Nutrition in Medical Education – the missing ingredient

With diet being the leading health risk factor in the United States[i], one would think that it would occupy a central position in medical education, continuing education and practice. But unfortunately that’s not currently the case. It turns out that, as a group, our nation’s physicians are not adequately trained in nutrition to provide the care their patients need.

A study of resident physicians in internal medicine showed that while 94% agreed that it was their obligation to discuss nutrition with patients, only 14% felt physicians were adequately trained to provide nutrition counseling[ii].  Even worse, only 2% of residents availed themselves of courses in nutrition when offered in medical school.

A recent article, examining the lack of nutrition in the training of medical doctors, concludes that “educational gaps in clinically applicable nutrition-related knowledge and skills leave many physicians without the expertise to identify and treat patients at nutrition risk.”[iii]

When nutrition is taught, it is often of little relevance to the needs of American patients. One doctor complained that “the most frequent questions gastroenterologists are asked about are diet, health, and disease; and some of the questions gastroenterologists are least comfortable answering are about diet, health, and disease. This disconnect occurs for several reasons. Although the subject of nutrition is taught in medical school, it usually covers malabsorption of nutrients, vitamins, and minerals that have limited relevance to the concerns of most patients. The modern physician does not see many cases of scurvy or beri beri.”[iv]

In his opening address at a 2013 conference hosted by the NY Academy of Sciences, gastroenterologist Gerald Friedman pointed out the following, “there is not a single medical specialty or subspecialty that would not benefit from increased emphasis on nutrition education. Eight out of ten of the leading causes of morbidity and mortality in the United States are nutritionally related. Specifically, cardiovascular diseases (e.g., hypertension, lipidemia, coronary artery disease), ischemic and embolic stroke, type 2 diabetes, hepatic steatosis and cirrhosis, cancer (breast, colon, pancreatic, endometrial), osteoarthritis, and childhood and adult obesity can, in many cases, be mitigated by attention to appropriate nutritional factors.” Friedman argued that “medical nutrition education is necessary now more than ever before because of the critical global impact of chronic, noninfectious diseases, with nutrition-related factors playing a central role in the prevention of these diseases.”[v]

The problem is not new. Back in 1985, the National Research Council Committee on Nutrition in Medical Education made the following statements and recommendations[vi]:

 “The teaching of nutrition in most U.S. medical schools is inadequate. The committee recommends that U.S. medical schools examine the nutrition component of their curriculum and, as explained below, take steps to remedy the deficiencies identified.

Nutrition is not taught as a separate subject in the majority of schools surveyed by the committee. Although some nutritional concepts are taught in conjunction with other courses, they are frequently not identified as such, and their impact and importance are accordingly diminished.

All students should be given a course or its equivalent in the fundamentals of nutrition during the same years in which other basic sciences are offered. These concepts should be reinforced during later clinical clerkships as students see and experience the application of nutrition to patient care.”

More recent studies confirm the need for nutrition education in medical schools. A study published in the American Journal of Clinical Nutrition in 2014 states, “Nutrition is a recognized determinant in 3 (ie, diseases of the heart, malignant neoplasms, cerebrovascular diseases) of the top 4 leading causes of death in the United States. However, many health care providers are not adequately trained to address lifestyle recommendations that include nutrition… in a manner that could mitigate disease development or progression. This contributes to a compelling need to markedly improve nutrition education for health care professionals and to establish curricular standards ...” [vii]

The same problem exists in other countries as well.  In 2010, a study commissioned by the British Journal, the Lancet, highlighted a call for major reform in the training of healthcare professionals for the 21st century, arguing that changes in medical education are needed “because of fragmented, outdated, and static curricula that produce ill-equipped graduates.”[viii] This reform needs to include an analysis of requirements for the nutrition education of medical doctors.

Without the guidance of their physicians, patients turn to the internet where inaccurate information is very common. One study found Wikipedia had a 90% error when it came to common health topics.[ix]

When it comes to nutrition, the current medical education system broken for both doctors and patients. Change in the medical school curriculum is therefore urgently needed.

Excuses for not going forward with medical education reform abound. One excuse is that there’s no room in the curriculum. However, if there’s no room in the curriculum for students to learn about the number one health risk (an unhealthy diet) faced by their patients, then what is there room for? Another excuse is that it’s too costly.  Yet this could be done by adding a specific separate class and clinical rotation only.  What education could be cheaper? No special equipment needs be purchased. Teaching nutrition in medical school would only require a professor for both the didactic and clinical portions.

It’s time to stop the excuses and make the necessary changes to the medical school curriculum so that students learn the importance of good nutrition, and how to prescribe good nutrition to their patients in a clinical setting.

[i] Christopher J. L. Murray and the US Burden of Disease Collaborators. “The State of US Health, 1990-2010 Burden of Diseases, Injuries, and Risk Factors.” JAMA. 2013;310(6):591-606

[ii] 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 Apr;27(2):287-98.

[iii] Dimaria-Ghalili RA, Edwards M, Friedman G, Jaferi A, Kohlmeier M, Kris-Etherton P, Lenders C, Palmer C, Wylie-Rosett J. Capacity building in nutrition science: revisiting the curricula for medical professionals. Annals of the New York Academy of Sciences Volume 1306, Annals Reports pages 21–40, December 2013

[iv] Sellin J. Dietary dilemmas, delusions, and decisions. Clin Gastroenterol Hepatol. 2014 Oct;12(10):1601-4;

[v] Dimaria-Ghalili RA, Edwards M, Friedman G, Jaferi A, Kohlmeier M, Kris-Etherton P, Lenders C, Palmer C, Wylie-Rosett J. Capacity building in nutrition science: revisiting the curricula for medical professionals. Annals of the New York Academy of Sciences Volume 1306, Annals Reports pages 21–40, December 2013

[vi] Nutrition Education in U.S. Medical Schools. Editors National Research Council (US) Committee on Nutrition in Medical Education. Washington (DC): National Academies Press (US); 1985

[vii] Kris-Etherton PM, et al. The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. Am J Clin Nutr. 2014 May;99(5 Suppl):1153S-66S.

[viii] Frenk, J., L. Chen, Z.A. Bhutta, et al. 2010. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 376: 1923–1958

[ix] Hasty RT, et al. Wikipedia vs peer-reviewed medical literature for information about the 10 most costly medical conditions. J Am Osteopath Assoc May 1, 2014 vol. 114 no. 5 368-373