Nutrition needs to be taught in medical school

The study of medicine can be overwhelming.  We’ve simply discovered too much for one person to master completely.  This is the challenge medical educators are tasked with – what’s so important that it must be allotted time in the brief 2 years of dedicated book learning doctors-to-be receive?

Students face a similar time-management challenge – first, we must decide what’s important enough to focus on, but the real question I think we wind up asking ourselves is this:  is it worth it to study this if no one will test me on it?  We quickly learn that things not emphasized in a particular course are typically not represented on the exams administered (at least not in a way that can hurt us).

Nutrition is, and will continue to be, a controversial and evolving aspect of medicine – but I also consider it to be one of the most fundamental.  So, why then, don’t doctors know about nutrition?  Because no one is teaching us.  The approximate time devoted to nutrition science over the first two years of my medical education is a measly 6 hours – that’s only two hours more than an average day of lectures at my institution.

A 1985 report commissioned by the National Research Council concluded the following:

“The teaching of nutrition in most U.S. medical schools is inadequate. . . All students should be given a course or its equivalent in the fundamentals of nutrition during the same years in which other basic sciences are offered.”

I’m afraid the commission would reach the same conclusion today.

During the brief period of my education dedicated to diet, we were instructed to use an online food log for a day and analyze the results.  It had a clumsy, cumbersome interface that was difficult to navigate – this is coming from someone who’s not bad with computers.  Most people didn’t even complete the exercise – now, do you think they’ll use that tool with their patients in the future?  I recommended FitDay.com and NutritionData.com, which I’ve written about in the past, as alternatives for this exercise in the future, but the instructor wasn’t interested.

I have a friend who is a medical student and I joke that he can barely manage to feed himself – he goes for days without adequate calories, then binge eats; and I assure you, the type of food he eats is as bad as his pattern of eating.  I have another friend who thought there was the same amount of sugar in a serving of vanilla yogurt versus plain.

And even when we do know what’s right and wrong, we often make poor choices ourselves – why should our patients listen to us?

We may study biochemistry and what happens to the components of food we eat, but we study very little about dietary choices and how to advise our patients.  In the hospital, we consult the dieticians when we need to make decisions about what exactly to feed our patients.  When patients ask us questions about diet and nutrition, we often deliver vapid, cookie-cutter answers that (rightfully) go in one ear and out the other.

This is absurd.  We are in the middle of an obesity epidemic that’s not only making us sick as individuals, but weakening us as a nation.  Nutrition is intimately involved in the pathogenesis, and sometimes (but not often enough) treatment, of chronic disease.  I hope this is one aspect of medical education that is reformed in the near future, because I feel it’s hurting us in ways we may not even recognize.

James Haddad is a medical student who blogs at Abnormal Facies.

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  • Anonymous

    I couldn’t agree more. I am a nurse and can assure you that nutrition is lacking in our education as well. I used to rely heavily on the dietitians in the hospital to evaluate my patients for nutritional deficits and make recommendations for specific diets. The physicians were typically agreeable to almost anything they suggested. Which is good but indicates that they really didn’t know either.

    Curriculum needs to change and I think it is, but as a snails pace.

    Thanks for the post!

    Renee Thompson, MSN, RN
    renee@rtconnections.com

  • http://pulse.yahoo.com/_3CY2U67646G7UIAHBQVTT2UP4Y Kristy S

    I was taught a bit about nutrition when I was in school to become a Medical Assistant, but that was only one chapter in the book that we had to work with.  That isn’t even enough to help further the education of the public about the best food/dietary choices to make in order to stay healthy.

    • http://abnormalfacies.wordpress.com/ Abnormal Facies

      It’s true, primary education is lacking in this area as well, but that’s another issue entirely.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Nutrition should be taught in medical school. It more importantly needs to be taught in middle school and high school. Due to budget constraints and teaching to the tests that are now a way of life in education, health education and home economics courses have become extinct in most areas when the population is getting heavier , less healthy and far more health illiterate than in the past. We need to re introduce these courses to young adults in their formative years and to health professionals at all levels.

    • Anonymous

      Bingo. Why not teach the people who are going to use the information? There is nothing complicated about eating healthy that any grade school child would not be able to understand. It would also be more cost effective than using the physician community for this monumental task.

      • http://abnormalfacies.wordpress.com/ Abnormal Facies

        Absolutely agree with both of you – but the misconception remains, patients think their doctors are well-versed in nutrition.

  • Angelea Bruce

    As a dietitian, I was dismayed, very dismayed, by the announcement from CMS the other day that they will now reimburse doctors and nurses to dispense weight loss advise, but not dietitians.  This blog post says it all.

    • Anonymous

      That was a very strange decision. Not very cost effective either.

    • http://www.facebook.com/people/RIchard-Feinman/100002248386290 RIchard Feinman

      Doctors, nurses and dietitians should be reimbursed for success. Dispensing advise is, as LeoHolmMD says, not cost effective.  One might go further and suggest that we have a crisis because neither the ADAs, AHA, NIH are accountable.  

  • Anonymous

    From another RD’s perspective:  It isn’t necessary to teach nutrition practice to physicians as long as you have nutrition professionals who specialize in nutrition assessment/education/research etc (called Registered Dietitians).  The problem is that physicians/nurses/PA’s regularly dispense advice (usually bad advice) to clients who don’t even realize that these professionals have little- to- no nutrition background.  The absolute best thing a physician can do when a patient requests nutrition information is to send that person to the RD for current, reputable and individualized education. 
    I agree with Angelea that the CMS decision is quite disturbing.  This sort of thing is exactly why I stopped paying dues to the ADA– they just aren’t cutting the mustard when it comes to advocating for RDs.

  • http://www.facebook.com/profile.php?id=644340872 Misty Nikas Elwood

    I am continually dismayed at the lack of knowledge of my family doctors about nutrition and our bodies’ ability to use whole nutrients to a heal a myriad of illnesses.  Not surprising are the beliefs and attitudes of my peers, that drugs have a more important place in health and healing than the basic components of the foods we eat.  The lack of nutrition education from an early age does a severe disservice to young people, and I agree with other posters that we need to get this fundamental subject back into schools.  Unfortunately, and this being my own personal view as a citizen and a parent, I believe nutritional guidance passed down by our government agencies is flawed and influenced by large food corporations, putting the interests of human health after profits.  As a parent, I know it is up to me to provide sound information to my child and follow my instincts – knowing that sometimes I will be at odds with the advice of my health care professional, fellow parents and most people I meet.  As if parenting isn’t challenging enough already. 

    • http://abnormalfacies.wordpress.com/ Abnormal Facies

      You hit the nail on the head, Misty.  In the end, it doesn’t matter who you are at odds with, the health of you and your children is most important.

  • Anonymous

    Fantastic article, but what do you propose to teach?  From my readings, nutritional science is becoming more and more faith oriented instead of science oriented, even among professionals. As a result, disagreements turn more evangelical, and the public who desperately need good advice don’t know where to turn.

    Do some searching on YouTube and there are many MD’s advocating low carb dieting to the disdain of the camp that advocates calorie restriction to the disdain of the group that advocates moderation and exercise.  Do we believe the advice of Dr’s Gott, Lustig, Atkins, Vernon et al, or Dr. Oz, Dr. Ancel Keys, et al and legislated nutrition advice that suggests a slice of pizza can count as a vegetable?

    So yeah, teach nutrition in med school through first grade…but maybe some time needs to be put into critically examining what we currently know (or think we know) while we are at it.

    • Angelea Bruce

      That’s the beauty of using registered dieitians: we are bound by ethics to teach patients only evidence-based information.  It’s not hip and we tend to sound like broken records, but we have been taught to evaluate, and reevaluate, claims based only on the best scientific evidence available. 

      • http://www.facebook.com/people/RIchard-Feinman/100002248386290 RIchard Feinman

        Evidence-based information.  Whose evidence? In a court of law, there are standards and a judge decides admissibility.  Registered dietitians are registered by a court that is judge, jury, prosecutor and defense attorney.  I tried to simply initiate a dialogue with New York chapter of American Dietetic Association, never mind introducing evidence.  They won’t even answer my emails. I don’t see that the organization even looks at the best scientific evidence.

    • http://www.facebook.com/people/RIchard-Feinman/100002248386290 RIchard Feinman

      mojonelli is right on.  We need some kind of critical examination of the problem.  I do teach nutrition to first year medical students as part of metabolism and we do tie in practical things to eat as a reflections of underlying biochemistry which, at least for diabetes and metabolic syndrome means carbohydrate-restriction.  And there is a good deal of disdain from people who may themselves have never studied nutrition but sit on the ADA and AHA boards.  My students understand what I teach and ask “what do they say?” meaning these self-appointed experts.I point out that “they don’t talk to me.  There is no dialogue.”  “But,” they say “what about the data.  What do they say about the data.” I have to admit that they can simply ignore the data because they largely control the study sections and editorial boards… and teaching. By the time they graduate my students know that if they recommend a low-carbohydrate diet they will have to do it themselves and suffer the disdain of the ADA. If they turn the patient over to a dietitian, they won’t have to worry about it although the patient will be in the hands of someone who must follow ADA guidelines and tell a person with diabetes “it is Ok to eat sugar as long as you cover it with insulin.”  Do they really say that?  They do. So, great to teach nutrition in medical school but who will teach it? Dr. Oz?  Who taught him nutrition? Oprah?

      I have suggested to many people that we need to reduce the “two worlds” effect and get everybody in the same room and even have a panel of scientists who are not tied to nutrition to evaluate all the data. I have simply suggested co-authoring papers that would even define what particular diets are. Anybody who wants to seek some cooperation on nutrition and what we should teach in medical school can contact me.  feinman@mac.com

      • Anonymous

        Thank you, Richard, for the work that you do. I think what you propose is sorely needed.

    • Melissa Carroll

      So not true – there are a number of scientific, evidence based journals as well as providers out there that base treatment on scientific evaluation. I worked in the field for ten years and I know there are some strange things out there, but it is NOT the standard and there are avenues available to learn science based nutritional approaches. Nutrition is the fundamental building blocks of our biochemistry and should be addressed, but most physicians don’t have the training. The information can be found in scientific journals everyday. The hard part is keeping up with it. Resources are available, yo just have to be willing to do some additional training.

      I suggest you look a little deeper.

      • Anonymous

        Thanks for the thoughtful response.  Out of curiosity, what’s not true? The notion that “nutritional science is becoming more and more faith-oriented instead of science oriented”, or the idea that more time and energy needs to be put into “critically examining what we currently know (or think we know)” about nutritional science?

      • http://www.facebook.com/people/David-Brown/692744221 David Brown

        Most of America’s registered dietitians are misinformed(1) about saturated fats and omega-6s due to the influence of big food on academia and government. Here’s how I think it works. The International Food Information Council Foundation, with
        it’s massive funding and aggressive educational agenda, generates a lot
        of inertia in terms of resolving nutritional controversies. I really
        don’t think the food companies aim to make people fat and sick. But
        they feel obliged to protect their interests and they have to
        play by the rules. Of course, its governments that make the rules. And it’s
        academia that informs governments. Unfortunately, its the industrial food system
        that informs academia. It’s a sort of information feedback loop that inhibits progress.

        Consensus of opinion has it that saturated fats are bad because they raise LDL cholesterol. Well, high carbohydrate intake raises LDL and also diminishes particle size to boot. But who worries about that? Certainly not the American Dietetic Association – at least not yet.

        Really, careful analysis of the research suggests that saturated fats are benign over a wide range of intakes as long as they are consumed in the context of adequate supportive nutrition. Moreover, any effect saturated fats may have on cholesterol levels (and the effect is really quite small(2) compared to the effects of other dietary components) is purely physiological, not pathological, and likely beneficial(3).

        References
        1. http://www.huffingtonpost.com/justin-stoneman/post_868_b_720398.html
        2. http://www.theheart.org/article/1267163.do
        3. http://www.eurekalert.org/pub_releases/2011-05/tau-cn050511.php

  • Karen Friend Smith

    James – thanks for sharing from your perspective. It’s going to be such a challenge to get everyone back to the basics, but it all starts by starting the conversation. Good work! – http://www.thekitchenskinny.com 

  • http://nonmaleficence.wordpress.com Nonmaleficence

    It was a requirement to take a course in nutrition at my medical school. I agree with you, I think this should continue and should be emphasized. Medical students will only truly learn something if they will be tested on it (or pimped by an attending in the hospital)
    What may be even better than emphasizing nutrition in medical school, would be public education on this subject. This could be in the form of commercials/advertisements and public awareness.
    As a current medical student, I have MUCH more time to sit and talk with a patient as compared to the resident or attending. I always take the time, especially when he/she has been diagnosed with diabetes, HLD, etc, to educate that patient on healthy choices of foods. Too many times I’ve had to tell that diabetic patient, yes orange juice is good for you, but drinking a liter of it for breakfast is causing extreme hyperglycemia in the morning. This is simply a public education problem that should be instituted before the patient comes to the doctor with the problem.

  • Anonymous

    Yep.  Haddad said it well.  We do a lousy job.  And we don’t do much better during residency training.  Mea culpa – I’m a professor of surgery.  Now, some of us are trying.  The American Society for Parenteral and Enteral Nutrition (ASPEN) is right now putting together a basic course in nutrition for residents – and for students.  Should be out in a year or two.  For you students out there, look for it and take it.  Even if you’re residents by then.  We’ve also worked with other organizations on improving the curriculum in medical schools for the last 20 years, but let me tell you, it’s an uphill battle.  There’s no Department of Nutrition to protect its turf, there are few physician nutrition specialists, and it’s hard to pry loose even a few hours in medical school curricula.
    And to all the RD’s out there, you do a great job.  But docs need to know this stuff as well.  That said, and as Angela Bruce points out, the CMS decision is just nuts.  We’ve an epidemic of bad nutrition out there, and we’ve just dis-enabled the largest group of experts.  Crazy.  

  • Angelea Bruce

    I’d like to add that the CMS ruling implies that dietitians are not part of the primary care team.  This is simply not true.  Every JCAHO-accredited hospital is required to have RDs on staff and we are bound by ethics to practice medical nutrition therapy, in any setting, under the direction of, and in coordination with, the patient’s physician.  In fact, the only reason there are not more RDs practicing in outpatient clinics or primary care settings is because of the lack of reimbursement – otherwise we cost the organization too much money and patients are not consistently willing or able to pay for our services.  

    Of course, proper nutrition is a key component of preventative medicine and would save millions, if not billions, of dollars in annual healthcare costs if implemented appropriately, but the government and insurers and healthcare corporations are only looking at the quarterly bottom line and have come to the conclusion that reimbursing a dietitian for their services is a waste of money.

  • http://twitter.com/DrLindaND Linda Lambert

    Nutrition is taught in medical school…..Naturopathic medical school.  I completed no less than six medical nutrition classes and use nutrition as one of several naturopathic modalities to treat patients. 

    I am constantly amazed that my MD and DO brethren do not focus on something so basic to human health but I do understand the limitations of the private insurance and Medicare systems.

  • Patrice Garrick

    It’s comforting to know that you feel this way. As a lupus patient, most of the nutritional adjustments I have made have been due to my own common sense, not my doctors’ recommendations. I hope things change. Thanks for writing this article.

    • http://abnormalfacies.wordpress.com/ Abnormal Facies

      Thanks for your feedback Patrice.

  • Patrice Garrick

    It’s comforting to know that you feel this way. As a lupus patient, most of the nutritional adjustments I have made have been due to my own common sense, not my doctors’ recommendations. I hope things change. Thanks for writing this article.

  • Tracy Krulik

    Great post. It’s reassuring to know that some of the next generation of doctors see things clearly. We’re moving in the right direction at least.

  • http://twitter.com/LittlePatient Haleh

    You are so right.  Nutrition is fundamental- sometimes the very thing that is the key to an illness. And doctors can’t learn everything.  I believe the solution lies in cooperative medicine.  The worst thing a doctor can do is pretend he knows it all.  Doctors should work hand in hand with nutritionists and other health experts.

    Haleh Rabizadeh Resnick, Speaker and Author of Little Patient Big Doctor
    http://www.littlepatientbigdoctor.com

    • http://abnormalfacies.wordpress.com/ Abnormal Facies

      Well-put, thank you.

  • http://profiles.google.com/molly.ciliberti Molly Ciliberti

    As a nurse, I had a full year of nutrition including basic, specific for diagnosis such as Diabetes. I was shocked that my husband had no nutrition education at the medical school he attended. You are what you eat.

  • Anonymous

    This is why naturopathic doctors like the Hippocratic saying, “Let your food be medicine and medicine be food.” Virtually every one of our diseases of “Civilization,” would be greatly alleviated by eating actual food, rather than processed foodstuffs.  In the old days, rich people retreated for a few weeks or months to spas on mountains or lakes, got plenty of fresh air and excercise, drank water instead of wine, and ate wholesome food, and regained their health after the social season. Who among us wouldn’t benefit from that today? Where are the “Betty Ford” clinics for the nutrition-related chronic conditions like diabetes and obesity?

  • http://abnormalfacies.wordpress.com/ Abnormal Facies

    Good to see you, David.