The Atlantic. (https://www.theatlantic.com/health/archive/2019/08/probitoic-foods/595687/)
- “Food is Medicine: Key Facts,” The Friedman School of Nutrition Science and Policy at Tufts University (https://nutrition.tufts.edu/sites/default/files/documents/FIM%20Infographic-Web.pdf)
- Tabata, Rena Christina (October 9, 2019) “Food as Medicine: What Biochemistry and Genetics Are Teaching Us About How to Eat Right.”.(https://www.forbes.com/sites/forbestechcouncil/2019/10/09/food-as-medicine-what-biochemistry-and-genetics-are-teaching-us-about-how-to-eat-right/)
- The US Burden of Disease Collaborators (April 10, 2018) “The State of US Health, 1990 – 2016, Burden of Diseases, Injuries, and Risk Factors Among US States,” JAMA. (https://jamanetwork.com/journals/jama/fullarticle/2678018)
- “The link between food, nutrition, diet and non-communicable diseases”. 2014. World Cancer Research Fund International. (https://www.wcrf.org/sites/default/files/PPA_NCD_Alliance_Nutrition.pdf)
- Sawyer, Bradley and Cox, Cynthia. “How does health spending in the U.S. compare to other countries?” (https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u-s-spends-disproportionate-amount-health)