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By now, most of us know it's not rocket science to eat well in order to stay well. The problem is we don't always know what to eat, when, or why. Since March is National Nutrition Month, we've provided a list of foods that can help you stay healthy and fight inflammation.

"Inflammation" is the new buzzword in health and nutrition, and is often blamed for a number of illnesses and chronic diseases. Experts also believe it plays a role in obesity and heart disease. Certain foods, however, have been found to fight inflammation so put these on the top of your nutritional go-to list:

  1. Nuts - especially almonds which are rich in fiber, calcium and vitamin E
  2. Dark leafy greens including spinach, kale, and broccoli
  3. Soy, found in tofu, soy milk and edamame, rather than processed soy foods
  4. Tomatoes
  5. Ginger and turmeric - often used in Asian and Indian foods
  6. Olive oil
  7. Fatty fish
  8. Beets
  9. Whole grains
  10. Berries, rich in fiber and antioxidants

Here's more from a list of foods that help the body better absorb the nutrients we need and lessen the harm in what we don't:

  • Eggs - atop a salad it can increase absorption of Carotenoids, the nutritional part of vegetables
  • Green lemon tea - squeezing lemon into green tea can preserve antioxidants
  • Pair spinach with an orange - to help absorb iron
  • Turmeric and black pepper - to better absorb the benefits of turmeric
  • Avocado and beef burgers - a healthier choice than simply a beef patty

(Sources: "Foods that Fight Inflammation," March, 2016; "The New Food Rules," Time, Dec 28, 2015 - Jan 4, 2016)

Healthcare Costs and the Choosing Wisely Campaign

Healthcare costs are worrisome to everyone—patients, practitioners, insurers, and governments (both state and federal). While the most significant drivers of healthcare costs include our aging population, the failure of preventive measures to stem the rising tide of chronic disease, and the advance of expensive technology, there is no question that waste is also a big factor. A frequently cited study by Berwick & Hackbarth (2012) reported that “in just 6 categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—the sum of the lowest available estimates exceeds 20% of total health care expenditures.” The authors estimated that overtreatment alone accounted for between $158 and $226 billion in 2011, third in line behind administrative complexity (#1) and fraud and abuse (#2). A study cited by Rao & Levin (2012) and done by America’s Health Insurance Plans claimed that “20% to 50% of all ‘high-tech’ imaging provides no useful information and may be unnecessary.” Every clinician knows that costs are not the only adverse effect of unnecessary procedures; inappropriate imaging, for example, “unnecessarily exposes patients to excessive radiation, inconvenience, and actual harms that come from the cascade of diagnostic and therapeutic interventions that often follow identification of a lesion that proves only to be an incidentaloma” (Rao & Levin). Overtreatment and overuse thus represent the natural targets of the Choosing Wisely Campaign, initiated by the American Board of Internal Medicine (ABIM) Foundation.

Each clinician normally makes the best decisions he or she can for an individual patient. However, there is persuasive evidence that many factors can interfere with optimal decision making: patient demand can have a powerful effect on practitioner decisions and so can outdated beliefs about the utility of diagnostic or therapeutic interventions (Cassel & Guest 2012). Brody (2012) reported that “futile interventions may be administered not solely because of patients’ demands but also by physicians acting out of habit or financial self-interest or on the basis of flawed evidence.” The ABIM Foundation has taken aim squarely at the roles played by both practitioners and patients. Securing the cooperation and participation of numerous specialty societies and consumer groups, the Foundation seeks to “help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.” The strategy that has engaged so many participants is to create lists of “Things Physicians and Patients Should Question,” developed by consulting the most compelling evidence about tests and treatments that are frequently overused.

While this might trigger nightmares about rationing or fears of applying evidence from clinical trials that don’t necessarily apply to the patient at hand, a review of some of these recommendations makes it clear that great care has been taken in the crafting of the list. Twenty-six specialty societies have released their “top 5” lists already, with another 20 due by the end of 2013. Consumer Reports has been ABIM’s primary collaborator on this project, but another 15 consumer organizations are also on board, including the nation’s largest—AARP. Cassel & Guest estimate that just the first 9 sets of guidelines released could potentially have reached 374,000 practicing physicians; a current estimate that would encompass the additional societies and the consumers was not found, but it isn’t difficult to see how big this campaign could become over time. Scope is very important: the campaign must reach a significant number of practitioners and, eventually, their patients if the effort is to have the desired impact on costs.

So, what exactly are these recommendations and what do they target? Rao and Levin evaluated the first 45 recommendations and noted that 24 of them concerned diagnostic imaging; as radiologists, they identified 16 which they agreed without question were overused. These included, for example, imaging for headache in patients without risk factors for structural problems; imaging in patients with low back pain in the absence of red flags; and PET, CT, or radionuclide bone scans in staging either early prostate cancer or early breast cancer, unless the patients are at high risk for metastasis. They added to the reasons for overuse physician fears of malpractice liability and described self-referral (meaning that the physicians have imaging equipment in their own offices and thus do not refer externally for such services) as a significant influence: “numerous] studies over the past 4 decades have shown that self-referral invariably leads to higher use of imaging studies.”

With a somewhat different position on diagnostic imaging, the Society of Nuclear Medicine and Molecular Imaging’s top five list (provided below without the rationales) includes only two of those mentioned in Rao & Levin’s list of 16, so there is as yet no single consensus list.

  • Don’t use PET/CT for cancer screening in healthy individuals.
  • Don’t perform routine annual stress testing after coronary artery revascularization.
  • Don’t use nuclear medicine thyroid scans to evaluate thyroid nodules in patients with normal thyroid gland function.
  • Avoid using CT angiogram to diagnose pulmonary embolism in young women with a normal chest radiograph; consider a radionuclide lung study (V/Q study) instead.
  • Don’t use PET imaging in the evaluation of patients with dementia unless the patient has been assessed by a specialist in the field.

For primary care functional medicine practitioners, American Academy of Family Practice and American Geriatrics Society recommendations may be of particular interest, as they are likely to affect a broad spectrum of patients and complaints; these are presented below with their rationales. Many of these may seem like common sense to functional medicine clinicians, while others may be more controversial. They all, however, merit serious consideration. Anyone who would like to examine the evidence sources will find them at the official list sites (see links below under More Information).

AAFP has a list of ten recommendations:

  • Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
  • Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.
  • Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
  • Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.
  • Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
  • DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients.
  • Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
  • There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.
  • Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
  • Most observed abnormalities in adolescents regress spontaneously; therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing, and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes.
  • Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks, 0 days gestational age.
  • Delivery prior to 39 weeks, 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks and 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.
  • Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.
  • Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care clinicians should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.
  • Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.
  • There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke, and myocardial infarction.
  • Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
  • There is adequate evidence that screening women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk provides little to no benefit.
  • Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.
  • There is adequate evidence that the harms of HPV testing, alone or in combination with cytology, in women younger than 30 years of age are moderate. The harms include more frequent testing and invasive diagnostic procedures such as colposcopy and cervical biopsy. Abnormal screening test results are also associated with psychological harms, anxiety, and distress.

The American Geriatric Society’s top five recommendations include:

  • Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.
  • Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status, and patient comfort. Food is the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.
  • Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  • People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary.
  • Avoid using medications to achieve hemoglobin A1C <7.5% in most adults age 65 and older; moderate control is generally better.
  • There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 1 0 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy.
  • Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
  • Large scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers, and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation, or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies.
  • Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
  • Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.

There are, of course, important concerns to be addressed; perhaps the most critical is how to proceed when the practitioner’s clinical judgment suggests that one of these procedures is indicated even though the patient may appear to reflect the norms of exclusion. Brody suggests that “an ethical system for eliminating waste will include a robust appeals process.” If and when these recommendations become part of the standard of care, such a process should be defined. While they are voluntary, an appeals process is probably unnecessary. Another extremely important concern is ensuring that these recommendations are regularly reviewed and revised if/when the evidence no longer supports them. But perhaps the greatest challenge is how to communicate in a credible way with both clinicians and patients that these are important recommendations to consider and that each of us needs to be informed enough to advocate for change in what we know is an unnecessarily costly system. In order to make real inroads in reducing waste, we all have to do our part—for that reason, IFM is sharing this information with you and urging you to investigate further and come to your own decisions on any of the recommendations that affect your practice and your patients.


Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.
Brody H. From an ethics of rationing to an ethics of waste avoidance. NEJM. 2012;366(21):1949-51.
Cassell CK, Guest JA. Choosing Wisely: Helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-2.
Rao VM, Levin DC. The overuse of diagnostic imaging and the Choosing Wisely initiative. Ann Int Med. 2012;157(8):574-6.

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