Making Nutrition Services Effective

How to remove the complexity in treating patients requiring medical nutrition therapy

By Michael L. Weinstein, MD, and Hagan Jordan

Nutrition is becoming an increasingly critical form of therapy and an intriguing service line for GI practices across the country. A recent global study published by the Rome Foundation indicated that four in 10 adults have a functional gastrointestinal disorder (FGID)1 and, for most FGIDs, medical nutrition therapy (MNT) is a critical element of the treatment protocol.

GI societies recommend nutrition therapy (i.e., specific dietary protocols) as first-line therapies and complementary treatments in the management of multiple GI disease states, including IBS, IBD, celiac, NAFLD, EoE, GERD, gastroparesis, and general weight loss. These disease states represent a significant percentage of a GI provider’s patient population, which makes adopting an efficient, clinically effective and, ideally, profitable nutrition program important.

Options now exist that enable GI practices to offer nutrition therapy in a way that is clinically effective, operationally efficient, and profitable.

Challenges with Nutrition Services

While most acknowledge the important role of nutrition in GI disease state management, nutrition therapies have historically been challenging for GI practices to adopt. Even as great technological advancements have been made in creating systems to make prescribing pharmaceutical drugs and/or performing surgical procedures simpler for physicians, a streamlined, efficient system for managing and achieving positive outcomes for patients with nutrition therapies has been more elusive.

For private practice gastroenterologists in particular, there have been consistent challenges with managing patients that could benefit from nutrition therapy: 1. Time: Most gastroenterologists and mid-level providers don’t have the time to manage these patients, as medical nutrition therapies require ongoing coaching and counseling.2 Furthermore, providers aren’t reimbursed adequately to spend the time it would take to “food journal,” find trigger foods, and interface on a regular basis to ensure patient compliance and outcomes. 2. Training: As a general rule, most physicians and midlevel providers don’t have in-depth training on nutrition therapies and specific dietary protocols.3 In a recent survey of 1,500 gastroenterologists, only 56% were

“comfortable” to “very comfortable” with providing dietary counseling to their patients.4 Due to this, and the limited time they have with patients, many GI providers offer information and educational materials to help patients adopt recommended diets on their own. Unfortunately, patient compliance is low, and the overall experience is impacted under this self-guided model. 3.

4. Access to a trained dietitian: While data shows GI-trained dietitians significantly improve outcomes for patients needing nutrition therapy and can provide the focused attention and guidance patients need, many GI practices don’t have an established relationship with a local GI-trained dietitian, leading to only 21% of gastroenterologists saying they “usually” or “always” refer their patients to a dietitian.5 Economics: The majority of GI practices that have tried to bring nutrition services in-house or hire a dietitian directly have found the economic challenges to be at the forefront, creating a break-even service line, at best. There are multiple reasons for this but, primarily, lack of insurance coverage, low reimbursement, and low patient willingness to pay out-of-pocket for these services top the list.

These challenges beg a very important question that the GI community has been asking for quite some time: “How can a GI practice offer a nutrition service line that is clinically effective, efficient, and profitable?”

Let’s start first with a specific disease state/diet example to illustrate the problem and then, of course, a solution.

Case Study: IBS/Low FODMAP

IBS patients present unique challenges for gastroenterologists. The global prevalence of IBS is 10–20% of the population6; however, most GI providers attest to the fact that a much larger percentage of their patient population experiences varying degrees of chronic IBS-like symptoms, such as abdominal pain, gas, bloating, diarrhea, and/or constipation.

Dietary modification, specifically the Low FODMAP diet, is considered a first-line therapy for IBS.7 The Low FODMAP diet is a powerful diagnostic tool to help patients and their providers understand the role that certain foods are playing in their IBS symptoms and, most importantly, identify those specific trigger foods. The protocol significantly decreases and then systematically reintroduces FODMAP subgroups, a collection of short-chain carbohydrates (such as some sugar and fibers), back into the patient’s diet. These foods may not be absorbed properly in the gut and can trigger symptoms in people with IBS. FODMAPs are found naturally in many common foods, even highly nutritious foods, such as wheat, apples, pears, onion, garlic, honey, agave syrup, sugar-free gum, mints, and some medicines.

The goal is to identify the specific FODMAPs that are triggering a patient’s IBS symptoms. Most patients aren’t sensitive to all categories of FODMAPs, so when they identify their specific FODMAP triggers, they can actually expand or liberalize their diet and better manage their symptoms long-term.

During this protocol, which typically runs six to eight weeks and is not a long-term “diet,” patients go through three specific phases—Elimination, Reintroduction, and Personalization—to identify their specific trigger foods and manage symptoms long-term. Most patients start to experience symptomatic relief in as few as two to three weeks.8

The Low FODMAP diet has been shown to be effective in improving chronic symptoms in up to 86% of patients with IBS.9 Low FODMAP is now the most commonly recommended dietary protocol by gastroenterologists for IBS patients, and 85% of gastroenterologist report Low FODMAP to be somewhat to very effective.10

So, What’s the Challenge?

Like many dietary protocols, the Low FODMAP diet can be challenging for a patient to successfully implement and complete without the support of a trained dietitian or healthcare provider and a system to make food preparation and cooking easier or less stressful for the patient.

In cases where a healthcare provider simply gives the patient a pamphlet or brochure and recommends the Low FODMAP diet, a very small percentage of patients successfully completes Elimination and Reintroduction, and never identifies their specific trigger foods. In fact, a recent study showed only 41% of patients who were recommended the Low FODMAP diet were able to adhere to it through the elimination phase.11 This is a primary reason why only 11% of IBS patients report a positive relationship with their provider and will, on average, visit 5.2 physicians as they seek answers.12

However, clinical data shows outcomes are improved when a patient is: 1.

2. Connected with an expert dietitian or healthcare provider to coach/counsel them through the Low FODMAP process. Compliance also improves.13 Provided food in some manner to make food sourcing, preparation, and cooking easier.

IBS and Low FODMAP are just one example of a disease state and corresponding nutrition therapy that illustrate the challenges that GI providers face. We could extend these examples into many other disease states requiring medical nutrition therapy, such as NAFLD and Eosinophilic Esophagitis, and see similar challenges.

A Solution to Improve Both Outcomes and Profitability

In early 2019, ModifyHealth launched a new service to make nutrition services more efficient and effective for GI providers and their patients. By partnering with ModifyHealth, GI practices get access to all of the necessary resources needed to provide a world-class nutrition service for their patients without having to build an internal program from scratch and hire a full-time dietitian(s). The GI practice is able to offer a nutrition service program to their patients while also accessing an ancillary revenue stream, if desired.

Starting first with IBS/Low FODMAP, ModifyHealth’s service enables a GI provider to refer their patients directly to ModifyHealth as an extension of their practice. All referred patients have access to a free, initial virtual consult with a GI-trained dietitian, where they receive focused time and attention as well as education, resources, and recipes. The free

85% Low FODMAP

is now the most commonly recommended dietary protocol by gastroenterologists for IBS patients and 85% of gastroenterologists report Low FODMAP to be somewhat to very effective.

Additional Resources

Nutrition therapy can be an effective option for many patients. Have questions or want to learn more about how these programs work? Here are some Low FODMAP and nutrition therapy resources: • Download ModifyHealth’s Low FODMAP Patient

Education Handout and Brochure for Patients • Check out the Monash University Low FODMAP

App (iOS, Android) • Find a Monash Low FODMAP and/or GI trained dietitian • Visit the International Foundation for Gastrointestinal Disorders (IFFGD.org)

consult encourages patients to engage with a dietitian to get the support they need. On average, 86% of referred patients participate in the free, initial consult while 40–50% sign-up for the full service with dietitian support and meals.14 The fact that the initial consult is both free and virtual removes barriers to patients getting the help they need.

The full service from ModifyHealth helps to simplify the Low FODMAP protocol and improves compliance. All referred patients receive: • A free, initial virtual consultation with a GI-trained dietitian • Three additional virtual dietitian consults and ongoing on-demand dietitian support • Medically-tailored, Low FODMAP meals delivered directly to the patient’s door • A patient-friendly app (iOS, Android) to track progress and connect with their dietitian • At the end of the program, the GI provider receives a summary report from the ModifyHealth dietitian

The program is a weekly subscription where the patient purchases affordable, medically-tailored, home-delivered meals (with free shipping) and pays a one-time $99 fee for all three dietitian consults and on-demand access. For practices that already have a GI dietitian, their patients can simply purchase the meals from ModifyHealth and continue working with their in-house dietitian. The program is very affordable and similar to what a patient is already budgeting and spending on food today, but with the benefit of medically-tailored meals and support.

The clinical results have been encouraging: • 85% of patients who sign up for the program complete the

Elimination Phase. • 79% of patients report significant relief as defined by at least a 50-point improvement in their IBS-SSS (Symptom

Severity Score). • The average patient reports a 120-point improvement in their IBS-SSS score.15

In addition to being clinically impactful, ModifyHealth offers an attractive ancillary revenue opportunity where a GI practice can benefit financially. The ancillary program is upon request and not required to refer patients to the service. This ancillary program enables GI practices to add another, new ancillary revenue stream to their practice that is passive in nature and requires no additional infrastructure or new employees. The risk is also minimal for the practice due to

For more information on the ModifyHealth service and how to add this service line to your practice, please contact providers@modifyhealth.com. Learn more about ModifyHealth at modifyhealth.com.

no to low upfront costs.

Note: The ModifyHealth service and meals are not reimbursed by any third-party, including any federal or state healthcare programs and therefore the sale of the meals is not subject to the United States Federal Anti-Kickback Statute. ModifyHealth and any physician practices entering into an ancillary service agreement intend to comply with all applicable laws and will modify or terminate the agreement upon any change in the laws which may impact the agreed-upon structure.

FOOTNOTES 1AD Sperber, et al., Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study, Gastroenterology (2020), doi: https://doi.org/10.1053/ j.gastro.2020.04.014. 2https://www.gastroendonews.com/In-the-News/Article/04-18/Role-of-Dietitians-Expands-as-DietsFor-IBS-Gain-Favor/48360?sub=81257C76C3B6DD78A83F75D86BCE5DE4F102F921FF83CA23 B58F26C6161435A 3Crowley, Jennifer et al. “Nutrition in medical education: a systematic review.” The Lancet. Planetary health vol. 3,9 (2019): e379-e389. doi:10.1016/S2542-5196(19)30171-8. 4Lenhart, et al. Use of dietary management in irritable bowel syndrome: results of a survey of over 1500 United States Gastroenterologists. J Neurogastroenterol Motil. 2018;24:437–451. 5Lenhart, et al. 437-451. 6Endo, et al. “Epidemiology of irritable bowel syndrome.” Annals of gastroenterology vol. 28,2 (2015): 158-159. 7Halmos et al. “A diet low in FODMAPs reduces symptoms of irritable bowel syndrome.” Gastroenterology vol. 146,1 (2014): 67-75.e5. doi:10.1053/j.gastro.2013.09.046. 8Nanayakkara, et al. “Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date.” Clinical and experimental gastroenterology vol. 9 131-42. 17 Jun. 2016, doi:10.2147/CEG.S86798. 9Nanayakkara, et al. 131-142. 10Lenhart, et al. 437-451. 11Mari, et al. “Adherence with a low-FODMAP diet in irritable bowel syndrome: are eating disorders the missing link?.” European journal of gastroenterology & hepatology vol. 31,2 (2019): 178-182. doi:10.1097/

MEG.0000000000001317. 12Drossman, et al. “International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit.”

Journal of clinical gastroenterology vol. 43,6 (2009): 541-50. doi:10.1097/

MCG.0b013e318189a7f9. 13PR Gibson. “The evidence base for efficacy of the low FODMAP diet in irritable bowel syndrome: is it ready for prime time as a firstline therapy?.” Journal of gastroenterology and hepatology vol. 32 Suppl 1 (2017): 32-35. doi:10.1111/jgh.13693. 14ModifyHeath Internal Data, April 2020. 15ModifyHealth Internal Data, April 2020. Michael L. Weinstein, MD, is President and CEO of Capital Digestive Care and the Managing Partner for the Metropolitan Gastroenterology Group division.

Hagan Jordan is the Chief Commercial Officer at ModifyHealth. Prior to ModifyHealth, Jordan helped launch EndoChoice from a startup in 2008 through its eventual sale to Boston Scientific in 2016.