Response to the 2011 Question of the Year
Medical nutrition therapy was once prominent in the armamentarium of physicians. In 1920, the Presbyterian Hospital in New York City could provide 54 unique therapeutic diets, a number typical of any major hospital at that time.1 The selection included 4 typhoid diets, 5 nephritic diets, and 10 gastric diets. Such diversity is no longer necessary. For example, peptic ulcers, then treated by selecting from among 5 therapeutic diets, are today treated with pharmacotherapy. Notwithstanding such therapeutic advances, accumulated evidence has allowed diet to retain a prominent role in medical practice guidelines for prevalent conditions including hyperlipidemia, diabetes, obesity, and hypertension. Patients expect and trust nutrition advice from their physicians, yet few patients receive such advice. Physicians face distinct barriers. These include limited time, reimbursement, and training, but not lack of interest.2 To preserve their time, physicians often delegate nutrition to allied health professionals. Doing this is prudent, but it does not absolve physicians from responsibility for nutrition, particularly when diet contributes to the cause and treatment of common conditions. The lack of time may be a result of inadequate reimbursement and training as much as congestion of the calendar. Reimbursement will improve somewhat under the Patient Protection and Affordable Care Act of 2010, which supports healthful diet counseling for adult patients with risk factors for diet-related chronic disease. Thus, inadequate nutrition training may become the only limiting barrier to physician engagement in this aspect of patient care.
Space in the medical school curriculum for nutrition is limited, and efficient use of learners' and faculty time demands that the curriculum be current and relevant to the needs of the population. Physicians today may go through their entire careers without encountering classically presenting nutrient deficiencies such as beriberi (caused by a diet of unenriched white rice) or pellagra (a diet of corn, molasses, and pork fat). In the 21st century, beriberi is more likely to present in a patient with previous gastric bypass surgery, and pellagra in a patient treated with isoniazid. Yet curricula include (and assessment covers) historic presentations of these diseases, often while other modern presentations are neglected. Updating context alone is not sufficient. Prevalence must determine priority. The population derives more benefit from physicians who can skillfully apply the DASH (Dietary Approaches to Stop Hypertension) diet to reduce blood pressure, effectively teach carbohydrate counting to manage diabetes, and encourage therapeutic lifestyle changes to better control hyperlipidemia than from physicians who can describe the symptoms of pantothenate (vitamin B5) deficiency, detail the difference between kwashiorkor and marasmus, or explain the no-longer-available Schilling test for diagnosing vitamin B12 malabsorption (all of this knowledge continues to be examined, as evidenced by inclusion in the popular guide, First Aid for the USMLE Step 1 [McGraw-Hill, 2010]). While an arsenal of 54 therapeutic diets, as was typical in 1920, is now superfluous, deft application of a few is still important.
Nutrition nestles comfortably into biochemical pathways learned during the basic science years, but it must reemerge during clinical training. Too often, nutrition training resembles pre-Oslerian medical education: Students acquire facts but have not the faintest idea how to apply them. Like other clinical skills, proficiency in nutrition and diet counseling is best acquired by working alongside experienced clinicians. Unfortunately, a dwindling number of physicians receive adequate training to teach the art and science of nutrition. For example, in 1990, 1,752 physicians were members in the American Society of Parenteral and Enteral Nutrition. By 2009, the number dwindled to 634.3 A similar decline in physician membership has occurred across all nutrition societies and in the number of physicians taking nutrition board exams (only 29 physicians in the United States passed any nutrition board exam in 2009).3 The public should be concerned that physicians-in-training do not consistently receive effective nutrition education. A recent summit addressed this gap and repeated the call for a nutrition physician expert at each academic health center.3 My institution, the University of Colorado School of Medicine, is fortunate to have several physicians on staff with nutrition expertise. The effects are tangible: Medical students have bestowed teaching awards for the series of nutrition lectures; ongoing research on diet adds freshness to the subject of nutrition and health; and the presence of a pediatric nutrition fellowship program demonstrates that a career in nutrition is feasible.
By training and hiring physician nutrition experts, academic health centers foster opportunities to trim the vestiges of a previous era and reinvigorate the context and content of nutrition in medical education.
1 Carter HS. Diet Lists of the Presbyterian Hospital. 2nd ed. Philadelphia, Pa: Saunders; 1920.
2 Kolasa KM, Rickett K. Barriers to providing nutrition counseling cited by physicians: A survey of primary care practitioners. Nutr Clin Pract. 2011;25:502–509.
3 McClave SA, Mechanick JI, Bistrian B, et al. What is the significance of a physician shortage in nutrition medicine? JPEN J Parenter Enteral Nutr. 2010;34(suppl):7S–20S.