How one physician used plant-based nutrition to help underserved patients
I met Jed Maddela, MD, at a conference on population health management in Phoenix, AZ. In the course of our conversation, I brought up my interest in plant-based nutrition to prevent and reverse chronic disease. Instead of the usual skepticism, he responded by saying, “Yes, of course! I recommend that to my patients all the time. I used to practice at a Federally Qualified Health Center. Now I am completing a Fellowship in Clinical Informatics at Banner University Medical Center.”
Not only was this the first time I had ever heard this from a primary care physician (aside from the ones that author books on this subject), but he was doing this work with patients at a center that is a healthcare safety net for the underserved. I had to interview him to find out how he had discovered plant-based nutrition and how his recommendations had been received by his patients.
[A plant-based diet is one that is based on un-processed plant foods, such as legumes, fruits, vegetables, whole grains, and nuts, with few or no animal products.]
How did you become interested in plant-based nutrition?
Dr Maddela first got turned on to plant-based nutrition through popular books and documentaries such as “Preventing and Reversing Heart Disease,” by Dr Caldwell Esselstyn and “Forks Over Knives. They present compelling evidence to support the claim that many chronic diseases can be controlled or even reversed through a plant-based diet.
“These books and documentaries influenced me even though I knew they were highly biased. I took what I could from those and incorporated the recommendations. I certainly knew they couldn’t do any harm.”
Dr Maddela also discovered the impact of a plant-based diet first-hand by adopting it himself and witnessing remarkable changes to his own health. He was sold.
How did you introduce plant-based diets to your patients?
“One of the most important things you need for success with a patient is shared decision making. I believe in plant-based diets and I would recommend them to patients that would benefit, which is most of them. However, if they don’t share that vision then it won’t go anywhere.
I had a panel of about 2,000 patients and many of them were adults with diabetes and children. Even with children, I would push the plant-based diet during their well visits.
It would start of with open ended questions, such as what does your child like to eat on a typical day? What are your thoughts on veggies, deep green veggies, etc. Some would say, yes we eat a few, and others would say, no we don’t eat any. Then, I would counsel them to consider the health benefits. I would often tell them that for a healthy growing child over five years old — they will not starve themselves. If anything, just have veggies available on the table that they can grab and eat when they are hungry.
Diabetics with a baseline level of motivation to change would do quite well. I would say about 10% of them had that level of motivation, but even that may be generous. I had one patient who took to the plant-based diet I recommended and got himself completely off his insulin. I would call him my “champion.”
Did you have a support network of other professionals?
Physicians do not have the time to go into a great deal with their patients on how to implement lifestyle changes, but fortunately Dr Maddela had the support of both an in house dietician and a behavioral health specialist as part of the patient-centered medical home.
“ If I recommended a plant-based diet, the dietitian would go in and discuss it with the patient to see how they could incorporate it. The behavioral health consultant would see what barriers there were in their lives and help them work around those barriers to try to implement the recommendations.”
What do we need to do to make plant-based diets to prevent and reverse chronic disease more mainstream?
“There aren’t enough clinical trials, as most of the research money goes to the pharma industry. We need to bring together more evidence-based recommendations regarding plant based diets and other lifestyle interventions, so that we can lobby CMS (Centers for Medicare and Medicaid) to add metrics to measure what we all know anecdotally.”
Did your center offer any group based lifestyle interventions?
“There was a huge push at our center to get a diabetes class started at our clinic. Some would have success and then fizzle out. One of our most successful campaigns was having an onsite dental visit. Every so often we would have an onsite nutrition-based program.
We opened up a new clinic and built a kitchen so we could offer cooking lessons. We had a large Somali population, so we had employees of Somali descent team up with the nutritionist to teach them how to cook their cultural foods in a healthier way. That’s something my wife and I are very passionate about! Filipino food is good for the soul, but not best for your heart. I always believe you should work with the community you serve.”
What role do lifestyle interventions play in population health management?
“Population health management segments patients into low, medium, and high risk populations. Interventions such as health coaching, counseling, nutrition guidance, annual visits, and immunization, are usually targeted towards the low risk patients. But, there are no metrics around health coaching, counseling, and nutrition guidance. It is cheaper to keep someone healthy than to take the high risk down to a lower risk.
For the medium risk patients, approaches are more focused on prevention of complications with less emphasis on wellness interventions. For example, we want to make sure that patients are on the right medications, coming in for timely appointments, adhering to their care plan, etc. We are trying to do anything that costs less than having them end up in the hospital.
For high risk patients, the interventions are very high touch and include things like care coordinators.
Once patients fall out of the low risk bracket, the leadership in health systems think of them as needing higher interventions like case managers and navigators. Nutrition and wellness fall by the wayside. Nutrition and wellness interventions should be sustained across the spectrum of risk.
What are the key elements of a really good population health technology solution?
I think there are so many people trying to get into the field that it is confusing. There are so many vendors and they all think that they are the solution. Everyone is saying that they have this set of items that will predict people that are sick and present them in a nice dashboard and good luck.
The companies that are going to be the winners are the ones saying “we have the predictive models and it’s user friendly, but we also have a team that’s going to understand your current processes and get to know the people that you have and work with you for the next 6–8 months until you can show the outcomes that you want.”
Conclusions and Reflections
- The physician provides the “why” and the support network provides the “how”: Dr Maddela once again emphasized the role of the physician in 1) selecting the patients who would be the most receptive, 2) catalyzing the change process by talking them about the link between their health and their lifestyle, and 3) monitoring the patient as they make change. After the initial conversation with the patient about ‘what’ to do, it was up to the support network, which in this case consisted of the dietitian and behavioral health specialist, to help the patient with the ‘how.’ Imagine how much more successful Dr Maddela and his patients could have been if the Health Center had a comprehensive lifestyle change program in place. I would envision a comprehensive program to also integrate group-based classes, apps, tele-counseling, cooking classes, exercise classes, linkages to other community based programs, a farmer’s market program, and more. However, this vision is unfeasible without the right funding and incentives in place.
- Physician champions modeling behavior: Dr Maddela started promoting plant-based nutrition to his patients after changing his own lifestyle and seeing the impact first-hand. Not surprisingly, the most enthusiastic lifestyle promoters are physicians that walk their talk and, better yet, have solved a personal health problem through lifestyle. Dr Maddela also noted that his personal example was very helpful in motivating his patients.
- Lifestyle interventions should be applied across the spectrum of risk: As a Fellow in Clinical Informatics, Dr Maddela pointed out that “wellness” programs seem to get edged out of the picture once a patient goes from low to medium or high risk. This is a mistake. We are robbing patients of their right to be educated on how to slow down or reverse their condition through lifestyle changes.
- We need metrics: There are also no good metrics (that I have seen or heard of so far) for quantifying outcomes from and engagement with lifestyle change programs. What gets measured, gets improved…and in the context of value based care even gets paid for. Promoting lifestyle interventions on a large scale absolutely depends on putting in place the right incentives and metrics.
- Could predictive analytics identify the “motivated” patients?: Dr Maddela found that only a small percentage of his patients were actually motivated to make change, but the ones that did met with great success. What if we could use predictive analytics to figure out what patients would the most receptive to change and what types of programs might best suit them? Or perhaps, we could more easily figure out the “stage of change” a patient is in and engage with them accordingly. The role of predictive analytics in lifestyle interventions will the the topic of several upcoming blog posts on Value Based Care Design Lab.
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