How much does your doctor actually know about nutrition?
Eat more fresh fruits and vegetables. Cut down on sweets and processed foods. Increase consumption of fish, nuts and legumes.
This rudimentary advice has been dished out to the public for decades, yet soaring rates of diabetes, obesity, high blood pressure and other chronic illnesses linked to poor diet – and which increase risks for stroke and heart disease – fail to reverse.
Part of the problem stems from the fact that doctors don't know how to provide information beyond the basics.
Inadequate instruction during medical school, residency and other additional training is a primary reason for this dearth of expertise, according to an American Heart Association science advisory published Monday in the journal Circulation that looked at gaps in nutrition education over the decades.
"Any nutrition education gained is likely to be lost if not reinforced and translated into practical how-to knowledge," the advisory authors write.
Dr. David Eisenberg, director of culinary nutrition at the Harvard T.H. Chan School of Public Health, applauded the AHA report, saying it documents "the total lack of requirement" in most medical schools to understand the practical skills necessary to advise patients struggling with their weight, blood sugar, blood pressure or heart disease.
"It is a scandal that health professionals are not introduced to these facts above and beyond minimal information about nutritional deficiencies in biochemistry, and that these things do not appear on their examinations to become a practicing physician," said Eisenberg, who was not part of the group that wrote the advisory. "Nor are they required on board certification, whether it's to become an internist, cardiologist, endocrinologist – you name it."
Gaps in nutrition education among medical school curricula go back decades, said Dr. Karen Aspry, the cardiologist who chaired the AHA advisory group.
She pointed out that after a 1985 survey of one-third of U.S. medical schools found "inadequate exposure to nutrition and health and disease," the National Academy of Sciences recommended a minimum of 25 classroom hours.
Yet, various studies conducted between 2000 and 2013 found few schools were meeting that goal. The most recent survey, in 2013, found that 71 percent of medical schools provide less than the recommended 25 hours.
"The average number of hours has actually declined to 19 hours. That means this is not keeping up with the recognition that so much obesity and cardiovascular disease is linked to poor nutrition and poor diet quality," Aspry said.
A poor diet was tied to nearly half of U.S. deaths from heart disease, stroke and Type 2 diabetes in 2012, found a study published last year in the Journal of the American Medical Association. "This is a huge problem," Aspry said.
The new advisory found that schools which exceeded the minimum recommended hours of nutrition education did so by integrating the training across the medical school curriculum instead of containing it to a single course.
Several universities have tapped into innovative ways to teach future physicians about how to manage their own diet to build a set of personal tips they can eventually pass on to patients. Schools are incorporating lessons through online, open-access programs, or by turning commercial kitchens into interactive classrooms where students learn about healthy cooking.
Andrew Del Re is benefiting from that kind of innovation. A first-year student at Brown University's Warren Alpert Medical School in Rhode Island, he recently completed a "Food + Health" elective that pairs medical students with culinary arts students from nearby Johnson & Wales University. The course was part lecture – on topics such as healthy cooking on a budget – and part hands-on learning, such as cooking low-sodium meals inside an actual kitchen.
"Becoming a better communicator is also a really big part of the course," he said. "You have to be able to transmit practical knowledge so the patient can leave the office saying, 'OK, now I know exactly what I need to do to live a healthier lifestyle, and change my behavior for the better.'"
Del Re is now leading this semester's Food + Health class with two other student assistants, adding more emphasis on nutrition and diet counseling, and possible ways to customize such lessons to the individual lifestyle of patients.
Other types of nutrition training can be found in medical school electives that focus on real-life lessons, the advisory pointed out. At Boston University, for example, medical students were challenged to limit their weekly food budgets to the amount provided by the state's Supplemental Nutrition Assistance Program formerly known as food stamps.
The report also highlights live continuing medical education courses being offered such as the annual "Healthy Kitchens, Healthy Lives" conference that teams the Harvard School of Public Health with the Culinary Institute of America to help bridge nutrition science, health care, and the culinary arts. Eisenberg created the conference 14 years ago to address "the huge gap" on the topic he and others saw in the medical profession.
Eisenberg also advocates for more medical schools to incorporate teaching kitchens into their curricula to help train the next generation of doctors.
"We've always had anatomy labs, maybe we need teaching kitchens," he said. "Teaching nutrition by giving people lists of facts is not the same as inviting students into the kitchen and having a clinician, a dietitian and chef talk to them collectively about how to advise patients about food choices, shopping, cooking, plating, portion control and the pleasure of food. We forget that at our collective peril because everybody eats."
More information: Karen E. Aspry et al. Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association, Circulation (2018). DOI: 10.1161/CIR.0000000000000563
Renata Micha et al. Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States, JAMA (2017). DOI: 10.1001/jama.2017.0947