We need to start teaching nutrition in medical school
Increases in obesity and associated conditions combined with the explosion of health information online necessitates a physician force that is well-read in nutrition science
Apologies for the extended break - last month I took my Step 2 exam and spent the last few weeks recharging and readjusting to normal life. I’m back in medicine mode and am ready to start writing again.
Recently, I accompanied my mother to an annual checkup with her PCP. Near the end of the visit, she expressed that she had been wanting to lose a couple of pounds that were gained during the winter holiday season (as happens to all of us) and asked the physician how to best approach this. The doctor said just a few words - follow a healthy diet - before leaving the room shortly afterwards. My mother and I left the clinic scratching our heads a bit. Of course we knew that much, but what does a “healthy diet” really mean?
I have seen many patients, especially in the outpatient setting, be counseled on lifestyle interventions such as a following a healthy diet to prevent chronic disease and improve quality of life. However, it was not until now that I realized how vague this advice could be from a patient standpoint. The phrase “healthy” could mean many things to many people, can vary depending on health needs, and can even vary from a cultural standpoint as well.
For an American who follows a typical Western diet, crafting a healthy diet can mean swapping red meats for leaner white meat and cutting out alcohol and ice cream. However, for someone such as my mother who eats a traditional Indian vegetarian diet, they may have to take a completely different approach. For her, some good advice may be to reduce the number of chapatis from 2 to 1 during meals or to replace basmati rice with cauliflower rice. Like anything in medicine, these issues have a level of nuance and it takes asking good questions for clinicians to identify what specific aspects of a patient’s diet can be further optimized.
The ability to modify a diet to be more healthy and adherence to that diet can also depend on socioeconomic factors, convenience, and resource availability. A single mom living in a food desert working 80 hours a week to support her 3 children is going to have a harder time getting the ingredients to make a kale and banana green smoothie. These are other examples of subtleties that can only be addressed with comprehensive history-taking and discussion.
Nutrition has become more important than ever before in our public health discourse given the surge in both obesity and type 2 diabetes in our population over the past several decades, especially among children. Despite this, the amount of nutrition education in medical school is extremely paltry. While the Liaison Committee on Medical Education requires at least 25 hours of nutrition education in medical school curriculum, a recent study found that over 70% of schools fail this requirement and over 35% of schools do not even satisfy 12.5 hours. I double checked my own medical school’s curriculum and found only 3 lectures totaling about 3.5 hours worth of content on nutrition-related topics, comprising less than 1% of total lectures given in the pre-clerkship period. Nutrition is similarly not tested much on the USMLE exams, which is likely a primary cause of why most medical schools do not include it in their curriculum. Unfortunately, we are seeing this play out real time, with a recent survey of resident physicians finding only 14% feeling confident about counseling patients about nutrition.
For primary care physicians working in inundated clinics with 8 minutes allotted per patient (unfortunately a reality in many places), it can be difficult to make time for comprehensive nutrition counseling. I saw this extensively during my pediatrics rotation, where clinic visits often required managing immunizations, injury prevention, and other big priority medical issues affecting this population.
However, we can no longer keep our eye off the ball as a profession. There is a clear desire from the public for advice on nutrition and health, with many turning to outlets such as YouTube and TikTok where “health influencers” have skyrocketed in popularity.
I will be the first to say that some of this content is truly great and provides evidence-based information that I have gained much from. As someone who has become very interested in healthy eating and fitness over the past few years, I have learned much actual science from these outlets. These include concepts such as basal metabolic rate, caloric deficit and surplus, macronutrient monitoring, and the physiology behind cutting and bulking cycles. I learned none of this information in medical school, yet I use it on almost a daily basis to guide my eating and exercise regimen.
But there is other content on these sites that spread misinformation, health fads not backed by science, and outright push unregulated and untested supplements while marketing them as a cure-all for chronic disease. The dietary supplement industry is estimated to be greater than $160 billion and it is nearly impossible these days to scroll through TikTok without seeing an ad for a new, organic plant-based supplement that claims to “cure diabetes” and “defy Western medicine.” This has been documented extensively.
So what can we do to solve this? I can think of three main solutions:
Test nutrition on the board exams and increase emphasis of nutrition science in the medical curriculum - the LCME should require this in order for schools to keep their accreditation.
For practicing physicians, read up to get the latest on proper nutrition and set extra time aside for at-risk patients. These patients should be given 20-30 minutes appointments to set aside time for thorough counseling. During visits, reconcile OTC supplements that patients take and explore why they take them. Also read up on popular supplements and when they should be used in a clinical setting.
Expand funding for updating and integrating nutrition education in medical school curricula. There was actually legislation introduced by Rep. Tim Ryan (D-OH) in 2017 called the Expanding Nutrition’s Role In Curricula and Healthcare (ENRICH) Act which would do exactly this. However, it has been in subcommittee gridlock since 2017.
It is high time for our priorities in medicine to be shifted towards prevention instead of treatment. This is best exemplified when it comes to nutrition advice for patients, which is only increasing in importance and public demand. Arming the future physician workforce with up-to-date knowledge and the skillset to address nutrition concerns is the first step towards creating a healthier populace.
What I’m Reading, Watching, and Listening To:
Dune - Frank Herbert
Severance - Dan Erickson and Ben Stiller
I Used to Run the N.I.H. Here’s What Worries Me - Harold Varmus