Wednesday, September 17, 2014
Saturday, September 13, 2014
Doctors Need to Learn About Nutrition
Doctors Need to Learn About Nutrition
Tricia Ward, Stephen R. Devries, MD
September 04, 2014
theheart.org | Medscape Cardiology: What prompted this commentary?
Dr. Devries: It's been clear to me for some time that nutrition
has not been high on the radar in clinical cardiology. I know from my own training
25 years ago that I received essentially no education in nutrition in 3 years
of internal medicine residency and 4 years of cardiovascular fellowship
training. Unfortunately, despite the knowledge gained in the interim about the
link between nutrition and health, very little has changed regarding the
paucity of nutrition education over the past 25 years.
It struck me as a peculiar paradox that clinical practice
guidelines highlight the primary importance of nutrition and lifestyle, yet the
physicians who are expected to implement these guidelines receive absolutely no
education in these areas during their residency and subspecialty training.
It seems hard to imagine that current accreditation guidelines in
cardiology, for example, outline very detailed requirements regarding
procedures, yet don't mention a word about nutrition. As I go around the
country speaking to this point, the reaction is an incredulous "How can
doctors not be required to learn about nutrition?"
Two years ago, I transitioned from a full-time academic practice
to become director of an educational nonprofit, the Gaples Institute for
Integrative Cardiology. One of our primary goals is to create a space for
nutrition education within all levels of medical training programs. This new
paper emerged as one of our efforts to emphasize the role of nutrition in
medicine.
theheart.org | Medscape Cardiology: What is the relationship
between the authors of this paper -- do they represent a particular body or
group?
Dr. Devries: Our goal was to bring together as broad a group of
physician educators as possible to help strengthen the message. My own work
over the years has involved critically evaluating the evidence for nutrition
and lifestyle practices, and the authors include many of the individuals I have
collaborated with along the way. My personal belief (and a guiding philosophy
of the Gaples Institute) is that we can best improve health care and the
patient experience by bringing together the wisdom of passionate experts who
may not normally be in dialogue with each other. Accordingly, the authors of
this work include highly published academicians, natural health advocates,
preventive cardiology researchers, directors of residency programs, and a
former medical school dean.
theheart.org | Medscape Cardiology: Are you advocating any particular
type of diet?
Dr. Devries: We're not aiming to promote a particular diet --
which is reflected in the diversity of authors, many of whom have slightly
different takes on an optimal diet. Our message is much bigger: Let's give
nutrition and lifestyle the attention they deserve in medicine. The goal is to
create a space that doesn't currently exist for nutrition in medical training
and practice.
And despite the diversity of opinions regarding diet, it's
important to recognize there is a great deal of common ground: the need for
greater consumption of vegetables and fruit, preferred intake of whole grains
over refined, and avoidance of sugar-sweetened beverages.
theheart.org | Medscape Cardiology: Why do physicians need to
learn about nutrition when there are dietitians? Can't they just refer patients
to the experts?
Dr. Devries: I'm glad you raised that point. First of all, it's
important to acknowledge that nutrition is a group effort and that patients can
benefit from a wide range of health experts -- including dietitians,
nutritionists, and nurses -- to help with dietary concerns. And certainly it's
not realistic to expect that doctors will be able to take the time for detailed
nutritional tasks, such as making daily meal plans, especially for those with
complex nutritional needs.
Nevertheless, a solid foundation of nutritional knowledge will
empower physicians to emphasize to patients that nutrition is a priority, and
to encourage patients that the food-based "medicine" they consume is
just as vital to their health plan as their medication. When it is apparent
that nutrition is a priority for the doctor, it becomes a greater priority for
the patient. Making that point doesn't take a lot of time.
Our goal is to leverage maximal impact from the physician's
limited time. If only 15 minutes is slated for a return clinic appointment,
devoting as little as 1 or 2 of those minutes to nutrition would be a huge
advance from the status quo. Spending a couple of minutes to encourage
vegetable and fruit intake or to discourage sugar-sweetened beverages is time
well spent. And for those who need more extensive counseling, an appropriate
referral is ideal -- and probably have all the more impact if the physician has
already "premedicated" the patient to appreciate the importance of
nutrition.
theheart.org | Medscape Cardiology: You state that nutrition is
arguably more relevant to physicians than organic chemistry. How would you like
to see it integrated into medical training?
Dr. Devries: The comment we made in the paper about organic
chemistry pertained more to the undergraduate requirement for medical school.
Although written a bit tongue-in-cheek, it referred to an article written by
Drs. Dalen and Alpert[3] in which the importance of nutrition was compared with
that of organic chemistry as a preparatory class for entrance into medical
school. The idea is that we could begin to marinate future physicians with
knowledge of nutrition early in their careers -- information undoubtedly more
relevant to their future medical practice than that gained from organic
chemistry.
theheart.org | Medscape Cardiology: What would be the timing and
context of this education?
Dr. Devries: Currently, an average total of 20 hours is devoted to
nutrition education in 4 years of medical school, and much of that time is
dedicated to the biochemistry of nutrients and to rare nutritional deficiency
states. Unfortunately, the little nutrition knowledge gained in medical school
is typically extinguished in later clinical years because it is not reinforced.
Our recommendation is that a meaningful curriculum in nutrition be
in place throughout medical training, from the basic sciences in medical
school, to early clinical training, and extending into residency and
subspecialty programs. Identifying clinical nutrition mentors is a challenge,
but one that can only be addressed by a push for more nutrition education --
including education to train the trainers.
theheart.org | Medscape Cardiology: Are you also recommending a
continuing medical education requirement?
Dr. Devries: Absolutely; continuing education in nutrition is
essential. Looking back at just the past year, key studies have been released
on nutritional topics ranging from the Mediterranean diet, all the way to the
cardioprotective properties of both blueberries and nuts. Keeping current in
clinical nutrition science through continuing medical education is one of our
key recommendations.
theheart.org | Medscape Cardiology: One of the frustrations for
healthcare professionals is the seemingly conflicting data on nutrition. How
can these professionals be assured that they are up to date with the evidence
base?
Dr. Devries: That's a great point. Consumers and health
professionals alike are understandably confused by seemingly conflicting nutrition
studies. The problem is fueled by dramatic headlines in the lay press with new
"breakthrough" studies that contradict previous findings. Seeing past
the headlines -- and most important, the ability to place the new information
into context on the basis of previous knowledge -- requires a solid foundation
of nutrition education that doesn't currently exist.
theheart.org | Medscape Cardiology: What can current medical
students and practicing physicians do to improve their nutrition knowledge and
counseling skills?
Dr. Devries: There are some innovative nutrition educational
programs that we referenced in our paper. The Gaples Institute also has some
useful information on our site and is working to develop much more.
theheart.org | Medscape Cardiology: Are there novel strategies --
group patient education, for example, or standardized diet-assessment tools --
that are effective and can save time in an already crowded physician visit?
Dr. Devries: The use of a previsit diet questionnaire saves time
and can be extremely helpful for evaluation of the baseline diet and to track
changes. Working with the patient to identify 1 or 2 especially relevant
dietary goals to be followed-up at the next visit is particularly helpful.
theheart.org | Medscape Cardiology: In June 2014, there was a white paper[4] from the Bipartisan Policy Center, American
College of Sports Medicine, and the Alliance for a Healthier Generation on
teaching nutrition and physical activity in medical school. Do you have any
plans to coordinate efforts with these groups, or do you see your paper as a
call to action for others to enact upon?
Dr. Devries: Our paper was intended to spotlight the deficiency of
nutrition education in medical training, but it's only the beginning. We are
also working hard to remove the obstacles to greater utilization of nutrition
in medicine, including accreditation and reimbursement issues. The Gaples
Institute has met with leaders in the US Congress, the American College of
Cardiology, and many other key stakeholders to help shape the future of
medicine and realize our vision of making nutrition a cornerstone of medical
care.