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For a Physician’s Weekly Podcast episode (listen below), we covered two major players in the field of preventive medicine: colorectal cancer screening and dietary interventions for type 2 diabetes (T2D). We spoke with Richard Rosenfeld, MD, MPH, MBA, about a recently published expert consensus statement he co-authored with the aim to assist clinicians in achieving remission of type 2 diabetes (T2D) in adults using diet as a primary intervention. In that publication, expert consensus was achieved for 69 statements pertaining to diet and remission of T2D, dietary specifics and types of diets, adjuvant and alternative interventions, support, monitoring, adherence to therapy, weight loss, and payment and policy. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty.
We also spoke with to Michael Kanter, MD, who has had oversight of the quality of care provided by 22,000 physicians to 12.2 million patients within the healthcare system nationally, and was responsible for the development of the organization’s national quality strategy. He works to significantly improve key clinical quality metrics, including cancer screenings, blood pressure control, and tobacco cessation. Colonoscopy has played a pivotal role in the declining US incidence of colorectal cancer in persons older than 50 years observed during the past 2 decades. Dr. Kanter discussed his “moonshot vision” of reducing mortality from colorectal cancer by 50% in 10 years by improving quality metrics in colorectal cancer screening programs.
Below, we summarize the perspectives of Drs. Kanter and Rosenfeld. For their full stories, listen to PW Podcast episode in the player above!
inDEPTH Perspectives from Our Contributors
Specialty: Lifestyle Medicine- Richard Rosenfeld, MD, MPH, MBA
More than one in seven US adults has diabetes, up from one in 10 just 20 years ago. About 25% of people don’t know they have it. Diabetes can lead to blindness, kidney disease, heart disease, circulatory issues, even worse COVID outcomes, and poor quality of life. Whereas optimal nutrition has always been part of management—often called medical nutrition therapy—it’s usually sort of secondary to medication, bariatric surgery, or weight loss. My colleagues and I are assessing it for the first time as a primary way to achieve remission.
Our work was prompted by a position statement published by the American College of Lifestyle Medicine on the same topic in 2020. Based on a literature review of nine key intervention studies with lifestyle interventions—most of which had a very low-calorie diet and some physical activity—they concluded that you could achieve remission of type 2 diabetes, both partial and sometimes complete, using diet as an intervention. At the time, they recommended a whole food, plant-based diet, but it was based on the opinion of a couple folks reviewing the literature. We wanted to see if we could get consensus from a very diverse group using a validated, very structured process. We wanted to know how you define remission, if diet can achieve it as a primary intervention, if it can sustain remission, and what diet is best. Our group consisted of 15 experts, about one-half of whom came from other medical societies. An extensive evidence review landed us with nine randomized trials, plus some observational studies, systematic reviews, and position statements. That was the starting point to formulate statements and see if we could reach consensus. To achieve consensus, the average of all 15 respondents had to be seven or higher—with nine being the highest level of consensus—and there had to be at most one naysayer who was two points from the mean. We achieved consensus on 69 statements.
We defined remission of T2D as normal glycemic measures for 3 months with no surgery devices or active pharmacologic therapy. We later agreed to be consistent with the new ADA definition in diabetes care in 2021 (A1C, 6.5). One of the most important, novel consensus statements was that diet as a primary intervention can achieve remission in many adults with T2D, which is related to the intensity of the intervention; some of the less-intense caloric reductions didn’t seem to work as well, but calorie intake can be brought down by reducing energy density, volume portion, food size, or a combination of these.
The bottom line is that there’s a remarkably empowering message here for patients and providers that you can achieve remission of diabetes just with diet. The diet should emphasize unrefined carbohydrates, and probably a whole food, plant-based diet is best. Diet alone is great, but we do advise and agreed upon the need for comprehensive lifestyle intervention, particularly some degree of physical activity, and we emphasize that diabetes self-management education is very important, as well as routine self-management of blood glucose levels.
We could not achieve consensus on a number of things, and I think those are areas for future research, particularly the role of reducing animal foods and meat. Is it just a matter of upping the whole grains, or do we need to reduce meat as well? A big question was how restrictive you need to be on a healthy, whole food, plant-based diet. Could people just eat what they want as often as they wanted given the low caloric density, or do you need to be restrictive? It would be nice to have randomized trials to really look at this, because the existing trials have focused on very low-calorie diets (often liquid diets or extreme things) to start, not necessarily on a more tolerable, whole food, plant-based diet. We’d like to know what promotes adherence and dissemination, but I think the bottom line from our work is that you can achieve remission in many adults; a high-nutrient, low-energy diet for the first couple months is ideal (primarily whole food, plant-based; and perhaps some time-restricted feeding between 8:00am and 6:00pm, but that’s a softer conclusion. Overall, I think our results offer a very empowering message and set the stage for clinicians to make informed decisions.
Specialty: Clinical Sciences - Michael Kanter, MD, CPPS
My colleagues and I decided to assess what could be done now, using current evidence, to decrease the mortality rate of a common cancer that we think is largely treatable and curable if caught early. We were measuring population-based mortality rates—as opposed to the more traditional 5-year survival rates—and from a quality improvement perspective, we identified an opportunity for improvement with colon cancer. We set a goal of a 50% reduction in mortality over 10 years. We called it a moonshot goal, and the numbers were somewhat arbitrary but based on an educated guess as what might be achievable. We started a regionwide initiative to use pretty much any means that seemed practical to reduce mortality rate in a systematic fashion. From a science point of view, there wasn’t a control group; we didn’t withhold some of our members, which creates some limitations on data interpretation, but we were able to show a sizeable drop in mortality over 7 years. This is an interim publication; we didn’t wait the full 10 years, and of course COVID interfered with a lot of the work we were doing, so we decided to publish up until COVID impacted our delivery system and published interim results that I think have some learnings for a lot of people.
We were able to show a reduction in mortality of about 23% over the 7 years; it’s a little behind goal, but it’s not clear what would happen in the 10 years. This approach is feasible with teamwork. We created teams at each of our medical centers that included oncologists, gastroenterologists, surgeons, pathologists, and primary care doctors who really needed to work together to examine what pieces of care could be improved and then set metrics and processes to improve those and follow through on it. We, in essence, did a series of rapidly repeating rapid cycle improvement projects on a whole host of things related to colon cancer that we thought might improve mortality rates.
I would like to see other healthcare systems try this, and I think President Biden has set a similar goal to reduce mortality from cancer. He gave us 25 years to do this across all cancers, but I’d like to see other people try this kind of approach, because I think it’s doable in other cancers; I think lung cancer is a prime target for this sort of approach, given all the new findings and complex delivery system changes that need to occur for that, and I think we could collectively learn from each other what works, what doesn’t, and how to approach cancer mortality in a more systematic way. We’re talking about reengineering delivery systems such that every person who needs to get a certain kind of care gets it; it’s about increasing the reliability of our cancer delivery systems and making them available for every person in the country with cancer, or before they get cancer.
I would like to see this attempted in a different setting, with a different approach. Every system will find different gaps in their system. I think there could be collective learning as to what works and what doesn’t, because we can’t tell what interventions actually move the dial and which ones were superfluous. That is another thing that might be learned over time. And I’d like to see such approaches studied with other cancers or with anything for which you can measure mortality rates in a population that is amenable to this approach.