The Non-Medicated Life:
The Essential Role of the Registered Dietitian

by Paul E. Lemanski, MD, FACP

Editor’s Note: This is the 14th in a series on optimal diet and lifestyle to help prevent and treat heart disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.

Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individual taking them, but also because they can be shown to work by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce heart attacks, strokes and cardiovascular death. It is not always appreciated that informed diet and lifestyle may accomplish many, if not most, of the benefits of medication. For example, a high omega-3 Mediterranean diet has been shown in a landmark clinical trial to reduce the risk of cardiovascular death and non-fatal heart attack by up to 70-percent.

But what exactly does one eat on a Mediterranean diet? The practical implementation of such informed diet and lifestyle is neither obvious nor easy and many times physicians themselves have neither the time nor the expertise to effectively help patients change their behaviors. To successfully live the non-medicated life (or the minimally-medicated life) requires the help of an essential individual whom many would acknowledge to be the single most important member of the preventive health care team – the registered dietitian (RD).

Registered dietitians must complete a minimum of a bachelor’s degree at an accredited college, complete a supervised practice program for 12 months, pass a national exam, and complete professional education requirements yearly to maintain registration. Registered dietitians are versed in nutritional biochemistry, medical nutrition therapy, medical disease states, preventive medicine and clinical outcomes research, and help treat a variety of conditions including hypertension, congestive heart failure, high cholesterol, diabetes, metabolic syndrome, obesity, gluten enteropathy and eating disorders. While all registered dietitians are nutritionists, not all nutritionists meet the strict standards required to be an RD. Typically, health insurances-both indemnity type as well as HMO-have RDs as part of their provider staff. Registered dietitians bring science and sense to a world filled with plethora of diets, vitamin preparations and supplements each claiming or suggesting health benefits which may not be supported by scientific evidence.

Typically, a patient is referred to an RD by the patient’s physician to treat a medical condition known from clinical trials to respond to medical nutrition therapy. Hypertension is a case in point. For those who are salt sensitive, a modest restriction in salt (sodium chloride) to 2,000 milligrams per day may decrease blood pressure obviating the need for medication. While some sources of sodium may be obvious, others are hidden. RDs will analyze one’s current sodium intake from three-day dietary recall and then both teach food label reading as well as suggest substitutions which may decrease sodium intake without appreciably altering enjoyment. The idea is not simply to impose a beneficial change, but to work with the patients own preferences in a way which can lower sodium intake and blood pressure in a non-medicated approach acceptable to the patient. For example, many patients do not appreciate that prepared soups may be very high in sodium and one bowlful in a salt sensitive person could elevate blood pressure for four days. Depending on the amount of soup consumed per week, lower salt prepared soups or home made soups low in sodium may be the only change necessary to control blood pressure. A dill pickle may contain 2,000 milligrams in one pickle and cutting back on pickle consumption may be an acceptable way to control sodium intake. For those not wishing to decrease sodium intake, the DASH diet which is high in potassium, magnesium and calcium and relatively low in fat may also lower blood pressure obviating the need for medication. While not complicated, the DASH diet is best taught to a patient in a face to face encounter with an RD during which the patient may ask questions and indicate preferences, thereby both individualizing the approach and ensuring the greatest chance of success.

High blood cholesterol is another condition for which the help of an RD may obviate the need for medication or decrease the amount of medication needed. Blood cholesterol is a result of the dietary cholesterol we eat as well as the saturated fat/trans-fat we consume. Dietary cholesterol may result in about 30-percent of the total serum cholesterol and saturated fat/trans-fat consumption may result in the remaining 70-percent. Thus, modest restrictions in saturated fat/trans-fat, even in the absence of dietary cholesterol restriction, may significantly reduce serum cholesterol. Dietitians will analyze current diets for cholesterol and saturated fat/trans-fat and teach patients to read food labels and plan meals so as to help restrict saturated and trans-fat. Restricting saturated fat/trans-fat to 15 grams per day may allow a 10-percent to 15-percent reduction in LDL or “bad” cholesterol. This may help obviate the need for cholesterol medicine or may allow one to use half of the dose of medication needed prior to the dietary change. Since the side effects of many cholesterol lowering drugs are dose dependant, such an approach may allow high risk individuals to continue to take medication proven to reduce cardiovascular death.

Patients may also ask to be referred or refer themselves – depending on health insurance allowances – to an RD to optimize health and prevent disease. However, the proven benefits of a high omega-3 Mediterranean diet may not be realized if one assumes that all Mediterranean diets are equally effective. Dieticians will teach a set of principles, give specific examples, and suggest recipes, cookbooks and restaurants. For example, Mediterranean diets will be low in saturated fat and trans-fat, but contain generous amounts of mono-unsaturated fats such as is found in olive oil, some nuts and canola oil. The ability to identify and calculate fat including trans-fat from food label information (not yet FDA mandated for individual listing) or a list of ingredients is taught by RDs. Moreover, high omega-3 Mediterranean diets while having generous proportions of carbohydrates will contain less refined, complex carbohydrates which enter the blood stream slowly (low glycemic index) and thus stimulate insulin release less. The moderating of insulin release may reduce artery stress or injury and thus lower cardiovascular risk. The beneficial use of carbohydrates in a high omega-3 Mediterranean diet is taught by RDs.

In summary, living the non-medicated life or the minimally medicated life requires leveraged knowledge and behavior change best taught by a registered dietitian. RDs take the complex science of promoting health and preventing disease through proven medical nutrition therapy and translate it into a simple and practical modification to one’s current daily diet and lifestyle. In this way, visiting a registered dietitian may truly help the individual avoid the proverbial bottle of pills to address our most significant healthcare problems. For our society, embracing the teachings of registered dietitians may reduce soaring health care costs and bring science and common sense back to the American lifestyle.

Paul E. Lemanski, MD, MS, FACP is a board certified internist with a master’s degree in human nutrition. He is director of the Center for Preventive Medicine, Albany Associates in Cardiology, Prime Care Physicians, P.C. Paul is an assistant clinical professor of medicine at Albany Medical College and a Fellow of the American College of Physicians.

Center for Preventive Medicine & Cardiovascular Health

at Mid-Valley Cardiology 111 Mary's Ave. Suite 3 Kingston, NY 845-339-3663

Main Office 400 Patroon Creek Blvd. Albany, NY 518-618-1100

at Glens Falls Associates in Cardiology 747 Upper Glen St. Queensbury, NY 518-793-1083