by Marion Nestle
Apr 21 2014

No nutrition in medical education? An old story that might be changing.

JAMA Internal Medicine invited me to comment on an article about the lack of nutrition education in medical schools.  This was written by Nathanial Morris, a second-year medical student at Harvard, who complains about the paucity of nutrition instruction in his curriculum.

Yet the course spanned just 3 afternoons, for a total of 9 hours of instruction…The course directors told us it would be the only time for dedicated nutrition education during our 4 years as medical students. There were no examinations nor interactions with patients. The 1 lecture on obesity lasted 45 minutes…As a medical student, I cannot fathom why medical schools continue to neglect nutrition education.

When I read his article, I didn’t know whether to laugh or cry.  I wrote almost identical articles in the 1980s based on my experience at UCSF (here’s one).

I asked a former UCSF colleague, Dr. Robert Baron, to co-author the commentary with me: Nutrition in Medical Education:  From Counting Hours to Measuring Competence.

Our interest in this issue started nearly 40 years ago, when we were both at the University of California, San Francisco (UCSF), School of Medicine. In 1976, one of us (R.B.B.) was, like Mr Morris, a medical student advocating for nutrition instruction, while the other (M.N.) was a lecturer newly recruited to provide that instruction. For the next decade, we worked together to create “NutritionUCSF,” a comprehensive program of nutrition training that at its peak encompassed 16 hours of preclinical instruction; regular lectures and ward rounds in several clinical rotations; an intensive, 1-month fourth-year clinical elective; an ongoing lecture series for the health professions community; and postgraduate continuing education courses.

In addition to our youthful interest and enthusiasm, we were able to achieve all this for a simple reason: we had funding. Funding came first from a curriculum development grant from the Health Resources Administration and later from a private foundation. These grants allowed us to pay faculty for a small portion of their time and leverage nutrition hours into the curriculum.

Our article explains how at UCSF and some other institutions, nutrition instruction is becoming integrated into overall reform of medical education:

Today’s medical education reform movement must respond to this call by including a broad competency-based approach to improving the nutrition-related skills of physicians. When it does, we may finally have the opportunity to include advice about healthful eating as a routine part of 21st century medical practice.

Some help from Congress?

It is interesting in this context that various members of Congress are introducing bills to improve nutrition education for medical professionals, for example, the EAT for Health Act and the ENRICH Act.  Thanks to Jamie Berger for alerting me to this legislation and for sending some fact sheets about the bills: EAT for Health / ENRICH.

It’s been nearly 40 years since my involvement in this issue.  Ever optimistic, I’m happy to see some progress at last.

And this just in.

The current issue of the American Journal of Clinical Nutrition has papers from a symposium on nutrition in medical education.  The first was in 1962, so the half-century saga continues.

  • Title page, program participants, and TOC:  Am J Clin Nutr 2014;99 1145S-1149S
  • Introduction to Nutrition Education in Training Medical and Other Health Care Professionals. Penny M Kris-Etherton, Charlotte A Pratt, Edward Saltzman, and Linda Van Horn. Am J Clin Nutr 2014;99 1151S-1152S
  • The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. Penny M Kris-Etherton, Sharon R Akabas, Connie W Bales, Bruce Bistrian, Lynne Braun, Marilyn S Edwards, Celia Laur, Carine M Lenders, Matthew D Levy, Carole A Palmer, Charlotte A Pratt, Sumantra Ray, Cheryl L Rock, Edward Saltzman, Douglas L Seidner, and Linda Van Horn. Am J Clin Nutr 2014;99 1153S-1166S
  • Nutrition education in medical school: a time of opportunity. Robert F Kushner, Linda Van Horn, Cheryl L Rock, Marilyn S Edwards, Connie W Bales, Martin Kohlmeier, and Sharon R Akabas. Am J Clin Nutr 2014;99 1167S-1173S
  • Residency and specialties training in nutrition: a call for action. Carine M Lenders, Darwin D Deen, Bruce Bistrian, Marilyn S Edwards, Douglas L Seidner, M Molly McMahon, Martin Kohlmeier, and Nancy F Krebs. Am J Clin Nutr 2014;99 1174S-1183S 
  • Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. Rose Ann DiMaria-Ghalili, Jay M Mirtallo, Brian W Tobin, Lisa Hark, Linda Van Horn, and Carole A Palmer. Am J Clin Nutr 2014;99 1184S-1193S
  • Policy approach to nutrition and physical activity education in health care professional training. Matthew D Levy, Lisel Loy, and Laura Y Zatz.  Am J Clin Nutr 2014;99 1194S-1201S.
  • Jessica

    While I do think its important for doctors to have some form of nutrition education (so they can not just give out random diet advice that may not be evidence based), I think its important that there is more communication and reliance on other allied health professionals – in this case, a dietitian. I’m not sure what it is like in the states – but in Canada we have a growing number of Family Health Teams that include not only a doctor but a nurse practitioner, dietitian, social worker, etc. Moreover in hospitals better interdisciplinary care is needed for better patient outcomes. I feel like if you put nutrition in the medical education – doctors now think they can be the experts in nutrition education when that is not the case. Dietitians have 4+ years of nutrition education along with an extensive hands-on clinical training program.
    We can’t expect family docs to do it all…
    More accountability, efficiency, and transparency is needed – that happens when the interdisciplinary teams knows their key roles and others key roles in patient centred care.

  • Annie K

    Jessica, you voiced my thoughts exactly. I definitely think it’s important for medical students to have some type of formal nutrition training. But at the same time, there are people who dedicate their entire careers to diet and nutrition – dietitians – why not, as you say, communicate and rely more on them? Creating a network of doctors and dietitians, for example.

  • Alicia

    I think doctors should have understanding of nutrition science to go along with the medical science. Medical doctors don’t need to be trained in food studies (that’s the no-science nonsense Nestle and Pollan preach) anymore than medical doctors should be trained in witchcraft or voodoo healing. Let medical doctors safeguard the science. Pollute psychologists and anthropologists with politically slanted food studies, if you must. I want my physician to know the science whereof she speaks and I am not particularly interested in her personal opinions about food or pets or her imaginative reminiscence of rainbows and unicorns lifestyle of yore.

  • Kevin Klatt

    I agree with what others are saying about teaching MD’s about how to interact with RDs more so. I think the issue gets a lot more complicated when you consider the effective usage of an RD inside vs outside the hospital, and the issues with reimbursement for those RDs effecting MNT outside the hospital. There’s also the issue of dietetics education being at a BS/MS level and not being a stand alone care model. tinyurl.com/lrkgvgv

  • StellaBarbone

    I’m a retired primary care doc. I spent a lot of time talking about diet, but referring people to the dietician and Weight Watchers was my preferred route. There is only so much time in one day and walking people through meal planning, portion control, etc. is not an efficient use of an MD’s time.

  • David Harrell

    This has been my concern (as an “incurable” chronic illness sufferer and therefore, nutrition autodidact) for a long time. When my father was diagnosed Stage 4 colon cancer, the ignorance of oncologists about nutrition was the subject of whispered comments by some of his nurses. I knew that this ignorance is what killed him.

    During the six weeks between his colon resection and the start of heavy chemo and radiation, Dad went on a modified Gerson diet, supplemented with additional nutrients as well as essiac — real chemotherapy — with encouragement and assistance from me and my brother. The change in his appearance, energy and overall well-being was amazing. He began to gain weight and look years younger. X-rays showed shrinkage in the masses in his liver. Yet the oncologists/radiologists explained this away as some sort of artifact or illusion.

    As the time for the bombardment neared, the nutritionally ignorant oncologists started pushing him to go off the diet and eat lots of junk to “bulk up.” he went off the protective nutrition, and it was not long — just a week or two — into the chemo that he could no longer eat or drink anything. It was a quick slide downhill. Within two months, he was gone.

    When I later put myself under the care of a DC with clinical nutrition certification, and described my dad’s treatment, he said to me, “Do you know that your father was murdered?” I told him of course. This DC says he’s seen plenty of patients like my dad cured of their disease.

    When an inexcusable situation such as this persists for decade after decade, deep-seated perverse incentives and corrupt institutional arrangements are at fault. Near-total ignorance of the basic constituents of the human body (i.e. nutrients) and how they work is entrenched as the “standard of care” and other body of regulation written by the industry itself. The health profession being a cartel, MDs may see this as an ego and turf issue; while Pharma sees it as more sickness and bigger profits for their drugs that don’t cure anything. Government health policy (as distinguised from the research side) lovingly tends this crop of ignorance and failure, since more illness also perversely benefits politicians and bureaucracy (cf. “Affordable Care Act”). Government itself being a monopoly, the more it fails, the more power and money it can demand. The time for this corrupt arrangement to change is yesterday.

    By the way, I’ve seen you on BookTv and I want to get your book as soon as possible.

  • Facebook User

    I think it represents a fundamental theoretical position. A shift in perspective at the bottom, will grow the fruits of institutional optimal nutrition. westcoastbeing.com

  • LowCarbonFootPrint

    check this article and think a little more broadly…

    A. M.Sc. ClinEpi

    http://www.culinate.com/articles/features/medical_awareness_nutrition

  • http://treadmillcoach.com James Betts @ Treadmill Coach

    it’s finnaly time that we take another perspective

  • TR

    As a Nutritionist in a public health dept., I see a lot of clients who beleive their doctors know more about nutrition than I do and so its hard for me to garner their trust and effect meaningful change in their lifestyle. If doctors, at least those around here, are to continue impressing this notion upon their patients they ought to at least back it up with the education instead of posing an authoritative position whilst delivering general, outdated advice. Or, set the record straight and refer those clients to a nutrition professional. I once saw a orthopedic surgeon about my spine and asked him what his advice was for nutritional support of bone healing. He couldnt even talk with me about nutrients involved in bone mineral transport and deposition and food sources for those nutrients. In short, I’m tired of hearing my clients say “but the doctor said…”

  • TR

    Medical doctors never really have been the vangaurd of nutrition science and cannot be expected to be. They are the vanguards of medical practice. Would you expect a general practitioner to perform neurosurgery? I hope not. I think you are seeing rainbows and unicorns…

  • http://www.drgourmet.com baiacou

    Have you heard about Tulane’s Goldring Center for Culinary Medicine? They’re teaching medical students how to cook along with nutrition science so that they can better communicate with patients about diet and nutrition. http://tmedweb.tulane.edu/mu/teachingkitchen/

  • maryannastea

    Registered Nurses have more nutritional education than doctors. The pharmaceutical companies write many of the medical textbooks. So under “treatment” medications are recommended. Nutrition is looked at as a treatment only once disease has set in, such as diabetes, then diet is considered.

    The truth is proper nutrition would prevent 75% of the disease doctors end up treating. It’s not just doctors who should be educated in nutrition, but every single person who puts food in their mouth. The responsibility for ones health begins with the individual. The government, pharmaceutical companies, insurance companies and medical device companies run the healthcare show and until the individual realizes this and takes responsibility for their own health via proper nutrition these powerful groups will continue to run the show.

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  • David Harrell

    “safeguard the science”? First, they have to be instructed in the science, and have to make at least some effort to keep up with developments. For this to happen, they need to be free of influence from the patent medicine pushers. The drugs could and should be a last resort in extreme and urgent cases — not the first line of treatment.

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  • David Harrell

    To those who have suggested that the solution is relying on the dietetics profession: I doubt it.

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