Nutrition and dietary guidelines: stirring the (policy) pot

At first glance, federal nutrition policy seemed to be an unusual topic for our Georgetown Health Policy Seminar for family physicians. As described in a recent JAMA Internal Medicine editorial, future doctors receive little formal instruction about healthy dietary habits. An accompanying commentary noted that to promote effective change, nutritional education in medical school should encompass much more than memorizing facts about biochemistry and metabolism:

Medical students and residents must also develop competence in the interpersonal and communication skills needed to counsel patients about behavior change and to perform motivational interviewing. ... They must learn to work in interprofessional teams with dietitians and other skilled health professionals to help patients make needed dietary changes. ... Just as medical students and residents must be taught to become antismoking advocates, they need to be taught how to advocate for healthier food environments as part of their role as future physician-citizens.

The USDA Food Pyramid, circa 1990.

Every five years beginning in 1980, the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services (HHS) have jointly issued the Dietary Guidelines for Americans, which serve not only to help citizens make healthy dietary choices but also to guide federal programs that support school lunches and supplemental nutrition assistance for low-income individuals and families. However, a recent analysis suggested that adhering to recommendations of the 2010 Dietary Guidelines to consume more potassium, dietary fiber, vitamin D, and calcium would add hundreds of dollars to an average person's annual food budget; potassium alone would add $380. In contrast, increasing intakes of saturated fat and added sugar are associated with lower food costs.

Current (2010) U.S. Dietary Guidelines.

Last year, former U.S. Secretaries of Agriculture Dan Glickman and Ann Veneman argued in Health Affairs that there is a "disconnect" between federal food and farm policies and evidence-based dietary recommendations:

On one hand, with obesity-related health costs rapidly rising, the federal government has encouraged people to make healthy dietary choices through efforts such as Let's Move! and MyPlate. On the other hand, the federal government spends billions of dollars on traditional agricultural commodity programs that fail to reinforce the kind of healthy dietary choices outlined in federal dietary guidelines.

Providing greater access to nutritious food options at affordable prices doesn't mean that people will purchase them, but is a necessary first step in realizing the potential of nutrition policy to reduce obesity and improve population health.

- Kenny Lin, MD, MPH
  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine

Forecasting and adapting to the family medicine workforce shortage

Projecting future physician workforce needs is a challenging calculation that must take multiple variables into account to avoid missing its mark. In the mid-1990s, the American Medical Association confidently predicted that the penetration of managed care would lead to a large "physician surplus" and convinced Congress to cap the number of graduate medical education (GME) positions subsidized by the Medicare program. Two decades later, there is a widespread consensus that the U.S. is actually experiencing a physician shortage that will worsen with population growth, the aging of the baby boomer generation, and an influx of newly insured from the Affordable Care Act.

Although medical schools have expanded to meet the anticipated demand for doctors, the AMA and others are still pushing for the GME cap to be lifted so that new medical graduates will have enough places to train. But how has the specialty of family medicine fared, and what else can be done to extend capacity of the existing primary care workforce? These questions were the subjects of two recent Georgetown University Health Policy seminars.

Image courtesy of the American Academy of Family Physicians

Modest gains in the numbers of U.S. and foreign medical graduates matching into family medicine residency programs over the past five years will fall well short of supplying an additional 52,000 primary care physicians by 2025, a shortage projected by the Robert Graham Center. A recent issue of Health Affairs examined potential strategies to extend primary care capacity in the absence of an (increasingly unlikely) surge in generalist trainees. For example, telehealth technologies could lighten the load on family physicians by promoting patient self-management of chronic conditions; improving medication adherence; and facilitating real-time specialist consultations. A more radical and controversial proposal aims to provide EMT-style training to a new profession of "primary care technicians" who could provide basic primary care services under the supervision of a physician, freeing physicians to "focus on patients with more complex conditions."

As our discussion pointed out, though, these proposals have serious disadvantages. By reducing face-to-face interactions, telehealth could easily make family medicine less rewarding. Family physicians who end up seeing only patients with multiple complicated chronic conditions could burn out faster, leaving even fewer in the workforce. As a broad cognitive rather than a narrow, procedure-focused specialty, family medicine is less likely to be suited to care by technicians than, say, anesthesiology or gastroenterology. Finally, given the persistent and growing income gap between family physicians and subspecialists, the real solution to the primary care shortage may still be staring us in the face.

- Kenny Lin, MD, MPH
  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine

Tapping the potential applications of mHealth

Mobile health, or "mHealth" for short, describes technology that allows clinicians or public health professionals to monitor and/or deliver health-related messages to patients via cellular phones, tablets, or other wireless devices. mHealth applications can complement and expand care provided at traditional face-to-face visits, and exploring their untapped potential to improve health in the U.S. and abroad was the topic of a recent Georgetown University Health Policy Seminar.

One popular mHealth initiative is the text4baby program, a public-private partnership launched in 2010 that sends free text messages to expectant and new mothers containing appointment reminders, safety alerts, and general prenatal and postpartum health advice. Smartphone apps now include a variety of self-management tools for weight loss, physical activity, and chronic diseases such as hypertension and diabetes. The U.S. Food and Drug Administration recently moved to regulate health apps that act as medical devices (e.g., electrocardiogram) and would pose safety risks to patients if they malfunctioned. However, the vast majority of health apps used by consumers will not require FDA approval.

In the developing world, "mHealth projects are launching at an exponential rate," declared a recent issue of Johns Hopkins Public Health Magazine. Cellular phones have made real-time communication with field workers routine and allowed teams of nurses and midwives to attend births in rural Bangladesh. However, the field of mHealth is hampered by a lack of evaluations of health outcomes and concerns about sustainability of successful interventions:

Using phones to advance public health isn’t as simple as it seems. Researchers are grappling with complex questions that have already doomed hundreds of mHealth projects: How do you know whether mHealth projects are really working and worth the investment? How do you conquer the phenomenon known as “pilotitis,” and scale effective strategies into health systems that have regional or national impacts? And how do you make sure these projects are long-lasting additions, instead of the public health equivalent of a dropped call?

We debated the types of policies that would be most likely to encourage innovations that make a positive difference for individuals and populations. How can we avoid creating "digital divides" that could worsen health disparities? Should state and local governments provide direct grants or tax relief to promising startups? Or should the central planners get out of the way and trust free market forces to produce the future of mHealth?

- Kenny Lin, MD, MPH

  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine