Martin Kohlmeier

Nutrition Training for Young Doctors Lacks Bite

October 19, 2017

Read the original article by Marlene Busko from MedScape.

Most US medical schools do not require medical students to learn basic nutrition theory, even though poor diet is the leading preventable risk factor for disability or early death in the United States.[1,2]

Kohlmeier

“It takes at least 25-30 hours of medical school instruction to achieve just basic nutrition competencies,” according to an expert committee of the Nutrition Academic Award Program of the National Institutes of Health,[3] Martin Kohlmeier, MD, professor in the Department of Nutrition at the University of North Carolina (UNC) at Chapel Hill and researcher at the UNC Nutrition Research Institute, told Medscape.

However, from 2000 to 2012, medical students only received a median of 16-20 hours of nutrition education, on the basis of surveys conducted by Kohlmeier’s team every 4 years since 2000.[1,4] Partial data from the 2016 survey show that “nothing has changed,” Dr Kohlmeier said. “Nutrition education in medical school continues to be inadequate.”

The US Burden of Disease Collaboration group identified that a poor-quality diet is “an even bigger problem than physical inactivity or obesity itself,”[2]Stephen Devries, MD, a cardiologist at Northwestern University in Chicago, Illinois, and executive director of the nonprofit Gaples Institute for Integrative Cardiology, told Medscape. “Poor-quality diet trumps all of those, including tobacco.”

Part of the problem is that “each medical school is free to address the issue [of nutrition education] as they wish,” according to Dr Kohlmeier. “Some are doing a much better job, and some are doing a poor job.” Medical students are not required to obtain a basic knowledge of nutrition, unlike anatomy, for example. “That’s the problem,” he said.

However, Dr Devries is cautiously optimistic. Some med schools now offer online nutrition courses or “healthy kitchen” programs, and stakeholders are working to bring about changes in accreditation.

‘Minimal’ Nutrition Education in Most MD, DO Programs

The survey of the 133 US medical schools with 4-year MD programs in 2012 showed that medical students received a median of 16 hours of nutritional education that year—roughly the same as in 2000, 2004, and 2008.[1]Meanwhile, the percentage of US medical schools that do not require medical students to receive any instruction about nutrition increased from 5% in 2000 to 10% in 2012. Only around 1 in 4 medical schools have a required nutrition course.

Typically, in the first 2 years of med school, students learn about the molecular structures of vitamins and metabolites, Dr Kohlmeier said. However, teaching students about “the structure of Krebs-cycle metabolites,” for example, “doesn’t teach them anything about diabetes.”

“Fewer than one half of all US medical schools offer any kind of clinical focus on nutrition—no rounds, no clinics—which reflects the reality in a lot of these teaching hospitals,” Dr Kohlmeier observed. “Even in those that offer something, the average is in the range of 5 hours at most, which is not enough.”

Students are not getting practice in “making patient assessments or understanding which patients are at risk from malnutrition before or after surgery,” nor are they learning how to help motivate patients to lose weight.

Nutrition education in schools of osteopathic medicine is not any better. An analysis of data from 2012 from 30 US colleges with a 4-year osteopathic medicine (DO) program revealed that most osteopathic colleges (87%) did not provide 25 hours of nutrition education, and close to one third only provided one half of the recommended minimum amount of nutrition education.[5] Only about 1 in 4 schools provided clinical training in nutrition; even then, it was for only about 4.1 hours.

Lack of Nutrition Training Persists in Residency

“I think that in general, nutrition relates to topics that are under the umbrella of prevention, and prevention is substantially underemphasized in medical training,” said Dr Devries. Some medical schools may feel that “there are just too many subjects to cover,” or that nutrition training is best left to registered dietitians.

“The problem is that there is not really a consensus on how important nutrition is, and what kind of nutrition should be taught,” according to Dr Kohlmeier. “There is certainly no accountability, because there are just a few questions on the board exams,” he noted.

And yet, doctors need to be able to “emphasize to patients that nutrition is a priority and help [motivate] patients to see a dietitian or nutritionist or health coach,” said Dr Devries. They need the knowledge and insight “to really impress upon the patients how important the nutritional component” of health is. “It gets even worse when they get into a residency program,” he continued. “There are far too few mentors and opportunities to learn about nutrition.”

A recent study found that only 14% of residents believed they were adequately trained to provide nutritional counseling, he noted.[6]

As reported recently in Medscape, among more than 900 cardiologists surveyed by Dr Devries and members of the Nutrition Working Group of the American College of Cardiology, 90% reported that they received minimal nutrition training or none at all during their cardiology training.[7,8]

Online Courses, CME, and ‘Healthy Kitchen’ Initiatives

“It took a major effort to really get everybody on board and say ‘OK, look, [smoking] is just not good,'” said Dr Kohlmeier. “We are still not at that point with poor diet.” However, some medical schools are showing that nutrition education can fit into a busy med school curriculum.

One half of all US medical schools and osteopathic schools and many international medical schools now use a free, online program that was developed by Dr Kohlmeier and other members of a Nutrition in Medicine team.

The current version contains 40 modules, ranging from 15 minutes to 1 hour long, that provide, among other things, virtual patient interactions with immediate feedback. The program is suitable for both med students and practicing clinicians.

As another option, the nonprofit organization that Dr Devries belongs to offers a 3-hour “essentials of nutrition” course that is focused on clinical pearls, includes “motivational interviewing” as well as links to the original literature, and costs $50, said Dr Devries.

Some med schools have taken steps to improve their nutrition teaching. New York University School of Medicine and University of Chicago Pritzker School of Medicine, which are part of the American Medical Association’s (AMA’s) Accelerating Change in Medical Education Consortium, “have incorporated nutrition education into their curricula…[and] are working to ensure that their medical students gain the knowledge they will need to help their patients make healthy food and beverage choices when in the clinical setting,” according to an AMA statement.[9]

“In an era when rates of obesity, diabetes, and other lifestyle-related diseases challenge medical educators and governments worldwide, it is necessary to consider novel educational strategies” to prepare health professionals to proactively advise and teach patients about diet and behavioral change, according to David M. Eisenberg, MD, executive vice president for health research and education, Samueli Institute, Alexandria, Virginia, and adjunct associate professor, Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, and colleagues.[10]

The group launched Healthy Kitchens, Healthy Lives—Caring for Our Patients and Ourselves in 2008—a continuing medical education program delivered at a 3.5-day annual conference, which is jointly sponsored by the Harvard School of Public Health, the Culinary Institute of America, and the Samueli Institute. It covers how to “advise patients about food, diet, nutrition, cooking, shopping, and…movement and exercise; judicious use of web-based devices and sites; and evidence-based strategies to achieve successful behavioral change,” Dr Eisenberg told Medscape. The next conference will be in February 2018.

Some med schools have adopted the “healthy kitchen” concept to train medical students about nutrition. The Goldring Center for Culinary Medicine at Tulane University in New Orleans, Louisiana, was the first to do so, and it provides “hands-on training for medical students through culinary medicine classes in the form of electives and seminars as well as continuing education for the healthcare and foodservice industries,” according to its website.

Efforts to Make Nutrition Training a Priority

Joey Johnson, DO candidate at Lincoln Memorial University’s DeBusk College of Osteopathic Medicine in Harrogate, Tennessee, and national president of the American Medical Student Association, suggested to Medscape that “groups that are passionate about this topic” should present their ideas at conferences of medical educators.

A few weeks ago, “a group of stakeholders [spearheaded by the American Society of Nutrition] met at the National Institutes of Health to discuss exactly that—continued development of curriculum guidelines,” said Dr Kohlmeier.

He ended his presentation with, “Something needs to change.”

“The tide, I believe, in terms of sentiment is beginning to turn,” said Dr Devries. “Now what needs to happen is to translate that sentiment into real action—changes in accreditation standards, board exam content, and a general understanding throughout the medical system that nutrition is a priority.”

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