Part 1: Do Physicians Really Need Nutrition Education?
It is a well-known adage that one should not reference the incendiary topics of politics, religion, or money in a civil conversation. I would posit that nutrition is quickly descending into this off-limits territory. Diet, weight loss, and exercise regimens populate the internet, and conversations about food pervade our social interactions. Food choices and eating behaviors are highly personal, and conversations about nutrition philosophies can become quite contentious. The difficulty in establishing a healthful plate is multifactorial; some of the largest include the proliferation of strategic marketing, the volume of information sources of variable repute, and the encumbrance of tediously analyzing the nuanced, methodologically-dissimilar academic articles in the field. And, of course, we are not reared in a vacuum; we each carry our tastes, preferences, cultural and personal experiences around food to these considerations.
Still, our food choices and movement routines comprise such a large aspect of our lives that we should try to ascertain how to eat to promote health and longevity. Physicians have served a conflicted role in this discussion. While often revered as compassionate ambassadors of medical knowledge and surgical interventions, many physicians actually provide little advice in the form of nutritional counseling. The dearth of nutrition courses in the curricula of most medical schools is becoming widely-known. In 1998, the Intersociety Professional Nutrition Education Consortium cited the prevalence of “nutritionally related chronic diseases” in the United States and called for an increase in the nutrition education for physicians by increasing the abundance of “Physician Nutrition Specialists” on the faculty of medical schools1. The Consortium then assessed the state of medical student nutritional education in 1990s and found that less than 25% of US medical schools required coursework in nutrition2 . Almost 50% of schools offered nutrition as an elective, but as few as 6% of students actually enrolled in these courses2. Many schools integrated nutrition concepts into their basic science courses; but studies around the time showed that students neither recognized the concepts as nutrition nor fully understood the role of diet in disease prevention in this context. There was even less time for the study of nutrition in the clinical years of medical school3. And another study observed that the students’ interest in nutrition waned as they progressed through their training4.
Twenty years later, nutrition education has not expanded very much. In 2015, only 27% of United States medical schools taught the recommended 25 hours of nutrition coursework5. Medical schools offer on average 19.6 hours of nutrition-related material throughout all four years, comprising less than one percent of the projected total lecture time5. Much of this teaching focuses on the biochemistry of macronutrients or the physiology of the gastrointestinal system instead of analyzing socioeconomic correlates of nutrition and disease pathology with practical solutions. Studies still observed a diminishing interest in nutrition as medical students aged. About 71% of entering medical students believe that nutrition is clinically relevant; upon graduation however, that number is below 50%6. Even more striking is this observation: fewer than 14% of practicing physicians believe they were sufficiently trained to provide nutritional counseling7. Perhaps these physicians are referring patients to Registered Dietitians for nutrition advice. But to separate the study of critical macro and micronutrient consumption from the study of the operations of the heart, stomach, kidney, lungs, or liver seems a nontrivial partition.
Thus, many clinical investigators have observed that nutrition education in medical school curricula is lacking, but how critical is the acquisition of this knowledge for young physicians? Will a medical course on the Recommended Dietary Intake values really improve outcomes for our future patients?
Indeed, numerous studies demonstrate the impact of nutrition status on disease pathogenesis. Chronic diseases such as cardiovascular diseases, diabetes, and cancer account for 7 of the top 10 leading causes of death in the United States8. They also constitute nearly 70% of all medical expenses in the country8. Fortunately, studies have shown that interventions to modify dietary intake and physical activity can act significantly to prevent these chronic diseases9. Consider a few specific examples. More than 86 million American adults have pre-diabetes, which adds a projected burden of about $322 billion to the American healthcare system10. But these authors also state that simple lifestyle changes such as not smoking, limiting alcohol use, being physically active, and maintaining a healthy diet can reduce patients’ chances for coronary heart disease by 82%10. Consider another example: more than 8% of the United States population has Type II diabetes mellitus11. A study by the Diabetes Prevention Program Research Group has shown that lifestyle interventions of an increase in physical activity to 150 minutes per week and a 7% reduction in body weight can lead to a 58% decrease in the incidence of Type II diabetes, a greater reduction than that achieved through pharmaceutical treatment11. Although these chronic conditions appear formidable, it should be comforting to recognize that lifestyle modifications can be very impactful in preventing chronic disease development in an individual.
Clearly there is an opportunity for nutrition counseling to improve patient outcomes. But before physicians can develop and implement practical solutions, they must first expand the education of nutritional knowledge in medical schools so graduating medical students can feel comfortable understanding the basics of this complex field of science and confident in their abilities to analyze the literature in their future practice.
1.) Bringing physician nutrition specialists into the mainstream: rationale for the Intersociety Professional Nutrition Education Consortium. The American Journal of Clinical Nutrition.1998;68(4):894-898. doi:10.1093/ajcn/68.4.894.
2.) Kushner RF, Thorp FK, Edwards J, Weinsier RL, Brooks CM. Implementing nutrition into the medical curriculum: a user’s guide. The American Journal of Clinical Nutrition.1990;52(2):401-403. doi:10.1093/ajcn/52.2.401.
3.)Swanson AG. Nutrition sciences in medical-student education. The American Journal of ClinicalNutrition. 1991;53(3):587-588.doi:10.1093/ajcn/53.3.587.
4.) Weinsier RL, Boker JR, Morgan SL, et al. Cross-sectional study of nutrition knowledge and attitudes of medical students at three points in their medical training at 11 southeastern medical schools. The American Journal of Clinical Nutrition. 1988;48(1):1-6. doi:10.1093/ajcn/48.1.1.
5.) Adams KM, Kohlmeier M, Zeisel SH.. Nutrition education in U.S. medical schools: Latest update of a national survey. Acad Med. 2010;85:1537–1542.
6.) Spencer EH, Frank E, Elon LK, Hertzberg VS, Serdula MK, Galuska DA.. Predictors of nutrition counseling behaviors and attitudes in US medical students. Am J Clin Nutr. 2006;84:655–662.
7.) Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL.. What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge. J Am Coll Nutr. 2008;27:287–298.
8.) Centers for Disease Control and Prevention; Council of State and Territorial Epidemiologists; Association of State and Territorial Chronic Disease Program Directors. Indicators for chronic disease surveillance. MMWR Recomm Rep 2004;53(RR-11):1–6.
9.) Ford ES, Bergmann MM, Boeing H, Li C, Capewell S. Healthy lifestyle behaviors and all-cause mortality among adults in the United States. Prev Med 2012;55:23–7.
10.) Dall TM, Yang W, Halder P, et al. The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes. Diabetes Care. 2014;37(12):3172-3179. doi:10.2337/dc14-1036.
11.) Reduction in the Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin. Obstetrical & Gynecological Survey. 2003;58(3):182-183. doi:10.1097/01.ogx.0000055759.75837.e7.