Most US physicians aren’t properly trained on this important health topic

Why aren’t physicians properly educated on the topic of nutrition during their medical training? With the ever-increasing amount of research supporting the importance of nutrition to overall health, it seems a question that is easily answered. But it’s not.

“Nutrition education in medical school is rudimentary, at best, and limited for the duration of graduate medical education for many specialties. Requirements for meaningful nutrition education in all phases of medical training are long overdue,” according to Stephen Devries, MD, FACC, executive director, Gaples Institute for Integrative Cardiology, Deerfield, IL, and fellow authors. They published their commentary online in JAMA.

The importance of nutrition in health cannot be overstated. Randomized clinical trials have hammered home the importance of proper diet in preventing and managing all types of disease, including, but not limited to diabetes and cardiovascular disease, as well as other health benefits. But, noted Dr. Devries and colleagues, “the substantial body of evidence that supports the benefits of nutritional interventions has not adequately translated into action in medical training or practice.”

Measuring the deficit

Consider that courses detailing nutrition are limited in medical school, usually totaling only 19 hours over 4 years. The focus of these courses remains on biochemistry and diseases associated with vitamin deficiency—which are not often encountered in the United States.

During the ensuing 3+ years of graduate study, nutrition education is not included.

And despite major updates made in July 2018 to the Accreditation Council for Graduate Medical Education Common Program Requirements for residency and fellowship training, no requirements for nutritional or dietary training are included. Such requirements are also lacking in specialty training programs.

In a 2017 survey completed by 930 cardiologists and cardiovascular team members conducted by Dr. Devries and fellow researchers, a full 90% reported receiving minimal or no nutrition education during fellowship training, 59% received none during internal medicine training, and 31% reported receiving none in medical school. A full 95% felt it was their personal responsibility to counsel patients with at least basic information about nutrition.

Other researchers, led by Kelly M. Adams, MPH, RD, LDN, Department of Nutrition, School of Medicine and Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, conducted a survey to determine the state of nutrition education in US medical schools, and compared it with recommended instructional targets. They surveyed 133 US medical schools with 4-year curricula, and received responses from 121.

A full 71% of these schools did not provide the recommended minimum of 25 hours of nutrition education, and 36% provided less than 50% of this amount. Further, less than 50% of all schools taught any nutrition in clinical practice.

Responding schools reported providing an average of 19 hours of nutrition education, but 36% required 12 or fewer hours of instruction. Of these, 9% required none.

These findings led Adams et al to conclude: “Physicians in the US are largely on their own when it comes to learning how to look for signs of nutrition problems, how to explain the significance of nutrition-related conditions and appropriate interventions, and how to refer patients to nutrition professionals.”

Do physicians even need nutrition education?

“Some might suggest that physicians do not need to be educated about nutrition because other healthcare professionals, including dietitians, are better trained and positioned to make dietary recommendations,” noted Dr. Devries and colleagues.

They argued that dietary counsel for patients should be addressed by a team of dietitians, nutritionists, nurses, health coaches, and chefs. It’s seems intuitive that the patient’s physician be a part of this team. Unfortunately, this is not the reality, in most cases.

“The problem is that, currently, most physicians do not have enough education in nutrition to contribute meaningfully to that team. At minimum, physicians need sufficient training to at least begin the nutrition conversation with their patients. Additionally, clinicians with a foundation of nutrition knowledge will be more likely to recognize the importance of diet and make more effective referrals,” they added.

According to Dr. Devries and colleagues, proper training in nutrition is a must for clinicians, and should be a priority in medical training for the following reasons:

1. Poor diet is the leading cause of death in the United States, according to a report from the US Burden of Disease Collaborators in 2018. The incidence of diet-related disease, and the ensuing costs in health care will only continue to increase.
2. The probability of a paradigm shift in the focus of health care from disease management to health promotion and prevention makes it essential for physicians to have a “solid foundation” in clinical nutrition.
3. Media coverage of health and diet bombards patients with new information constantly; physicians must play a role in helping them interpret and sort through the glut of stories.
4. With more focus on wellness and self-care of residents and fellows, education in clinical nutrition can improve physician self-care, as well as patient health. This will also enable physician to more effectively counsel patients on nutritional matters.

Incorporating nutrition education into medical training, according to Dr. Devries and colleagues, may be successful if nutritional concepts could be integrated into already existing content.

“In this way, nutrition can be more appropriately understood as a vital, practical determinant of health rather than as an isolated discipline,” they concluded.

Researchers led by Adams concur: “Many US medical schools still fail to prepare future physicians for everyday nutrition challenges in clinical practice. Nutrition is a dominant contributor to most chronic diseases and a key determinant of poor treatment outcomes. It cannot be a realistic expectation for physicians to effectively address obesity, diabetes, metabolic syndrome, hospital malnutrition, and many other conditions as long as they are not taught during medical school how to recognize and treat the nutritional root causes.”

A remedy to the dearth of nutrition education in medical schools is clearly needed.

 “It is unacceptable that we keep finding the same systemic instructional failures decade after decade and still just hope for the best. What counts in the end is the readiness and ability of physicians to recognize and effectively address nutrition-related challenges in their patients. The reported educational deficits of medical school curricula go a long way to explain why many physicians miss opportunities to use nutrition as an effective healthcare tool,” concluded Adams et al.