Scurvy and the challenge of food insecurity

On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham explore a surprising case of scurvy. The conversation builds on the CMAJ practice article “Scurvy in a 65-year-old woman with severely limited function and social supports,” co-authored by Dr. Sally Engelhart, an internal medicine specialist at Mount Sinai Hospital.

Dr. Engelhart recounts the case of her patient, whose unexplained bruising and other symptoms led to a diagnosis of a rarely seen condition, scurvy. She explains how food insecurity and a diet lacking fruits and vegetables contributed to the patient’s condition and discusses the practical steps taken to diagnose and treat her.

Dr. Gary Bloch, a family physician at St. Michael’s Hospital and Inner City Health Associates, expands on the broader issue of food insecurity as a driver of nutritional deficiencies. He shares actionable strategies for identifying at-risk patients and connecting them with community resources, while highlighting the importance of addressing the social determinants of health in medical practice.

This episode offers valuable insights into recognizing and managing scurvy and other conditions linked to food insecurity, reminding physicians to think beyond the lab results

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The CMAJ Podcast is produced by PodCraft Productions

Transcript

Dr. Blair Bigham:
I'm Blair Bigham.

Dr. Mojola Omole:
I’m Mojola Omole. This is the CMAJ Podcast.

Dr. Mojola Omole:
So today is a very surprising case report that the inner teen in me wants to make so many sailor jokes about, but,

Dr. Blair Bigham:
And it's not just a case report. This has been in the news recently. Today we are talking about hypovitaminosis, that is not enough vitamin C, also known as scurvy.

Dr. Mojola Omole:
Which I have not heard about in eons. I think I remember learning it once in medical school and then completely forgetting about it.

Dr. Blair Bigham:
Right.

Dr. Mojola Omole:
So you are in emergency. Have you had this? Have you had patients?

Dr. Blair Bigham:
No. Well, maybe, I mean, I don't know now, but I mean, I've never diagnosed scurvy. I've definitely diagnosed beriberi, which is like a B1 deficiency. I mean B12 deficiency or overdose, I've diagnosed, but not scurvy, not vitamin C. And in the CMAJ, we have this case study of a 65-year-old woman who went to an emergency department and ended up getting diagnosed with scurvy. And Jola, scurvy has been in the news a lot recently. We've heard of 27 people in Northern Saskatchewan who were diagnosed with it.

Dr. Mojola Omole:
And it seems that it's all linked to food insecurity.

Dr. Blair Bigham:
That's right. People don't have access to, I mean, healthy foods, sure, but foods with enough vitamins in them. That seems like a pretty low bar.

Dr. Mojola Omole:
And I think everyone complains jokingly about, oh, the price of eggs. But the reality for a lot of people and a lot of, when I drive by the local church that does food drives, I've noticed more and more in the last few months, the lines outside of them are long. And so food insecurity is a huge issue. And often at those places, it is non-perishable foods, which will not prevent you from having vitamin deficiencies such as vitamin C deficiency.

Dr. Blair Bigham:
We're going to speak with the co-author of the article about scurvy before delving into other nutritional deficiencies and food insecurity with Gary Bloch. 

Dr. Mojola Omole:

That's coming up.

Dr. Blair Bigham:

Dr. Sally Engelhart is a co-author of the practice article in CMAJ, entitled “Scurvy in a 65-year-old woman with severely limited function and social supports.” Dr. Engelhart is an internal medicine specialist at Mount Sinai Hospital. Sally, thank you so much for joining us today.

Dr. Sally Engelhart:
Thank you for having me.

Dr. Blair Bigham:
Take us back to the moment when you first got involved in this case.

Dr. Sally Engelhart:
So this is a patient that was admitted to me in the 2023 calendar year. And when the case was initially presented to me, it was presented to me as a case of functional decline and a spontaneous hematoma.

Dr. Blair Bigham:
Like that typical emerge consult of, ah, they're weak, they don't feel good, they might be falling, I don't want to send 'em home. That type of thing.

Dr. Sally Engelhart:
Absolutely. And the patient's chief complaint was these extensive ecchymosis and hematomas in her legs. And after speaking with her, she insisted she hadn't had any trauma, she hadn't had any falls. So my initial approach here was as a case of abnormal bleeding.

Dr. Blair Bigham:
Right. Easy bruising, that type of thing. 

Dr. Sally Engelhart:

Exactly. 

Dr. Blair Bigham:

When did you first start to suspect scurvy?

Dr. Sally Engelhart:
It crossed my, well, we did a workup for abnormal bleeding, checking coagulation factors, looking for things like factor deficiency, von Willebrand disease. We sent cryoglobulins and all of that was coming back normal. So we went back to the bedside and reexamined the patient, repeated our history and physical exam. And on that second look, we found some of the classic textbook findings of scurvy or vitamin C deficiency. It was at that point that it crossed my mind that we might be looking at a case of scurvy.

Dr. Mojola Omole:
So did you look at the textbook and then, or was it kind of like, oh, this might be scurvy or did you have to look it up? Just curiosity.

Dr. Sally Engelhart:

It was a bit of both.

Dr. Blair Bigham:
Jola is just jealous. She’s like you actually think about scurvy?

Dr. Mojola Omole:
Yeah, I mean, honestly, I'm limited in what I think about throughout the day, so I would just be like, huh, I should Google that.

Dr. Blair Bigham:
I've never asked myself, could this be scurvy? So congrats on ya.

Dr. Sally Engelhart:
The biggest clue for me was the gingival disease. So this patient had gingival bleeding hypertrophy, and that forced me to go back and do a more detailed dermatologic exam. When we went back to look, we saw the classic perifollicular hemorrhages and petechiae. I won't give myself too much credit. And I'll say, if you go to the UpToDate article for easy bruising or spontaneous bruising, deep down in the lower half of that page, you're going to come across scurvy. So starting to put those pieces together, it made us start to suspect, and then we sent off a vitamin C level. But even at our institution, the turnaround time for that test is something on the order of two weeks and...

Dr. Blair Bigham:
Whoa.

Dr. Sally Engelhart:
So in order to make a diagnosis of scurvy, you need to have consistent features, signs, and symptoms on history and physical exam and combine that with the laboratory testing. But in our case...

Dr. Blair Bigham:
Why does it take, why two weeks to send out?

Dr. Sally Engelhart:
I think it’s a send out test  and these tests get batched and sent on certain days of the week. So, depending if you get lucky or unlucky, in our case, yeah, it took up to two weeks.

Dr. Blair Bigham:
So did you make the diagnosis before it came back?

Dr. Sally Engelhart:
So we were able to, so the patient had a really strong clinical suspicion, and then someone on my team went back and did a really deep dive in their old labs on Connecting Ontario, our provincial wide database where you can access labs from other institutions. And they found from a few years prior, a different physician had sent off a vitamin C level, not exactly sure why, but it had come back undetectable. So we were able to say, look, a few years ago this patient had an undetectable vitamin C level, and what we're seeing now is quite consistent with scurvy or low vitamin C, and that allowed us to start treatment and not wait the full two weeks to get that confirmatory lab test back.

Dr. Blair Bigham:
So for years, had this patient had scurvy and people actually should have known about it, but nothing was done or...

Dr. Sally Engelhart:
Unfortunately, I think yes. I mean, I think there were a lot of factors in this case that made follow-up difficult. My guess is with that slow turnaround test time and who knows what it was a few years ago when it was tested, it's just the kind of thing that could slip through the cracks.

Dr. Blair Bigham:
Totally. If it takes two weeks to come back. Was this one also undetectable when you had sent it off?

Dr. Sally Engelhart:
So yeah, when we did get our test result back, it came back undetectable.

Dr. Blair Bigham:
I mean, not that I would know what the normal range of serum vitamin C is, but okay, so this patient had no vitamin C in their body essentially. And you've made the clinical diagnosis of scurvy ahead of blood tests. What's the next step?

Dr. Sally Engelhart:
So we started vitamin C treatment, and there's really no guideline or evidence-based regimen that we could find. So we went based off what other people have used and what's been case reported. We chose to start with IV vitamin C just because we had it so readily available at our institution. Maybe that was a bit of treating ourselves. It just feels maybe more effective if we're going to give it intravenously. But if someone has a functioning GI tract, they haven't had sections of their small bowel removed, if they don't have a malabsorption syndrome, then oral should be adequate. But we did elect to give a few days of IV vitamin C before switching over to an oral regimen.

Dr. Blair Bigham:
As an inpatient.

Dr. Sally Engelhart:
As an inpatient.

Dr. Blair Bigham:
Over a couple of days, could you see an improvement or is this something that takes a few weeks to kick in?

Dr. Sally Engelhart:
So some of the symptoms improve quite rapidly. Even within 24 hours, you can start seeing improvement in the integrity of the blood vessels or capillaries, improvement in some of the nonspecific symptoms like fatigue, weakness, malaise, myalgias. Some of the skin lesions that you see can take longer to improve, a few weeks, two to three weeks maybe, but you can start seeing rapid improvement within a day or a few days of starting treatment.

Dr. Mojola Omole:

That's impressive. 

Dr. Blair Bigham:
Wow. Let's widen the lens here and talk a little bit more broadly. Why did this patient have a vitamin C deficiency? What was going on? What did you learn about their life that led to this diagnosis?

Dr. Sally Engelhart:
It's an excellent question, and this was what I didn't mention before is one of the keys here in making this diagnosis or increasing our suspicion that this could be scurvy was when we took a detailed dietary history. And on that dietary history, it came out this patient was exclusively eating highly processed foods. So essentially tuna melt sandwiches—so Wonder Bread, canned tuna, processed cheese—and their diet was entirely devoid in produce, fruits, and vegetables, and that's...

Dr. Blair Bigham:
Zero.

Dr. Sally Engelhart:
Zero. They had told us they had zero fruits and vegetables for some number of weeks to months.

Dr. Mojola Omole:
Oh, wow.

Dr. Sally Engelhart:
And this patient had other medical comorbidities, including pretty bad vascular and neurogenic claudication, making walking difficult and mobility difficult. They also didn’t have a family locally in Toronto. They didn’t have a big social support network, and they were ordering groceries and ordering non-perishable foods because that’s what they had been able to do to sustain themselves. And I think that definitely played a factor here.

Dr. Blair Bigham:
So what was your dispo plan? Like you dispo home on vitamin C or you dispo home with a dietitian? Dietitian visits her before she goes and says, you got to eat more than tuna melts. What's the long-term plan here once she's able to leave the hospital?

Dr. Sally Engelhart:
So this patient was seen by the dietitian in the hospital, and ultimately they left acute care and went to a rehab facility afterwards, before returning home to work on some of the functional limitations and functional losses that they had. We did elect to discharge them on oral vitamin C as well as a multivitamin, just thinking if they're deficient in vitamin C, maybe they're deficient in other vitamins or nutrients that we're not testing for. But really, that's a Band Aid solution, right? To discharge someone on supplements when eating a healthy and nutritious diet comprised of a variety of foods and food sources—that's the ideal situation to prevent scurvy and to prevent any recurrence of scurvy in the future. We did elect to send this patient out on supplements because of our concern for a dramatic change in how they were going to eat when they returned home.

Dr. Blair Bigham:
Was there any community follow-up to, I don't know, what can you do to make sure that the diet, I mean, diets are hard to change on a good day, let alone if you are resource-restricted, mobility-restricted. Were you able to get any confirmation that her diet had in fact been more anti-scurvy when she got home?

Dr. Sally Engelhart:
So definitely social work was involved when the patient was in the hospital and working to connect the patient to community resources. And one of the things that I think was working in the patient's favor in this case is they had a great family doctor that was connecting with them even when they were at home and able to send someone in to do lab tests and that kind of thing.

Dr. Mojola Omole:
Oh, wow.

Dr. Sally Engelhart:
So I think having that ongoing for when the patient returns home, because really in acute care we see patients for such a brief period of time, and sometimes it can feel hard to address these bigger underlying issues. And I feel very grateful that this patient had a family doctor that was able to follow them in the community despite their functional limitations, their mobility issues, and that kind of thing.

Dr. Mojola Omole:
Has this case changed your practice, like how you practice?

Dr. Sally Engelhart:
Yes, but I'll say I'm couching that in the fact that I'm trying to be cognizant of not letting myself be too susceptible to recency bias because after seeing a case of scurvy, it does make you want to see scurvy everywhere. But I don't think that it's good medicine for me to be sending a vitamin C level on every patient I see that presents with nonspecific symptoms. But what I will say is I now know firsthand, and I think one of the messages from this case report is to share with physicians in Canada more broadly that this isn't an archaic diagnosis, that it still exists today, and it should be considered on the differential if patients are presenting with compatible symptoms. And especially if patients are presenting with compatible symptoms and they are at higher risk for scurvy because of their diet, malabsorption syndromes, medical comorbidities, smoking lowers your vitamin C level. So that's another risk factor as well. Yeah, smoking increases the catabolism of vitamin C, so smokers do need to have a higher intake of vitamin C to sustain normal levels. So if your patient has risk factors or multiple risk factors and is presenting with a compatible picture, then scurvy belongs on the differential. And one of the lessons learned is not to forget about things like nutritional deficiency because it can exist, especially if people are eating a restricted diet or eating a diet that's totally lacking in certain kinds of food. So keeping that kind of front of mind and at least keeping it on the differential.

Dr. Blair Bigham:
Fascinating. This has been an awesome chat. Thank you so much for joining us today.

Dr. Sally Engelhart:
My pleasure. Thanks so much.

Dr. Blair Bigham:
And congratulations on diagnosing scurvy. I don't know, I feel like there's diagnoses I want to tick off my list—that's so egotistical, but I think scurvy is one of them.

Dr. Mojola Omole:
Dr. Gary Bloch is a family physician at St. Michael's Hospital and Inner City Health Associates, which specializes in serving marginalized populations. He's the chair of the St. Michael's Hospital Family Health Team Social Determinants of Health Committee. Thanks for joining us again, Gary.

Dr. Gary Bloch:
It's my pleasure.

Dr. Mojola Omole:
So have you come across a case of scurvy before?

Dr. Gary Bloch:
Well, I mean, I've never diagnosed a case of scurvy, but I got to say, after reading this article, I wonder how many people I've seen might have scurvy.

Dr. Mojola Omole:
What are some other general clinical signs of other nutritional deficiencies that we should be cognizant of?

Dr. Gary Bloch:
I mean, I'm no expert on nutritional deficiencies, and I think what's pretty clear to me is that the signs of these types of deficiencies, nutritional deficiencies, and I would just lump in food insecurity and social deficiency in general. I mean, these can be very general, they can be very subtle, and they need to be something that we have on our mind at all times. So when we are seeing symptoms that don't have another obvious cause, even if they're very general symptoms, and if we are matching those to a social story that suggests that someone may not be able to access their basic needs or the basic social foundations that they require to survive, I think we need to really just be broadening our outlook and our thinking and our differential diagnoses to include things we would not have included otherwise. So I will say that what really jumped out at me as I read this article was the fact that they made this diagnosis without lab tests.
They made this diagnosis based on a patient's story and based on her presentation, which was a very general presentation, but they didn't wait for the lab results to come through, which I thought was very brave and very impressive and turned out to be exactly the right thing to do in this situation. And really reminds me that we need to trust our ability to gather people's stories, to hear people's stories, and to act on our best understanding of what those stories lead us to suspect from a medical perspective in sort of bringing together an understanding of what may be going on in sometimes a seemingly opaque case like this.

Dr. Blair Bigham:
Gary, other than low vitamin C, what other nutritional deficiencies do you have on your mind when you're meeting somebody who you think has food insecurity? Or is this something that just isn't top of mind?

Dr. Gary Bloch:
I'll check for things like iron deficiencies, B12 deficiencies, and thiamine deficiencies. I'll look for calcium magnesium levels. I mean, the sort of micronutrients that are easy for me to look for. Vitamin D is another one that I certainly look for. And these are the ones that I have some familiarity in exploring with my patients, and I certainly find deficiencies in all of these, and especially amongst people living in marginalized social situations. So having done work in these types of settings for a couple of decades now, this is not unfamiliar to me. What is unfamiliar is the idea of vitamin C deficiency. And again, I do wonder what else we could be looking for and might be missing in this story. And these are things that, again, I mean, they go beyond what I've been trained in, but that's the kind of realm of what I've tended to look for over the years. What I will also say about these types of nutritional deficiencies is that if we're identifying one, or even if we suspect one, I mean there's a pretty good chance there's others, number one, and there's a pretty good chance that the treatment for that is an adequate diet, and that is certainly what I am aiming towards as opposed to worrying too much about the specific replacement of the exact nutritional deficiencies someone has.

Dr. Mojola Omole:
So do you formally screen for food insecurity? Should there be screening for food insecurity?

Dr. Gary Bloch:
The answer is yes, and I do. So I screen for poverty first of all. I mean, I certainly make it a priority to understand my patient's income situations from the get-go. And I do that ongoing with people as their lives and as their social situations change. As part of those conversations, I definitely bring in conversations about their ability to access decent food. I do that in various ways. Sometimes I will be as blunt as asking whether someone has missed a meal in the past month because they're not able to afford it, which I think is a relatively well-accepted screen for food insecurity. And sometimes I'll ask that about people's children actually, or if they've diverted food from themselves to their children, for example, which is another well-accepted way of looking for food insecurity within families. Sometimes I'll just ask how many meals someone has missed over the last week. And it's often quite telling. People will often turn to me and say, well, how many have I missed? I mean, I am only able to manage a meal a day, for example, or sometimes less than that. And that's not particularly unusual in the settings in which I work in. I mean, this is often hidden. People don't often offer up this information upfront. It usually does take a kind of opening-the-door question to get into this level of understanding of how people's lives are affecting them and how they're forced to live their lives. People are often embarrassed about not being able to afford decent food, but once that door is open, I find that people do open up. I mean, this is very relevant to their lives and to their self-perception of their wellbeing and of their ability to maintain their health.

Dr. Blair Bigham:
Gary, you mentioned earlier that the treatment isn't to prescribe vitamin C, the treatment is a good diet. How do you prescribe a nutritional solution to somebody? It just sounds like you'd be stuck. I don't know. What can a family doc do in that circumstance?

Dr. Gary Bloch:
Yeah, I mean, so on some level we are stuck. I mean, there are big systemic issues at play here that we're not going to solve on the front lines of our offices, like the inadequacy of income support systems in our society. But there are definitely things we can do on a smaller scale that can help people. So some of the obvious ones are referral to food security organizations like food banks or community food centers. In my practice, we have a fund that supports immediate basic needs, including providing food cards for people, grocery cards, and that's just something that we fundraise for every year and we keep that available. We do a lot of work, I think that is possible for most family physicians and other physicians to do work, to connect people with easily accessible income support benefits. I'm talking about the most obvious things.
Someone's not on social assistance, get them on social assistance. If someone's not receiving disability supports, and they should, help them navigate those processes, for example. And the other piece, I think, just having a sense of the community organizations in our local areas that support people who are living in poverty and living with food insecurity. And I think those organizations and social supports exist pretty much in every community across the country. I mean, they're obviously more robust in some communities, but I do think that with just a little bit of research, using services like 211, for example, we can pretty quickly find out which are the main community social support services around us and just be ready to refer patients on to those services or sometimes call the service and make a warm handoff. And I think that can be extremely effective. In my experience, those organizations are really thankful for referrals coming directly from physicians.
I will also say that more and more of our practices are becoming interdisciplinary. I think that it doesn't all have to fall on the physician to do this work. So I think our nurses can be extremely effective at doing this. Obviously, social workers are extremely well-trained and highly expert in doing this type of work. Dietitians, if you happen to have access to them, are also incredibly expert in doing this work. And so we should start to build up our team's capacity to address these types of issues, whether that team is very small or very big. In some cases, it's front desk staff, clerical staff, and receptionists that can be incredibly effective at doing this work.

Dr. Blair Bigham:
I'm glad you brought that up. I was going to push back a little bit only because it seems like in most of our podcast episodes, one of our solutions is for family doctors to just take on more work and just do more. And you and I, Gary, we've had a lot of conversations about advocacy and that idea of, in a one-on-one clinical patient-physician relationship, going that extra mile. But when you go that extra step, or even an extra step, over and over again for 20 visits a day, five days a week, six days a week, it's a lot of extra work. This is a leading question, Gary, but when you talk about these other team members, so many family docs work in a setting where there just aren't any. Where do you see those roles coming in in a more systematic way in the future? What can we do to really help these underserved communities without having family docs have to walk around and take note of all of the community supports?

Dr. Gary Bloch:
Yeah, I mean, that's such an important question. And I guess there's a couple of pieces to that. One is that if we are increasingly, I hope, recognizing that primary care is the foundation of our healthcare system, family medicine and primary care teams are the foundation of our healthcare system, we really need to think about what that means. We really need to think about, does that mean that everyone will have access not just to a family doctor or nurse practitioner, but to a team with a capacity to holistically deal with someone's health issues from a full and broad perspective? And second of all, are we willing to build teams that take a true holistic understanding of health that includes not just physical and mental health, but also social health into the core of their understanding of who they are and how they will structure themselves to provide care to the people that they are serving?
And I think this is a huge issue. I mean, especially I'm looking at the situation in Ontario, where we've just put in place a huge commission to redesign the primary care system and access to primary care. I truly hope that whatever the vision is that comes out of this new system will include that type of holistic understanding of health. Without that, we're going to have a lot of trouble reducing pressures on the healthcare system. I mean, primary care is the place where we can start to move upstream, and we can start to really think about impacting those factors that will ultimately reduce pressure on the downstream elements of our healthcare system. So that's thinking slightly longer term and bigger picture than what we've been talking about, but again, we are going to have to think at that level if we want to see a real shift in our ability to tackle the types of issues we're talking about here. Not just the nutrient deficiencies which are downstream, but the food insecurity, the poverty, and other factors that determine who is being affected by these deficiencies and why.

Dr. Mojola Omole:
This is great. Thank you. 

Dr. Blair Bigham:
That's a mic drop right there.

Dr. Mojola Omole:
I know. That's a great closing. I have nothing else to say.

Dr. Blair Bigham:
Awesome. Thank you so much, Gary.

Dr. Mojola Omole:
Thank you.

Dr. Blair Bigham:
Okay, thank you.

Dr. Mojola Omole:
Dr. Gary Bloch is a family physician at St. Michael's Hospital and Inner City Health Associates.

Dr. Blair Bigham:
Okay, Jola. So we have this case of scurvy in a 65-year-old. We have scurvy being reported in Canadian media, it seems left, right, and center. And we have, on a broader level, people with iron deficiency and other vitamin deficiencies. And it all comes down really to the same problem: food insecurity.

Dr. Mojola Omole:
Social determinants of health, which is the theme of our podcast.

Dr. Blair Bigham:
And also the bane of every family doctor's existence.

Dr. Mojola Omole:
Because it's one of the hardest parts of medicine because we have direct control over your blood pressure is high, here's medication, you have a heart attack, here's an angioplasty, your appendix is bothering you, let's take it out. However,

Dr. Blair Bigham:
I'm surprised it took you three examples to get to the surgical one. 

Dr. Mojola Omole:
I was really trying hard…

Dr. Blair Bigham:
You're very good there

Dr. Mojola Omole:
…to not be a surgeon all the time.

Dr. Blair Bigham:
You even included an interventionalist. Oh my goodness.

Dr. Mojola Omole:
I know. I was just trying to be a physician.

Dr. Blair Bigham:

How generous.

Dr. Mojola Omole:

I know. I think what the scurvy, at least for me, has done is highlighted how much food insecurity and access to fresh foods that Canadians are really suffering with. I think as physicians, we have to recognize that we have a bias. Most of us have rich friends, and most of us have family members that—even if maybe you have family members that could be lower income—not such low income that they can't buy fresh fruits and vegetables.

Dr. Blair Bigham:
So you're saying we're in a bubble.

Dr. Mojola Omole:
We are in a bubble. We don't know the lived experience of people. That's why I rail constantly about how hospitals and healthcare administration make decisions. Because the reality of people is the majority of people are not driving. If they live in the city, they're using public transport. They don't have access to getting fresh fruits and vegetables. They're buying the cheapest thing available to feed their families.

Dr. Blair Bigham:
And Gary mentioned that importance of the narrative of a patient, of eliciting that lived experience, because like Gary said, people aren't going to maybe volunteer that. No one's going to come in and say, I have a terrible diet. I can't afford certain types of food.

Dr. Mojola Omole:
Or they might not even realize that it's a terrible diet, right? Because it's like, well, you know what? I bought a bag of frozen corn for 99 cents or a dollar 99 or whatever, how much it is. You mix that in with some ground beef and rice—seems like a complete meal. And so I think that if we really want to improve healthcare and reduce, because if you think about how much it costs to have that patient in the hospital, it's so much cheaper to find her accessibility to fresh fruits and vegetables, income support, and helping her in terms of her mobility so she has more independence because sooner or later, all the other health concerns are going to get worse too. Preventative medicine is the answer. Our public health colleagues have been saying this forever, but no one listens to them.

Dr. Blair Bigham:
And at the end of the day, your body suffers from disease because of what goes into it,  It's the toxins you bring into it, or in this case, a lack of nutrients that you bring into it. It’s air quality, it’s water quality, it’s food quality, it's shelter over your head. It's Maslow's hierarchy of needs. That's medicine. And to fix it, we can't just prescribe drugs. We have to actually be engaged in community building.

Dr. Mojola Omole:
Which is something that we talk a lot about on the podcast, is social determinants of health and how to improve the health of Canadians.

Dr. Blair Bigham:
That's it for this week on the CMAJ Podcast. If you liked what you heard, please download, share, or leave a comment wherever you get your audio. The CMAJ Podcast. The CMAJ Podcast is produced by PodCraft Productions and our incredible editor, Neil Morrison. Thanks so much for listening. I'm Blair Bigham.

Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.

Dr. Blair Bigham:
Eat well.