Nutrition education lacking in medical training

A group of physicians are questioning how well doctors can provide nutrition information and counseling to patients, particularly those with CVD, obesity and diabetes. In a paper published in the September issue of the American Journal of Medicine, the group calls for extensive and integrated nutritional education to become part of medical school curriculum at all stages.

“Nutrition is the low-hanging fruit in medicine — a low-cost intervention with untapped potential for optimizing health,” coauthor Stephen Devries, MD, said in a press release.

Devries is a cardiologist and executive director of the nonprofit, 501(c)3 Gaples Institute for Integrative Cardiology, which advocates for greater emphasis on nutrition and lifestyle in health care.

Nutrition education needed

According to Devries and colleagues, there is an unmet need for nutrition education among physicians at all levels of training. Data from a recent survey indicate that fewer than 20 hours of nutrition education are given over the course of 4 years at medical school, the researchers wrote.

What’s more, guidelines for specialty training in CVD published by the Accreditation Committee of Graduate Medical Education contain no requirement for nutritional training, “and in a 35-page ACGME document for Internal Medicine residency training, from which many doctors go on to serve as primary care physicians, the word ‘nutrition’ is absent,” they wrote. Yet results from the Lyon Mediterranean Diet Heart Study published in 1999 showed a 72% decrease in CV events for those on the diet, which, according to Devries and colleagues, is about twice the effect seen in statin trials.

In their paper, the researchers wrote that nutritional education should be required through all stages of medical school, and the knowledge gained should be formally assessed. They cited a recent study that showed only 14% of resident physicians believed they were trained adequately to share nutritional advice with patients, but paradoxically, another study showed that 61% of patients surveyed believed doctors were a “very credible” source for nutritional counseling.

Put it on the menu

Devries and colleagues recommend “meaningful didactic and clinical training in nutrition” and accreditation requirements in the later stages of training in all specialties and subspecialties.

“Nutrition education in subspecialty training programs could ideally reinforce general principles of nutrition, as well as emphasize aspects of particular relevance in each discipline,” they wrote.

Additionally, certifying exams should include nutritional concepts, and longitudinal nutrition curricula should be part of medical and ongoing training. They also wrote that CME should include “topics in nutrition research, as well as instruction on how to critically evaluate new findings.”

In addition to incorporating nutritional concepts into standard medical education, the group said other changes are needed “to promote health and wellness through nutrition,” including resources beyond the field of medical training.

“The optimal approach would involve a team effort, including a wide range of health professionals and coaches,” the authors wrote. “And public health initiatives need to support sensible food industry policies.”

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Co-author James E. Dalen, MD, MPH, executive director of the Weil Foundation and dean emeritus and professor emeritus of medicine and public health at the University of Arizona, told Cardiology Today that nutrition education could replace a less-relevant curriculum. Specifically, he said pre-med programs, whether for physicians, dentists, optometrists or others, “all look the same” and include organic chemistry, which he believes is irrelevant.

“Nutrition [training] should start in college,” he said.

Have the conversation

In an interview, Devries told Cardiology Today he believes that “doctors would like to help address nutrition issues, but often lack the training to most effectively counsel their patients.”

Despite this, Dalen said physicians have an opportunity to learn about patients’ nutritional habits before meeting with them for the first time.

“When we have patients fill out their medical history, we don’t ask them about their diet at all,” he said, adding that physicians rarely ask other important questions, such as whether or not the patient is taking any supplements.

Devries recognizes that physicians are often burdened with time constraints that may make them hesitant to take time to talk about nutrition, and offered his advice:

“First, let the patient know that good nutrition is the foundation of health. A good 1-to-2 minutes is enough time to let them know that what they eat is just as important as the medicine they are taking,” he said in the interview, and added that referring a patient to a dietitian or nutritionist can also be a positive step.

Spreading the word

The writers acknowledged gaps in understanding about which diets may be best for certain individuals, but said that enough is already known to formally integrate nutrition education into medical education.

“Although we have much to learn about the optimal diet for each individual and how best to deliver nutritional counseling, we need no more studies to know that we must take nutrition education seriously — immediately,” the group wrote.

The benefits of such training would not be limited to improved health for patients.

“The annual cost of [CVD] in the U.S. was recently estimated at $315 billion,” they wrote. “Imagine the savings if, as the data suggests, we could reduce the risk of vascular events by at least one-third with widespread adoption of proven nutritional strategies.”

The group is taking further steps to spread the word about their initiative. Devries told Cardiology Today they are in the process of sending similar letters to key societies and collegial organizations, advocating for the inclusion of nutritional education into MOC and CME activities. – by Shirley Pulawski

Disclosure: Devries and Dalen report no relevant financial disclosures.