Abstract
A poor-quality dietary pattern is a leading risk factor for chronic disease and death in the United States, and the costs of medical care continue to unsustainably rise. Despite this reality, nutrition training for physicians fails to adequately prepare for them to address the complex factors that influence diet-related disease. Expanding nutrition education for physicians-in-training is imperative to equip them for the growing demand of food is medicine services and is also supported by recent policy efforts in the United States as well as the governing bodies of graduate and undergraduate medical education. A multisector approach that links graduate medical education, clinical care delivery innovation, and health and food policy experts provides momentum to advance nutrition education as a core strategy for food is medicine expansion globally.
Critical Role of Nutrition in Health
The leading risk factor for death in the United States and globally is a poor diet.1,2 A nourishing diet rich in fruits, vegetables, legumes, nuts, seeds, whole grains, herbs and spices, however, can prevent and treat many costly chronic diseases.2-8 In addition to health benefits, improving dietary quality on a large scale has profound implications for increasing healthcare costs. Experts conservatively estimate that the annual cost related to cardiometabolic deaths from poor diet is over $50 billion, 9 making diet-related disease a leading driver of healthcare spending.
Recent research demonstrates the utility of food is medicine services 10 to lower healthcare costs. These services respond to the connection between food and health by helping to prevent and treat diet-related disease, such as produce prescriptions, medically tailored meals and groceries, and population-level programs that coordinate food access and culinary nutrition education. 11 For example, Blue Cross Blue Shield (BCBS) North Carolina demonstrated that providing $60 worth of healthy food twice monthly reduced food insecurity and improved health indices including body mass index and self-reported physical and mental health. 12 Participants who completed the 6-month program saved BCBS $139 per member per month, translating to savings of $8.5 to $13.1 million annually. Another study reveals a broader scope of possibility, including evidence that national implementation of medically tailored meals for people with diet-related health conditions and impaired ability to perform activities of daily living in the United States could avert 1.6 million hospitalizations and save over $13 billion in health care expenses in 1 year. 13 A recent produce prescription program study for people with diabetes and food insecurity showed potential to dramatically reduce cardiovascular disease events, add quality-adjusted life years, and promote health system and societal cost savings. 14 While there remains much to learn in terms of ideal populations, implementation strategies, and dosing, using food alongside traditional health interventions appears promising.
Focusing on nutrition interventions thus can improve both health and economic outcomes. However, the traditional lack of emphasis on nutrition education in both undergraduate (UME) and graduate medical education (GME) in the United States neglects this vital strategy for cost-effective health.15-17 Physicians-in-training need evidence-based, clinically relevant nutrition education to equip them to provide patients with accurate information within their scope, refer to registered dietitian nutritionists (RDNs), and promote the importance of nutrition in health, including advancing the science of food is medicine interventions. In many cases, RDN services are not covered by a patient's health insurance without a referral from a physician. Inclusion of nutrition education, particularly with interprofessional partnership, has been shown to increase physician awareness of the role and skillset of RDNs, expand referrals to RDN colleagues, and advance interprofessional collaboration.18-22
Past Efforts and Inadequate Progress
Efforts to improve nutrition education for physicians began nearly 3 decades ago, but progress has been slow and inadequate, without widespread adoption, consistent standards, or integrated strategies.18,19,23-25 While many calls for nutrition education focus on UME, insufficient action 15 necessitates engagement in GME. Tailored education within GME is particularly important for developing the skillset needed for delivering evidence-based nutritional guidance to the physician-in-training's specific patient population. 20 Physicians need to work alongside dietitians, guiding patients through confusing messaging and combatting misinformation with evidence-based nutrition advice. A framework for GME approaches can be tailored by specialty and focus on population-specific application. Ideally, this would build upon basic competencies in UME, developing a continuum of competency-based nutrition education.
The State of Nutrition Education in Graduate Medical Education
Evidence suggests that residents pursuing various specialties feel ill-equipped to provide nutrition counseling to patients.26,27 A cross-sectional survey of medical, surgical, and obstetric interns at 6 programs evaluated preparedness to handle clinical cases requiring nutrition knowledge and found that only 29% of interns felt adequately prepared, and higher preparation correlated with more training during medical school. 28 Vetter and colleagues similarly found that while 94% of internal medicine (IM) residents believed nutrition counseling to be essential, only 14% felt adequately trained. 29
Lack of adequate nutrition education is particularly problematic for cardiologists, given the impact of nutrition on cardiovascular disease, the leading cause of mortality. The 2019 American Heart Association/American College of Cardiology Guideline on the Primary Prevention of Cardiovascular Disease emphasizes lifestyle therapies as primary treatment, 30 but most cardiologists feel unprepared. In 2017, a survey of 646 cardiologists revealed that while 95% believed discussing nutrition information to be part of their role, only 10% felt adequately prepared. 31 The application to many other specialties including primary care, 32 gastroenterology, 33 endocrinology, 34 and critical care 35 is clear, demonstrating widespread opportunity for GME nutrition innovation.
Positively, a study of IM and obstetric residents demonstrated that elective training in obesity, nutrition, and physical activity counseling significantly increased both self-efficacy and positive attitude scores toward counseling. 36 Evidently, most graduating medical students are not equipped to manage common nutrition scenarios, but clinically relevant education successfully bridges the gap.
Intersection with Health Policy
The intersection of nutrition education with health policy is increasingly important as policymakers recognize the burden of diet-sensitive disease and the need for relevant physician education. In May 2022, the U.S. House of Representatives enacted a bipartisan resolution (H.R. 1118) calling on UME and GME programs, as well as federal agencies, to take steps to ensure more meaningful nutrition education. 37 The resolution highlights the economic implications, as the federal government bears much of the cost of diet-related disease in the form of Medicare coverage, while the Medicare program also provides the majority of funding for GME.
In September 2022, President Biden convened the White House Conference on Hunger, Nutrition and Health and announced a national strategy to end hunger and reduce the burden of diet-related diseases in the United States by 2030. 38 The plan highlights nutrition education for health professionals as a key priority but falls short of outlining specific steps. With collaborative guidance from nutrition scientists and experts, this sets the stage for medical education leaders to take strategic action.
To advance nutrition education and maintain oversight of the approach, educational leaders have an opportunity to collaborate with policymakers. Recognizing the impact of policy levers, the team at Harvard Law School's Food Law and Policy Clinic compiled an extensive report outlining potential strategies. 39 In the section focusing on GME, the authors propose that the Accreditation Council for Graduate Medical Education (ACGME) could amend its accreditation standards in the Common Program Requirements to require nutrition education, reaching over 135 000 residents and fellows. However, Common Program Requirements are intentionally broad, necessitating simultaneous attention to specialty-specific requirements tailored to specific patient populations and practice settings. Successful curricular change will require educational champions, dedicated time, and implementation of both acute and long-term strategies. The report 39 articulates other strategies for nutrition education expansion in GME, including addition of meaningful nutrition-related testing material on licensing and board exams.
Investing in physician nutrition education to advance prevention and food is medicine interventions has potential to reduce healthcare expenditures, especially costs borne by the Medicare program. Government investment in nutrition education—including strategies such as provision of incentive payments to UME or GME programs with high quality nutrition education or grant funding to support scalable nutrition education approaches and curricula—thus would have high predicted return on investment. Most boldly, as described in the report and echoed by H.R. 1118, the federal government could condition GME funding on the inclusion of nutrition education in the residency curriculum if other strategies are insufficient.
Emerging GME Approaches and Future Directions
In response to these recent events and the growing chorus calling for reform, the ACGME, in partnership with Association of American Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM), hosted a Summit on Nutrition in Clinical Practice in March 2023. 40 Summit attendees included nutrition education expert panelists alongside leaders from Residency Review Committees, specialty-specific boards, and physician and RDN organizations. During this historic gathering, passionate nutrition educators and scholars presented a compelling case for the why of nutrition education and the vital need for enhanced awareness. The group made thoughtful progress to define the what and the how, emphasizing collaboration to advance universal core competencies and assessment measures.
Many are already exploring strategies to better equip learners to address diet-sensitive disease and to prepare for potential educational requirements. Educators share common concerns, including limited time, need for intersection with social determinants of health and health equity promotion, and the importance of sharing existing resources to reduce the up-front investment needed for nutrition education. Many educators have already developed innovative curricula to teach nutrition in a variety of formats ranging from workshops to community settings to teaching kitchens and culinary medicine models that promote nutrition education alongside practical skills and personal well-being.41-44 Table 1 provides an overview of notable examples. These existing tools and curricula merit further study for both replicability and overlap with competency measures.
Representative examples of common types of nutrition education.
Advancing the bold goals of the House of Representatives resolution and White House Nutrition Conference 38 necessitates multifaceted, multisector strategies and requires alignment of nutrition education efforts with high quality research, innovative clinical practice, and equity promotion. We encourage GME leadership to explore resident and faculty perspectives, seek and train institutional faculty champions, and map a course for filling the gaps to equip the next generation of physicians, scientists, and innovators. The time is more than ripe.
Conclusion
The rising rates of illness linked to diet, as well as growing evidence in support of food is medicine interventions, necessitate increased knowledge of nutrition among physicians. US policymakers in Congress and the White House have shown support for these changes, making this an opportune time to demonstrate leadership from the UME and GME sector. Ensuring baseline nutrition education of physicians can ensure patients receive correct nutritional information, achieve an understanding of how important nutrition is to health, receive referrals to RDNs for in-depth nutrition guidance, and access a growing range of food is medicine services. It bears repeating that in many cases, access to RDN services or food is medicine supports require a referral, making it essential to educate physicians about when referrals are warranted. Each stakeholder in this space can help to make change: medical students or residents can ask their institutions for relevant coursework; GME or UME programs can support faculty in developing new course offerings or can establish nutrition education requirements; ACGME or the equivalent UME accrediting body (eg, the Liaison Committee on Medical Education) can implement competency requirements for accreditation; policymakers can create new incentives or restrictions in the funding streams for public support for medical education. Each step helps ensure more physicians are prepared to understand the importance of nutrition and have the tools to best serve their patients within the current landscape.
Footnotes
Acknowledgments
We want to acknowledge the many passionate medical educators who have laid the foundation for the advancement of this vital work. We are grateful to ACGME, AAMC, AACOM for robust engagement at the Nutrition Summit, inspiring the need to summarize the state of the field in this piece. We are indebted to the passionate registered dietitian nutritionists (RDNs) who have long held the torch of nutrition work and we look forward to continuing our interprofessional collaborations.
Author contributions
The authors have all made significant contributions to this work. JA and EBL conceptualized this paper. JA completed a literature review and developed an outline. BA wrote an initial draft of the manuscript. JA and EBL revised the manuscript. All authors approved the final version.
FUNDING
The authors received no financial support for the research, authorship, and/or publication of this article.
DECLARATION OF CONFLICTING INTERESTS
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
