Many patients in my primary care practice feel judged when their after-visit summary lists “morbid obesity” (ICD-10 code E66.01). Given the number of conditions associated with obesity, it may be startling to know some activists object not only to the stigma often attached to large body size but also to the pathologization of fat. Obesity’s complex present reflects its complex past. Indeed, the obesity epidemic itself has a history. It is typically said to have begun in 1998, when the National Institutes of Health (NIH) revised the upper limit of a normal body mass index from 27.8 kg/m2 for men and 27.3 kg/m2 for women down to 25 kg/m2 for everyone. This brought the United States into line with World Health Organization definitions while promoting 29 million Americans from “normal” to “overweight” overnight. Yet, when the American Medical Association adopted Resolution 420 declaring large body size a disease in 2013, it did so against the advice of its advisory committee. The history of nutrition isn’t just interesting, it is important for understanding how we reached a time when dieticians struggle to be recognized as certified professionals in a market crowded with “nutritionists,” and patients ask their doctors about weight-loss medications from advertisements. Meanwhile, many physicians cannot offer more specific advice than “eat less, exercise more” and struggle to set realistic weight-loss goals with patients, but insurance companies will pay for bariatric surgery if providers label patients “deathly fat.”

How did we get here, and how do we improve trainee competence in nutrition? As Frantz, et al, explain, the mismatch between doctors’ perceived role as experts in nutrition and the proportion of medical training devoted to it dates to at least the 1950s.1 Medical schools trained mostly male physicians, while the mostly female field of dietetics developed a parallel track for what are now registered dietician [nutritionists] (RD[N]s). In the 1980s, clinical nutrition enjoyed brief popularity, when the new technology of total parenteral nutrition (TPN) promised to support patients undergoing extensive surgery or debilitating chemotherapy. Simultaneously, the most commonly cited guidelines for nutrition instruction in undergraduate medical education were devised: the Committee on Nutrition in Medical Education (1985) and the American Society of Clinical Nutrition (1989) recommended 25-30 and 37-44 contact hours, respectively. However, the risks of blood clots, bloodstream infections, and liver damage tarnished TPN’s reputation as a panacea and (temporarily) diminished the demand for specialized nutrition training for doctors.

There were renewed efforts in the 1990s. For instance, the National Heart, Lung & Blood Institute and the National Institute of Diabetes and Digestiveand Kidney Diseases granted Nutrition Academic Awards to 21 medical schools to create shareable content.2 One of the most successful was the Nutrition in Medicine (NiM) project at the University of North Carolina, which disseminated 29 free, interactive cases for medical students, first on CD-ROM in 1995 and later via an interactive website (www.nutritioninmedicine.org). These were followed by Nutrition Education for Practicing Physicians modules for residents and fellows. In-depth (post) graduate medical education in nutrition became available when The Intersociety Professional Nutrition Education Consortium, founded in 1997 and likewise funded by the NIH, developed training standards and an independent board certification for Physician Nutrition Specialists®.

Even while the influence of diet and exercise on body size, shape, and composition has garnered increasing public attention after 2000, regulatory and grassroots interest in medical training in nutrition seems to have diverged. Most U.S. and Canadian medical schools have not met the benchmark of 25 hours, especially in the crucial clinical years.3 In 2013, the Association of American Medical Colleges declined to require nutrition as a competency for graduation. The NiM project ended in 2017 with its funding, and the online content so often touted in the secondary literature is inaccessible since the third-party Flash browser plug-in required to access it was discontinued at the end of 2020. While just a dozen, unaccredited fellowships in clinical nutrition exist today, multiple bills and resolutions have been proposed in the U.S. House of Representatives over the last decade to urge “meaningful training” in the subject (e.g., EAT for Health Act [unpassed] and HR 1118 [passed 2022]). Trainees are clamoring for more exposure to nutritional education,4 writing letters to journals,5 and rearranging their schedules to take electives such as the one I created.

“Medical Nutrition: Past & Present Theories & Practice” includes multiple modes of both synchronous and asynchronous instruction—lectures from experts, student research presentations, group activities, and readings for discussion—that can be accomplished in person or online. (I teach it remotely.) Each week is dedicated to a different topic: 1) general principles of (adult) nutrition and the so-called lifestyle diseases of diabetes mellitus, hyperlipidemia, and hypertension; 2) pediatric nutrition from breast- and formula-feeding of infants to disordered eating in adolescents; 3) obesity medicine, bariatric surgery, and the Health At Every Size® anti-dieting movement; 4) surgical nutrition, including peri-operative management of food and drink and artificial nourishment via tube feeds and TPN. The syllabus blends clinical knowledge on screening, diagnosing, and treating nutrition-related conditions with their sociocultural and historical background, for instance the popular but debunked “African gene theory” of hypertension. Students receive tips for counseling their future patients and practice skills such as calculating IV fluid rates. And the course encourages the kind of interdisciplinarity rarely seen in MD and DO training programs: guest instructors include not just physicians and surgeons but nurses, dieticians, social workers, historians, and/or patients. We want to impress upon students both the importance of nutrition to the current practice of medicine and demonstrate the complexity of the subject to motivate life-long learning.

During the unfunded pilot, 17 fourth-year students enthusiastically debated the health benefits of butter versus margarine, walked to their local non-grocery store to prepare a meal on a strict budget, and filled the Zoom chat with comments when their classmates presented on fad diets. My colleagues have confessed that they wished that they had had the opportunity to take such as course. Afterward, 100% of students somewhat agreed (41%) or strongly agreed (59%) that the course had enhanced their clinical skills, and 100% somewhat agreed (24%) or strongly agreed (76%) that it had enhanced their historical knowledge. They found the course equally relevant to their foundations of clinical knowledge courses (e.g., anatomy, 59%), foundations of clinical skills (e.g., interviewing, 71%), other medical school electives (e.g., anesthesiology, 53%), and professional enhancement electives (e.g., POCUS, 41%). 47% and 53% found the pilot more relevant than other electives and opportunities (unpublished data).

A working group of both trainees and faculty is now bringing this educational innovation to multiple medical schools as “Hungry for Nutrition in Undergraduate Medical Education: An Elective Course in Knowledge, Skills, and History.” Thanks to an internal faculty grant, we will analyze pre- and post-course survey data on both knowledge and attitudes, and we will collect “lessons learned” from the implementation process. Challenges so far have included finding time in an already jam-packed four-year curriculum; recruiting guest lecturers, especially at smaller or non-academic centers; and agreeing upon a standard set of course objectives and a metric by which to measure whether they have been met. Sometimes it feels as though we are re-inventing the wheel of nutrition education despite decades of literature arguing for its importance to the health and lives of both patients and practitioners. We will eventually offer interested teachers this vetted syllabus of topics, readings, learning objectives, discussion questions, and student projects that can be adapted in whole or in part, either as a stand-alone elective or integrated into existing rotations (e.g., outpatient medicine). But our efforts will remain just one more curricular intervention among many unless and until competency in nutrition is mandated by curriculum committees, accreditation bodies, and licensing organizations.

References

  1. Frantz DJ, et al. Current perception of nutrition education in U.S. medical schools. Curr Gastroenterol Rep. 2011 Aug;13(4):376-379. doi: 10.1007/s11894-011-0202-z.
  2. Van Horn L, et al. Advancing nutrition education, training, and research for medical students, residents, fellows, attending physicians, and other clinicians: Building competencies and interdisciplinary coordination. Adv Nutr. 2019 Nov 1;10(6):1181-1200. doi: 10.1093/advances/nmz083.
  3. Bassin SR, et al. The state of nutrition in medical education in the United States. Nutr Rev. 2020 Sep 1;78(9):764-780. doi: 10.1093/nutrit/nuz100.
  4. Leggett LK, et al. A suggested strategy to integrate an elective on clinical nutrition with culinary medicine. Med Sci Educ. 2021 Jul 6;31(5):1591-1600. doi: 10.1007/s40670-021-01346-3.
  5. Xie JY, et al. Nutrition education in core medical curricula: A call to action from tomorrow’s doctors. Future Healthc J. 2021 Mar;8(1):19-21. doi: 10.7861/fhj.2020-0207.

Issue

Topic

Advocacy, Clinical Practice, Health Policy & Advocacy, Medical Education, Medical Ethics, SGIM

Author Descriptions

Dr. Ehrenberger (ehrenbergerka@upmc.edu) is assistant professor of Medicine and Pediatrics at the University of Pittsburgh School of Medicine and associate editor for medical history of the Journal of General Internal Medicine.

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