Primary Care's 2014 Lessons: The Research Changing Practice

Linda Brookes, MSc

Disclosures

December 18, 2014

In This Article

The Microbiome: Not Quite Ready for Prime Time?

In the past 5 years, over 3500 scientific articles have been published about the human microbiome, reflecting the increase in studies of microbiota colonizing the gut, skin, and mucosal surfaces of the body. As the clinical implications of the microbiome in human health and disease become better understood, the microbiome appears likely to become a more central consideration in primary care, and it is likely that all clinicians will need to have a basic understanding of it.

To that end, the Mayo Clinic issued a clinicians' "primer" on the microbiome.[56] The authors cautioned that the composition and function of a healthy gut microbiota remain to be clearly defined. Several disease states have been correlated with alterations of the gut microbiota, but it is not clear whether these alterations are a cause or a consequence. The key questions pertaining to the gut microbiota that remain to be answered are whether alterations in the microbiota are causative or merely associations with diseases, and whether therapeutically manipulating the gut microbiota by dietary changes, microbiota restorative therapies, or immune modulation will alter disease course. Current enthusiasm regarding the use of over-the-counter probiotics for the treatment of conditions that may stem from disruptions in the microbiome has not proven to be curative. Fecal microbial transplantation, a more successful technique, is not approved but is permitted by the FDA for Clostridium difficile infection after discussion of risks and benefits with patient. In an article on Medscape, John Bartlett notes that stool transplantation now appears to be the most effective method to treat the patient with multiple relapses (the current IDSA guidelines recommend considering this approach after at least two relapses), and no significant differences in outcome have been demonstrated for specimens inserted by mouth (in pill form), endoscope, or enema.[57]

Other reviews published in 2014 also warned that some of the enthusiasm for the microbiome and what can be achieved by changing it may be premature. The authors of these reviews criticized research methodologies and the lack of transparency in describing techniques for designing microbiome studies and analyzing data.[58,59] There was also criticism of the media "hype" of microbiomics and skepticism about companies offering microbial analysis of personal fecal samples.[59] "I do have some fear—we all do in the field—that the hype and the potential overpromise, and the idea that somehow this is going to be different—there is a terrific fear that it will all backfire," said Lita Proctor, PhD, head of the Human Microbiome Project at the National Institutes of Health, in an interview.[60]

More Nutrition Education Needed in Medical Training

Despite the importance of healthy weight maintenance for the prevention of CVD, diabetes, and cancer, only 14% of physicians feel qualified to offer nutrition counseling to their patients.[61] The reason for this, according to several papers published in 2014, is the lack of nutrition education included in physician training, residency programs, and continuing medical education (CME). When last surveyed, only 25% of medical schools offered a dedicated course on nutrition as required by the National Academy of Sciences. A call for more nutrition education in specialty training was made earlier this year in a paper authored by a group of academic healthcare professionals from around the United States, who noted that the Accreditation Committee of Graduate Medical Education makes no requirement for nutrition education for training in either CVD or internal medicine residency training.[62]

In a recent commentary, Stephen Devries, a Medscape advisor, and colleagues decried the lack of funding and dearth of trained and interested faculty necessary to address this educational gap.[63] The paper speculated that other reasons include the belief that nutrition is insufficiently science-based for rigorous medical education and the focus of training on treatment rather than prevention of disease. However, the authors were optimistic that medical education is changing rapidly and that "desirable curriculum changes can at last be achieved."[63] The University of North Carolina has developed the Nutrition in Medicine project, which offers a free online nutrition curriculum used in a number of US medical schools, and many schools, such as University of California, San Francisco, have developed their own nutrition curricula for integration into medical education.

An attempt to tackle the problem is also being made through public policy. In April, two bills were introduced in Congress: the Expanding Nutrition's Role in Curricula and Healthcare (ENRICH) Act, which would provide funding for the integration of a nutrition curriculum in accredited medical schools,[64] and the Education and Training for Health (EAT) Act of 2014, which would ensure that every primary care health professional employed by federal agencies has at least 6 credits of annual CME in nutrition.[65] Each bill is sponsored by a broad coalition of organizations, including the Association of Medical Colleges, the American Association of Colleges of Osteopathic Medicine, the American College of Preventive Medicine, the American Society for Nutrition, and the American Heart Association.

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