Dr. Jaclyn Albin still recalls learning about nutritional biochemistry while she was a student at The George Washington University School of Medicine & Health Sciences. But by the time she graduated in 2009, nutrition’s relevance to disease states and patient care hadn’t been addressed.
“Historically, nutrition education has been mostly rooted in biochemistry, pathology, and physiology with nutrient-focused content,” says Albin, who’s now an internist and pediatrician in Texas. “For example, we would learn about vitamin C and how it impacts various pathways in the body, as well as what deficiency might look like. These things are important, but students then struggle to relate this to patient care. It’s challenging to translate education hyper-focused on nutrients to the real-life questions a patient may have about food.”
That’s similar to what Dr. Milan Shah, a urologist in Los Angeles, experienced when he attended the University of Pennsylvania, graduating in 2013. He says his medical education was excellent in terms of physiology and pharmacology, but nutrition training was introductory at best.
“This is a concern, because nutrition training for physicians is extremely important but grossly undervalued,” he says. For example, in his specialty, nutrition can play a significant role in urologic health, which is why he’s spent considerable time researching the topic on his own, so he can discuss nutrition with his patients. But he would have liked to have had a more comprehensive approach from the start.
“Nutrition should be thoroughly integrated into the study of anatomy, physiology, and pharmacology, which will not only serve to educate future physicians but will also lead to more research,” he says. “Most of all, it will affect the treatment of patients.”
Anecdotes like these are common among physicians, even those who are recent graduates. Although nutrition education varies by school, a 2021 survey of medical schools in the U.S. and U.K., published in the Journal of Human Nutrition and Dietetics, found that most students receive an average of 11 hours of nutrition training throughout an entire medical program. Part of this training is typically student-run, and it may include culinary classes.
Attention has centered on this shortfall for decades. In 1985, the National Academy of Sciences recommended at least 25 hours of nutrition education in medical school, but a survey of U.S. medical schools in 2010 found that only 27% of programs met that recommendation. Lack of interest isn’t always the culprit, Albin notes.
“Over the past two to three decades, passionate nutrition experts have tried a number of strategies to advance nutrition education without a lot of success,” she says. “This is largely due to lack of funding, broad support, and agreement about how much it matters. Experts have published cries for more attention to this vital issue, but we haven’t seen momentum until quite recently.”
Promising steps forward
Although research indicates that nutrition training is limited in scope and duration at many medical schools, there are indications that attitudes—and in some cases, curriculum—may be changing.
For example, Albin is director of UT Southwestern Medical Center’s culinary medicine program, which offers online modules for students and practicing physicians to learn about nutrition and understand how to apply that education to patient scenarios. Doctors might learn how patients can use food as a nutrient source instead of or in addition to supplements, and how to accommodate food allergies in cooking. Culinary medicine, in general, has been sparking interest as a popular elective at a number of prominent schools, Albin adds, including her alma mater, George Washington University. “Experiential learning in a teaching kitchen builds not only nutrition knowledge, but also provides a way to discuss food with patients,” Albin says.
Examining nutrition within a larger context is another promising step forward, says Dr. Raja Jaber, a family medicine physician at Stony Brook Family and Preventive Medicine in New York. Most notably, she highlights that lifestyle medicine is gaining traction in medical education coursework. Such an approach blends nutrition with other components of a healthy life, like stress reduction, social support, and physical activity. That’s part of a larger pivot in how doctors are being trained. It’s taking time to manifest, but it could have meaningful results for patients—and for how physicians care for their own health, potentially reducing burnout and helping doctors model healthy habits, Jaber says.
“The present state of nutrition education in our medical schools is sad,” she adds. “It’s part of a legacy of a treatment model based on pharmacology and surgery. But the emphasis on prevention and lifestyle is gaining momentum, due to many studies showing the impact of lifestyle modifications on the prevention of chronic disease.” However, Jaber notes, there’s always a lag time between science and its applications.
One possible push toward shortening that delay may be legislative action and more attention from government as well as medical education leaders. In May 2022, a bipartisan resolution authored by Congressmen James McGovern (D-MA) and Dr. Michael C. Burgess (R-TX) passed the U.S. House of Representatives. It highlights the need to prioritize and advance nutrition education in medicine. Prior to the resolution’s passage, McGovern said on the House floor that “we cannot continue to ignore the correlations between diet and health.”
In September 2022, the White House Conference on Hunger, Nutrition, and Health focused on what’s needed to address food-related disease and disparities. One of its pillars is to prioritize the role of nutrition and food security in overall health, including disease prevention and management, noting that the health care system should play a significant role in that effort.
More recently, in early March, leaders across the governing bodies of medical education and practice convened at a summit in Chicago, which Albin says is the first time that medical board and accreditation groups formally discussed the topic. “It was music to my ears to hear the chorus of agreement on the problems, barriers, and need to develop core competencies in nutrition across the medical education continuum,” she says.
While medical students in the future may benefit from these changes, some physicians are taking a more active role in educating themselves. For example, Dr. Lauren Lemieux remembers having only one lecture on vitamin deficiencies before graduating from the University of California-Irvine in 2015. But a lifelong passion for nutrition and its impact on health led her to do a residency in clinical nutrition at UCLA. She’s now board certified as a physician nutrition specialist, in addition to certifications in internal medicine and obesity medicine. Although she was happy to put in the time and effort to focus on nutrition, she admits it would have been ideal if the topic was part of the medical school curriculum.
“Unfortunately, as most doctors get little training in nutrition during their medical education and beyond, many find themselves ill prepared to provide evidence-based nutritional recommendations to their patients,” she says. “It would be wonderful for students to get exposed to nutrition early on and receive training from experts who can teach practical, clinically applicable skills related to nutritional counseling.”
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How much training is needed?
Because of the importance of nutrition for preventing chronic disease and improving many treatment regimens, understanding how food choices affect health is crucial. However, one major question looms over whether physicians actually need extensive training: How realistic is it to expect doctors to master a subject that registered dietitians (RDs) spend at least four years learning about?
Conversations with patients are already limited by factors like time restrictions, and adding the type of comprehensive and personalized recommendations necessary for meaningful nutritional changes can rarely be shoehorned into a spare few minutes. Plus, even patients who discuss nutrition with their doctor will often need to meet with an RD to tap into a wide array of services.
In addition to curating meal plans, RDs provide insights related to cultural factors around food choices, and can dispense nutrition advice for those dealing with an eating disorder or another specific condition. “We’re providing medical-nutrition therapy, counseling patients and physicians, working with home health care agencies, working with insurance on getting special formulas approved for patients, and talking about food safety,” says Dana Hunnes, a senior clinical registered dietitian at UCLA Medical Center. “We’re not just scooping up food in the hospital kitchen; we’re the experts in all things nutrition.”
Should a surgeon have detailed knowledge of protein requirements for a patient who’s recovering after a gastrointestinal procedure and needs nutrition through an IV? What about an internal medicine physician whose patient is Muslim and follows halal practices, but needs a new eating plan for reducing blood pressure and high cholesterol? There’s also complexity around how certain foods interact negatively with medications, potentially preventing a drug from working the way it should, or worsening the side effects.
These are all topics that RDs cover extensively, Hunnes says. Expecting medical education to dive deeply into these considerations, even though they’re a crucial part of care, may be unrealistic. That doesn’t mean punting all nutrition-based decisions to clinical nutrition professionals, but it could offer patients a wider range of insights to make up for any knowledge gaps on the topic within a health-care team.
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Finding a balance
Given the depth and breadth of nutrition’s contribution to medicine, an increase in physician training may be advantageous for many patient conversations, but perhaps the most useful aspect of that education would be recognition of nutrition’s importance—and how that may include increased collaboration with RDs and other nutrition specialists.
“The issue of nutrition is frequently put off if doctors only have 20 minutes to complete an annual checkup,” says Dr. Denise Pate, medical director with Medical Offices of Manhattan, a group of primary-care doctors. “I believe that multidisciplinary collaboration is crucial. Physicians must be made aware of the value of nutritional knowledge, and working with a trained dietitian is essential.”
The bottom line is that there are many aspects of healthy lifestyle habits that aren’t covered extensively in most medical education programs. For example, how much do physicians really learn about prescribing a specific exercise regimen based on the fitness level of each patient, or delve into the nervous system improvements achieved with meditation? In many ways, nutrition falls into this category as well, Pate says.
Like so much in medicine, the solution likely distills to blending several strategies together, including adding more nutrition to medical school curriculums and cultivating more collaborative relationships between doctors and those who specialize in nutrition, integrative therapies, and lifestyle medicine.
“It’s important to note that we are not trying to make doctors become dietitians, but rather to understand that our neglect of this topic has done harm and led to a very poor understanding of the underlying root causes of many diseases such as poor quality food,” Albin says. “We must move past this and prepare the next generation to prescribe food as medicine.”
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