Incorporating Nutrition Counseling into Lifestyle Medicine

Abstract

Despite considerable evidence that plant-based diets can significantly improve health, medical professionals seldom discuss this with their patients. This issue might occur due to minimal training received in medical education, lack of time, and low self-efficacy for counseling patients about diet. Nutrition and lifestyle change should be considered a core competency for all physicians and health professionals looking for cost-effective ways to improve patient health outcomes and reduce nutrition-related chronic diseases. Strategies for health professionals to acquire nutrition counseling skills in medical training and clinical practices are discussed.

This paper provides recommendations for developing efficient training and multidisciplinary team practices helping patients, clinicians, and allied health professionals with evidence-based decision-making regarding nutrition counseling.

Plant-based diets (PBDs) have been associated with weight loss, ¹ a lower diabetes prevalence, ² and a reduced risk of cardiovascular diseases. ³ In the current issue, Jakše and colleagues ¹ presented the long-term sustainability of PBD’s beneficial effects, such as reductions in body mass and fat. Although a continuously growing body of evidence supports the health advantages of PBDs, the latest findings in this area have not found their way into clinical practice. ⁴ Nutrition counseling is often not included in medical training and is often not considered in medical practice apart from fields where nutritional care is a foundation of treatment (e.g., diabetes and renal failure). ⁵ Most medical trainees possess inadequate nutrition knowledge and low self-efficacy for counseling patients about diet. ⁶ However, numerous specialties have a clear link to nutrition. For example, proper nutrition and lifestyle modification can provide a 72% reduction in cardiovascular events. ⁷ Still, family medicine or cardiology postgraduate programs do not have any formal nutrition-related requirements for program completion. ⁵ This suggests the need for nutrition to be a core competency in medicine in order to treat multiple chronic diseases. ⁸

Translating evidence into clinical practice is a complex issue involving the consideration of the best available nutrition evidence, patients’ values and preferences regarding lifestyle changes, and abilities and resources to make the changes that may influence their outcomes. ⁹ Such a task requires training to increase physician competence and healthcare team approaches to reduce physician burnout. This paper will provide recommendations for developing efficient training and multidisciplinary team practices for helping patients, clinicians, and allied health professionals with evidence-based decision-making regarding nutrition counseling.

Curriculum Modification

In the past decade, medical education has seen significant changes with the development of new curricula, pedagogies, and forms of assessment. ¹⁰ However, even with the recent emphasis on competency-based curriculum and diverse clinical experiences, medical schools have struggled to deliver students with 25 h of nutritional education, the minimum recommended by the National Academy of Sciences (NAS) set in 1985. ¹¹ A common concern expressed by medical schools is the lack of faculty explicitly trained in nutrition. ¹² Also, many medical students have concerns about the lack of time to focus on nutrition education due to the already onerous medical curriculum. ⁶

Basic understanding of nutrition among medical students may be achieved by requiring an undergraduate introductory course in nutrition for medical school admission, just as other science courses are required by the Association of American Medical Colleges (AAMC). For example, multiple medical school committee members have indicated that students matriculating to medical school with a nutrition-related degree have a strong background in the nutritional sciences and are an asset to their colleagues. ¹³ While majoring in nutrition may not be required for pre-med students, adding a nutrition course to the AAMC’s required course list would enable students to better understand nutrition, how nutrition influences health, and the role of nutrition in providing medical care.

At the medical school level, registered dietitian nutritionists (RDNs) can be influential in instructing medical students on evidence-based dietary patterns for health promotion. ¹⁴ This interaction facilitates medical students learning how to effectively counsel patients on lifestyle behaviors, about the role of RDNs in the healthcare team, what expertise RDNs offer, and how medical nutrition therapy provided by RDNs benefits patients. Training medical students can be in the form of community cooking demonstrations, where students can gain experience counseling patients on nutrition while simultaneously understanding social determinants of health. ¹⁵ RDNs can also aid in integrating a fruit and vegetable prescription (FVRx) program as part of a mentorship program with the students. ¹⁶ The mentor–mentee program, including a culinary medicine service-learning activity, would enable students to understand upstream factors at the community level that influence fruit and vegetable consumption. Developing this perspective would benefit medical trainees’ professional development. As interprofessional communication between physicians and RDNs increases, physicians may be more willing to refer their patients to RDNs for medical nutrition therapy, improving the quality of patient care and patient outcomes. ¹⁴

Another mechanism to increase medical trainees’ understanding of nutrition is to incorporate nutrition and nutrition counseling techniques into residency programs. A recent study demonstrated that nutrition education curriculum during internal medicine residency is associated with a greater frequency of dietary counseling, independent of nutrition education received during medical school. ¹⁷ This highlights the need for nutrition education during residency training to create change and encourage physicians to discuss nutrition with their patients. The American Academy of Family Physicians has an excellent outline of suggested nutrition-related competencies. ¹⁸ Making nutrition education and counseling a required component of continuing education of physicians at regular intervals can ensure continued competency to provide evidence-based nutrition-focused care to their patients. ¹⁹ These courses can be field-specific, as modeled by the Enhanced Recovery After Surgery (ERAS) initiative. ²⁰

Creating Multidisciplinary Team

Integrating lifestyle changes, such as PBDs, into a patient’s regular lifestyle and achieving long-term adherence requires a physician to provide long-term social support, tailor instruction, and consider the role of social norms (e.g., cultural and economic factors) and the food environment (e.g., food availability and accessibility) in maintaining behavioral patterns. ²¹ It is challenging for a physician to complete such a task single-handedly in a short session. ⁸ A multidisciplinary team approach is critical to alleviating much of the burden for the busy clinician. ²² RDNs can provide ongoing support, education, guidance, and cooking demonstrations. There is a common concern that PBDs will cost more, so educating patients that the converse is true is essential. For patients with limited financial resources, social workers can connect patients with community and government resources to increase access to healthy, plant-based foods. Psychologists or counselors may help to facilitate behavior change strategies for behavioral patterns resistant to change.

Multidisciplinary approaches to nutritional care are increasingly emphasized and recommended. ²² However, creating such a team might not be possible in every clinical setting. Practitioners should be prepared to address some of these barriers by establishing a framework for increased contact and referrals to outside recourses. Clinicians may guide their patients by recommending specific tools and support services, including psychologists, group counseling, community organizations, or family members. ²³ Clinicians can also provide a list of resources, such as recommended documentaries, books, podcasts, or smartphone apps. ²³ Additionally, clinicians can develop a community map highlighting food access programs (e.g., food pantries and community gardens), grocery stores available in the community, and clinical and community resources that are low cost and/or typically covered by insurance plans. ⁸ Collectively, these resources are critical to increasing patients’ likelihood of successful dietary adherence.

Conclusion

Nutrition is clearly a significant predictor of human health, and physicians would benefit from a better understanding of how to help their patients make sustainable health-promoting dietary changes. There are numerous barriers patients face in changing their diets, but multidisciplinary teams and providers, who have had adequate training on the diverse skills needed to help patients make these changes, are likely to see significant improvements in patient outcomes. Over the past 20 years, the medical literature in the US has highlighted the importance of improving nutrition training in medical education and the benefits of working collaboratively with other disciplines. Despite these calls, there has been slow progress in this area. Although the barriers to these changes occurring are beyond the scope of this commentary, this area remains a source of opportunity to further promote health at both the individual and group level. Finding innovative ways to actually adopt these long-standing principles will not only have a clear benefit for healthcare providers but also for the patients they serve.