The need for nutrition education in med schools

It is depressing how often people laugh when I mention that I am trying to teach doctors about nutrition. The scant amount doctors learn about nutrition has been an embarrassment for at least 120 years. In fact, W.G. Thompson, a famous medical educator, complained about it in the introduction of his medical textbook on nutrition in 1895.

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Not only are we doctors poorly educated in nutrition, but there is a serious absence of funding to properly answer some of the most important questions that all nutrition specialists are being asked. The result is an unremitting epidemic of obesity and a multitude of preventable nutrition-related diseases on the one hand, and "experts" promoting opinion as fact, guidelines that are moving targets, and a public expecting to be able to rely on nutritional supplements as magic cures on the other.

The fact that obesity is one of the most devastating health crises we have recently faced is no secret. Recent estimates put the incidence of being overweight in the U.S. at near 70 percent, and obesity (medically significant overweight) above 35 percent of adults. Obesity was already adding an estimated annual $147 billion and approximately $1,500 per person to medical costs in 2008. Add a slew of diseases believed to be preventable by proper nutrition, and our healthcare system cannot afford not to find solutions and train practitioners in effective nutritional interventions. Research has already shown that overweight patients were more likely to be aware of their obesity and to have attempted weight loss if their physician had discussed it with them, but only 45 percent of overweight people report that their physicians had done so.

The ability of doctors to counsel patients on nutrition has only gotten worse. In a recent survey, physicians reported that fewer than 25 percent felt competent to discuss diet and exercise, and that fewer than one in eight visits included nutritional counseling. The most recent survey on nutrition education in medical schools, which is being done every five to six years, found that only 25 percent (down from 30 percent in 2006) of medical schools provided a required nutrition course, and that students received on average 19.6 hours of nutrition instruction (down from 22.3 hours in 2004). The next survey is being compiled. I am not optimistic. The National Academy of Science has recommended that students receive a minimum of 25 hours of nutrition-related content during the four years of medical school.

While there has been little progress, there are significant efforts underway. Notably, there are two bills before Congress which if passed will be an excellent start toward better physician education in nutrition. The Education and Training (EAT) for Health Act, H.R. 4378, requires six hours of annual continuing education in nutrition for primary providers employed by the federal government. The Expanding Nutrition's Role in Curriculums and Healthcare (ENRICH) Act, H.R. 4427, establishes a grants program for medical schools to incorporate nutrition into the curriculum.

Following on the heels of these bills is the recent release of a white paper by the Bipartisan Policy Center, in partnership with other health-promoting organizations, which summarizes the justifications and offers specific recommendations for incorporating more nutrition into medical curricula. With strong supportive documentation like this, the House bills have an even better chance of passing. But, in the event the bills fail, at least we have powerful updated guidelines.

Grants for nutrition curricula are not a new idea. The 1997 Nutrition Academic Award established similar funding, as well as a consensus guideline on what should be included in the curricula; it resulted in an initial increase in nutrition content in medical curricula, but was only active for five-year periods. As evident in the surveys quoted above, nutrition content has waned since the program ended. Without funding, who is going to insure nutrition curriculum is present in medical curricula? Much of the content of medical school curricula is developed and taught by people with multiple other responsibilities, and without remuneration. Many of my colleagues who direct medical school nutrition curricula across the country tell me there would be no nutrition in the curriculum in the absence of a passionate volunteer. This is obviously not sustainable.

Clinical nutrition continues to diminish its own credibility by insisting on denying the weaknesses in the research upon which we base our recommendations. I am too often embarrassed to have to explain why we have changed our mind about dietary recommendations (again), because we sounded so certain when we promoted the last set of recommendations. Proper nutrition research is difficult, expensive, and takes years and thousands of subjects willing and able to comply with the intervention. Most nutrition recommendations are based on observational or epidemiological research, which is easier, less expensive and can be accomplished in shorter order, but cannot establish cause and effect relationships.

It is time we start talking about how much we don't know, while distinguishing between proven fact and our educated guesses when offering our recommendations. Otherwise, we risk continuing to inflate people's expectations of our abilities to provide durable targeted nutrition recommendations, and risk continuing to ruin our credibility while diminishing the perception that more research funding is needed.

In the face of a catastrophic and financially crippling nutritional epidemic, with little understanding and too few effective solutions for these problems, even what we do know is not being taught. We need funding to properly and durably answer the important questions. How do we combat obesity? What are the other dietary interventions that will reduce disease? How do we effectively help our public change diet and exercise habits? And we need funding so we can teach what we do know to our most impactful practitioners. It should be self-evident that the benefit to society resulting from solving these devastating problems and teaching the solutions — the improvements in health and quality of life — will certainly justify the cost.

Seres, M.D., is associate professor of medicine in the Institute of Human Nutrition, director of the Nutrition Curriculum at Columbia University College of Physicians and Surgeons, and a Public Voices Fellow with the Op-Ed Project. He is this year's recipient of the Excellence in Nutrition Education Award from the American Society for Nutrition.