Adding the principles of lifestyle medicine to a busy emergency department is daunting. I always find it difficult to decide when to talk about it and who will be interested in listening. I finally learned to use the same approach that I take with my patients with substance use disorders.
It’s almost impossible to know when patients are ready to change, but if I don’t give them a chance today, they’re extremely unlikely to change today. Invite everyone to change whether you think they are ready or not.
I was surprised at how responsive patients were to this approach when we couldn’t find a clear etiology for their symptoms. It can be a simple tool to add to your comforting conversations and give them something tangible to consider.
It can also be generalized to almost any lifestyle principle that needs to be addressed, but we will delve into nutritional prescriptions. The challenge obviously is that we are not going to follow up on these patients, so emphasize that they should discuss these plans with their primary care physicians.
Lifestyle prescription writing is an essential skill in lifestyle medicine. (JAMA. 2010;304:202; https://bit.ly/3dTqIqQ.) They should follow a focused approach and be specific. Using the SMARTEST mnemonic is a great starting point. (Am J Lifestyle Med. 2020;14:271; https://bit.ly/3wr5ozs.)
T: Connected to time
E: Based on evidence
As an emergency physician, however, I need a much shorter acronym. The American College of Lifestyle Medicine recommends that nutritional prescriptions (still being tested for validity) take the form of TAF:
T: Type of food (the more specific, the better)
A: amount of food
Important concepts to consider and remember include:
- Nutritional recommendations should focus on a diet that is mostly plant-based, whole foods, encouraging less meat and dairy.
- Positive prescriptions are better than negative ones. Patient compliance increases when you ask them to add something to their lifestyle rather than asking them to take something away.
- Start slow and remember that less is more. Prescribing too many items at once can be overwhelming for patients. Make sure you have an idea of what the patient can handle.
- When writing nutrition prescriptions, consider medications that can be affected by certain foods, such as vitamin K-rich foods that reduce warfarin levels and foods that inhibit cytochrome P450 such as grapefruit that increase antidysrhythmic levels (and other drug classes like statins). (J Lifestyle Med. 2017;7:1; https://bit.ly/2SUNffA.)
- Recommending an increase in the consumption of high-volume, high-nutrient-dense, but low-calorie-dense foods can have a huge impact on weight, digestion, and overall health, especially for chronic conditions. In other words, recommend colorful vegetables as much as possible.
- When prescribing antibiotics, consider prescribing prebiotic foods that improve gut health in addition to prescribing probiotic pills and foods, such as those high in fiber (legumes and grains). Probiotic foods are those fortified with live cultures, such as most yogurts (including plant-based yogurt substitutes). Tetracyclines and fluoroquinolones, however, can bind to calcium in the gut, so ingesting foods high in calcium like dairy products can reduce absorption. (J Lifestyle Med. 2017;7:1; https://bit.ly/2SUNffA.) Alternatively, they can eat a plant-based yogurt alternative a few hours after the antibiotic.
- Americans are severely deficient in fiber and rarely meet current USDA recommendations. (Am J Lifestyle Med. 2016;11:80; https://bit.ly/3yHb3D7.) Encourage your patients, especially those with diabetes, to increase this important macronutrient. Taking certain medications such as digoxin with fiber-rich foods can reduce absorption. If in doubt, recommend not taking medication with high fiber foods.
Start the conversation
Nutritional prescriptions that can be used in the emergency department include:
- Add a serving of dark leafy greens (spinach or kale) to your daily diet for the next 30 days. Please speak with your GP to find out if you think this had an impact and discuss a plan for moving forward. (Do not give it to patients taking warfarin.)
- Add one serving of legumes (beans, lentils, chickpeas) to your daily diet for the next 30 days. They are high in fiber and an easy way to boost your daily fiber intake. If you have diabetes, monitor your blood sugar closely, as increased fiber can lower your blood sugar, which may require an adjustment to your medications.
- Add an apple to your diet every day for the next 30 days. They are high in fiber and an easy way to boost your daily fiber intake. Please discuss this dietary change and how it made you feel with your treating physician. If you are diabetic, please monitor your blood sugar carefully.
Starting discussions about nutrition in the emergency department may seem out of the ordinary, but hopefully these tools will break down some of those barriers and get the conversation started. As emergency physicians, when we reassure patients, we hope to have directed the patient to the right next steps. We think we understand our impact, but what we’re starting in the ER extends far beyond hospital walls. Let’s make nutrition a part of that! As Hippocrates said, “Let food be your medicine, and medicine your food”.
Learn more about lifestyle medicine from the American College of Lifestyle Medicine at https://lifestylemedicine.org. Find more information on nutritional prescriptions and more practical tools on prescribing nutritional interventions in the ACLM course, “Food as Medicine,” at https://bit.ly/3hsEiU8.
Dr. Harrisonis board certified in emergency medicine and lifestyle medicine, and practices emergency medicine at Bridgeport Hospital-Yale New Haven Health. Learn more about the intersection of emergency medicine and lifestyle medicine by visiting his website atwww.acute2root.com. Find more information about the American College of Lifestyle Medicine athttps://www.lifestylemedicine.org. Follow her on Twitter@acute2root.