Feature Research / September 2019
New systematic review reveals world-wide deficiency of nutrition education in doctor training

A study entitled 'Nutrition in medical education: a systematic review' has been published this month in The Lancet Planetary Health. The study looks at medical students' experiences with nutrition education, pulling together findings from 24 studies (both qualitative and quantitative) from around the world, including the US, Europe, the Middle East, Africa, Australia, and New Zealand. The study also considers the viewpoints of medical educators, and offers some insight into how things could be improved.

What this study acknowledges...

The authors recognise that 11 million deaths each year result from dietary factors. They acknowledge that poor diet is the single leading cause of death worldwide, and that this is even more burdensome than cigarette smoking.

The authors also point out that, over the past half century, diets low in fruits and vegetables and high in fats and salt have contributed to the "growing burden on health care, population health systems, and, increasingly, on Earth systems."

The study also recognises that health-care services should play a major role in supporting healthy eating among populations, and that doctors themselves have a highly important part to play in this respect. In many countries too, doctors are expected to be able to provide effective nutrition care- in other words, to counsel their patients so as to effectively manage nutrition and lifestyle-related chronic disease.

The authors state that doctors therefore require "adequate nutrition knowledge, skills, and attitudes to support the integration of nutrition care into routine clinical practice."

The authors also point out that, in order for doctors to be effective members of a multi-disciplinary team, they must also be able to recognise when referral to another health professional (e.g. a dietitian) is required, so as to offer more advanced nutritional support. Adequate nutrition education is needed to support this process as well, so that doctors can be confident in their decision-making around referrals.

According to a study commentary recently published in The Lancet by Stephen Devries (executive director of the non-profit Gaples Institute for Integrative Cardiology) :

"Patients generally rely on their physicians for guidance and there is ample evidence that physician discussions of diet make a positive impact on patient dietary choices."

Despite the need for physician involvement in nutrition care, the medical nutrition education literature has told a different story over the past 50 years. Internationally, the literature has consistently pointed out that graduating medical students report dissatisfaction with nutrition education,  and that they feel ill prepared to support dietary behaviour change among their patients.

What this study found...

The studies reviewed consistently showed that "nutrition is insufficiently incorporated into medical education, regardless of country, setting, or year of medical education. "

Importantly, a lack of education in this area was shown to greatly impact students' knowledge, skills, and confidence.

The studies similarly revealed that medical students "do not feel prepared to manage situations in which definitive nutrition therapy has the most potential to affect patient outcomes."

The collective findings are very clear in showing that, despite wanting to receive nutrition education, graduating students are not given enough support so as to be able to provide high-quality, effective nutrition care to patients.

According to study findings, medical directors and faculty also believe that the amount of nutrition education provided to students is insufficient.

Commentary by Devries in The Lancet states:

"In defiance of the obvious need for physicians to possess, at minimum, solid foundational skills in clinical nutrition, medical education in nutrition across the globe is decidedly lacking."

"Previous research has shown that keen interest in nutrition among incoming medical students typically wanes by the time of graduation. It is easy to imagine why. When medical students do not see nutrition substantively incorporated into their curriculum and do not observe clinical mentors incorporating nutritional interventions into their care plans, what else can they conclude but that nutrition is not as important as they had once believed?"

Where to from here?

According to the study authors, although various countries or individual medical programmes have done better in terms of integrating nutrition into undergraduate curricula, this is often discretionary. There are still factors that greatly limit the advancement of nutrition education in medical schools around the word, including curriculum crowding and scarcity of nutrition advocates.

Nutrition competencies must be established, according to the authors. More allocated time for nutrition education and skill-building is needed, and in a variety of teaching formats. This must be prioritised and purposefully integrated within medical curricula, and strong institutional commitment to such changes must be evident.

The authors state that:

"the required level of nutrition knowledge [for medical students] should be established as a global benchmark for universities."

"The potential for shared learning on advancement in medical nutrition education among countries with comparable tertiary education systems, continuing medical education, language of delivery, and health-care needs of the population suggests that a joint strategic approach would promote uniform content and could minimise duplication of effort and resources."

The authors also suggest that students should be supported to learn about their own personal health and diet as they progress through the medical programme, and about "theory and practice of behaviour change relating to diet and lifestyle."

They point out too that students should be adequately supported to understand the environmental and climate implications of various eating patterns, and they advocate for the alignment of global standards in medical nutrition education with the findings of the 2019 EAT-Lancet Commission report, which emphasises the importance of plant-based eating in helping to mitigate our current global health and climate crises.

Finally, the authors call for innovative curriculum initiatives and research efforts that inform the planning and design of improved nutrition education.

Commentary by Devries in The Lancet states:

"The obstacles to delivering meaningful nutrition education appear to be similar on every continent studied—a perceived lack of interest and expertise among faculty members in nutrition, low-quality nutrition curriculum that did not appear to be prioritised, and few examples of nutritional counselling during clinical years to serve as models for emerging physicians."

"Promising approaches include integration of nutrition-related topics in lectures on disease pathogenesis and treatment, self-paced online curriculum, teaching kitchens, and greater utilisation of inter-professional education. Identification and training of clinical mentors in nutrition is a key challenge."

"Our patients deserve much better. And so does our planet."

Collectively, it is clear that despite the centrality of nutrition to healthy lifestyle, graduating medical students are not supported through their education to provide high-quality, effective nutrition care to patients—a situation that has gone on for too long.

-The Lancet Planetary Health 2019

Topic / Medical education

Introduction /
The triple benefit of plant-based eating: health, cost, environment

EAT-Lancet /
Eating in the Anthropocence

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September 20, 2019

Anna de Mello & Jono Drew

Founders, Plant-Based Living Initiative