It is well known that sub-optimal dietary choices and the current food environment can lead to the development of chronic diseases such as diabetes, obesity, cardiovascular disease, and cancers.1However, nutrition education in most medical schools is lacking overall.2 Most medical students spend less than 12 hours on nutrition education over the course of 4 years,3 and this time is often spent discussing vitamin or mineral deficiency syndromes.
Physicians are not trained in culinary skills, preparation, or behavioral nutrition.4 This limited exposure often does not help answer the question of what and how patients should eat to improve or stabilize their diabetes. As such, a simple recommendation to “eat healthy” is often inadequate. The growing reliance on processed foods and convenience options is coupled with a lack of sufficient guidance, leaving individuals with limited support in creating a nourishing and balanced dietary pattern.
The burden of these diseases is exponentially rising. In 2022, the economic burden of diabetes was estimated to be $412.9 billion, with 74% ($306.6 billion) in direct medical costs and 26% ($106.3 billion) in indirect costs.5According to a recent report published by the Milken Institute in 2023, the cost related to the chronic disease of obesity is more than $1.4 trillion annually.6
What is Culinary Medicine?
Culinary medicine underscores the proverb, “Give a man a fish, and you feed him for a day; teach a man to fish and you feed him for a lifetime.”
In day-to-day practice, culinary medicine means integrating food and nutrition into the prevention and management of diseases. This approach emphasizes the therapeutic potential of a personalized and balanced diet and teaches patients to recognize the profound impact of food choices on their health. It aims to help a person achieve a healthful eating pattern by focusing on how to choose, shop for, and prepare meals within their resources.
Why I Use Culinary Medicine in the Treatment of Diabetes
Diabetes is characterized by either insufficient insulin production, or insulin resistance. Since dietary choices can directly impact blood sugar levels, counseling patients on how to navigate the food environment is essential.
Focusing on food should not undermine the value of available therapeutic options for the treatment of diabetes. As we know, there is robust HbA1c-lowering data associated with our current therapeutics. However, medications only do as well as the lifestyle modifications that accompany them. In many cases, close attention to long-term dietary patterns may decrease the need for chronic therapies or polypharmacy.
Asking patients to simply “cut carbs” often demonizes carbohydrates as “bad” or a guilty pleasure. Instead, by educating patients about how certain foods may affect blood sugars, they will have a better chance at creating a sustainable dietary pattern.
The goal of individualized dietary guidance for diabetes is to help in the maintenance of blood sugar control throughout the day. This method involves truly gaining an understanding of the quantity and quality of carbohydrates consumed. Incorporating a balanced mix of proteins, healthy fats, and fiber is essential to support overall nutrition, but also to allow stabilization of blood sugars. Diabetes self-management education and support (DSMES) can help by answering patient questions and making personalized recommendations during yearly training.
The reason that culinary medicine and nutrition guidance become essential is that patients often need instruction as to how to actually make these changes. Explaining what a diabetes-friendly dietary pattern looks like and how to put one together can greatly benefit their treatment adherence (more on this below).
Explain What a Diabetes-Friendly Diet Includes
For people with diabetes, the goal is to select carbohydrates that have high nutrient value – rich in fiber, vitamins, and minerals, with limited added sugars, sodium, and saturated fats. High-fiber foods aid in digestion and gut health, but also with blood sugar stabilization.
Choosing these foods can be confusing for some. For example, many people have come to believe that fruit is bad for them. As we know, fruits are whole, minimally processed, high-fiber carbohydrates; however, canned fruit cups are extremely high in sugar, and often mistaken as being a “healthy” option. Other high-fiber carbohydrates include starchy vegetables (such as squash, sweet potatoes, and carrots), quinoa, brown rice, oats, whole grains, farro and other grains, beans, and lentils.
These high-fiber carbohydrate options should be incorporated into the diabetes plate method, which recommends that 50% of the plate is full of non-starchy vegetables, 25% is a lean protein, and 25% is a healthy carbohydrate. This distribution is separate from refined and highly processed carbs, which often spike blood sugars; these include desserts, sugar-sweetened beverages, and refined grains such as white bread.
Understand Your Patient’s Time and Resources
Patients come from varied backgrounds and resources. They may not be at home enough to cook their meals due to work travel, or not have the confidence to put a meal together in the kitchen. Your patient may live in a food desert, where the availability of fresh foods is more limited, and their diet may consist of more processed foods given their surroundings. Your patient may be a busy parent of three, who is responsible for driving the children to their afterschool activities and does not have time to put a healthy dinner together.
As a result, a “one-size-fits-all” dietary approach is not always effective.
It is important to meet people halfway, such as asking patients to consider eating out one to two times per week, rather than daily, for example. Discussing a person’s attitudes toward cooking or healthy foods can help break down misconceptions and bias, and welcome individualized approaches to sustainable nutritional shifts.
Employ Nutrition Referrals and Resources
Even with all of this information, a common question I get from patients is, what do I put onto my plate?
Empowering our patients to seamlessly integrate these dietary patterns into their lives needs to be a collaborative effort between clinicians and dietitians. Referring patients to diabetes education (DSMES) or medical nutrition therapy with a registered dietician nutritionist (RDN) can give them the support they need to make dietary shifts.
Despite the constraints of limited time and bandwidth in today’s medical settings, even small yet valuable pieces of advice have the potential to reshape a patient’s approach to health and nutrition. Providing accessible examples, and simple, diabetes-friendly meal suggestions or easy recipes can be immensely beneficial. Consider recommending the American Diabetes Association’s Diabetes Food Hub, which provides a number of useful resources for patients, including meal planning guidance and sample grocery lists. Another helpful resource is Oldways, a nonprofit that provides Mediterranean diet based recipes, among other culturally inspired eating patterns.
I don't generally advise that patients track their eating with food diaries or apps because it can increase anxiety around food, but for patients who might find it beneficial, MyFitnessPal is a useful free nutrition tracking site and app.
See also, our Case Breaks Podcast series on Patient Nutrition:
Support the Therapeutic Relationship
Clear, practical guidance can be influential, and patients look to receive such advice directly from their physicians.7
Some patients may fear judgment or be averse to strict directives. Building trust and collaborating with them to establish achievable goals that align with their willingness to commit is crucial. Dispelling the stigma that healthy food is bland or boring requires open and constructive conversations with patients, capable of transforming their perception entirely.
Ultimately, as physicians, our aim is to guide patients toward healthier lives, recognizing the pivotal role that dietary habits play in achieving this goal.
