Training in nutrition was limited during my undergraduate pharmacy studies. There were a few of lectures about gluten-free foods and infant formula milks, along with the occasional mention of vitamins and minerals, but the general (yet false) gist was that where food is plentiful, the deleterious impact of malnutrition is rare.
This experience is not unique to pharmacists: it is similar for doctors. In September 2019, a systematic review of 24 studies across the world concluded that although we know that nutrition is central to a healthy lifestyle, “medical students are not supported to provide high-quality, effective nutrition care”
. The ‘NHS long-term plan’, published in January 2019, has already acknowledged that nutrition training for doctors is insufficient in the UK
There has never been a bigger focus on the prevention of disease in the NHS, where pressure on funds is high, but an NHS that understands nutrition can prevent disease and reduce demand on its services.
Some doctors are starting to realise their own shortcomings in nutrition; some even acknowledge that it is no longer defensible to be ignorant of nutrition, for example, when managing type 2 diabetes mellitus (T2DM)
Pharmacists should also no longer plead ignorance and, as a profession, we too must admit that pharmacy is not well equipped when it comes to nutrition. This needs to change in pharmacy, both in undergraduate and professional settings.
Nutritional medicine should not be the preserve of postgraduate qualifications
Nutrition is sidelined
After qualifying as a pharmacist, I studied for an master’s in nutritional medicine. Everything I had been taught about how we must manage illnesses — predominantly with medicines — started to unravel. I learnt that the aetiology of several chronic diseases is related to lifestyle and, in particular, diet.
Not every pharmacist is able to study after qualifying; nutritional medicine should not be the preserve of postgraduate qualifications. There is a huge void between what pharmacists need to know and the nutrition training that is currently on offer to pharmacy undergraduates.
Diet can control diabetes
It is simplistic and reductionist to consider that only those who are underweight are malnourished, or that it is mainly people who are overweight who are at risk of dietary-induced illness; it is possible to be a normal weight and be malnourished.
For many years, we have been led to believe that T2DM is a progressive condition. I was taught that it inevitably results in end organ damage, including diabetic retinopathy, nephropathy, peripheral neuropathy and, for some people, sight loss and amputations. I also learnt about different pharmaceutical approaches to avoid or lessen the ‘inevitable’ damage.
However, it is now becoming more widely acknowledged that T2DM can be put into remission by following a low-carbohydrate diet
. For some people, this means being able to reduce their medication and some may even stop taking medication altogether.
For example, a British GP demonstrated better quality of diabetes control than neighbouring practices and was able to keep his diabetes drug spend static for three years
, by teaching his patients about this nutritional approach and offering advice on diet and lifestyle around the management of hyperglycaemia as a possible alternative to lifelong medication. This approach, scaled up to every practice in the UK, could save millions of pounds for the NHS.
Not just for diabetes and heart health
We pharmacists must consider our contribution beyond our role in dispensing — for example, in giving meal replacements in the form of sip feeds, percutaneous endoscopic gastrostomy feeds, parenteral nutrition, or selling over-the-counter nutrient supplements. We also need to leave behind the idea that dietary advice is relevant primarily in obesity, diabetes, cardiovascular disease and frailty.
Let’s consider asthma: how many healthcare professionals make nutritional recommendations to optimise clinical outcomes for people with asthma? My guess would be not many.
But the asthma guideline from the British Thoracic Society and the Scottish Intercollegiate Guidelines Network makes several non-pharmacological recommendations
. Breastfeeding confers a potential protective effect in infants against early asthma
. Reduced intakes of selenium and vitamin E during pregnancy are associated with an increased asthma risk in the child
. Low magnesium intake is associated with a higher asthma prevalence, and increasing intake can result in reduced bronchial hyper-responsiveness and better lung function in children
. In both adults and children, a high intake of fresh fruit and vegetables is associated with lower prevalence of asthma and better pulmonary function
. In adults with mild-to-moderate asthma on inhaled corticosteroid treatment, vitamin D has been shown to reduce the risk of severe asthma exacerbations
Side effects of asthma medicines can result in the need for further prescribing – for example, antifungals to manage oral thrush with inhaled corticosteroids, or bisphosphonates for the management of osteoporosis from oral corticosteroids. So, a nutritional approach may not only reduce the burden of disease, and the need for medicines to treat the primary condition, but also reduce the need for medicines to treat complications and side effects.
Healthy-eating behaviours have been associated with fewer symptoms and better asthma control
. Dietary changes may not work for everyone, but, at the moment, a focus on nutrition to manage asthma is certainly not a routine recommendation for anyone. The lack of interventional studies is a huge barrier to these potential recommendations becoming part of routine clinical practice.
Despite this paucity of data, patient cases show how a focus on nutrition can transform people’s lives
. If we could scale this experience up to the population at large, it could have huge implications for deprescribing and subsequent savings for the NHS. But importantly, it could vastly improve quality of life for many patients.
We need nutrition and pharmacy schools’ support
Treatment decisions should be based on evidence-based outcomes from interventional studies, but we undoubtedly need more clinical research. A good place to start might be collaborations between schools of pharmacy, nutrition and dietetics departments, and medical schools, to investigate the benefits of nutritional interventions in a clinical setting. This collaborative working could involve training undergraduates; some elements of the nutrition and dietetics curricula could also be taught to pharmacy and medical students, to develop pharmacists and doctors who understand the value of nourishing, as well as treating, patients.
Nutritional medicine is not rocket science. Every structure, organ, cell, neurotransmitter or hormone in our bodies is made from the foods that we eat.
It is not only medicines that affect health; if we don’t eat the right foods, we can’t expect our bodies to work at their best. It is time for pharmacists to consider nutrition and push forward the prevention agenda.
Lisa Jamieson, pharmacist and nutritionist, Surrey
 NHS England. 2019. Available at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf (accessed November 2019)
 Unwin D. 2019. Available at: https://www.rcgp.org.uk/clinical-and-research/resources/bright-ideas/working-on-weight-loss-with-type-ii-diabetic-patients-dr-david-unwin.aspx (accessed November 2019)
 Scottish Intercollegiate Guidelines Network, British Thoracic Society. 2019. Available at: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ (accessed November 2019)
 Robinson J. 2018. Available at: https://www.pharmaceutical-journal.com/careers-and-jobs/career-profile/from-pharmacist-to-patient-to-researcher/20204526.article (accessed November 2019)