A global deficiency of nutrition education in physician training: the low hanging fruit in medicine remains on the vine
Authors: Stephen Devries
Journal: The Lancet Planetary Health (2019)

According to the 2019 Global Burden of Disease Study of 195 countries,1Afshin A Sur PJ Fay KA et al.Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2019; 393: 1958-1972Summary Full Text Full Text PDF PubMed Scopus (984) Google Scholar dietary factors are the single leading cause of death, exacting an even greater health burden than smoking. For that reason, if medical education were to be based solely on the needs of patient and population health, nutrition would surely be meaningfully addressed. But, in defiance of the obvious need for physicians to possess, at minimum, solid foundational skills in clinical nutrition, medical education in nutrition across the globe is decidedly lacking. That is the conclusion of the study by Jennifer Crowley and colleagues in The Lancet Planetary Health.2Crowley JJ Ball L Hiddink GJ Nutrition in medical education: a systematic review.Lancet Plan Health. 2019; 3: e379-e389Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar The report summarised findings from 24 studies of nutrition education in medical schools throughout USA, Europe, the Middle East, Africa, Australia, and New Zealand. The studies examined several facets of the nutrition-related experience of medical students, including attitudes, knowledge, and confidence in recommending nutritional interventions. Although the methods and survey tools varied among the studies evaluated, the findings worldwide were remarkably similar. Nutrition knowledge and confidence in counselling among medical students were uniformly low, as was the students' perception of both the quality and quantity of their nutrition education. Despite the paucity of nutrition curriculum in medical school, the study found that interest among medical students in nutrition is uniformly high. Previous research has shown that keen interest in nutrition among incoming medical students typically wanes by the time of graduation.3Weinsier RL Boker JR Morgan SL et al.Cross-sectional study of nutrition knowledge and attitudes of medical students at three points in their medical training at 11 southeastern medical schools.Am J Clin Nutr. 1988; 48: 1-6Crossref PubMed Scopus (23) Google Scholar It is easy to imagine why. When medical students do not see nutrition substantively incorporated into their curriculum and do not observe clinical mentors incorporating nutritional interventions into their care plans, what else can they conclude but that nutrition is not as important as they had once believed? The review by Crowley and colleagues2Crowley JJ Ball L Hiddink GJ Nutrition in medical education: a systematic review.Lancet Plan Health. 2019; 3: e379-e389Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar adds to the existing medical literature4Aggarwal M Devries S Freeman AM et al.The deficit of nutrition education of physicians.Am J Med. 2018; 131: 339-345Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar in framing the gap in nutrition education in medical school as a global phenomenon as well as providing a glimpse of a blueprint for moving forward. The obstacles to delivering meaningful nutrition education are well described in this study and appear to be similar on every continent studied—a perceived lack of interest and expertise among faculty members in nutrition, low-quality nutrition curriculum that did not appear to be prioritised, and few examples of nutritional counselling during clinical years to serve as models for emerging physicians. Each geographic region has a unique set of predominant nutritional challenges and opportunities, nevertheless, a global need exists for physicians to understand the strong connection between nutrition and health. For example, in the past 30 years, the global prevalence of diabetes has nearly doubled.5WHOGlobal report on diabetes. World Health Organization, Geneva, Switzerland2016Google Scholar Beyond the lost opportunities for improving patient health, this study correctly frames the global lack of nutrition education in medicine as an issue that impacts planetary health, as described in the EAT-Lancet Commission on healthy diets from sustainable food systems.6Willett W Rockström J Loken B et al.Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems.Lancet. 2019; 393: 447-492Summary Full Text Full Text PDF PubMed Scopus (1639) Google Scholar This Commission emphasises the importance of a global tilt toward a more plant-based diet both for individual as well as environmental health. But if physicians are not adequately trained in nutrition, how can they take a meaningful role in aiding this dietary shift toward a plant sourced diet so necessary for both personal and planetary health? There is no question that dietary intake, both on an individual and population basis, is a function of a great many inputs including food access, economics, cultural traditions, marketing, and more. Nevertheless, patients generally rely on their physicians for guidance and there is ample evidence that physician discussions of diet make a positive impact on patient dietary choices.7International Food Information Council2018 Food & Health Survey.https://www.foodinsight.org/2018-FHS-Report-FINAL.pdfDate: 2018Date accessed: September 3, 2019Google Scholar As aptly described in the review by Crowley and colleagues "a poorly trained medical workforce can be viewed in and of itself as one structural contributor to diet-related disease."2Crowley JJ Ball L Hiddink GJ Nutrition in medical education: a systematic review.Lancet Plan Health. 2019; 3: e379-e389Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar Also noted in the study, nutritional interventions in medicine are best considered a team effort delivered by a group of health professionals skilled in nutritional care. But without a solid foundation of clinical nutrition knowledge and skills, physicians worldwide are generally not equipped to even begin to have an informed nutrition conversation with their patients and to fully identify opportunities for referral. There is much to learn about the most effective strategies to incorporate nutrition curriculum into medical training. Promising approaches to enhance nutrition education in medical education include integration of nutrition-related topics in lectures on disease pathogenesis and treatment, self-paced online curriculum, teaching kitchens, and greater utilisation of interprofessional education. Identification and training of clinical mentors in nutrition is a key challenge. But what is already crystal clear, is that the worldwide state of nutrition education in medicine is inadequate. Our patients deserve much better. And so does our planet. SD is the executive director of the educational non-profit Gaples Institute for Integrative Cardiology that offers continuing medical education approved nutrition courses for sale to health professionals. The courses are developed entirely through philanthropy to the Gaples Institute, a non-profit that does not seek or receive corporate support. SD reports that he receives compensation from the Gaples Institute but receives no royalties or other personal financial consideration from the sale of these courses. Nutrition in medical education: a systematic reviewDespite the centrality of nutrition to healthy lifestyle, medical students are not supported to provide high-quality, effective nutrition care. Medical education can be enhanced by institutional commitment to make nutrition education compulsory in medical training, establishment of nutrition competencies to provide a benchmark for nutrition knowledge and skills to be included in curricula, and supported by funding for innovative curriculum initiatives. These initiatives will improve nutrition in medical training to support future doctors for the 21st century. Full-Text PDF Open Access