Money Matters

Nutrition has a new spokesperson in the form of Bill Clinton. Yesterday CNN posted clips from an interview with Dr. Sanjay Gutpa, in which the former president discussed how changing to a plant-based diet has saved his life and transformed his health. And my first thought was how in those two minutes Clinton may have done more for nutrition, for making the connection between food and health than the ADA has done in years.

To be clear, I am referring to the American Dietetic Association and not the American Diabetic Association (ADA) nor the American Dental Association (also, ADA) and definitely not the Americans with Disabilities Act (again, ADA). But the confusion over their acronym is only the beginning. Even more confusing is their message: "If consumed in moderation with appropriate portion size and combined with regular physical activity, all foods can fit into a healthful diet."

Founded during World War I, ADA initially sought to help the government preserve food and improve the public's health and nutrition. Over time its purpose and mission have evolved and currently it is "committed to improving the nation's health and advancing the profession of dietetics through research, education and advocacy." It is a professional organization, primarily of registered dietitians (RDs), the certification that is bestowed by the ADA upon an individual who has completed a CADE-accredited dietetics program (at either the bachelor's or master's level), an accredited dietetic internship program and then passed an exam.  Much of the organization's advocacy work is spent educating the public and the government about RDs, and establishing them as the authorities on food and nutrition. There are so many people posing as nutritionists these days that some qualifications and credibility are called for and I appreciate that there is a group committed to this task. But ADA receives significant funding from companies like Mars, ARAMARK, Hershey, Coca Cola and the National Dairy Council.  Isn't it a bit problematic when the organization trying to position itself as the unbiased expert on food and nutrition is sponsored by major food corporations built on selling the public on calories and food-like items they don't need and can potentially harm them? 

This appeared at the bottom of ADA's Knowledge Center email on 8/18/11

One day perhaps I could write an entire dissertation on the complexity of these relationships between health organizations and companies that generate most of their profits by saturating the market with high-sugar, high-calories, chemical-laiden, nutrient-poor products that contribute to the rise in nutrition-related chronic diseases.  Despite their "wellness" divisions, their corporate philanthropy and commitments to "healthy living" these ADA sponsors are best known for soda and chocolate bars (and not the high-cocoa content, fair trade varieties). Coca-Cola, for example, doesn't even pretend that its raison d'etre is to feed or nourish people. It's mission statement is simple: "To refresh the world...To inspire moments of optimism and happiness...to create and make a difference." Remember those joyous ads? 

I'm actually more moderate than I sound. Last year I started working with an organization called Cooking Matters (formerly known as Operation Frontline), a nationwide program that provides cooking and nutrition classes to low-income populations. While the program and its curriculum are sponsored by ConAgra and Walmart, the classes are taught by volunteers chefs and nutritionists and as a volunteer I was free to take some liberties with the program. (During the week that focused on calcium, for example, I provided lists of non-dairy dietary sources.) True the funding came from major corporations, but the program was very effective - in some cases truly transformative - without supporting any corporate agenda. We live in a time when corporations have money - let's use their money for good. 

My gripe with ADA's sponsorship is not really that they take money from these companies, it's that they do not address it or demand accountability. ADA constantly comes under attack for their ties to big industry and has never issued a statement explaining their position. In fact, back in May the president sent an email to ADA members stating:

Levelheaded criticism is different from deliberate misinformation, which ADA and many other credible organizations are occasionally subjected to. Blogs and other communications that contain falsehoods about our Association are easily written and – with a click on a keyboard – posted and re-posted the world over. I want to assure members that ADA will not be distracted by engaging in point-by-point rebuttals of disparaging untruths and insults every time they appear on the Internet.  ADA will not issue formal responses to ill-informed attacks or outright lies. Such responses would only lend credibility to erroneous arguments and baseless charges and elevate their authors. This is the intent of our detractors.

First of all, I'm not sure which "falsehoods" they are referring to, since their ties to the food industry are posted on their website. Secondly, to disparage blogs and communications that are "easily written...posted and re-posted" makes them sound as dated and out of touch as their detractors claim. Finally, to defend a position that has come into question does not lend credibility to the argument, it allows an organization to reiterate, clarify and hone its stance. As a card-carrying member of the ADA, I would appreciate a position paper of ADA sponsorship policies. Their website does say:

ADA’s procedures and formal agreements with external organizations are designed to prevent any undue corporate influence particularly where there is a possibility that corporate self-interest might tend to conflict with sound science or ADA positions, policies and philosophies.

Personally I would feel more comfortable if I understood how they get around the "possibility" of corporate self-interest with their current sponsors (for amusement, see the page on "What Our Corporate Sponsors Think").  Additionally, I would like to see more statements calling upon these companies to employ more responsible and honest marketing practices, including the elimination of advertising to children. I don't feel ADA needs to refuse their money, but should use their relationship with Big Food to push an agenda of their own, namely one that promotes public health nutrition, education, greater transparency and increased access to healthy foods. 

It may sounds optimistic, but I do believe the ADA has the potential to be a more potent and effective change leader in national nutrition discourse. Maybe I'm just rationalizing how I could accept scholarship money from the ADA Foundation toward my internship while I criticize ADA for accepting money from corporations with dubious intentions. Can the ends justify the means if the money is going toward quality nutrition programming, toward the training of future nutrition professionals, toward the education of groups that would not otherwise be reached?  I considered this for a moment when I received notification of the award but quickly realized it did not for a moment change my beliefs about nutrition practices, science or politics. If anything, it encourages me to cling to my position, continue doing what I'm doing and work toward changing the field of dietetics from within so that Bill Clinton is not the only harbinger of dietary changes in this country.

Market Day

Some people think of Wednesday as hump day. For the next month Wednesday is also Market Day - the day I arrive at the farm early to harvest greens, pack tomatoes into pints, arrange the beets and carrots and peppers in an old fashioned wooden wagon in the main hall of the hospital where I am working on the next rotation of my internship. The hospital is one of the first in the country to start its own farm that now boasts two hoophouses for year-round growing.  Just last week the ADA posted a link to a Food Sleuth podcast interviewing the RD who developed the project that turned 15 acres of hospital property back into farmland last April (a great podcast!). Then in July the farm began to sell its produce at a farmer's market in the hospital. The hours correspond with the hours during which most patients are discharged (11am) and also during staff lunch breaks. The idea is not only to sell fresh, local (!) produce, but send a message, linking farm and hospital, food and health.

Tomatoberry variety of cherry tomatoes

Working at the farmer's market earlier today made me feel like a local celebrity. People's faces lit up when they saw the cart. Shoppers commented on the fragrance of the basil, the colors of the chard stems, the perfection of the tomatoes, and they began to swap ideas on how to use the produce, recommending recipes, sharing what they grow in their own yards and asking me for suggestions as well. Some customers were bold enough to try something new, some were returning to buy the Sungold tomatoes after trying them last week (my favorites!). 

A bunch of Bright Lights rainbow chard

I'll be spending the next month on the farm and I'm sure I'll have plenty to share. It's the most exhausting work I've ever done but it's exciting to be onboard with a hospital that is committed to investing in preventative care through food and nutrition. 

Lessons from LTC

I was not looking forward to my rotation in long-term care. And when I started, I was relieved that it would only last for two weeks. But by the end I had gotten so comfortable there, so used to the smells, the sights, the residents that had scared me at first and I was sad to leave behind the routine, the meetings, the familiar faces to start all over again at a new site.

My time in long-term care (LTC) was mostly spent on my feet. While the dietitian I worked with had an office, she was hardly ever there unless it was to update residents' meal preferences or enter quarterly and annual assessments. Otherwise I tried to keep up as she breezed through the halls, whipping in and out of patients' rooms, checking up on them, tracking their weights, seeing how they were eating - did they need a speech or an OT consult? Were they have swallowing problems or difficulty holding their utensils? Were they able to meet their nutritional needs through oral intake or did they need liquid supplements? Were they getting their meals as they ordered it, and if so, was the temperature appropriate by the time it arrived from the kitchen? These were just some of the dietary concerns at the facility where I was working. Through these daily tasks I got to know the residents and their mannerisms, the ones who liked puzzles and the ones who ordered takeout food, the ones who spoke inappropriately to women and the ones who would grab your hand and not let go if you got too close. I learned who had their own set of teeth, who wore dentures and who preferred not to wear their dentures. I learned who was 105 and who was 85 and who was 55 and who must always always always get two cartons of chocolate milk at every meal or else. Then there were the harder parts.  I sat in on meetings with families of residents who were recommended for hospice care. During my two weeks there two residents died. I observed wound care on a patient whose foot had bad gangrene and pressure ulcers but refused amputation despite doctor recommendations.

During my first week I was focused on the sad parts, the decaying people, the empty shells of what were once vibrant lives - or were they? Many of the residents were homeless or alcoholics or, as my supervisor said, "had made poor life choices." A number of them had mental disorders and acted out and threw their trays and had temper tantrums. But there were lighter times too, and by the second week I grew to appreciate these even more, adapting in the ways people do who work in this environment for extended periods of time without losing their minds or their faith in humanity.  I joked around with the staff before the morning meetings and worked the tray line in the kitchen, hairnet and all, and laughed with the head of medical records and helped out with the Hawaiian staff bbq. I smiled at every person I made eye contact with and tried to learn the residents names to say hello to them every day. I learned that treating people with respect and dignity is paramount. I realized that everything can change in the span of two weeks.

Running DMC

My first week at a long-term care rotation left me feeling physically and emotionally exhausted. I have a great supervisor who exposes me to all sorts of different conditions (colostomy, anyone?) and personalities (paranoid, bi-polar). We're on our feet all day and the breadth of her work provides a broad experience of dietary work within a long-term care setting. But when I get home I just crash.  I was determined to break this cycle of somnolence over the weekend. And so, in effort to keep up my running I finally ventured over to Motor City for a 10k race.

Going to Detroit felt like a big deal. The big city. A strange feeling for someone raised in New York City. But the way people here speak of Detroit has instilled in me a fear I can't quite shake. Stories of white flight, abandoned building, crack houses. "Just avoid those areas," I'd been repeatedly warned. But without any sense of the city, I wondered how I would know where to go and where to avoid. Then the voice of reason would kick in.  "People said this about New York City for years," I would remind myself. Still, I waited for a good "safe" excuse to check out the city for myself. I was in for a treat.

As it happened I had signed up for the inaugural race benefiting the Detroit Tigers Foundation, so the 10k started and ended at Comerica Park, home of the Detroit Tigers. Now it's been awhile since I've been to a MLB field but this is the first one I've ever seen with a carousel and ferris wheel in the park. Pretty cool.  Security seemed to be pretty lax and runners were allowed to wander around, so I made myself at home.

The 10k course went downtown, where the city's impressive architecture took me by surprise. Further on we hit the waterfront and ran along the RiverWalk, which continues for several miles and reminds me of Hudson River Park in New York, except across the water is not New Jersey, but Canada.  Perhaps the best part was the last leg which took us out onto right field at Comerica Park, around and along the first base line to cross the finish at home plate. Even without 45,000 screaming fans filling the seats, it was a thrilling feeling.

I had considered spending more time in the city, but soaked with sweat and doused with water at 9am, I was ready for a shower.  I left Detroit knowing that I'd be back. There's a pulse and energy there despite the empty buildings and demolition crews. And after spending a full month in a small town, I was reminded how exciting the city can be.

I hope that future outings to Detroit will include more arts and culture and eating (not that I'm complaining about the post-race Sabra hummus sample). Right now within the food movement, all eyes are turning to Detroit as a model city for community farms and gardens farming, food justice work and local food initiatives. And with a rich history and lots of determination it's not hard to imagine that in a few years the empty buildings will be converted to pricey lofts and condos, that young people will flock there in droves on their bicycles to raise chickens and goats. Or maybe it's already happening.

Women, Food and Nutrition

Most of the students in my nutrition graduate program were women. I graduated with one guy in my class, am one of thirteen female dietetic interns and am supervised by female dietitians. Nutrition is traditionally known as a "women's field." But my interest was piqued when I received this email from the American Dietetic Association (ADA) earlier in the year:

Over 84 percent of food and nutrition professionals are white and over 94 percent are women. How do you feel about this? What should ADA do to increase diversity? ADA wants your opinion.

Well it may be a few months late, but here are my thoughts.

I am proud to be part of a profession that is working toward the betterment of health and wellbeing of all citizens, regardless of age, race or gender. I firmly believe in the power of nutrition, of food and eating and nourishment, of the potential for improving quality of life through prevention and management of chronic disease.  I can only imagine that others who go into this field do so out of similar conviction, since I have learned that there isn't a whole lot of money to be made helping people in this way, unless you plan to create a functional food, write a fad-diet bestseller, manage a large scale food service site or sell a lot of supplements. Most insurance companies do not cover nutrition services unless a patient is diabetic or perhaps has renal impairment. Even morbidly obese patients who qualify for bariatric surgery are only entitled to one to two nutrition education sessions, when clearly nutrition plays a major role in the success or failure of their surgery. And so while nutrition may have played a key role as a mode of early intervention to prevent disease progression, most patient do not qualify for such benefits until they have fully developed a condition that needs to be managed. This is simply unjust.  And I believe it is largely because nutrition is viewed as a nice but nonessential "women's field."

I could surmise the origins of this phenomenon. Perhaps working in dietetics is a natural progression from working in the kitchen, so it was reasonable for women to flock toward this field. But such an argument  collapses when you look at the statistics on male vs. female chefs who actually work in the kitchen. Women are underrepresented in the executive chef category overall and they tend to earn significantly less than their male counterparts. A better comparison might be to the medical profession, where nursing reports similar gender statistics (only 5.% of nurses were male in 2009), or even the case of female physicians who earn 40% less than their male counterparts on average.

So why haven't men and minorities been flocking to the field in droves? Looking at the numbers, why would they? It is extremely competitive (in 2009, only 52% of nutrition graduates matched for dietetic internships, required for credentialing). Internships are almost a year long and not only are they unpaid, but most require tuition (ranging up to $40,000), typically without financial aid eligibility.  For the most part nutrition services are not covered by insurance. See below for the Department of Labor, salaries of dietitians vs. nurses, just as a point of comparison:

Registered Nurses Wages, May 2010

Dietitians and Nutritionists Wages, May 2010

Gender studies is not my area of expertise, and my rationale is not evidence-based.  But the numbers speak for themselves. There are financial barriers to entering the field and it's not a very lucrative profession. I haven't even started my career and yet I fear that my outrage will continue to grow and then eventually fade into apathy.  At the end of the day, most nutrition jobs tend to have more flexibility for working moms and that is an important feature for many women. A few months ago, a friend posted this TEDTalk on Facebook and I found it hit the nail on the head. Discussions of women in the workplace inevitably involve complicated questions of childrearing and priorities and failure to fight for a "place at the table." I have very mixed feelings about the American Dietetic Association but I am happy there is an organization in place to advocate for my field.

So, ADA, what can you do to increase diversity? Might I offer the following:

1. Remove the insurmountable barriers to receiving dietetics credentials by reinstating alternate routes to the RD that would allow competent, educated graduates to practice in the field and offer financially viable ways to complete the credentialing process.

2. Advocate for expanded insurance coverage, relying on the data supporting nutrition as a crucial mode of prevention and treatment of chronic disease, reducing length of hospital stays, healthcare costs, employee absence and improved quality of life.

3. Boost your own credibility by displaying greater transparency in regard to sponsorships, demanding more accountability from the food industry giants who fund your nutrition initiatives by profiting from the sale of food-like items that undermine the very dietary guidelines you espouse.

Signed,
A white, female nutrition professional

Keeping It Simple

On the first day of my rotation this week, I introduced myself to the dietitians I would be working with. One was significantly older and the other had recently had her second child. They were talking about the challenges of being working parents and when I said I was the new intern, a recent graduate, they recommended I "keep it simple a little while longer." The question of living simply and what that means has stayed with me throughout the week.

This first rotation, which continues for another week, is very hands-on and I am exposed to patients at all stages of the process of bariatric surgery. I observe the consult group where the surgeon explains the different types of procedures, the nutrition classes for patients about the undergo surgery, post-op visits to hospital rooms 24 hours after surgery, phone calls one week later, and follow up appointments with patients six months, one year and two years out. Eligibility criteria for bariatric surgery includes a BMI of >40 or BMI >35 with co-morbidities, such as diabetes, and nearly all the patients I observe have multiple complications and medications. And many of them are young. Younger than me. Their lives are far from simple.

Simple living has become a new aspiration in the green era. I recently watched No Impact Man, the documentary that follows one NYC dwelling man and his family as they try to live "simply," ie. in a manner that generates as little waste and environmental impact as possible. In our modern world, one could argue that living "simply" is a fallacy - in fact, living without many of the conveniences that carbon-emitting technology affords makes life much more complicated. The film reinforces this and after watching No Impact Man, I have a newfound appreciation for my refrigerator. At the same time, the family spends more time together, watches less television, and is far more conscious of the food they eat, traits we associate with simplicity.  

Somehow I felt a strong connection between this film and my work this week. I had mixed feelings about doing a rotation in a bariatric center. Like many people I wonder whether surgery is really the only option for people struggling with their weight. In the consult group I was happy to hear the doctor state that surgery is the last option when all others have been exhausted. When he insisted that the long-term success of the procedure would depend on how well patients had addressed the underlying emotional issues that had led them to this place, I was further encouraged that it was not being marketed as a quick fix surgery. And after watching a laparoscopic gastric bypass, the cynical voice in me that suggested that patients might simply opt for surgery because it was covered by their insurance, that it was easier than actually losing weight, was quieted. The surgery is invasive and the recovery takes time. Even post-op, losing all the excess weight is not guaranteed, as I witnessed in patients who had the surgery years ago and displayed varied levels of success. Whether or not I would recommend it, bariatric surgery provides a second chance for patients to simplify, to start over, create a new relationship with food and new behaviors. I found this reinforced in speaking with patients after their surgery and wished them to best of luck in cultivating new healthy habits.  Today my supervisor told me that last week a patient cried tears of joy when she learned that she could finally transition from the all liquid diet to eating pureed foods. Learning to eat all over again brings such bliss - a good reminder to enjoy life's simple pleasures.

Orientation

A lot has happened in the past month since school ended. I left Seattle, got engaged, drove to Ann Arbor and started a dietetic internship program at the University of Michigan's School of Public Health.  Back in April when I "matched" at UM, I rationalized all of the reasons it would be the best program for me. I remember thinking how being far away from my friends and community would allow me to focus my energy on the internship, and perhaps work on some side projects that never receive any time or attention.  Now I wonder how I will have time to focus on my internship at all, when my thoughts are occupied with Skype dates, travel arrangements and potential wedding plans. So in attempt to devote some reflection time to my various rotations, I hope to use my blog to capture my experience as both an intern and a Michigander over the next six months.

My personalized lab coat.

My internship started last week with orientation. I am one of 13 dietetic interns, but one of only two who did not attend UM for my master's degree. And I am also the only one who has never lived in Ann Arbor (AA) before. I guess that makes me the outsider, though by the end of the first week I certainly didn't feel that way. We spent the first week at school filling out paperwork, touring some of the rotation sites, and attending lectures and presentations on a variety of topics that are either important enough to warrant review (eg. a full-day crash course in food service management!) or were likely not covered in our degree programs (eg. palliative care, hospice). My house turns out to be only a 20 minute walk from school, so I enjoyed a week without use of my car and I'm sure the Echo appreciated a break after the 2,500 mile drive out here. And it only took me about a week to re-adjust to the constant state of sweat that comes with summer's 90 degree temps.

On Friday we went on a field trip to the Henry Ford Hospital in West Bloomfield, MI. I was surprised at how much it reminded me of a mainstream hospital equivalent of the Bastyr Center for Natural Health in its integrative approach to patient health and wellness. Unlike other hospitals, the entrance seems more like a shopping mall or resort, complete with concierge and valet services, a spa and shop selling local products. Just past the shop is the Demonstration Kitchen where classes are taught for the general public by a chef and a registered dietitian.  We peeked in on summer camp program for kids, and noted the space, which could easily serve as the set of a cooking show on the Food Network. 

We toured of the facilities, led by the Culinary Wellness Director (!), a trained chef who explains to us that food used to be used as medicine and it's important that we remind people of that. He showed us the cafeteria, Henry's, where instead of hiring food service workers, the hospital employs cooks who prepare the food on the spot using fresh ingredients. Other interesting tidbits about the place: they host a weekly farmer's market, there are in-house pet "therapists" or trained dogs who visit patient rooms, the salon stylists are trained to recognize melanomas, and every single room has a view of nature.  The attention to detail is so completely impressive - from the room service menu model to the private rooms to the massage therapists that make room calls - I really walked away with the impression that patient satisfaction is paramount.  We were told that the hospital was designed to reduce stress and alleviate fears  and it certainly achieves that effect. In fact, we noticed several groups of women from the community utilizing space in the atrium to play bridge and mah jong. 

Henry, one of the hospital's pet "therapists" takes a rest.

I couldn't help but wonder, who pays for these services and who does this hospital serve? (The question was later answered by my roommates who explained that West Bloomfield is the wealthiest township in the state.) Part of me wondered about the increasing income gap, and as I continue to hear how economically devastated Michigan is as a whole and Detroit in particular, I hope to gain a better understanding of the socio-economic landscape around me. Still, I walked away from the Henry Ford feeling like maybe in this Midwestern pocket I'm not as far away from Seattle as I feel, maybe the Bastyr bubble is larger than I imagined and maybe there are some ways in which our country is moving in the right direction.