Primary Care Pearls

"A refrigerator full of ice cream" - Nutrition Medicine (Part IV)

• Primary Care Pearls (PCP) Podcast • Season 1 • Episode 13

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In this episode, Nate and Justin discuss ways that Tina could modify her food environment to keep moving toward her health goals. They also discuss the tricky aspect of social determinants of health and how that may (or may not?) hamper our efforts to help patients achieve healthy lifestyles.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1:  Food Environment
3. Chapter 2: Social Determinants of Health
4. Chapter 3: Concluding the Nutrition Series
5. Conclusion

=== Learning Points ===

  1. Setting up an environment for success and encouraging new habits are the most important strategies for success in changing eating patterns. 
  2. While it’s important to understand the effects of social determinants of health, our patients are resilient in enacting change and should not be underestimated. 
  3. Many fad diets and trends exist within mainstream cultures. At the end of the day: point patients to an evidence-based lifestyle (such as eating a whole food, predominantly plant-based diet).
  4. Time within the office is limited. Provide patients with brief, targeted teaching while they are within the office, and additional resources for patients to explore after the visit.


=== Our Expert(s) ===

Dr. Justin Charles is a graduate of the Yale Primary Care Internal Medicine Residency Program.

His clinical interests are in Lifestyle Medicine, the use of evidence-based lifestyle interventions to not only prevent, but treat and reverse chronic disease from a root cause perspective. He has received training in Plant-Based Nutrition through the T. Colin Campbell Center for Nutrition Studies and eCornell, as well as Dr. John McDougall's Starch Solution Certification Course. 


=== References ===

Re: similarities between processed foods and “illicit” drugs:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334652/  

Re: our environment being obesogenic: https://www.sciencedirect.com/science/article/abs/pii/S0091743599905856 

Structures being a fundamental cause of disease:
https://www.jstor.org/stable/2626958 

Re: systemic solutions mentioend at the White House Conference: https://www.whitehouse.gov/briefing-room/statements-releases/2022/09/28/fact-sheet-the-biden-harris-administration-announces-more-than-8-billion-in-new-commitments-as-part-of-call-to-action-for-white-house-conference-on-hunger-nutrition-and-health/ 

*For additional resources discussed in the episode, check out our transcript!


=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.


Hosts: Nate Wood
Producers: Nate Wood, Helen Cai, August Allocco
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Dan Henig, Bobby Richards, Asher Fulero, Jesse Gallagher, VYEN

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

[00:00:00] Nate: hi, everyone. Welcome to primary care pearls. A podcast made by learners for learners, and most importantly led by our patients' stories 

[00:00:11] Justin: everyone tells them they're nothing and they're no good. And most people who have negative self-talk have had external negative self-talk come at them. And I think saying, I think you can do this. I think you can really make changes in your life.

[00:00:25] Look at how you've raised four children and lived your life in poverty and still been managed to make enough ends meet, to feed your children and worked all these jobs.

[00:00:35] look at all of these skills that you have. Imagine if you applied it to this, no one could stop. You. People get really jazzed up and they want to prove you. Right.

[00:00:44] Nate: today. We're continuing our discussion on food by focusing on the barriers our patients often face when making lifestyle changes. During our discussion Today, we'll be joined by a patient, struggling with Nutri. 

[00:00:55] Tina: this is Tina Westin 

[00:00:57] Nate: We'll learn more about her experience with different eating patterns, her personal motivations for changing her nutrition plan and the emotional struggles she has faced while doing. So we'll also be joined by a resident expert from the Yale school of medicine.

[00:01:13] Justin: I'm Justin Charles. I'm one of the residents in the Yale primary care program, really passionate, interested about nutrition and lifestyle medicine

[00:01:22] Nate: our discussion today is the final part of a four part series where we've been exploring strategies for the primary care provider to help patients eat healthier, regardless of external barriers in their life, such as their food environment and socioeconomic status. My name's Nate wood, and I'll be your host for this episode.

[00:01:40] We hope that through this discussion, you'll be able to listen empathetically for the structural barriers that prevent our patients from sometimes living healthy lives and how we can support and partner with them to overcome some of these barriers with the ultimate goal of helping them to achieve their personal health goals.

[00:01:56] Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you or a loved one is suffering from anything discussed in today's episode, please be sure to discuss it with a medical expert. Let's get started.

Chapter 1: Food Environment

[00:02:14] Nate: In our previous episode, we explored tools that providers can use to help patients find their own inner motivation to live richer and fuller lives by changing their eating habits. But sometimes no matter how motivated patients might be, they still face seemingly insurmountable obstacles as they try to make some of these changes in their lives. So how can we learn to recognize these obstacles and help patients overcome?

[00:02:40] so I think this actually brings up a really interesting discussion that we need to delve a little more into, which is so many people do embark on this quest to improve their diet or to achieve a healthy, nutritious way of eating and. It's so hard to stick to, and some people can stick with their diets once they start them and some don't. So why is that? What are some of these barriers that people are coming up against that at least at the time, just seem so insurmountable. 

[00:03:13] Justin: Great question. And there's a lot, I think hearkening back to what we've already talked about, the underlying psychological, emotional, spiritual issues, I think are a big barrier that a lot of people don't realize. I think not having a deep enough why that can help us gain that strength in the midst of a storm. Those are two really, really important ones. Those are maybe a little bit deeper. We also touched on feeling like they're not going to be able to socially interact have support from their family, that food's going to become this joyless tasteless thing. And we've already talked about that. I think a lot of it is also habit formation. 

[00:03:55] We talk so much about willpower and everyone thinks I'm I only had the willpower to do this, I'd be motivated. Willpower is over rated it's about habit formation and changing our environment. 

[00:04:07] It is way, way easier to not eat the cookies that are not in your house than it is to not eat the cookies that are on your counter, begging for you to eat them.

[00:04:17] Tina: I have my daughter with a refrigerator full of ice cream. Then everyday she's saying the same thing. I say, I'm going to lose weight. And I just look at her and I'm like here. Right? And then I bring stuff and she'd say, stop buying this stuff.

[00:04:26] And I said to her, you stopped buying it. Then my grandson wants it. So then we have to buy it because he wants it. But then we eat it up from him. 

[00:04:34] Justin: So a lot of it is really helping people set up an environment that's healthier for them because we live in an obesogenic environment. You can drive anywhere in the world at any time during the day and the place that's going to be open is the place selling the most calorie, dense, least healthy food. 

[00:04:52] Their advertisements everywhere, constant temptations and triggering things for people to eat these unhealthy foods that they're already using everything in their string to avoid.

[00:05:03] So we need to help people set up the strongest environment that they possibly can have with as few of these cues until they get to a point where they've developed a habit. this is making the healthy decision easier and creating a lot of friction with the less healthy decision. So throwing out the food in your pantry that you don't want to eat and not having it in your house at all.

[00:05:29] So then you'd have to go out somewhere else to get it and leaving the healthy food right out on your counter. So it's right there. You see it all the time and you're much more likely to eat it, doing things like batch cooking, if you can, at the beginning of the week. So the thing in your fridge has already the healthy thing. So really looking at this habit, science, not relying exclusively on willpower. 

[00:05:51] Nate: I just Want to pull out one thing in particular, which is really maximizing your chances at success by changing the architecture of your environment.

[00:06:00] And what I mean by that is just really controlling what foods are within your eyesight, in your pantry and your refrigerator. Um, and I, I just want to share a tip that I heard recently that I had never fully thought about before. This is from a friend of mine from medical school. Who's now a practicing primary care physician himself, Dr.

[00:06:17] Carl Baker. He mentioned that. If you are grocery shopping more than one, or maybe even two times a week, you are effectively using the grocery store as your environment. If you go grocery shopping once a week, say you have one chance to quote unquote slip up and buy some of those Oreos, some of those tempting things, and then stocking your environment at home with those foods that are hard to say no to.

[00:06:44] But if you're in the grocery store all the time, that gives you a lot of chances. You know, maybe you have a headache after a long day. Maybe someone said something really mean to you, that you're perseverating on. You know, who knows what emotional baggage you're bringing to the grocery store. But the point being that you want to create your environment at home and set it up in a way that's going to make it easy for you to eat healthily so that you don't have to have all that willpower. And that going to the grocery store super frequently can actually undermine that. And I thought that was really interesting. 

[00:07:11] Justin: That makes a ton of sense. And I think it's really, really apt to point that out. And they're also part of our patient's environment and our environments that we don't have control over. How's your relationship with between food and family? What's that like for you? Um, 

[00:07:30] Tina: the whole thing is she'll buy stuff and I'll buy stuff. Then it turns into a big argument. Don't eat my stuff. So then when you ate my stuff, I'm eat your stuff, you know, like that more control, right? Each has gotten to the point where she starts writing her name and my grandson's name on stuff. So I'm like, well, I paid electricity I'm going to eat it too. 

[00:07:49] Nate: First of all, I really feel for her because this is a problem that I experienced a lot growing up. And that was being an environment where there was chips and dip. When I am around chips and dip, I cannot have any control. I eat as many as there are. And so how I have modified my environment is that I cannot buy chips and dip.

[00:08:08] I do not keep them in the house because they all get eaten within a 24 hour period. But when I go home to see my family and there's chips and dip, you know exactly what happens. And this is, I think exactly what she's describing this environment, where there's ice cream, you know, and she can't say no. And the ice cream wasn't for her.

[00:08:25] She tried to keep it away, but it's still there and she's still eating it. So I think this perfectly exemplifies this issue that we're, you know, really trying to figure out how to solve. And it is a matter of controlling your environment, the best you can, which is simple, but not easy. 

[00:08:41] Justin: And think about the power of these influences, I mean, we're talking. about, I know that it's not good for me, but I just can't stop. I just, you know, I got this craving and it was in front of me and I, I couldn't help it. I mean, these are similar kind of ways that we describe drugs and addiction, and I don't want to equate the two exactly. But there are a lot of similarities between processed foods and illicit drugs and neuro biologically environmentally. 

[00:09:14] When you look at the diagnostic criteria for substance use disorders, and then you look at processed foods, it's, there's a lot of similarities and it's no accident. People didn't have lays potato chips. Don't happen to be really in craving inducing. These companies spend billions of dollars trying to fit the exact perfect shape and sugar and crunchy and fatty and salty to make it the most addictive it can be possibly. And that's the environment that we're facing. And that's really hard. And I think even sharing with patients, not in a defeatist way of, well, there's nothing you can do, but wow. You know, it really is hard to say no to the ice cream and the potato chips, because those things were created to make it really hard for you.

[00:10:08] And to give that people that, yeah, I get it there, there are some evil people out there that don't really care about your health that just want to make a buck and they're going to figure out any way they can do it. It kind of takes the weight out of the room from why can't you avoid those potato chips.

[00:10:24] Of course you can avoid those potato chips. That's why they're created to make you not be able to avoid them. So I think it's really important to be able to view this environment like that, where there are these hyper palatable foods that cue our reward system to go absolutely haywire. And that's what we're competing with. 

[00:10:42] Nate: Okay. Now I'm really craving potato chips. 

Chapter 2: Social Determinants of Health

[00:10:46] Nate: During the course of recording this episode, August who is a Yale medical student, one of our producers, and a really cool guy had a really, really important question to ask our resident expert. In fact, we were of the same mind in bringing this up. Let's hear what he had to say.

[00:11:03] August: Well, this is a question that I have, cause you've referenced now a couple of things. One is the, the fact that we don't live in a perfect world, right.

[00:11:12] We can prescribe certain things to our patients based on, you know, what we think is best or what we think it would be most effective, but that's just not going to happen. Right. Um, And you've also touched a lot on, you know, the motivations for why we eat are complex. And sometimes they're very deep rooted and sometimes it's, not something that you're going to unpack in your 20 minute primary care visit.

[00:11:35] And so it's something that I feel like I struggle with as a new trainee is like, We learn all this wonderful medicine, but so much of health is socially determined. So, you know, my question for you as a practicing primary care doc is how do you, how do you reconcile that, right? How do you keep yourself going in this environment?

[00:11:58] You know, can sometimes feel like this, the Sisyphean task of fighting these social determines of health that are largely out of your control, or at least it's easy to perceive that they're very largely out of your control. 

[00:12:09] Justin: That's a really good question. And one that I get a lot. For one never underestimate your patient. And I think we do that a lot and say, oh well, they're living in this certain situation. They have these social determinants of health. So I'm not going to say this. This might be insulting to them, but some people really have resilience and can make things work. And if we tell them what ideal is. They can really work toward it and make amazing changes.

[00:12:36] And that happens more than you'd think when we let that happen. And we're never going to live in an ideal world. I think that we should, and we'll continue to try, but we're never going to address all of the social determinants of health. There's always going to be people with less resources and more disadvantage.

[00:12:55] And we can say, oh, well then let's just stop there. But we can really help people still gain self-efficacy and find creative ways to do better given their non-ideal situation. We can help people, even who are on snap benefits, eat healthier and make healthier choices. And in some ways even save money, we can help people who they can't leave their house because it's unsafe.

[00:13:22] So they can't run an exercise around their neighborhood, find ways to work out indoors and work out in ways that are still feasible for them. And I think we can really focus on. Not letting the social determinants of health be an insurmountable barrier, but something that we need to be creative with each other to understand and we need to be able to trust our patients and say, here's what I think we should do and not underestimate them because people are very, very resilient and can really surprise you with how much they can do. While also being mindful of people's social determinants of health and counseling them accordingly, but improving people's self-efficacy And reminding them of their strengths is really important. A lot of times everyone tells them they're nothing and they're no good. And most people who have negative self-talk have had external negative self-talk come at them. And I think saying, I think you can do this. I think you can really make changes in your life.

[00:14:28] Look at how you've raised four children and lived your life in poverty and still been managed to make enough ends meet, to feed your children and worked all these jobs. I mean, when you put your mind to something, you can really do. And I think that you have the skills to really make changes here, seeing the look that changes on people's face.

[00:14:48] When you say that not a, you better do this. Here's another thing you do wrong. Like look at all of these skills that you have. Imagine if you applied it to this, no one could stop. You. People get really jazzed up and they want to prove you. Right. And I think being mindful of people's disadvantages is crucial, but letting it be what defines them, I think really unders is, is under-serving to our patients and underestimates them in ways that that make a big detriment to their health.

[00:15:19] Nate: I think it's so important that you bring that up because a lot of the resistance that we sometimes get, this is our last to be sure I promise.

[00:15:26] And then you're off the hook is that this way of eating is just not feasible for our patients for any number of reasons. What are some of the other tips that you have for incorporating patients, cultural backgrounds, socioeconomic status, or maybe even some potential food insecurity into your discussions with them about how to improve their. 

[00:15:46] Justin: I think lifestyle medicine and plant-based nutrition often gets billed as this super bougie thing. we think, oh, well, people have to give up all of their favorite cultural foods, or this means that you have to eat super expensive foods and go buy organic produce over at whole foods. And it doesn't, you can really work with people in the environment they're in dealing with the factors. They can't change to say, how can we help you buy healthy food on a budget I think it starts with getting more information.

[00:16:19] What is food like for you? Screening people for food insecurity, asking people where they get their food from asking people what their budget for food is. If they have any assistance, assistance programs with food and plugging them in, if they don't have that and really getting a good understanding of what someone's socioeconomic standpoint is when it comes to food.

[00:16:41] Do you have any grocery stores nearby you? Where's the closest one. How would you get there? Maybe they live in a food desert. Maybe there's a creative way around it. Maybe they could use something like Instacart that takes snap benefits and will allow them to have food shipped to them from a little further away. Maybe there's a new grocery store that opened up that they didn't know about. Really helpful to get a better understanding of that. healthy food. Doesn't need to be fresh vegetables. It could be frozen vegetables. It could be beans in bulk brown rice and. bulk sweet potatoes in bulk things that actually are probably cheaper than fast food and what a lot of people are, are buying with their groceries. Now they might say, well, I really like to eat rice. That's a, you know, a staple of so many different cultures. Okay. Instead of eliminating rice, like a lot of times we try to do let's switch it to brown rice. Or if you don't like brown rice, let's do half white rice and half brown rice that tends to help people.

[00:17:39] Or we don't cook with vegetables. Well, sure you? Do you just think of vegetables as this big steaming plate of spinach? If you add peppers and onions to something, and cook it long enough, You won't even recognize it. there, but you're still getting a lot of that nutritional value from it. So it's not trying to take someone out of an environment that we don't have the power to do.

[00:17:59] And we can't change everyone, social determinants of health, but we can help people work in their non ideal environment to make it as ideal of a situation while we're working on all these injustices in the world, we still need to do the best with what we've got. 

[00:18:14] And we're always going to live in a world with injustices, as much as it pains me to say that, and we should keep fighting the good fight to fix those and remedy them where we can. But while we're living in this non-perfect non-ideal world, we still need to really help people where they're at do as much as they can. And we're really not serving our patients well and missing out on a lot of the resiliency they have when we think, oh, well, they probably can't do this. Ask them open the conversation, find out what the barriers actually are and help work together to figure out creative ways to solve them.

Chapter 3: Concluding the Nutrition Series

[00:18:52] Nate: As we kind of draw to a close here. I just want to get your take on just a couple more things. And so just to kind of summarize here, what folks can take away from this discussion and how they can apply it to their practices and their patients, how can patients and doctors, even for that matter, understand how to evaluate the quality of foods and diets.

[00:19:14] Justin: I think you just said it there, the quality of foods lends itself to the quality of diets. Chances are, if it sounds too good to be true, it is there's this new diet that comes out. Actually it can eat chocolate and cake and all of this and all of your favorites and bubba. It's probably not something that's healthy or sustainable. there's also a lot of myths associated with proper eating and we hear things like, where am I going to get my protein from? Where am I going to get my calcium don't I need milk to build strong bones, all of these different questions that people have, which sometimes are genuine and sometimes excuses. So they can go back and eat the same unhealthy foods that they wanted to eat before. 

[00:19:55] And I love the phrase, uh, Dr. McDougall, one of the leaders in lifestyle medicine. People love to hear good news about their bad habits. It's probably not worth listening to that always makes my red flag go up. I think really focusing on that food quality, what are the foods that contain the health promoting compounds and that have minimal amounts of the health harming compounds really boils down to eat real food, not too much, mostly plants from great uh, michael pollan, one of my favorite quotes. And then, especially for physicians, when we're analyzing the evidence, who's funding it. What are the potential conflicts of interests whose name is on it? Because it's really easy to design a study to find a thing you want. And when you're saying, oh, look at this food, it's healthy. Okay. We'll compare to what this diet, okay. Compared to what, and really helping us have this refined view of the evidence and looking to leading experts who really seem like they take all of this into account. And sometimes those are medical societies and leading guidelines, and sometimes they're not. 

[00:21:03] So being really careful about where you get information from and being critical about it. I know I always, even though I have a certain, uh, tend toward a plant-based diet, I really try to be critical and not dogmatic about it because we need to be scientists. We can't be dogmatists. And that's really, really important, especially when talking to patients and then just realizing that any little bit counts. It's great. If people can dramatically change their diet, but it's a spectrum. It's not all or nothing. The middle ground is really important. And we shouldn't be speaking to our patients about that. You don't need to be all the way on one side. There's no such thing as perfect. Let's just move together in the direction towards where we want to go and how fast we get there. is not as important as the fact that. we're going there. 

[00:21:50] Nate: Absolutely taking the quality of data, analyze it, and then make small changes to move towards where you want to be. I think that's completely accurate advice. 

[00:22:00] Justin: And sometimes that small changes and sometimes that's big changes. I like to ask patients, are you the let's dive all the way in are you let's dip our toe in the water.

[00:22:10] And if you try to make small incremental changes with someone that's like, I'm ready to throw out everything, take a cooking class and dramatically change overnight. And you miss that opportunity. That's on us. We shouldn't assume people are like that. Just the way we shouldn't assume people are slow, incremental step takers. And so just asking people, how do you like to make changes in your life? 

[00:22:32] Again, getting more information, being patient centered, utilizing motivational interviewing can help us not miss those opportunities for people who want to revolutionize their lives overnight. 

[00:22:42] Nate: So as we look at this level of detail, there's already so much to think about teaching our patients in the office interview that you like, like you said, is already crunched for time.

[00:22:50] And of course that's only a very small amount of everything that we have to teach our patients, even when it comes to just nutrition. So when you're in with a patient, how do you triage that? How do you kind of decide what to discuss during the visit versus after, as part of the out of office teaching? 

[00:23:06] Justin: Really good question. 

[00:23:07] We cannot do it all in office. And we need to rely on our patients doing some self-learning. As long as we're providing good resources directed at their level of understanding and level of education. I use the office visit to build the relationship with someone, figure out what their motivations are and align counseling with their motivations and provide some brief targeted teaching on nutrition for the first visit.

[00:23:34] It might be a little bit more cause I want to brief them on what healthy nutrition is, but then I'll couple that with giving them some really good resources and say, here, go home and read this. You don't have to read it, cover to cover, but take a look, watch forks over knives or another documentary. And that's where you can get into all of the nitty-gritty detail, but that can happen. 

[00:23:57] Whenever that sometimes takes hours. I don't need to teach them all of that because they can go home and do it. And as long as I give them the resources that will work. so really office visit for aligning motivation, forming that relationship, answering specific questions, addressing barriers they might have. Hey, I tried to do that, but then oh man, I bought ice cream so many times this week.

[00:24:21] Okay. We'll problem solve together and to the office is more the problem solving and the motivation and at home is the information gathering. 

[00:24:30] Nate: I like that a little asynchronous learning for our med ed folks out there. 

[00:24:33] Well, Justin, I know we could talk about this for a million years and we already have talked about it for quite some time, but a lot of people out there are going to be wanting more.

[00:24:43] And so for those listeners who are interested in some more resources, what can you recommend, you know, for providers, resources that they can use to learn more themselves about how to support their patients in eating healthy diets or for patients resources, to help them learn more about how to eat healthfully. 

[00:25:02] Justin: There's some really great resources. I personally love American college of lifestyle medicine. I think they have very good clean visually appealing pun intended, easily digestible resources for patients to use and for clinicians to use as well, to have a more detailed understanding about plant-based nutrition and the different aspects of it. They particularly have this food as medicine jumpstart guide, which is a 20 something page guide. Full with a lot of the evidence, but in a way that patients can understand some recipes, lots of pictures, of really good tasting food, cause that's what our patients want and care about as well. And that's a great resource that I'll often print and give to patients. 

[00:25:45] Uh, planned trition project is another great one. They have a quick start guide. Again, really just goes into the basics and nitty gritty a little bit more about, um, the ways of eating and a plant-based diet. For those who want to get a little bit more into detail on nutrition, facts.org, uh, Dr. Michael Greger has curated this immense evidence-based archive of really looking at all of the studies and the methods and critiquing them and putting things to the test to figure out the best evidence behind individual foods. In general patterns of eating. I also have tried to curate my own starter kit for people, especially clinicians who want to use more, who want to learn more about. the primary literature, summaries of the evidence books to read recipe, repositories, et cetera, that I'm happy to make available to people in the show notes. 

[00:26:41] Part of primary care is you're seeing patients for months and years, and these habits didn't develop over days and you're not going to fix them over days. be kind to yourself that this stuff is, is really hard and that it's a process. , we can plug away and we can make small changes at a time and I don't need to fix this entire person's life in 20 minutes in a clinic visit. If I can make a little difference and have them know that they can come back to me and we have a relationship, that's really a lot of value because I know when I started, I was like, oh my God. But they have so many problems in their diabetes and their hypertension and they need a colonoscopy and it's like, chill, we'll get there. We have time. 

[00:27:22] Tina: I got to try to do better. I know I had to try to do better. I am going to do better. Yeah, this is, this is the like in pool. You want to 

[00:27:32] Justin: you're at the edge of the diving board, ready to finally take the dive in? 

[00:27:37] Well, you know, we're, we're on this journey together. We'll, uh, you know, Wade in the deep end together, and sometimes you, uh, have a great swim. Sometimes you stub your toe and need to get out of the pool, but as long as you finish the race at the end of it, right? Yup.

Outro

[00:27:51] Nate: At the risk of taking this pool in diving board metaphor a little too far. I, I just wanna reflect on the fact that for so many patients, they are really close to the edge of that diving board. They are really close to being ready to jump into the pool and to try out a new dietary pattern, a new healthier way of eating to improve their health.

[00:28:11] It's our job as the physician or the provider. To get them to the edge of that board and really support them and make them feel like they have a good plan for once they get into the pool to give them the motivation or that extra oomph, if they need it to make that dive. And what happens after that is really hard to predict.

[00:28:28] Some patients are going to really partner with their provider, take their advice and really. You know, start swimming and swim very far. Other patients are going to struggle because of any number of reasons or any new barriers that may crop up in their life or negative self talk or any of these other things that we've discussed during this series, they may turn around really quickly and grab onto the side of the pool and get themselves out as soon as possible.

[00:28:55] And like we've discussed in this episode, some patients may be diving into that pool with extra weights attached to them. Things like food insecurity, difficulties with their finances, a lack of social support, a need for mental health treatment or a deficit in some way of knowledge. We can help our patients dismantle some of these barriers and others of these barriers.

[00:29:16] We have to find a way for our patients to get over them or around them so that they can still improve their health by improving their nutrition in a way that's feasible for them. and this isn't to say that it's necessarily going to be an easy swim, a straight shot from one end of the pool to the other, like Justin said, sometimes we'll stub our toe and need to get out of the pool.

[00:29:38] Sometimes we'll get tired halfway through while we're swimming and need to take a break on the side. But as long as we finish the race, as long as we're working toward getting to the other end of the pool and with a healthy dose of self love and understanding, that really is what matters. I'm so glad that Justin and Tina got to have this conversation today.

[00:29:57] I can tell she's ready to dive into that pool. And we're all so excited to watch her swim. Okay. The metaphor ends there.

[00:30:06] Here are some key takeaways that I took from today's episode and hope you will too. Number one, it's often much easier to not eat. What's not in our reach, advising patients on how to adjust their personal food environment is a powerful tactic to decrease their reliance on their own willpower, which our resident expert witfully sites remember as being so overrated.

[00:30:29] number two. It's so important for us to remember the structural barriers that our patients face in making healthy eating choices, but it should not stop there. We need to become comfortable with thinking creatively with our patients on how they can overcome those barriers in very practical, feasible terms.

[00:30:48] And number three, as a broad takeaway from our nutrition series, we need to meet our patients where they're. And move them toward eating real food, not too much and mostly plants all the while, keeping their own personal goals at the center of the discuss. Well, this concludes our episode for today and also concludes our nutrition science series.

[00:31:11] We hope you enjoyed it. I know I certainly did. Our series was made possible by contributions from our patient, Tina and Dr. Justin Charles. He served as our patient interviewer as our expert, and also provided peer review for this project. Special, thanks to our producers, Madison swallow, August Eloco Helen SI and Dr.

[00:31:31] Joshua Aygo as well as our faculty advisor, Dr. Katie, Eson be sure to follow us at PC pearls on Instagram, where you can expect to get sneak peaks, additional learning content, and the most UpToDate details on show release times. Thanks again so much for joining us today. Farewell from all of us here at the primary care pearls podcast. We'll catch you in the next one.


References
Re: similarities between processed foods and “illicit” drugs:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334652/  

Re: our environment being obesogenic: https://www.sciencedirect.com/science/article/abs/pii/S0091743599905856 

Structures being a fundamental cause of disease:
https://www.jstor.org/stable/2626958 

Re: systemic solutions mentioend at the White House Conference: https://www.whitehouse.gov/briefing-room/statements-releases/2022/09/28/fact-sheet-the-biden-harris-administration-announces-more-than-8-billion-in-new-commitments-as-part-of-call-to-action-for-white-house-conference-on-hunger-nutrition-and-health/ 

The resources that Justin recommended in the episode: 

Other resources for clinicians and patients:  

Spanish: https://books.leannebrown.com/bueno-y-barato.pdf