Why nutrition should be the first prescription

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The evolution of modern medicine has seen the development of wonderful pharmaceuticals and devices, but has also lead to physicians relegating the importance of lifestyle and dietary advice. This edition reminds us of the importance of prescribing diet to our patients, especially in the field of women’s health.

The reminder is especially timely given the recent publication of the Cochrane review evaluating the impact of omega 3 long chain fatty acids (Omega 3 LCFA) on preterm birth [1]. The Cochrane review findings mimic those of an early large randomised trial, DOMINO, which contributed 2399 women to the final analysis and set the stage for global research to identify a nutritional solution to preterm birth [2]. The key findings of the Cochrane review were that Omega 3 LCFA supplements in pregnancy resulted in a significant reduction in both early preterm birth (<34 weeks) and preterm birth (<37) [1]. Another large randomised trial of omega-3 LCFA supplementation in pregnancy (ORIP) involving 5540 women is due to be published and will augment the Cochrane findings and refine the timing of supplements [3]. This appears to be the holy grail that has been long sought [4]. Preterm birth is the leading global cause of death and disability in children. The impact of prematurity can carry into adult life with social and economic consequences for the individual and their wider family. Apart from vaccination and smoking cessation programs, most interventions to manage preterm birth are beyond the resources of developing countries, where rates of preterm birth are highest. We now have a nutritional intervention that costs less than 25 cents a day that reduces early preterm birth and preterm birth that could be funded through foreign aid programs and be widely implemented at a population level in both developed and developing countries. Whilst clinicians and the public may be awed by the magic of robotic surgery and expensive clever prescriptions individualised to our genetic code, a dietary solution to the global challenge of preterm birth is a timely reminder to focus on the basics like nutrition.

This edition contains two key papers that explore the role of nutrition in women’s health. The first randomised trial evaluates whether there is a role for Omega 3 LCFA in premenstrual syndrome [5]. Premenstrual dysphoric disorder is a severe form of this condition and impacts upon the educational, social and economic lives of women. Higher dietary concentrations of omega 3 LCFA tip the eicosanoid balance toward less inflammatory activity [6] and this may help alleviate secondary enzymatic cascades that precipitate luteal phase symptoms in some women. A nutritional solution would be particularly useful as this condition often starts in adolescence and pharmacological and hormone free management options are sought by many patients.

The second randomised trial evaluating a nutritional supplement evaluates the impact of myo-inositol and metformin on polycystic ovarian syndrome (PCOS) [7]. Nutrition already holds a central stage in the management of this common condition which impacts upon the lives of one in five women during their reproductive years. Whilst there is universal agreement that maintaining a healthy weight is important for management and that weight loss can facilitate management if patients are overweight or obese, specific diets have not be adequately studied such that one can be recommended over another. The novel findings reported in the study by Jamillian et al deserve replication in larger trials and may help refine the types of nutrition of benefit in this multisystem condition [7]. It is likely that the majority of the effect is caused by metformin, but he findings warrant further research as to whether myoinositol has an additive effect.

These research outcomes reinforce the need for clinicians to explore nutrition with patients and provide evidence based nutritional advice. It’s time to start prescribing dietary advice in addition to our pharmacological and surgical interventions. We need to spend more time educating patients and less money on expensive interventions.