Eat What I Say Not What I Eat?
Meeting planners for the Council on Medical Specialty
Societies 13 medical societies (including
internal medicine, pediatrics, surgeons, obs…over
250,000 docs; over 2 million planned meals and
snacks) found that doctors eat what is served, happily.
MDs are still served dessert at every meal and soda at
every break. No MD was involved in menu planning for
any annual meeting. No meeting was planned to include
a vegetarian meal, or to exclude potato chips, snack
mixes or candies at breaks.
The research was published this month in the quarterly,
international, peer-reviewed journal Disease Management.
Click “MORE” for the entire research study.
DISEASE MANAGEMENT
Volume 6, Number 4, 2003
© Mary Ann Liebert, Inc.
LA PUMA ET AL.
MEALS AT SPECIALTY SOCIETY ANNUAL MEETINGS
Point of View
Meals at Medical Specialty Society Annual Meetings: A Preliminary Assessment
JOHN LA PUMA, M.D., F.A.C.P.,1 DAVID SCHIEDERMAYER, M.D., F.A.C.P.,2 and JENNIFER BECKER, R.D., L.D.3
1Medical Director, The Santa Barbara Institute for Medical Nutrition and Healthy Weight, Santa Barbara, California 93105
2WAUKESHA MEMORIAL HOSPITAL; WAUKESHA, WI 53226
3Clinical Oncology Nutritionist, Midwestern Regional Medical Center, Cancer Treatment Centers of America, Zion, Illinois.
ABSTRACT
Little is known about how meals are chosen for medical meetings. We surveyed the annual meeting planners for 20 major specialty societies. Thirteen (65%) responded; all were currently planning their next meeting. Attendance in 2000 was reported at 113,477 physicians, with 2 million planned meals and snacks.
Decisionmaking. No physician was named as responsible for food choices: the meeting planner and staff were primarily responsible for deciding what food to serve, excluding exhibit halls. Twelve (92%) respondents rated “available budget” as the most important factor. “Nutritional guidelines” were rated “very important” by 8/13 (63%). However, no specific nutritional guidelines could be identified by any planner. All respondents indicated that members would attend a meeting if “healthy” food were the only option.
Meal Quality and Evaluation. For 2000, 100% of respondents indicated that for each lunch and for each dinner, a dessert had been included. No annual meeting and no planned 2001 meeting excluded potato chips, snack mixes or candies at breaks; soda pop was offered with each break. Most respondents (89%) relied on a concluding questionnaire about the meeting facilities to evaluate the food. Respondents reported no difference in charges for “special meals,” including vegetarian and kosher meals.
Physicians may be unaware that some food served at medical meetings may impair learning, with excessive calorie, fat and carbohydrate consumption. Small changes can improve the quality of food and beverages selected, without increased cost, and provide choices which conform to national nutritional guidelines. Medical meetings should serve flavorful, healthful food.
INTRODUCTION
Most physicians report that they observe dietary restriction.1 Recent national survey data, however, bring these data into question. Obesity and obesity-related diseases have increased in every sociodemographic and economic class, including the most well-educated and affluent.2
One of the few venues in which physicians can actually be observed while eating is during their annual medical society meetings. Little is known about how the meals are chosen for medical meetings.3 Robb-Smith4 notes “we must turn from physiologists to the doctors who actually wrote cookery books, though we cannot be sure that these physicians all fulfilled Andrew Boorde’s requirements that they should be ‘very experte in cokeing.’” Irrespective of their expertise in the kitchen, physicians do expect food and drink at medical meetings,5 and attend more often if meals are provided.6
We wondered how those responsible identify the parameters used for choosing meals, snacks, and beverages for annual national medical meetings. We also wondered whether physicians had input into the process of meal selection, and were curious about whether nutritional guidelines played a role in the food and beverage selection. Finally, we wondered whether physicians were observed to follow nutritional guidelines. Physicians who practice a health habit themselves are significantly more likely to counsel patients about that health habit.7
METHODS
A structured, pre-tested questionnaire was developed by J.L.P. and then presented, reviewed, and analyzed at the Medical College of Wisconsin Internal Medicine Research Methods Seminar by D.S. The questionnaire instrument was submitted and initially reviewed by the Institutional Review Board, and was returned to the investigators after being exempted from further review. The questionnaire was administered in July 2001 by J.B.
To determine the process involved in meal selection, we identified the 20 professional organizations, which comprise the membership of the Council on Medical Specialty Societies (CMSS) (Table 1). The CMSS is a non-profit association whose members are national medical and surgical specialty organizations representing more than 365,000 doctors nationwide. We then contacted the annual national meeting planners at each Society by telephone.
We asked respondents for information about themselves and their meeting planning efforts. We asked how they planned for, selected, and monitored the meals and snacks at their annual meetings. We asked respondents to rank 10 decisional factors on a 3-point scale of importance in selecting the food, snacks, and beverages for the previous year’s annual national Specialty Society meeting. We also asked for respondents’ methods of evaluation of the food served, and for the feedback they received from meeting attendees about the food, including what they said they liked and disliked, and which, if any, special meals were made available to attendees. We also requested menus for the most recent meetings.
Specifically, our questions were:
1. Who was primarily responsible for deciding what food to serve during the Annual Meeting, excluding the exhibit halls?
2. How important were each of 10 factors in actually deciding what to order, including nutritional principles and dietary guidelines?
3. Were “healthy alternatives” offered and selected and, if so, how often?
4. Was dessert offered at lunch and dinner, and was soda pop offered at snacks?
5. Was the food at the annual meeting evaluated and, if so, how?
6. How important would each of the 10 named factors be next year in deciding what to order?
7. What foods do physicians as a group tend to like and to dislike?
8. Is the meeting planner certified, and has she taken continuing education classes for food selection?
RESULTS
Thirteen of the 20 meeting planners (65%) agreed to be interviewed; nine respondents completed the standardized interview questionnaire orally with the interviewer, and four respondents self-administered the questionnaire. Nine had planned the last annual meeting; all 13 were currently planning the next meeting. Twelve were female; their mean age was 39.7 years (range 28–50 years). Respondents had been planning meetings for 12 years (median 12 years, range 0.25–25 years); five respondents were Certified Meeting Planners, for a mean of 4.6 years.
Respondents represented a combined membership of over 250,000 physicians. Attendance for their 13 meetings in the year 2000 was reported to be 113,477 physicians (mean 8,729 physicians, median 9,311, range 300–25,000) over a mean of 4.6 days per meeting. These physicians consumed more than 2 million planned meals and snacks. Respondents identified the meeting planner and the meeting planning staff as primarily responsible for deciding what food to serve during the annual meeting, excluding the exhibit halls, in 11 of the 13 meetings. The Continuing Medical Education Director was responsible in one case, and the meeting sponsor in another. No physician was named as responsible for meal or snack choices.
Twelve of 13 respondents rated “available budget” as the most important factor in deciding what food to serve attendees (Table 2). Only two respondents offered average per person costs for meals: $9–$20 for breakfast, $15–$30 for lunch, and $40–$60 for dinner. One respondent reported that her total budget for the meeting’s food was $150,000 for more than 10,000 attendees.
Nutritional guidelines were rated “very important” by eight respondents. However, no specific nutritional guidelines could be identified by any planner. “Avoiding foods people may feel that are bad for you”…“varies”…“heart healthy”… “vegetarian”…“low fat options”…“kosher” were the guidelines which seven of the eight respondents considered. All respondents (nine of nine) indicated that their attendees would attend a meeting if “healthy” food were the only option. Most (seven of 10) respondents reported that catered functions offered them the choice of a “healthy alternative.” All (nine of nine) reported choosing this “healthy alternative” for their attendees each time it was proffered. No planner utilized any “fad diet” in making food and beverage selections. The same 10 decisional factors were ranked by anticipated importance for the coming annual meeting, without change in factor ranking. “Overall healthy” were the nutritional guidelines most commonly anticipated.
For the year 2000, all (11 of 11) respondents indicated that for each lunch, a dessert had been included; all (11 of 11) indicated that for each dinner, dessert had been included. The respondents identified many foods that physicians as a group tend to like and only a few they tend to dislike. In order of ranking, fish and chicken were the top foods identified as liked, followed by beef, baked goods, turkey, vegetables, salads, and fruits. Foods identified as disliked included, in order of ranking, pork and ham, beef, and heavy sauces. Desserts served at lunch or dinner included angel food cake, brownies, cake, cheesecake, chocolate/sweets, cookies, dessert display, key lime pie, plated desserts, and upscale dessert.
Most (nine of 12) respondents asked attendees to evaluate whether the food at the annual meeting was successful. Most (eight of nine) relied on a general written questionnaire about the meeting facilities, including the promptness of the food service, at or near the meeting conclusion. One respondent specifically evaluated the quality of the food, on a descriptive scale of very good to poor. Five of eight respondents reported receiving written compliments on the food, one commenting favorably on the ample supply. Two respondents reported receiving written complaints about the food: “not enough,” and “the food was terrible.” One respondent reported neither compliments nor complaints.
Special meals, most commonly vegetarian or kosher, were reported to have been requested by an estimated 2–20% of the attendees. Respondents reported no difference in charges to their medical society for these meals. No meeting, according to the respondents (11 of 11), provided “extras” such as green tea, soy milk, or substituted olive oil for butter on the tables. No annual national meeting was planned to include a vegetarian meal, according to respondents (13 of 13); no meeting excluded potato chips, snack mixes, or candies at breaks (13 of 13).
One-third (three of nine) of respondents reported serving wine or beer to attendees at lunch; over half (58%) at dinners, and nearly all (92%) at receptions. Only one planner reported accompanying a snack break between meals with alcoholic beverages. All planners reported offering soda pop with each snack break. Printed menus from past meetings were unavailable.
DISCUSSION
Our exploratory analysis of the process of choosing over 2 million meals and snacks for the annual medical meetings of 13 major medical specialty organizations reveals that physicians have little input into the process and provide almost no feedback to meeting planners about the food they eat. No physicians were involved in food selection, in identifying useful nutritional guidelines, or in menu development or supervision. While it is possible that physicians pursued largely healthful choices outside of their medical meeting meals, and indulged in these meals as special ones, physician eating habits have not been carefully studied.
The “nutritional guidelines” respondents named were vague and unassociated with any governmental, culinary or professional organization. Indeed, no specific guidelines were cited by any respondent for any national medical meeting. Responding planners appeared to use their own, personal impressions of what was “healthy” and what was not in ordering the food for their medical meetings. Evaluations of food quality were cursory, and respondents were concerned about the potential for negative comments of any kind. It appeared that meals were a value-added item, with more planner concern about quantity than quality. One planner noted, “the worst thing that can happen is to run out of food.”
Physicians were perceived as an easy-to-please group by the respondents, as they appeared to dislike only a few foods. Yet physicians were also perceived as health conscious. For example, though red meats, heavy sauces, and pastries were reported to be enjoyed by physicians, those same foods were identified as disliked foods more often than were other foods.
It is well known that Americans consume too few fruits and vegetables, too much saturated and trans fat, and too many empty calories. Only 3% of people consume at least three daily servings of vegetables.8 Potatoes (primarily frozen) are the most widely consumed vegetable in America.9 Nutrient-dense foods, such as fish, fruits, and vegetables, which were not disliked at all by physicians, might be served more often as physicians learn more about their nutritional qualities and banquet and catering chefs prepare them in flavorful and healthful ways.
Physician attendees appeared to have prominent “sweet tooths” to the respondents, who planned desserts accordingly. Dessert was reportedly served at every meal in every annual meeting, as was soda pop. The served desserts described are generally rich in calories and high in saturated and trans fats, and especially high in sugar.
Planners appeared to order rich celebratory foods for annual medical meeting meals. Foods served on special occasions in contemporary society tend to be high in calories, large in portion size, and low in nutrients. While food at medical meetings should be delicious and special, special can mean something other than highly caloric and sedating. Special occasion food served regularly may make the special occasion somewhat more common and less special.
Input from meeting attendees played a very small role in responding meeting planners’ choices. For example, “special meals” (i.e., alternative to the main served entrée) appear to be much more often requested than actually served. It is unclear whether requests for special meals were not honored or if the requesting physicians simply made do with the portions of the meal that suited their dietary preferences. Better physician feedback to planners, and innovative thinking “outside the box lunch” among sponsors and meeting staff, may advance physicians’ roles in these choices.
Although wine was sometimes served as a beverage at meals, especially at dinner, it was most commonly served at receptions with food. Although the cardiovascular benefits of limited alcohol intake have been reasonably well demonstrated, wine appeared to be offered by meeting planners in large part for its social rather than medical benefits. For both social and nutritional reasons, wine is best served with food at meetings: food in the stomach slows the absorption of the alcohol, slowing any toxicity. It has been previously observed that if alcohol was a drug under FDA scrutiny for approval, it would fail quickly: its potential detriments (including addiction, cirrhosis, and dementia) when abused are familiar to nearly all clinicians.
It is not surprising that medical meeting planners (instead of physicians themselves) select the meals for the meeting—indeed, meeting planners specialize in just this arena. Nor is it surprising that these meals have a celebratory quality. Physicians typically enjoy such foods at their annual national meeting. It is also not surprising that the composition of the meals appears heavy (both rich in fats and simple sugars), as physicians eat out four or five times weekly (J. La Puma, P. Szapary AND K. MAKI, unpublished data) and often eat commercially prepared meals provided in the medical office and hospital. Meals prepared outside the home have been shown to have higher calorie and lower nutrient profiles than meals cooked at home.
We know little of physician dietary behavior outside of these examined meals. From 30–58% of physicians self-report their body weights as overweight,10,11 and a smaller number (8–18%) categorize themselves as obese.12 As in the general public, diabetes11 and all-cause mortality12 are much higher in overweight physicians than those who are of healthy weight. Investigators in the Women Physician’s Health Study (2000)13 identified self-reported cooking, shopping, and meal preparation habits of female physicians, finding them to possess “relatively healthy diet-related habits.”
This small, exploratory study has several limitations. We could estimate neither actual composition of individual meals nor entrée serving size. Standard fine dining restaurant entrees are 8 ounces for fish and chicken, and 10-12 ounces for beef and pork; paradoxically, serving sizes in “casual dining” restaurants can be much larger, though of lesser quality. Respondents were understandably reluctant to share their balance sheets and menus, and so organizations’ actual food, beverage and hospitality costs were unavailable. Menus, however, do not reveal calories, portion size or culinary preparation, and thus would be difficult to analyze for nutritional content. Exhibit hall food, especially continental breakfasts, snacks, and boxed lunches, were not included; they should be assessed in a future study. Finally, although respondents’ observations of physician behaviors are qualitative, the large number of meals for which respondents are responsible, and respondents’ years of experience makes their observations a valuable starting point for improving medical meals.
We believe that physicians may wish to model personal nutritional choices for their patients, as physicians and medical students are now modeling anti-smoking behavior. Less than 10% of physicians14 and just 2% of medical students15 choose to smoke, compared with 24% of the adult population overall.16 This medical student achievement is especially significant, almost 40 years after the U.S. Surgeon General’s Report focused attention on tobacco-related diseases; over 42% of American adults smoked in the early 1960s.17
CONCLUSION
We found that meeting planners are well-intended, experienced individuals who work within their budgets as a first priority, who may be unaware that the food at national medical meetings does not conform to nutritional guidelines. They receive some compliments and very few complaints about the meals they order. In planning meals, they try to please attendees’ tastes, and emphasize celebratory, special occasion foods despite their own stated interests in more healthful choices. Physicians are uninvolved in any of these decisions, and may be unaware that the food at national medical meetings does not conform to medical guidelines. Many of the meals served and consumed contain ingredients, entrees, beverages, and desserts for which there are healthier, tasty alternatives.
Physicians are also, at the moment, unaware that the food at national medical meetings does not conform to nutritional guidelines. It is possible that this food may actually impair physician learning, increase fatigue, and cause postprandial sedation because of excessive calorie and unhealthful fat intake. Several simple changes in food and beverages would measurably improve the meeting’s attendees’ performance, alertness, and health. Basic recommendations follow:
RECOMMENDATIONS
Areas for future study include the affect that this food has on physician learning, conference performance, and ability to contribute within the medical meeting: excessive calorie intake has been associated with impairment in each of these areas, and with overweight and obesity.
In addition, the following 12 basic suggestions for medical meals and coffee breaks and snacks will improve the nutritional profile of the meals and be acceptable to physicians based on the data presented above. The recommendations reflect the now common medical knowledge that saturated and trans fats contribute to arterial disease, and that monounsaturated and polyunsaturated fats may work against it, and thus the latter are favored. Similarly, large quantities of highly sweetened foods carry few nutrients and may carry a high glycemic load, minimizing satiety, and promoting weight gain; foods that are naturally sweet and are of smaller size are generally eaten more judiciously and contribute to satiety.
Coffee breaks and snacks: basic suggestions for medical meetings
1. Eliminate sugared soda and “energy drinks.”
2. Add bottled water, including carbonated water, to the beverages.
3. Provide whole fresh fruit, preferably ripe and in season (e.g., apples, oranges, pears, bananas, plums, peaches, apricots).
4. Eliminate tortilla and potato chips that are deep-fried, especially those that are fried in hydrogenated or partially hydrogenated oils. Eliminate the mayonnaise and sour cream-based white dips and dressings that accompany them.
5. Substitute chips and crackers that are baked or fried in olive or canola oil for the chips, and substitute tomato-based salsa and guacamole for the white dips.
6. Offer toasted tree nuts (e.g., almonds, walnuts, hazelnuts, pecans, macadamias) on the snack table.
Main Meals
1. Substitute fish for red meat as an entrée.
2. Reduce the size of the fish entrée from 8 ounces to 6 ounces.
3. Increase—nearly double—the portions of vegetables, fruits, whole grains and legumes on an entrée plate.
4. Offer olive oil on the table instead of butter for bread.
5. Serve no dessert or baked good that contains hydrogenated fats or trans fats.
6. Serve desserts that are small but intensely flavored and of high quality.
ACKNOWLEDGMENTS
Dr. La Puma has been compensated for consulting with four medical conference sponsors over the past 4 years to create and supervise healthful conference meals. Project support comes from the Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; and from CHEF Clinic, a nutritional medical corporation, Santa Barbara, CA.
REFERENCES
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2. Mokdad AH. The continuing epidemic of obesity in the United States. JAMA 2000;284:1650–1651.
3. La Puma J. Meals at medical meetings: mixed messages. P&T 2002;27(3):161.
4. Robb-Smith AHT. Doctors at table. JAMA 1973;224:28–34.
5. Kassirer J. Financial indigestion. JAMA 2000;284:2156–2157.
6. Lohiya GS. Free meals from the pharmaceutical industry. JAMA 2001;285:165–166.
7. Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians’ prevention-related practices. Findings from the Women Physicians’ Health Study. Arch Fam Med 2000;9:359–367.
8. Available at http://www.health.gov/healthypeople/document/html/objectives/19-06.htm. Accessed December 6, 2002.
9. Lin B-H, Lucier B, Allshouse J, Scott-Kantor L. Market distribution of potato products in the United States. J Food Prod Market 2001;63–78.
10. Wells KB, Lewis CE, Leake B, Ware JE Jr. Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA 1984;252:2846–2848.
11. Bortz WM. Health behavior and experiences of physicians. Results of a survey of Palo Alto Medical Clinic physicians. West J Med 1992;156:50–51.
12. Neser WB, Thomas J, Semenya K, Thomas DJ, Gillum RF. Obesity and hypertension in a longitudinal study of black physicians: the Meharry Cohort Study. J Chron Dis 1986;39:105–113.
13. Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians’ prevention-related practices. findings from the Women Physicians’ Health Study. Arch Fam Med 2000;9:359–367.
14. Garfinkel L, Stellman SD. Cigarette smoking among physicians, dentists, and nurses. CA 1986;36:2–8.
15. Mangus RS, Hawkins CE, Miller MJ. Tobacco and alcohol use among 1996 medical school graduates. JAMA 1998;280:1192–1195.
16. Cigarette smoking among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:869–873.
17. Tobacco use—United States, 1900–1999. MMWR Morb Mortal Wkly Rep 1999;48:986–993.
Address reprint requests to:
John La Puma, M.D.
CHEF Clinic
P.O. Box 24039
Santa Barbara, CA 93121
WWW.DRJOHNLAPUMA.COM
TABLE 1.MEMBER SOCIETIES OF THE CMSS
American Academy of Allergy, Asthma & Immunology (AAAAI)
American Academy of Dermatology (AAD)
American Academy of Family Physicians (AAFP)
American Academy of Ophthalmology (AAO)
American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS)
American Academy of Pediatrics (AAP)
American Academy of Physical Medicine & Rehabilitation (AAPMR)
American College of Medical Genetics (ACMG)
American College of Obstetricians & Gynecologists (ACOG)
American College of Physicians-American Society of Internal Medicine (ACP-ASIM)
American College of Radiology (ACR)
American College of Surgeons (ACS)
American Psychiatric Association (APA)
American Society of Anesthesiologists (ASA)
American Society of Clinical Pathologists (ASCP)
American Society of Colon and Rectal Surgeons (ASCRS)
American Society of Plastic Surgeons (ASPS)
Society of Neurological Surgeons (SNS)
Society of Nuclear Medicine (SNM)
Society of Thoracic Surgeons (STS)
TABLE 2. IMPORTANCE OF DECISIONAL FACTORS IN MEETING PLANNERS’ MEAL CHOICES (N = 13 PLANNERS)
Decisional factor Very important Somewhat important Not at all important
Available budget 12 1 0
Nutritional guidelines 8 3 2
Avoiding complaints 6 5 2
Successful items from previous years 5 6 2
Creating a feeling of luxury 4 6 3
Conformance with a culinary, entertainment, or other theme 4 6 3
Hotel’s suggestions/menu 3 9 1
Requests from members 3 4 6
Gathering compliments 2 9 2
Popular diet books 0 1 12