A Conversation With Jül Gerrior-Schofield, R.D.
Myles Helfand: On the topic of cardiovascular risks: Especially in the context of the recently updated statin guidelines, we're looking at an ever-more aggressive medication treatment approach when it comes to managing cardiovascular risk. At what point does a clinician say, "I don't have the time or the space to deal with this whole deep, complex series of issues that patients may be facing in their life that prevents them from having proper access to well-balanced diets"? It would seem a lot more convenient to just say, "We're just going to give you a statin and try to make sure there's no drug interactions."
Jül Gerrior-Schofield: It's an easy out, so to speak. To be honest, I just don't think that nutrition is on their radar, in general. It doesn't take priority. Unless you have a dietitian in the clinic that's waving their arms -- "I'm over here! I'm over here!"
Generally, dietitians will prescreen the clinics as they come in. But with more cutbacks and financial problems, in some of these health centers there's just less room for services like nutrition. So it does lie on the provider to try to ask these questions.
In Boston, we're very fortunate -- and I know in Manhattan, you're fortunate -- because there are a lot of programs out there that are geared toward HIV-positive individuals that provide access to meals, or subsidized SNAP benefits. In Boston, for example, we have farmers' markets, where patients who have these SNAP benefits -- it's like the new food stamp where they can double their bucks -- they can go to buy five dollars' worth of vegetables, and they can get double that for the value. So they can get $10 worth of fruits and vegetables with their Bounty Bucks.
It comes down to knowledge and awareness. I'm afraid that we just don't see this happening enough in our HIV clinics today.
Myles Helfand: You just identified two major barriers to this kind of access: funding and a general lack of awareness. It's interesting: In our HIV Management Today series, we started this year with another aspect of HIV care that I think -- not in an identical way, but in a similar way to nutrition -- is frequently neglected: the critical effect that mental health issues and psychological issues can have on every aspect of HIV care.
What you've been seeing so far suggests that it's the same kind of thing for nutrition; it's this often-neglected area that nonetheless can have effects across the board for a person living with HIV. But yet there is that -- almost a barrier to awareness, not just on the part of the patient, but on the part of the clinician, right?
Jül Gerrior-Schofield: Yes, definitely. We [at Tufts] are lucky -- again, I keep saying we're lucky because we study this, and so we have a focus on it -- we have a different mentality when it comes to talking about nutrition and getting the message out there. People know of our study. They've been in it for many years. So we're fortunate like that. But there are still a lot of people who just don't know about our services.
I don't think that providers realize how food insecure their patients are, because I think the patient doesn't want to discuss this often. It's a humbling experience to have to go in and say, "I don't even know where I'm going to get my next meal."
I've been doing a lot of work with women, and women are generally at risk, mostly because they are the last priority for themselves. They have grandkids and kids, and they just don't take precedence in their own care. They're a huge population that I worry about, in terms of just getting access to food and generally taking care of themselves.
We have a fantastic program in Boston for women called HOCC or Healing Our Community Collaborative. This program is for women who are HIV positive, at risk for, and affected by HIV. They are served a hot meal once a month coupled with education and health promotion by community partners in the health field (nurses, dietitians, social workers). More programs like this are needed to support these vulnerable populations.
Myles Helfand: Where is the line in terms of responsibility? Is it the responsibility of you guys to go reach out to all of these various clinics, hospitals and doctors' offices, to try to educate them and advocate for a greater level of awareness and intervention with their patients on nutritional aspects of care? Or is it for them to somehow become more aware? Is it for them to try to change their mindset?
Jül Gerrior-Schofield: It probably goes both ways. It's important for us to be out there, as nutrition providers, and really get the message out. We generally are pushing this only because we may have a new study, for example, and we're looking for participants. Then we go out and canvas all of our clinics in town and say, "We're looking for people who want to go on this special protein to help reduce diarrhea," for example. But I think it goes both ways.
We're fortunate also at Tufts because the medical students that come out of our institution actually have a lot of nutrition training. That's, again, because we have this very nutrition-centric focus. But if you poll the medical schools across the country, you're going to find that very few have nutrition courses. If we could change the structure of how things are going, I think it starts there -- to get people thinking of nutrition. But we both need to be advocates for this.
Also, empowering patients is huge. We do this in our studies. We're able to educate them on the right types of foods. We try to stay away from the supplement business, and encourage more food -- whole food -- and how to get your calories from these nutrient-dense sources. Then they can tell their friends, and they can educate their families.
Empowering the patient is really critical, as is empowering the patient to then talk to the doctor about some of these questions, and therefore rolling it back to the doctor, referring to nutrition.
Dietitians need to take more of a presence in these clinics and in this environment. There's a lot of us out there. It's just tough to get the message across everywhere, especially rural areas and other places where resources are limited.
Myles Helfand: What do you do on that front? How do you access those patients? What can you say to providers in rural areas who might throw up their hands at all of this and say, "What am I supposed to do about this?"
Jül Gerrior-Schofield: Perhaps we use a little more technology -- we can put on conferences and maybe Web-based programs for places that are more rural. I think education is going to have to be the push to try to get the messages to the physicians.
The truth is, it can be very simple messages. Some of the things I say are just, "Are they able to eat breakfast?" for example. Whole grain cereal with a low-fat dairy -- milk or equivalent -- and a piece of fruit. They can get a third of all their fiber grams just in the morning. So it shouldn't take long to start asking simple questions.
In a way, it feels like we have this huge task on our hands. But if we can just start educating these institutions, these community centers, and hope there's going to be some trickle down, I think that's our best bet.
Myles Helfand: It's interesting, the way that you just put that: It can start with just asking questions. It doesn't even necessarily have to be like you've got this encyclopedia of information as a provider that's ready to go. You just start asking that question, and it might get everybody's minds thinking more in that direction.
Jül Gerrior-Schofield: Right. That's my hope, really. They're not asking the questions. There's just this void. Like I said before, the barrier for the providers is that they have so many other things on their mind. "I want this guy in a drug addiction recovery program," for example. I see that person and I see, if they're actively using, they're probably grossly underweight and malnourished, and not prioritizing their nutrition. And that's understandable, given their state.
All these things have to get in line. Just asking the questions and getting people access to food -- there are some basic things that are going to go a long way.
Myles Helfand: I don't suppose you guys have a one-page checklist? Like, The 60-Second Provider's Guide to Asking Questions?
Jül Gerrior-Schofield: Honestly, I don't. But based on all of these questions, I'm going to come up with one.
Myles Helfand: It sounds like that's exactly where this line of thought is going: If a provider doesn't have time, and they're not thinking about nutrition -- well, maybe if they had a sheet of paper that had the questions listed on it, they would.
Jül Gerrior-Schofield: Maybe they're worried about opening Pandora's Box. That's what your point was earlier: They don't have time for this; they don't want to kind of deal with all this. But get the nutrition resources in place: Find where your dietitian is, what's his or her number, how does a patient get in contact. You can leave it with the patient. But you've got to ask the question first, or we're never going to know. I think that's the key.
I know in Manhattan, and I'm sure in other communities:, we have Community Servings; we have the Boston Living Center; we have a couple of really key organizations that provide meals to people who are HIV positive. It's wonderful. People need to be linked with these services that are out there. They just need to have access.
Myles Helfand: Which is a challenge in this funding climate, as you have said before.
Jül Gerrior-Schofield: Right. Absolutely.
Myles Helfand: You had mentioned earlier in the conversation that you guys are not a huge fan of supplementation if people have deficiencies. Why is that?
Jül Gerrior-Schofield: It's different if they're deficient. If people are diagnosed with vitamin D deficiency, then we would want to fill up their tank with vitamin D supplements. But what I want to get away from is people, rather than eating quality nutrition and getting their adequate intake, relying on these supplements. "I'm taking a multivitamin. That way, I don't have to eat my fruits and vegetables, because I'm going to get my antioxidants and my other things in the pill." We want to get away from that.
We actually recommend a 100% complete multi-mineral complex. I would recommend that for everybody who is HIV positive, just to get that insurance. But I'm not necessarily going to start recommending extra C, extra D -- which is what I used to do. We used to do that, as a general rule, based on the literature back then, which suggested that people would progress to AIDS more rapidly if they were low in selenium, for example, or B12. So we would push all these supplements for our patients.
Nowadays, the evidence is really murky. There's really not a lot of evidence to suggest that they're actually going to do better with all these vitamins. So we'd rather put that money that they're going to spend on vitamins into the food. We want to teach them where to get your vitamin D in food, rather than a pill.