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Doctor and Patient
Teaching Doctors About Nutrition and Diet
By PAULINE W. CHEN, M.D.
Published: September 16, 2010

Within days of being accepted into medical school, I started getting asked for medical advice. Even my closest friends, who should have known better, got in on the action.

“Should I take vitamins?”

“What do you think of this diet?”

“Is yogurt good for me or not?”

Each and every time someone posed such a query, I became immediately cognizant of one thing: the big blank space in my brain. After all, even with medical school acceptance in hand, I was no more a doctor than they were.

But I also soon realized that many of their questions had nothing to do with medications or operations, or even diseases. With all the newspaper and television reports about newly discovered carcinogens and the latest diets and miracle nutrients, what my friends and acquaintances really wanted to know was just what they should or should not eat.

Years later, as a newly minted doctor on the wards seeing real patients, I found myself in the same position. I was still getting a lot of questions about food and diet. And I was still hesitating when answering. I wasn’t sure I knew that much more after medical school than I did before.

One day I mentioned this uncomfortable situation to another young doctor. “Just consult the dietitians if you have a problem,” she said after listening to my confession. “They’ll take care of it.” She paused for a moment, looked suspiciously around the nursing station, then leaned over and whispered, “I know we’re supposed to know about nutrition and diet, but none of us really does.”

She was right. And nearly 20 years later, she may still be.

Research has increasingly pointed to a link between the nutritional status of Americans and the chronic diseases that plague them. Between the growing list of diet-related diseases and a burgeoning obesity epidemic, the most important public health measure for any of us to take may well be watching what we eat.

But few doctors are prepared to effectively spearhead or even help in those efforts. In the mid-1980s, the National Academy of Sciences published a landmark report highlighting the lack of adequate nutrition education in medical schools; the writers recommended a minimum of 25 hours of nutrition instruction. Now, in a study published this month, it appears that even two and a half decades later a vast majority of medical schools still fail to meet the minimum recommended 25 hours of instruction.

Researchers from the University of North Carolina at Chapel Hill asked nutrition educators from more than 100 medical schools to describe the nutrition instruction offered to their students. While the researchers learned that almost all schools require exposure to nutrition, only about a quarter offered the recommended 25 hours of instruction, a decrease from six years earlier, when almost 40 percent of schools met the minimum recommendations. In addition, four schools offered nutrition optionally, and one school offered nothing at all. And while a majority of medical schools tended to intersperse lectures on nutrition in standard, required courses, like biochemistry or physiology, only a quarter of the schools managed to have a single course dedicated to the topic.

“Nutrition is really a core component of modern medical practice,” said Kelly M. Adams, the lead author and a registered dietitian who is a research associate in the department of nutrition at the university. “There may be some pathologists or other kinds of doctors who don’t encounter these issues later, but many will, and they aren’t getting enough instruction while in medical school.”

For the last 15 years, to help schools with their nutrition curriculum, the University of North Carolina has offered a series of instruction modules free of charge. Initially delivered by CD-ROM and now online, the program, Nutrition in Medicine, is an interactive multimedia series of courses covering topics like the molecular mechanism of cancer nutrition, pediatric obesity, dietary supplements and nutrition in the elderly.

“Physicians have enough barriers trying to provide their patients with nutritional counseling,” Ms. Adams said. “Inadequate nutritional education does not need to be one of them.”

Ms. Adams and her colleagues believe that the fully developed online curriculum helps address two issues that frequently arise: the relative dearth of faculty in a medical school with appropriate expertise and the lack of time in an already packed course of study.

The flexibility of the online program has already helped students at the Texas Tech School of Medicine in Lubbock. Medical school teachers at Texas Tech, which has one of the best nutrition education programs in the country, were finding that they had difficulty maintaining the intensity and quality of instruction once more senior medical students began working in hospitals scattered across the school’s widely dispersed campuses. Students at a hospital that had the luxury of a trained faculty member, for example, would be immersed in a diabetes workshop that involved “becoming diabetic” for a week and regularly checking blood sugar readings and self-administering “insulin” through a needle and syringe, while students at another hospital would be left with no instruction at all. The online Nutrition in Medicine course allowed all the students to continue learning about diet and counseling patients despite their disparate locations and resources.

“We didn’t have to reinvent the wheel at other campuses when we already had these online courses that are so well done,” said Katherine Chauncey, a registered dietitian and a professor of clinical family medicine at Texas Tech.

More recently, Ms. Adams and her colleagues have begun working on online nutrition education programs geared toward practicing physicians. “Many of them are realizing that their training wasn’t adequate enough to make them feel comfortable counseling patients,” Ms. Adams said. Short, focused and relatively easy to navigate, these courses are meant to help fill in those gaps in knowledge for older doctors. Eventually, practicing physicians may even be able to earn continuing medical education credits, a requirement of many hospitals, state licensing boards and specialty boards.

“It’s extremely difficult to get people to change their diets and their habits around food,” Ms. Adams said. “Anything that improves a doctor’s confidence and skill set will go a long way in helping patients.”

Added Dr. Chauncey: “You can’t just keep writing out script after script after script of new medications when diet is just as important as drugs or any other treatment a patient may be using.”

Problem is that the 25 hours of nutritional training they would get would likely be the typical low fat, high carb, whole grain dogma. Of course, this is what they hear from the media anyway, so what difference would it make? They would just have a better understanding of the low fat dogma.

Any doctor should be able to link their biochemistry training to basic nutition and know about the effects of carbs on bs and insulin - yet how many times do we hear about diabetics who were told by their doctor to reduce fat intake and increase healthy grains and fruit!

Lee

It's amazing that the government/media/anyone who talks to the general public puts a huge emphasis on things like diet, dental work, physical activity, stress reduction (etc.), but doctors have no idea how any of these things work.

We know fats are bad, but ask a doctor and they'll just tell you that. They won't tell you why. They fall back on some nonsense about "researchers" and often degrade into strange, logical circles on "good fats" and "bad fats." But gdit, ask them how Crestor works and they can rattle off the brochure like the Star Spangled Banner.

Ditto on dental care. My mother just had a tooth extracted and it was highly infected. No more tooth and the infection was let loose. Her oral surgeon gave her antib's and told her to call her doctor, but her doctor was seemingly oblivious to the mouth-blood-heart link when her BP went through the roof. "Hmm...maybe we need to double your dose?" Hmm...no, maybe you need to treat what's causing the BP spike!

I few years ago, I went to a lecture given by the author of the SBD, Dr. Agatson. It was at Cornell Weill Med School and was given to the health care professionals there.
Interestingly enough, he was talking to them about the Paleo diet and encouraging them to learn about it. It was very surprising for me!

Yep, doctors get virtually no training in this area, so then all they know what to say is something vague about saturated fat. Sigh. On the other hand, giving them more training might make things worse if they are given outdated information that we know to be false. I really wish that they'd just have more time to read the scientific literature on nutrition, that would help a lot more than them taking a class taught by dogmatic dieticians.

--Melissa

I asked Dr. Mike Eades in his blog once, about doctors being lacking in this. He said he started teaching himself about nutrition when he realized the importance, and that it was not that hard.

Why are we not expecting that of all doctors?

Doctors are the ones who set up their own training, license enforcement, and state laws protecting their profession.
If it's becoming clear that docs need nutrition education, and they aren't scrambling to get it - why is that.

Ah but apparently, yes you can.