Transcript
Dr. Ramnarine:
In patient care, nutrition is often treated as supportive, but what happens when we start thinking of it as foundational?
Welcome to NutritionEdge on ReachMD. I'm Dr. Shelina Ramnarine, and today we're taking a closer look at how we can better integrate nutrition into everyday care. Joining me for this conversation is Ms. Jessica Clancy-Strawn, a registered dietitian specializing in kidney health and chronic disease prevention in Houston, Texas.
Ms. Clancy-Strawn, thanks for being here today.
Ms. Clancy-Strawn:
Thank you. I'm really glad to be here. Looking forward to the conversation.
Dr. Ramnarine:
So to start us off, when you think of the role of nutrition in today's clinical landscape, where does it fit into patient care, and where is it most often overlooked?
Ms. Clancy-Strawn:
Nutrition is foundational to every system in the body. Sadly, it is often only implicated once those systems begin to weaken or fail. In practice, nutrition is typically introduced when there's billable, reimbursable diagnoses, meaning it's offered after a condition is established rather than early on.
Nutrition should be part of prescreening—simple intake questions and even basic healthy living referrals. But instead, it's usually reserved for later stages of disease when the opportunity for early intervention has already passed. Commonly overlooked areas include elevated glucose levels, prediabetes, elevated liver enzymes, declining kidney function, high blood pressure, digestive symptoms, and unintentional weight changes.
Why are these opportunities missed? Time constraints in primary care, lack of nutrition training among many providers, fragmented care teams, patients arriving late with advanced disease, and most importantly, many doctors not knowing where or how to refer patients to a dietitian. They may not know which dietitian specializes in that patient's condition. They may not know which referrals are covered by insurance. They may not know how to integrate nutrition into the care plan, so the referral never happens even when nutrition is needed.
Dr. Ramnarine:
Let's build on that further. What mechanisms and processes are occurring in the body before patients show up with symptoms or abnormal labs?
Ms. Clancy-Strawn:
Under the surface, the body has been compensating for months or years. By the time symptoms or abnormal labs appear, the body has already been working overtime to maintain balance. Common compensations include the kidneys filtering harder, the pancreas producing more insulin, the liver storing excess fat, and the bones releasing minerals to correct imbalances.
Metabolic shifts are already underway. Early metabolic dysfunction often goes unnoticed: insulin resistance long before glucose rises, elevated inflammation before pain or swelling, and fatty liver developing before liver enzymes increase. Micronutrient depletion has already occurred. Deficiencies build slowly and don't show up in labs until stores are low. This includes vitamin D, iron, B vitamins, and magnesium. Hormonal and appetite regulating systems are disrupted. Chronic stress, poor sleep, and inconsistent eating patterns alter cortisol, ghrelin, leptin, and thyroid hormones. These shifts influence hunger, cravings, weight, and energy long before labs catch up. Chronic inflammation is already influencing tissues. It affects blood vessels, joints, gut lining, and immune function. The inflammation is silent; patients don't feel it until it becomes symptomatic. Kidney function has already declined before labs show it. By the time creatinine rises, GFR drops, and protein appears in urine, the decline has already been happening for years. GI dysfunction has been present long before; symptom changes in the gut microbiome, motility, and indigestion, often precede bloating, reflux, constipation, and food intolerances.
Patients often think these symptoms came out of nowhere, but the groundwork was already there. Patients have often experienced irregular eating, high stress, poor sleep, sedentary patterns, food insecurities, and limited access to healthy foods. By the time symptoms or abnormal labs show up, the body has already been whispering for a long time. Those whispers become shouts, and that's usually when patients finally get referred. Nutrition is the tool that helps us intervene during the whispers, not just after the shouts.
Dr. Ramnarine:
You mentioned this a little bit at the beginning, but how does delaying or deprioritizing nutrition affect patient outcomes and treatment complexity over time?
Ms. Clancy-Strawn:
It can influence delayed healing, which increases readmissions and higher acuity care. When nutrition is not addressed early, patients experience slower recovery, higher complication rates, and more frequent returns to hospitals, long-term care, and rehab. Longer recovery affects multiple body systems.
Poor or delayed nutrition can worsen inflammation, impair wound healing, weaken immunity, and reduce muscle strength. This impacts mobility, independence, and the patient's ability to care for themselves, which can also reduce motivation to make positive lifestyle changes.
Patients with multiple comorbidities become harder to treat when nutrition is not addressed early. Conditions like diabetes, hypertension, kidney disease, and obesity compound each other. This makes it difficult for providers to stabilize the patient and improve outcomes for patients with multiple comorbidities. Dietitians often have to prioritize which condition to treat nutritionally first. Sometimes one condition must take precedence over another to support survival and overall wellbeing.
Food insecurity accelerates disease progression. Limited access to nutritious food or relying on low-quality, low-nutrient options can worsen symptoms and mask early warning signs. Local resources may not meet nutritional needs, which further accelerates disease progression. Unaddressed food insecurity affects entire families. When food insecurity is not identified early, the risk of chronic disease increases not only for the patient, but also for their children and household members. This perpetuates a cycle of poor health across generations. Younger populations are becoming sicker earlier. We are seeing systemic diseases appear at younger ages than previously projected.
Early nutrition intervention is one of the most powerful tools we have to change outcomes, reduce costs, and support long-term health.
Dr. Ramnarine:
For those just tuning in, you're listening to NutritionEdge on ReachMD. I'm Dr. Shelina Ramnarine, and I'm speaking with Ms. Jessica Clancy-Strawn about how nutrition shapes long-term health.
So to continue the conversation, Ms. Clancy-Strawn, let's look at this from a systems perspective. How does an early and intentional approach to nutrition begin to support multiple physiological pathways at once?
Ms. Clancy-Strawn:
There is so much new research out there on how nutrition affects systems. According to a 2017 review by Calder in Biochemical Society Transactions, omega-3 fatty acids help control the immune system and inflammation. Omega-3s influence gene expression, immune activity, inflammation, and cell signaling all at the same time, which means they support multiple systems at once. Omega-3s help with chronic inflammation, joint pain, autoimmune conditions, and metabolic inflammation. Omega-3s also improve endothelial function, reduce plaque-related inflammation, and support healthier lipid profiles.
EPA and DHA support brain cell membrane fluidity, neuroinflammation reduction, and healthy signaling between neurons. This is why omega-3s are linked to mood, cognition, and brain health.
When we talk about omega-3 supporting multiple systems—the immune system, inflammation, cardiovascular health, brain health, and even gene expression—we're really talking about the foods that deliver EPA, DHA and ALA. For EPA and DHA, the most active forms you get are from fatty fish. And if someone doesn't eat fish, algae oil is the only true plant-based source that provides EPA and DHA directly. Then you've got the plant-based omega-3s—the ALA sources—foods like walnuts, chia seeds, black seed, hemp seeds, and soy. These don't fully convert into EPA and DHA, but they still support metabolic health, inflammation, balance, and overall nutrient density.
Next, a review on the Mediterranean diet in metabolic syndrome published in Nutrients looked at how this eating pattern affects the major components of cardiometabolic risks. What the authors found is that metabolic syndrome responds extremely well to the Mediterranean diet, and the reason is that this way of eating doesn't target just one biomarker; it works across multiple systems at the same time.
The Mediterranean diet is rich in fruits, vegetables, whole grains, legumes, nuts, olive oil, and moderate amounts of fish and poultry. Because it's high in unsaturated fats, polyphenols, antioxidants, and fiber, it reduces inflammation, improves insulin sensitivity, and supports healthier lipid metabolism.
Dr. Ramnarine:
And when you're thinking about real-world care, how do you assess whether a patient's nutrition plan is actually working for them?
Ms. Clancy-Strawn:
There's several things that we look at. One of those is subjective progress. The clinician will compare what the patient shared during the initial visit with what they report in follow-up sessions. They listen for changes in how the patient feels, their level of engagement, their confidence, and their motivation to stay consistent. The patient's language, tone and energy often reveal progress before objective data does.
The clinician monitors measurable indicators such as lab trends, weight patterns, blood pressure, glucose patterns, inflammatory markers, and imaging results. The clinician performs a nutrition-focused physical exam—NFPE—to assess muscle mass, subcutaneous fat stores, and fluid status. They also observe functional strength—how the patient walks, their mobility, their ability to perform daily activities, and possibly the level of endurance that they're at from beginning to end.
The clinician evaluates improvements in energy levels, sleep quality, GI regularity, wound healing, and physical performance. The clinician looks for reductions in pain, swelling, and inflammatory flare-ups, including skin, digestive discomfort, and brain fog. Symptom relief is often one of the earliest signs that the plan is effective.
The clinician assesses whether the patient is becoming more independent and less reliant on the healthcare system, taking ownership of their habits, and demonstrating confidence in sustaining the plan. The clinician looks for evidence that new habits are being practiced consistently. They evaluate whether the patient can teach back.
The clinician monitors whether the patient is tolerating medications better, requiring fewer medications, or experiencing a reduced pill burden as their nutrition improves.
Dr. Ramnarine:
Finally, Ms. Clancy-Strawn, what's one practical shift clinicians can make to start integrating nutrition more consistently into everyday care?
Ms. Clancy-Strawn:
Doctors set the tone for the culture of care. Nutrition wasn't emphasized in most medical training programs, not because doctors didn't value it, but because the system didn't prioritize it. Yet physicians still carry the responsibility of guiding patients through complex health decisions.
Even simple questions about eating patterns, hydration, or daily routines can open the door to meaningful change. With medical nutrition therapy now reimbursable, physicians can confidently refer knowing that nutrition support is covered and accessible. It empowers physicians to include dietitians as part of the treatment plan. This expands the tools available to support patient outcomes and strengthens the physician's impact.
Physicians can shift the culture with one simple statement. A practical, immediate shift is saying, "Nutrition is essential, and I want you to see a dietitian." This one sentence elevates the value of nutrition and signals to the patient that it is a core part of their care.
Dr. Ramnarine:
What a great way to round out our discussion. I'd like to thank my guest, Ms. Jessica Clancy-Strawn, for joining me to explore how we can take a more proactive approach to nutrition.
It was really great having you on the program.
Ms. Clancy-Strawn:
It's been a pleasure. Thanks again for having me.
Dr. Ramnarine:
For ReachMD, I'm Dr. Shelina Ramnarine. To access this and other episodes in our series, visit NutritionEdge on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.
