When Anita Ramsetty, MD, started teaching, she was motivated by a goal that will be familiar to many health professions educators: “I wanted to help my students be better doctors than me,” she said. “That’s why I got into this.” For Dr. Ramsetty, who splits her time at the Medical University of South Carolina between clinical work, helping to run the free clinic, and teaching, this meant thinking about areas of her own training that she felt were lacking. Her focus turned to the crucial topic of nutrition.
“Nutrition is vital to the health of our patients,” she said. “But medical schools still are not adequately teaching nutrition in a real-world way that acknowledges the challenges many patients face in accessing healthy food.”
Dr. Ramsetty was determined to revamp and improve how her institution was teaching nutrition. She started by going back to school herself.
After looking at certificates and continuing education in nutrition and dietetics, she realized that neither set her up with the practical expertise that she knew was essential to help patients. She ultimately landed on a certificate in culinary medicine, which looks at food and nutrition in the same way that patients do. Rather than focusing on nutrients through the lens of disease, culinary medicine takes a holistic approach to what and how patients eat to promote good health.
“It’s great to be able to talk with a patient about vitamin B and why it’s important, but that’s not really the way patients look at nutrition,” said Dr. Ramsetty. “Patients want to know what they can cook and eat, particularly what is available to them in their own environments.”
For Dr. Ramsetty, it was also impossible to look at how best to teach nutrition without looking at the racial disparities and inequities surrounding access to food and food insecurity. In the US, before the coronavirus pandemic, it was estimated that one in five Black people was food insecure, including one in four Black children. And according to the US Census, 28% of the people living in poverty are Latino, even though Latinos make up only 19% of the total population of the US.
Add these inequities to problems of implicit bias and stereotypes that doctors may have, and it became clear that teaching nutrition effectively means figuring out how to prepare students to truly understand how issues of food insecurity, structural racism, and their own implicit biases affect their patients.
After becoming a certified culinary medicine specialist, and with support from the Josiah Macy Jr. Foundation, Dr. Ramsetty set about to see how practical nutrition education could be integrated into an already packed curriculum, and how that curriculum could train future doctors to help address food insecurity among patients.
Her goal for pre-clinical students was to ensure that 100% of students were exposed to nutrition not as an elective but as foundational to patient care. She crafted small group case studies, that focused on food insecurity among patients, to replace existing cases. One case features a patient with diabetes expressing concern about their high blood sugar. Students are directed to talk through not only what the lab numbers mean but how to answer their patient’s questions around what food to eat. Students learn to ask about what types of meals the patient prepares and eats, what kind of food they buy or can afford, and the availability of fresh fruits and vegetables where they live. These lead the students to identify obstacles the patient may be facing in accessing healthy food to reduce their high blood sugar.
“Patients face many barriers to accessing healthy food. For example, a patient may say they eat regularly, but they may be eating Snickers bars because they only have time for a snack.”
The cases that Dr. Ramsetty developed help provide students with a framework to identify underlying challenges in accessing healthy food and tackle nutrition and food insecurity in ways that can help their patient make changes that work for their situation. Some of those questions can be uncomfortable to ask, but the cases provide students with the language and practice they need to understand and address their patients’ food needs.
Modules for Clinical Rotations
Dr. Ramsetty is also working to help better integrate nutrition into medical students’ clinical rotations in year three. She began with a listening tour, meeting with each of the rotation directors to better understand what would be valuable in nutrition-focused cases for each specialty and the types of nutrition challenges they face with their patients. Using that information, Dr. Ramsetty is now building computer-based interactive cases for each of the clinical rotations. All the cases cover aspects of food insecurity and train students to screen for access to food regardless of what they may assume about their patient. For example, in family medicine, the case focuses on a patient struggling with obesity and diabetes. The general surgery case addresses nutrition and food insecurity in a perioperative screening. Dr. Ramsetty has also developed cases about nutrition and pregnancy for OBGYN and a well-child visit for pediatrics. She hopes to have modules built and implemented for all seven clinical rotations in the near future.
As was the case for many over the past year, the pandemic stalled Dr. Ramsetty’s plans and the implementation of her program. At the beginning of the pandemic, Dr. Ramsetty went into full-time clinic duty, but she has begun to transition back into her regular schedule and continue implementing her program.
The final element is a senior elective providing a true culinary medicine capstone. The elective focuses heavily on talking with patients about food and food insecurity and crafting plans to help patients overcome the issues they are facing. This elective will include time in a cooking clinic, which will provide students with hands-on knowledge and expertise in not only talking to their patients and advising them about what food to eat, but also how to prepare it.
Dr. Ramsetty notes that the coronavirus pandemic has not only brought food insecurity issues to light, but it has also made them worse. According to Feeding America, before the pandemic we saw the lowest overall food insecurity rate in more than twenty years. In 2019, 35 million people overall, including 11 million children, were food insecure. In 2021, it’s projected that 42 million people, including 13 million children, will experience food insecurity. Doctors will soon be seeing the results of this, if they haven’t already.
“The pandemic has highlighted many areas of existing inequity, food insecurity included, and clinicians I think are struggling with how to address it,” said Dr. Ramsetty. “Doctors are recognizing that if a patient has to choose between food and medicine, they are going to choose food or go halfway on both, neither approach being ideal. We need to develop curriculum that equips doctors with the tools they need to have these conversations and empower their patients.”