Nutrition Education and Behavioral Science

The New England Journal of Medicine recently published an article entitled “Simulation of Growth Trajectories of Childhood Obesity into Adulthood.” The models in the study projected that 57.3% of today’s children will be obese by age 35.¹ The bleak predictions of future health trends such as these reaffirm the need for health professionals to be knowledgeable about nutrition.

Patients expect physicians to be sources of information related to nutrition. In fact, 61% of respondents to an American Dietetic Association (now the Academy of Nutrition and Dietetics) survey stated that they believe physicians are a “very credible” source of nutrition information.² At the same time, though, in a study of internal medicine interns, 86% of respondents admitted to being inadequately trained to provide nutritional counseling. This inadequacy starts early in a physician’s career, with 51.1% of medical school graduates in 2005 reporting that they received insufficient nutrition education during medical school.³

Take the field of cardiology, for example, where a recent study found that, among a cohort of 930 cardiologists, 90% believe their role includes providing patients with basic nutrition information. In the same group of physicians, though, 90% stated that they had received little-to-no training in nutrition during their fellowship, 59% stated that they had received no nutrition during internal medicine training, and 31% reported no nutrition education in medical school.⁴ Simply put, the perceived role of physicians and the training they are given don’t match up.

This is not a matter of self-reported opinion either, because curricula also lack dedicated nutrition training, and this is not a new phenomenon. In 1962, the American Medical Association (AMA)’s Council on Foods and Nutrition held a conference pertaining to the “inadequate recognition, support and attention” given to nutrition education in medical schools. The council acknowledged that nutrition is intimately involved in the pathogenesis of chronic and degenerative diseases and that the medical curriculum was lagging with respect to advances in nutrition science. ⁵ The interrelatedness of medicine and nutrition was recognized by the council as more than the just the treatment of isolated nutrient deficiencies.

In 1976, the AMA conducted a mail survey to better understand the status of nutrition education in U.S. medical schools. When 102 medical schools responded to the surveys, fewer than 20% of schools reported requiring a nutrition course.⁶ The schools cited lack of funds, inadequate number of physicians trained in clinical nutrition, and limited amount of time available in the curriculum as limitations for increased nutrition education. This forty-year-old survey also highlighted the increased interest in nutrition from students and faculty at these institutions.⁷ We can only assume this interest has since grown.

The scientific conferences and congressional hearings in the decades leading up to the 80s drew attention to the need to improve nutrition education in U.S. medical schools. As a result, the National Research Council Committee on Nutrition in Medical Education published recommendations in 1985 stating that a minimum of 25 to 30 classroom hours during preclinical years should be allotted to covering the topics in nutrition that were underscored by the committee.⁶ For the past two decades, research spearheaded by University of North Carolina at Chapel Hill has tracked the state of nutrition education in U.S. medical schools every four years. Unfortunately, the data show no sign of changes in the average hours required in nutrition education since 2000. The most recent survey during the 2012-2013 academic year included 121 medical schools, with an average of 19 hours (SD =13.7) of nutrition education in their curriculum. The survey showed that 71% of medical schools failed to meet the minimum recommendation of 25 hours, 36% provided 12 or fewer hours, and 9% provided none.⁸

Current nutrition education is evidently not translating into practice when only 10% of primary care physicians include weight counseling for patients, and fewer than half of obese and overweight patients are advised to lose weight.⁹ Primary care practitioners overwhelmingly support requiring additional training so that they will be better informed about the care they provide to their patients with obesity.¹⁰

The Association of American Medical Colleges has recently declined to incorporate nutrition into its new blueprint for medical competencies.¹¹ The 2013 American Council for Graduate Medical Education (ACGME) program requirements for Graduate Medical Education in Cardiovascular Disease neglects to mention nutrition. ¹² This continues to be the case in the most recent iteration of the ACGME requirements along with the ACGME for Internal Medicine.^13,14 These examples show that both medical schools and graduate medical education have yet to legitimize the value of incorporating nutrition training through their competencies.

Three programs that have become recognized for their innovative approach to nutrition curriculum at medical schools include:

1. The Nutrition in Medicine (NIM) Project – since 1995 this program has aided in the development and distribution of nutrition curriculum for medical students through comprehensive online courses free of charge. The curriculum is a 29-unit curriculum covering basic science content along with clinical applications through cases. About 50% of medical schools actively use the NIM curriculum and the flexibility of the curriculum has allowed for varied implementation at these schools .¹⁵ A more recent initiative by the NIM team is the Nutrition Education for Practicing Physicians for residents, fellows, and practicing physicians. These online modules differ from the medical school resources through the greater level of clinical detail and practical applications (https://www.nutritioninmedicine.org/).
2. Healthy Kitchens, Healthy Lives – The Culinary Institute of America and the Harvard T.H. Chan School of Public Health have collaborated as a strategy to enhance physician ability and motivation for nutrition counseling through interactive cooking experiences. The program uses teaching kitchens to demonstrates how nutrition science can be translated into nutritious meals. This initiative has shown to be successful in changing physicians’ dietary practices and their inclination to offer nutrition counseling at a 3-month follow-up.¹⁶ Currently, over 6,000 health professionals have taken the course. This initiative has expanded to 32 organizations located in 16 different states, plus Italy and Japan. The kitchens are active in universities, hospitals, and corporate buildings. (https://www.healthykitchens.org/)
3. Tulane University School of Medicine’s Goldring Center for Culinary Medicine – this is the first teaching kitchen implemented at a medical school. The center trains medical students and professionals through culinary medicine classes in the form of electives and seminars as well as continuing education. The idea is grounded in the idea that the knowledge to cook nutritious meals encourages patients to buy vegetables and fruits that they previously avoided because they didn’t know how to prepare them. Tulane offers an institutional and away rotation at Johnson & Whales University in Providence Rhode Island where students can participate in hands-on culinary and culinary nutrition classes as well as an academic research project related to medical nutrition therapy. Medical students can also opt to take an 8-class culinary medicine elective during their first or second year of school. (https://culinarymedicine.org/)

The physician is the head of the care team and is responsible for directing care and allocating personnel and resources. Physicians see many patients when they are most in need of nutrition guidance. Therefore, physicians should be able to assess and recognize nutrition-related problems, and appropriately coordinate patient care. Let us hope that these programs are increasingly adopted in medical education so that physicians will be better equipped to address the health of their patients.

References:

1. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-2153. doi:10.1056/NEJMoa1703860.
2. Nutrition and You: Trends 2008.; 2008. https://www.eatrightpro.org/~/media/eatrightpro files/media/trends and reviews/nutrition and you/trends_2008_are_you_already_doing_it.ashx. Accessed November 30, 2017.
3. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge. J Am Coll Nutr. 2008;27(2):287-298. https://www.ncbi.nlm.nih.gov/pubmed/18689561. Accessed November 30, 2017.
4. Devries S, Agatston A, Aggarwal M, et al. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130(11):1298-1305. doi:10.1016/j.amjmed.2017.04.043.
5. Council on Foods and Nutrition. JAMA. 1963;183(11):955. doi:10.1001/jama.1963.03700110087015.
6. National Research Council (US) Committee on Nutrition in Medical Education. Nutrition Education in U.S. Medical Schools. Washington, DC; 1985. doi:10.1007/BF02427708.
7. Cyborski CK. Nutrition content in medical curricula. J Nutr Educ. 1977;9(1):17-18. doi:10.1016/S0022-3182(77)80110-6.
8. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. J Biomed Educ. 2015;2015:1-7. doi:10.1155/2015/357627.
9. Kraschnewski JL, Sciamanna CN, Pollak KI, Stuckey HL, Sherwood NE. The epidemiology of weight counseling for adults in the United States: a case of positive deviance. Int J Obes. 2013;37(5):751-753. doi:10.1038/ijo.2012.113.
10. Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open. 2012;2(6):e001871. doi:10.1136/bmjopen-2012-001871.
11. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Acad Med. 2013;88(8):1088-1094. doi:10.1097/ACM.0b013e31829a3b2b.
12. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014;127(9):804-806. doi:10.1016/j.amjmed.2014.04.003.
13. ACGME Program Requirements for Graduate Medical Education in Cardiovascular Disease (Internal Medicine). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/141_cardiovascular_disease_2017-07-01.pdf. Accessed November 30, 2017.
14. ACGME Program Requirements for Graduate Medical Education in Internal Medicine.; 2017. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_internal_medicine_2017-07-01.pdf. Accessed November 30, 2017.
15. Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: nutrition education for medical students and residents. Nutr Clin Pract. 2010;25(5):471-480. doi:10.1177/0884533610379606.
16. Eisenberg DM, Myrdal Miller A, McManus K, Burgess J, Bernstein AM. Enhancing Medical Education to Address Obesity: “See One. Taste One. Cook One. Teach One.” JAMA Intern Med. 2013;173(6):470. doi:10.1001/jamainternmed.2013.2517.