Physicians do not receive adequate training in nutrition

As an MD, nutritious and healthy cooking and eating are very important to me.

We as physicians do not receive adequate training in nutrition, healthy lifestyle choices, and disease prevention in general while in medical school or in residency.  On top of that, we work long and difficult hours, often overnight shifts during which we consume processed, fatty foods, void of any nutritious value and we find ourselves suddenly with an extra butt cheek and elevated cholesterol levels and we ask, “how did that happen?”

I remember being the resident in the intensive care unit.  I always carried around about 3 snack bars, a pack of Swedish fish and those hospital graham crackers in my pockets.  Making rounds on each critically ill patient seemed to go on forever and when the attending physician (my boss) wasn’t looking, I’d shove an entire snack bar in my mouth praying both that he/she wouldn’t notice and that I avoided aspirating any contents into my own lungs which would put me in a similar position as the patients I was caring for.

Throughout the day as a resident, I would receive innumerable texts, “it’s Bobby’s birthday today, cake in the treatment room” … or “a patient’s wife dropped off fresh baked cookies on 7, come by quick” … or “drug rep lunch, gnocchi in the conference room.” And so every day, I would make multiple stops to “re-fuel” at these “stations” losing sight of the numbers and types of calories I was allowing myself to ingest.  I would justify my careless consumptive behavior by telling myself I was too busy tending to sick patients and trying to decide what tests to order next or what medication to discharge them on, and too busy amidst the constant pages from nurses and my interns and too tired having been up since 5:30 am and now it being 2 pm with another full 17 hours to go.  So, it was okay that at 3 AM on call in the intensive care unit, I was shoveling (literally with a fork in one hand and a spoon in the other) buttery noodles drenched in marinara sauce topped with a crispy chicken parm delivered from across the street straight into my mouth.  But it wasn’t okay.  It was the opposite.  I, like the majority of my colleagues, was a hypocrite.

I spent the bulk of my day, “educating” my patients both in and out of the hospital that the key to longevity and fighting preventable disease was making healthy decisions with respect to lifestyle, diet and exercise.  And yet, there I was, making the unhealthiest decisions myself.  I was almost as bad as the cigarette smoking pulmonologist who would reek of tobacco and counsel his patients on smoking cessation.

Preventive medicine should be a critical component of medical school and residency training and it is not.  We as doctors focus so much of our effort and energy in this area when educating our patients, which our training so desperately lacks.  And add to this the lifestyle that a resident is expected to lead; with 24-36 hour workdays, under monstrous pressure with people’s lives at stake.  We are just mere mortals after all and at some point like other humans need to fulfill basic human functions like eating, sleeping and using the bathroom.  So how can we be expected to educate our patients on making healthy lifestyle choices when our training has deficits in these exact areas and our own lifestyles are not conducive to practicing what we preach?

These questions motivated me to find answers during my training and led me to take a great interest in nutritional medicine.  As part of an initiative to incorporate nutrition into the internal medicine residency training program, I applied and was selected to partake in a course for resident physicians designed to provide doctors with the tools and knowledge we need to guide patients to make healthy decisions about their lifestyles, specifically how to plan and cook nutritious meals.  In addition to education on nutrition as a medical science and with respect to evidence based research, we participated in kitchen sessions in our city’s culinary institute with instructor chefs who taught us culinary techniques as well as tips for developing nutritious meal plans, the importance of serving sizes and the health benefits of balanced and wholesome food preparation.

I further pursued my great interest in nutrition and preventive medicine by undertaking an extensive research project on the Mediterranean diet specifically deconstructing specific components of the diet, the impact of adherence on mortality, the impact of each element on cardiovascular health and its implementation in a clinical setting.  I delivered this medical conference to my department of internal medicine in New York City as well as the department of endocrinology at the United States Air Force Base.

To me, there is nothing more peaceful or rewarding than creating a healthy meal with fresh ingredients and enjoying it with friends and family.  My blog is part of my effort as a doctor to promote healthy eating.  My hope is that my food-related experiences with respect to my cultural background, and my medical knowledge will serve as a source of information to empower you to make the right decisions when it comes to dietary habits so that you can play an active role in fighting preventable disease.

Solmaz Amirnazmi is an internal medicine physician who blogs at Of Pomegranates and Saffron.

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  • Anonymous

    I thought it was up to the Dietition ?

    • Anonymous

      you know, people reference dieticians, but for all their training, even they generally know very little about gluten sensitivity, except for its obvious effects for full-blown celiac sufferers.  i had one dietician try to suggest that being on the paleo diet would be bad because the body would “forget how to deal with carbohydrates.”  i was gobsmacked.  i did not even waste my time reminding her that fruits & vegetables include plenty of carbs (& fibre & bioavailable nutrition, as opposed to grains).
      it might interest people to know that the italian government itself did a study which concluded that 1 out of every 3 italian schoolchildren should be on a gluten-free diet (no pasta, no bread, all you mediterranean diet fans!).  everyone i’ve ever known who went completely grain-free felt even better than just being gluten-free.  sadly, i have never, ever encountered a physician or a dietician who was educated about these things (thank god i know a biophysicist who is).
      the food pyramid is a dirty lie, & i am living proof.  i do not eat grains, except some white rice (all the phytins are in the hull, so it’s actually not really harmful).  i do not eat beans or lentils but maybe every couple of months.  i eat meat, eggs, fruit, vegetables, tubers, cheese, nuts, & seeds, & i eat tons & still weigh 88 pounds (i’m 5 feet tall with a gracile build, so no, i am far from cachectic).  i used to weigh 103, thought i was adhd, & was very nervous & high strung.  the interstitial swelling & psych symptoms are totally gone.  i encourage everyone who is interested in helping people to eat better to look into this type of diet & recruit the help they need to understand why it works.  the information is out there; it’s too bad that most practitioners in the health care industry are so dismissive of anything they didn’t hear in the mainstream.

  • Anonymous

    I have seen/met so many doctors that are either smokers and/or overweight.
    It is such an irony for health practitioners to physically show how unhealthy ‘they’ are.  There is so much more to treating the sick with medication.  So much can be done with great eating habits and a balanced diet.  I don’t expect to go to a doctor and have him/her tell me what I should or shouldn’t eat, that is for the dietician/nutritionist, but a little preventive medicine could do no harm by simply advising on a healthier route.
    As for how doctors treat their own health, I suppose they do want they can to strive and survive in such a busy, hectic environment.  But it is sad indeed.

  • Anonymous

    While better nutrition education would have been great (ie, more about actual food and maybe less about TPN, infant formula, and nutritional supplements), I think the biggest issue with nutrition is the hypocrisy of our lives as physicians, as you touch upon.  As residents, we spent lots of time providing healthcare and nutrition education to patients, while ourselves eating an erratic diet consisting of little or no “whole food” most of the time.  It goes beyond diet, of course, discussing mindfulness, stress management, and sleep hygiene seemed even more ridiculous to me, working 80+ hours a week, many of those on overnight shifts.  It got slightly better after training, but my life has remained very hectic most of the time.  And the “resident lifestyle” was more pervasive than I realized at the time — it took me years afterward to get back to (usually) eating regular, home-cooked meals, the rest I’m still working on.  At some point, all of us as physicians need to address to start walking the walk, so to speak, and address our own health habits to provide better care to our patients.  I think there’s a limit to how much good we can actually do as care providers, working in the current system that so strongly encourages us to neglect our own health and well-being. 

  • http://twitter.com/Bethsimmons5245 beth simmons

    Yes, nutrition and prevention. Organic and non-GMO. Fruits and veggies. Stay away from sodas and fast food. Get rid of sugar in the diet.

  • Anonymous

    I respect the purpose of the article, and the author is correct. However, physicians need to remember that while they play a major role in healthcare treatment, it is not a one-man-show. Allow the dietician, the nurse, the respiratory therapist, physical therapist be the highly trained experts that they are. Their job is not to simply respond to doctor’s orders.Allow them into your circle as colleagues, not as minions. Physicians have enough pressure just doctoring (and all that comes with it). Stop perpetuating the notion that they have to know everything and let the experts in. The patients will get better, and the docs will be happier. 

    • Krista Arneson

      I agree that referring to other disciplines is important.  When I was a dietetic intern, part of my competencies was knowing when to refer patients.  I would not perform a swallow evaluation on a patient, but I definitely refer that patient to the SLP when I have concerns about swallowing.  That being said, I do understand what a swallow evaluation entails.  I am all for MDs understanding more about nutrition, but am amazed at how many patients that would obviously benefit from diet education (low sodium for CHF, diet for DM) are never referred to someone who can help.

  • http://pulse.yahoo.com/_RITXPVK5FC2SCK73YUQLFIIOUQ stephen p

    this article is spot on. i went to 2 physicians in my area and had to tell tell about vitamin D and folate B-12 levels to get a test….  more research is needed here the docs need more education about this rather than drugs…

  • http://twitter.com/CavemanDoctor Caveman Doctor

    Great article, especially when touching on the hypocracy that so often occurs in medicine.  Multidisciplinary tumor board meal of choice for lunch is often pizza, yet in the same day I preach to patients about eating a healthy diet…  Something has got to change.  Also, looking at food patients are often given when in-house or even the food that many cafeterias in the hospital offer, as physicians, we have have our work cut out for us. 

    One thing to keep in mind when considering the inadequacy of nutritional education we recieve as physicians, is the inadequacy of healthy recommendations coming from the top.  When our governing authorities are pushing recommendations backed by no data, like the food pyramid, while ignoring randomized trials that tell us something totally different when it comes to losing weight, it is an uphill battle, often leaving patients (and physicians) confused.

  • Blair Masters

    If there was a profit in it for the drug companies, MD’s would have the latest research

  • natsera

    I just love the doctors who tell their patients to “watch their diet” which brings me the image of a woman sitting in a chair with her arms crossed, observing her plate!!!! LOL!!

  • http://www.facebook.com/usmanraza1 Usman Raza

    So refreshing to see this coming from the doctor’s side finally. There’s so much more about prevention beyond nutrition that is missing in the medical curricula. I believe the whole paradigm has to change towards health rather than focusing primarily on removing disease. And even more so for low resource settings.

    • http://www.alliswellthateatswell.com/ Solmaz Amirnazmi

      So true.  Just think how wonderful it would be if there were a shift towards a healthcare system focused on disease prevention.  We need to prioritize health promotion and target healthy individuals to proactively participate in their own health, maintaining positive habits to avoid or delay the onset of disease. 

  • http://www.twitter.com/alicearobertson Alice Robertson

    Good on you!  You are a good doctor, but poor capitalist:)  If patients give up their vices….well now….what will that do for the business model?  To be really effective, sometimes it’s means doing the right thing for the patient…..and helping them to help themselves beyond the medicine cabinet (realizing drugs are necessary at times, but people are often able to ditch the drugs when they follow your model).  Instead of developing drugs that make us think we have outwitted our bodies (statins is one that is way overused and not as effective as we are told), you are trying to teach patients to work with their bodies.  I like it!

  • http://www.alliswellthateatswell.com/ Solmaz Amirnazmi

    So great and
    interesting to read all of your comments.  Glad you enjoyed the
    piece.  Both patients and non-patients
    don’t know what the best things are to eat or how to maintain a proper dietary
    balance.  Our culture is more obsessed with losing weight/crash dieting
    than with achieving nutritional health and overall wellness.  We forget
    that by making healthier decisions with respect to diet (and exercise of
    course) that not only will we stay healthier in the long run from a medical
    standpoint, but we will also shed unnecessary pounds.  Sadly, the choices
    that are presented to us in say hospital or school cafeterias (or at the
    various hospital meetings we attend throughout the day) are nutritionally
    inadequate.  The system makes it difficult for us both as doctors in
    training and as health care providers to make proper dietary choices for
    ourselves and to guide our patients to do so.  Lack of time, money and
    easy access are barriers.  I feel strongly that making proper nutritional
    choices is a fundamental step in fighting preventable disease and as such,
    doctors do need training in nutrition.  Of course, the nutritionist,
    dietician and entire medical team play a crucial role in efficiently and
    effectively rendering medical care and we as internists need to utilize these
    expert services.  In an ideal world, every patient would receive
    counseling from a nutritionist but unfortunately this is often not the case as
    we know it is hard enough for most patients to keep up with visits to their
    internists.  And when they do they look to us for guidance.  Merely
    advising patients to “eat healthy” is an abstract concept.  We
    need tangible and concrete material such as a resource for simple and healthy
    recipes (see mine at http://www.alliswellthateatswell.com) or a pre-made shopping list
    with attached recipes and locations of nearby farmer’s markets to distribute to
    our patients.  But first, in order to educate our patients, we as
    physicians need education, which begins at the residency training level so it
    can become smoothly integrated into our culture of medicine.  This was my
    first post in KevinMD and as such I felt it important to address the problem at
    hand- my plan is to delve into solutions in future posts.  A special thank
    you to Dr. Pho for providing such an outstanding forum where we can share and
    bring new ideas to the table in hopes of improving the system for everyone
    involved, care providers and patients!  

  • Anonymous

    Thank you for this worthwhile reading article! We all need to take back our own health by deciding when to say yes or no to the foods in front of us. Food seems to hold such power over us that we often forego our better judgement because of the comfort, ease and pleasure obtained by eating. Moderation and variety of good wholesome foods throughout our day will yield the best health. Moderation, variety and wholesome are the terms we need to correctly define and implement.
    Once again thank you for your article…would love to see more!

    • http://www.alliswellthateatswell.com/ Solmaz Amirnazmi

      Thanks so much for your kind comments.  Indeed moderation and variety of wholesome ingredients are key.  I will be writing more on this in the future and I am so glad you enjoyed the read.