AMSA: Is nutrition getting its just desserts in medical school?

Is nutrition getting its just desserts in medical school?
The New Physician, April 2009

by Linda Childers	Volume 58, Issue 3

“An apple a day keeps the doctor away” might be a good mantra for medical students and residents. Experts say physicians-in-training need an increased understanding of nutrition to effectively meet the current and future demands of the medical profession.

“Nutrition is a high priority among medical professionals across the nation, and a huge primary health indicator when it comes to conditions including osteoporosis, cancer, heart disease and diabetes,” says Dr. Patrick McBride, associate dean of students at the University of Wisconsin School of Medicine and Public Health (UW) and a family physician specializing in preventive cardiology. McBride recently served as chairman of the Association of American Medical Colleges committee that drafted curriculum guidelines for teaching students about overweight and obesity.

In the past, nutrition education hasn’t always been a part of the core curriculum at many medical schools. If the subject is taught, it’s often incorporated into other courses, like biochemistry or pathology, or offered as an elective. Responding to concerns about the prevalence of nutrition education in medical schools, in 1994 the National Academy of Sciences called for improved nutrition education at all U.S. medical schools. In addition, the Healthy People 2010 report, published by the U.S. Department of Health and Human Services, also identified the need for physician counseling and education relating to diet and disease.

While nutrition education in medical school has increased over the past two decades, experts say there is room for improvement. A study published in the April 2006 issue of the American Journal of Clinical Nutrition found that 60 percent of medical schools in this country are not meeting minimum recommendations for their students’ nutrition education.

Historically, one of the barriers to medical nutrition education has been a lack of consensus on what concepts should be taught.

Without a clear home for nutrition, some came to view the subject as alternative medicine. “We don’t see nutrition as complementary and alternative medicine. We see it as an emerging mainstream medical specialty,” says Dr. Lisa Neff, who sits on an ad hoc subcommittee within the American Society for Nutrition’s Graduate and Professional Education Committee. “Much of complementary and alternative medicine has not been science-based or evidence-based, although that is changing somewhat…. But nutrition has always been a science-driven field.”

Neff, a clinical scholar at Rockefeller University, believes that views are changing. “There are probably some schools where nutrition is still not as represented as we’d like it to be, by clinical nutrition experts.”

This changed nine years ago when the National Heart, Lung and Blood Institute selected 21 medical schools to receive a five-year, $1 million Nutrition Aca¬demic Award. UW was one of the schools to receive the grant.

In addition to the Nutrition Academic Award, Step 1 now has a nutrition sub-score. Though individual students can’t find out their own sub-score, schools do find out how their students as a whole score on nutrition. Asking the school about its students’ performance on the nutrition sub-score could lend some traction to curricular change.

Learning How to Prevent Disease

According to the Centers for Disease Control and Prevention (CDC), obesity in America has increased dramatically in the past 20 years. As a result, doctors are seeing more patients with metabolic syndrome, a cluster of cardiovascular disease and diabetes risk factors.

McBride co-directs a comprehensive clinical preventive cardiology program with more than 20 professional staff members. The program includes inpatient and outpatient cardiac rehabilitation, one of the United States’ first preventive cardiology and cholesterol clinics, and a diabetes prevention program.

“There’s a bevy of medical literature that says diet and exercise can be just as effective as medication in treating and preventing illnesses,” McBride says.

While most doctors agree on the importance of nutrition education for patients, some disagreement remains about who should provide patients with this kind of counseling. With the New England Journal of Medicine reporting that the average medical office visit lasts 18 minutes, many physicians may feel they don’t have the time, or expertise, to make nutrition recommendations.

Partnering With Dietitians

Lisa Hark, a nutrition expert and director of the Nutrition Education Program at the University of Pennsylvania School of Medicine, advises medical students to shadow a dietitian and for residents and doctors to partner with nutritionists who can help guide their patients in making smart lifestyle choices.

Hark, a registered dietician who holds a doctorate in education, has partnered with Dr. Darwin Deen, a family physician and professor of family medicine at the Albert Einstein College of Medicine, to write several books, including The Complete Guide to Nutrition in Primary Care, that help clinicians counsel patients on diet and lifestyle. The book offers practical guidance on nutrition counseling in the office setting and nutritional recommendations throughout life.

Doctors can use such resources to build a team approach to nutrition education in their practices.

“There are so many resources out there to help doctors,” McBride says. “In many cases dietitians are underutilized.”

“If you are a primary care physician, for example, you are going to get all kinds of questions about nutrition, many of which you may not be able to answer if you haven’t had appropriate training in nutrition,” Neff says.

In this case, physicians need to be able to turn to a registered dietician.

“As busy professionals, [physicians] may not—or probably will not—have the time to keep up on all the literature, and so a dietician, who will keep up on the nutrition literature for you and counsel your patients, that is a really important relationship to have.”

The issue of reimbursement has also been an obstacle in promoting nutrition education among physicians. While in¬surance companies don’t readily reimburse physicians for preventive nutrition counseling, McBride says he has had suc¬cess in working with insurers directly.

“I’ve found many insurers who are very interested in the concept of preventive education and are willing to provide reimbursement for programs that benefit health outcomes,” he says.

Nutrition Begins in the Medical School Cafeteria

Over the years, medical schools have discovered that students become more interested in nutrition when they see how it applies to their own lives. In addition to their classroom nutrition studies, medical students at UW are served a hot buffet-style lunch that meets nutrition guidelines and demonstrates a healthy eating plan.

McBride says these meals show students that healthy food can also taste good, and that moderation is key. Students also learn by logging the food they have eaten over a two-day period in a computer program that tells them how closely their selections match the national food pyramid. Some studies have shown that doctors who make improvements in their own eating habits are more likely to give good nutrition ad¬vice to their patients.

“We also teach our students to ex¬amine their eating habits through the eyes of a person who may have diabetes or high cholesterol to see where they might make dietary changes,” McBride says.

At Gundersen Lutheran Health System in La Crosse, Wisconsin, nutrition is simplified through a healthy eating program called the 500 Club, coordinated by registered dietitians and recommended by physicians. In the hospital cafeteria and throughout the region, grocery stores, vending machines and restaurants carry selections with the 500 Club logo. Those selections contain 500 calories and 15 grams of fat or less.

Doctors and medical residents at Gundersen use the 500 Club brochures when talking to patients about dietary changes. The medical center’s Winning Weighs program complements the 500 Club selections with 12-week programs offering practical dietary advice.

The Future of Nutrition In Medicine

With research showing that lifestyle interventions can be very powerful, often reducing the need for medications, more patients are turning to their doctors for nutrition advice.

“It’s important for physicians to start the nutrition conversation with patients, even if they ultimately refer them to a dietitian,” says Jo Ann Carson, a professor of clinical nutrition at University of Texas Southwestern Medical School, who holds a doctorate in nutritional science. “Most patients view their doctor as a trusted source of information, and they do pay attention to their [doctor’s] recommendations.” Even patients who are on prescription medications can benefit from sound nutrition advice.

“Sometimes prescribing a pill can seem easier than finding out the sources of saturated fat in a patient’s diet,” Carson says. “But learning your patient drinks five sodas a day and suggesting they switch to water can have a significant impact on their overall health.”

With the CDC reporting that 1.7 million Americans die and 25 million are disabled each year by chronic diseases caused or made worse by unhealthy lifestyles, the need for medical students to learn lifestyle medicine has never been greater.

“It’s so important to help patients understand how their daily habits and practices can impact their health and quality of life,” Carson says. “Showing them how to make good nutrition choices and lifestyle changes is often the best medicine.”

Resources

The American Society for Nutrition encourages nutrition education for physicians-in-training through awards and support materials. www.nutrition.org

The American Journal of Lifestyle Medicine is a compendium of prevention-focused, peer-reviewed research that reaches 20,000 physicians every other month. ajl.sagepub.com

The Nutrition in Medicine series is a comprehensive guide to nutrition designed to educate medical students about key health issues. The series is based on the nationally acclaimed nutrition curriculum developed at the University of North Carolina at Chapel Hill. www.pogohealtheducation.com

The book Food and Nutrients in Disease Management (CRC Press, January 2009), developed for doctors by Hopkins-trained Dr. Ingrid Kohlstadt and written by 64 doctors and experts, addresses 60 recurrent and chronic medical conditions where food and nutrients have proven to be beneficial. Recipients of the Nutrition Academic Award came up with a 65-page curriculum guide that includes coverage of nutrition counseling, clinical nutrition care, pediatric nutrition, hypertension and a host of other topics. www.nhlbi.nih.gov/funding/training/naa/curr_gde.pdf