f his patients were interested in nutritious foods, Dr D contracted with a registered dietitian nutritionist (RDN) to develop this component of his practice.
The RDN might select copies of MyPlate,5 the US Department of Agriculture’s food guide, in the languages most often spoken by Dr D’s patients and train Dr D’s medical assistants to use this free resource, which includes printable material and a smart phone app. The approach taken in the training is to focus on realistic portion sizes—minimizing large amounts of energy-dense foods in favor of smaller portions of nutrient-dense, familiar foods—and avoid labeling specific foods as “good” or “bad.” Dr D might also provide incentives for his medical assistants to attend an online health coaching program to learn behavior change skills that they could apply to several health behaviors including consumption of nutritious food, smoking cessation, and exercise.
At a first in-service training for the medical assistants, the RDN would likely present a resource list that could be distributed to patients. Had Dr D and his partners reviewed it earlier, they might be surprised to learn about several previously unknown community resources and nutrition programs that were available to their patients. There were food pantries, including several that had a strong nutrition education component because they were affiliated with the foods and nutrition department at a local university. The nutrition department at the hospital where Dr D and his colleagues admitted patients offered classes on various nutrition topics as part of their commitment to the surrounding community and provided a series of classes about preparing quick, nutritious meals on a budget on their website. There was a community food bank that accepted donations from nearby restaurants and also distributed produce grown in a community garden. The mission of one of these programs was aligned with the goals of Dr D’s practice, so he might add it to a list of charitable foundations he supports. Dr D and his colleagues might also learn that the Supplemental Nutrition Assistance Program (SNAP) is accessed by many of his patients as a popular way to encourage purchasing fresh produce at nearby farmers’ markets.
In the Community
Dr D could delegate development of a nutrition component for his practice and open time in his schedule to concentrate on improving the diets of community members. Consistent with Opinion 11.1.1 in the AMA Code, he might do some reading so that he could apply best-available evidence to the health care services he provides.6 For example, Dr D might find data suggesting that people purchase the same types of foods regardless of where they shop7,8—whether in a corner store in a food desert like the one surrounding his practice or in a distant full-service grocery like the one in his neighborhood. Dr D might not favor building a full-service grocery store near his practice for other reasons. He might know that costs for building a full-service grocery store can exceed several hundred thousand dollars depending upon the business model selected.9 Some community activists might oppose full-service grocery stores because they fear negative effects of community development and gentrification. Finally, because corner stores can be viewed as a community resource and because they can be more successful in promoting nutritious foods than full-service grocery stores, Dr D might decide to help strengthen the existing business community by engaging corner store operators in an intervention to stock nutritious foods. Dr D might also know of an initiative to implement minimum stocking requirements for nutritious foods in stores that accepted SNAP and that merchants objected to these requirements because perishable items such as low-fat milk and fresh fruit were unpopular with consumers and often spoiled before they sold.10 To lessen the problem of spoilage, Dr D could encourage small store owners to stock whole grains, dried peas, dried beans, dried fruits, and nuts used in cooking traditional foods enjoyed by members of 