Doctors Need to Learn About Nutrition

Tricia Ward; Stephen R. Devries, MD


September 04, 2014

Editor's Note: A commentary[1] in the September issue of the American Journal of Medicine criticized the deficiency of nutrition education in medical training. Citing a 2013 report[2] on US health that identified dietary factors as the single most significant risk factor for disability and premature death, the authors (who included diet gurus Drs. Dean Ornish and Andrew Weil) call for changes in medical school curriculum to address the deficit. Lead author Stephen R. Devries, MD, spoke with | Medscape Cardiology. | Medscape Cardiology: What prompted this commentary?

Dr. Devries: It's been clear to me for some time that nutrition has not been high on the radar in clinical cardiology. I know from my own training 25 years ago that I received essentially no education in nutrition in 3 years of internal medicine residency and 4 years of cardiovascular fellowship training. Unfortunately, despite the knowledge gained in the interim about the link between nutrition and health, very little has changed regarding the paucity of nutrition education over the past 25 years.

It struck me as a peculiar paradox that clinical practice guidelines highlight the primary importance of nutrition and lifestyle, yet the physicians who are expected to implement these guidelines receive absolutely no education in these areas during their residency and subspecialty training. 

How can doctors not be required to learn about nutrition?

It seems hard to imagine that current accreditation guidelines in cardiology, for example, outline very detailed requirements regarding procedures, yet don't mention a word about nutrition. As I go around the country speaking to this point, the reaction is an incredulous "How can doctors not be required to learn about nutrition?"

Two years ago, I transitioned from a full-time academic practice to become director of an educational nonprofit, the Gaples Institute for Integrative Cardiology. One of our primary goals is to create a space for nutrition education within all levels of medical training programs. This new paper emerged as one of our efforts to emphasize the role of nutrition in medicine. | Medscape Cardiology: What is the relationship between the authors of this paper -- do they represent a particular body or group?

Dr. Devries: Our goal was to bring together as broad a group of physician educators as possible to help strengthen the message. My own work over the years has involved critically evaluating the evidence for nutrition and lifestyle practices, and the authors include many of the individuals I have collaborated with along the way. My personal belief (and a guiding philosophy of the Gaples Institute) is that we can best improve health care and the patient experience by bringing together the wisdom of passionate experts who may not normally be in dialogue with each other. Accordingly, the authors of this work include highly published academicians, natural health advocates, preventive cardiology researchers, directors of residency programs, and a former medical school dean. | Medscape Cardiology: Are you advocating any particular type of diet?

Dr. Devries: We're not aiming to promote a particular diet -- which is reflected in the diversity of authors, many of whom have slightly different takes on an optimal diet. Our message is much bigger: Let's give nutrition and lifestyle the attention they deserve in medicine. The goal is to create a space that doesn't currently exist for nutrition in medical training and practice.

And despite the diversity of opinions regarding diet, it's important to recognize there is a great deal of common ground: the need for greater consumption of vegetables and fruit, preferred intake of whole grains over refined, and avoidance of sugar-sweetened beverages. | Medscape Cardiology: Why do physicians need to learn about nutrition when there are dietitians? Can't they just refer patients to the experts?

Dr. Devries: I'm glad you raised that point. First of all, it's important to acknowledge that nutrition is a group effort and that patients can benefit from a wide range of health experts -- including dietitians, nutritionists, and nurses -- to help with dietary concerns. And certainly it's not realistic to expect that doctors will be able to take the time for detailed nutritional tasks, such as making daily meal plans, especially for those with complex nutritional needs. 

Nevertheless, a solid foundation of nutritional knowledge will empower physicians to emphasize to patients that nutrition is a priority, and to encourage patients that the food-based "medicine" they consume is just as vital to their health plan as their medication. When it is apparent that nutrition is a priority for the doctor, it becomes a greater priority for the patient. Making that point doesn't take a lot of time. 

Our goal is to leverage maximal impact from the physician's limited time. If only 15 minutes is slated for a return clinic appointment, devoting as little as 1 or 2 of those minutes to nutrition would be a huge advance from the status quo. Spending a couple of minutes to encourage vegetable and fruit intake or to discourage sugar-sweetened beverages is time well spent. And for those who need more extensive counseling, an appropriate referral is ideal -- and probably have all the more impact if the physician has already "premedicated" the patient to appreciate the importance of nutrition. | Medscape Cardiology: You state that nutrition is arguably more relevant to physicians than organic chemistry. How would you like to see it integrated into medical training?

Dr. Devries: The comment we made in the paper about organic chemistry pertained more to the undergraduate requirement for medical school. Although written a bit tongue-in-cheek, it referred to an article written by Drs. Dalen and Alpert[3] in which the importance of nutrition was compared with that of organic chemistry as a preparatory class for entrance into medical school. The idea is that we could begin to marinate future physicians with knowledge of nutrition early in their careers -- information undoubtedly more relevant to their future medical practice than that gained from organic chemistry. | Medscape Cardiology: What would be the timing and context of this education?

Dr. Devries: Currently, an average total of 20 hours is devoted to nutrition education in 4 years of medical school, and much of that time is dedicated to the biochemistry of nutrients and to rare nutritional deficiency states. Unfortunately, the little nutrition knowledge gained in medical school is typically extinguished in later clinical years because it is not reinforced.

Our recommendation is that a meaningful curriculum in nutrition be in place throughout medical training, from the basic sciences in medical school, to early clinical training, and extending into residency and subspecialty programs. Identifying clinical nutrition mentors is a challenge, but one that can only be addressed by a push for more nutrition education -- including education to train the trainers. | Medscape Cardiology: Are you also recommending a continuing medical education requirement? 

Dr. Devries: Absolutely; continuing education in nutrition is essential. Looking back at just the past year, key studies have been released on nutritional topics ranging from the Mediterranean diet, all the way to the cardioprotective properties of both blueberries and nuts. Keeping current in clinical nutrition science through continuing medical education is one of our key recommendations. | Medscape Cardiology: One of the frustrations for healthcare professionals is the seemingly conflicting data on nutrition. How can these professionals be assured that they are up to date with the evidence base?

Dr. Devries: That's a great point. Consumers and health professionals alike are understandably confused by seemingly conflicting nutrition studies. The problem is fueled by dramatic headlines in the lay press with new "breakthrough" studies that contradict previous findings. Seeing past the headlines -- and most important, the ability to place the new information into context on the basis of previous knowledge -- requires a solid foundation of nutrition education that doesn't currently exist. | Medscape Cardiology: What can current medical students and practicing physicians do to improve their nutrition knowledge and counseling skills?

Dr. Devries: There are some innovative nutrition educational programs that we referenced in our paper. The Gaples Institute also has some useful information on our site and is working to develop much more. | Medscape Cardiology: Are there novel strategies -- group patient education, for example, or standardized diet-assessment tools -- that are effective and can save time in an already crowded physician visit?

Dr. Devries: The use of a previsit diet questionnaire saves time and can be extremely helpful for evaluation of the baseline diet and to track changes. Working with the patient to identify 1 or 2 especially relevant dietary goals to be followed-up at the next visit is particularly helpful. | Medscape Cardiology: In June 2014, there was a white paper[4] from the Bipartisan Policy Center, American College of Sports Medicine, and the Alliance for a Healthier Generation on teaching nutrition and physical activity in medical school. Do you have any plans to coordinate efforts with these groups, or do you see your paper as a call to action for others to enact upon?

Dr. Devries: Our paper was intended to spotlight the deficiency of nutrition education in medical training, but it's only the beginning. We are also working hard to remove the obstacles to greater utilization of nutrition in medicine, including accreditation and reimbursement issues. The Gaples Institute has met with leaders in the US Congress, the American College of Cardiology, and many other key stakeholders to help shape the future of medicine and realize our vision of making nutrition a cornerstone of medical care.


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