A global shortage of nutrition education in medical curricula

A systematic review recently published in Lancet Planetary Health on nutrition in medical education has reported that “nutrition is insufficiently incorporated into medical education, regardless of country setting, or year of medical education”.

The review, conducted by Dr Jennifer Crowley (University of Auckland), Dr Lauren Ball (Griffith University) and Dr Gerrit Jan Hiddink (Wageningen University, Netherlands), aimed to investigate the ‘evidence-practice gap’ between the knowledge, skills and attitudes required to provide nutrition counselling to patients in accordance with some current clinical guidelines, and what is currently being taught to medical graduates – who consistently report being insufficiently trained to do this with any confidence. The authors hope the findings will provide insight into how nutrition education can be improved to meet the needs of future doctors.

The review included 24 studies published between 2013 and 2018. Most of the studies were from the USA (n=11), followed by Europe (n=4), Australia (n=4), New Zealand (n=2), Middle East (n=1), Africa (n=1) and Asia (n=1).

The authors suggest that foundation nutrition education should provide graduates with enough knowledge to engage in behaviour change conversations with their patients. However, their findings indicate that medical students consistently report inadequate knowledge and confidence, whether this is assessed objectively or subjectively.

Medical students themselves saw nutrition counselling as a vital aspect of clinical practice, particularly with high risk groups. They indicated a desire to receive nutrition education to develop their skills in nutrition care and that the current level of what they are taught is inadequate. Faculty’s perception of nutrition education mirrored that of the students. They noted that the time devoted to nutrition education in the medical curriculum was inadequate, as was the content.

According to the authors, medical students perceived their nutrition education as inadequate for a number of reasons including poor integration of nutrition into curricula, absence of priority for nutrition education, absence of faculty to provide nutrition education, poor application of nutrition science to clinical practice, absence of scientific rigour in the teaching curriculum and poor collaboration with nutrition professionals.

The authors propose making an institutional commitment to making nutrition education mandatory, adopting nutrition competencies that universally benchmark what is an adequate level of nutrition knowledge for universities and investing in innovative curriculum as means by which we can support future medical doctors to provide nutrition care and create a primary care workforce that is responsive to the needs of today and the future.

The publication of this review comes at a pertinent time. Globally it is the United Nations ‘Decade of Action on Nutrition’ 2016-20251. The role of nutrition in both human and planetary health, was highlighted earlier this year in the publication of The Lancet Commission on the Global Syndemic of Obesity, Undernutrition and Climate Changeand the EAT- Lancet Commission on Healthy Diets and Sustainable Food Systems3. These publications reflect a growing awareness of the need to address poor diet and nutrition in its broader social and environmental context.

World-wide, 11 million deaths are attributable to dietary factors4. In Australia most of this disease burden is due to excess intake of energy-dense, nutrient-poor foods, excess intake of sodium and inadequate intake of health promoting foods such as, vegetables, fruits and wholegrain cereals5. Worryingly, less than 1% of the population report they eat a diet that is consistent with the Australian Dietary Guidelines5.

GPs are in a unique position to influence patient attitudes and behaviours, to intervene and to recommend or refer as appropriate6. It is estimated that 85% of Australians visit a GP each year and more than a third of Australians visit their GP more than six times per year7. Sixty to 70% of these visits are for lifestyle-related chronic conditions8. Yet any level of nutrition counselling is provided in only 15% of primary care consultations in Australia9. This is despite research indicating that patients want to receive nutrition and dietary advice from their GP10,11. As indicated by this review, this discrepancy appears to be due to a lack of training and confidence in this area. This finding is consistent with previous research9,12-16.

The findings of the review didn’t come as a surprise to those working in the field. Speaking to Medical Republic, Timothy Gill, Professor of Public Health Nutrition and Research Programs Director at the Boden Institute at Sydney University, reflected that “nutrition should be an important aspect of medical training, yet it never gets any attention”. In an interview with healthline, Dr. H. Clifton Knight, Senior Vice President of Education at the American Academy of Family Physicians, stated that the reason for this was because “whenever you add more of something, then you’ve got to take something out”, which is unfeasible considering how important all the materials to be covered in the medical curriculum are. Moreover, it would be simplistic to think that simply including more nutrition education would solve the problem. Short consultation times11,12,17,18, patient-driven agendas18, limitations of compensation or reimbursement11, clear understanding of roles12,13 and practice resources17 are just some of the barriers to the provision of improved nutrition care in general practice.

Nevertheless, as Dr Mark Harris, a key author in RACGP’s Smoking, Nutrition, Alcohol and Physical Activity (SNAP) risk factor framework states in newsGP “It’s not rocket science, but [it’s important for GPs to have some] basic understanding so they can give patients general advice” and to know when to refer the patient on. For this to occur, more needs to be done to integrate nutrition into medical education and potential ways of doing so, such as case-based postgraduate education or online education deserve exploration.

This sentiment is echoed by Dr Chris Ganora, President Elect of the Australasian Society for Lifestyle Medicine and a Fellow of the Royal Australian College of General Practitioners, speaking to us about this review states, “As GPs, our patients often bombard us with anecdotal and popularist dietary perspectives. We should feel appropriately informed and confident enough to engage in robust discussion about those nutritional ideas with professionalism and integrity”.

  1. United Nations. United Nations Decade of Action on Nutrition, 2016-2025 [Internet][Available from: https://www.un.org/nutrition/un-decade-action-nutrition-2016-2025.
  2. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet. 2019;393(10173):791-846.
  3. Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019;393(10170):447-92.
  4. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2019;393(10184):1958-72.
  5. National Health and Medical Research Council (NHMRC). Australian Dietary Guidelines. Canberra: NHMRC; 2013.
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  8. Australian Institute of Health and Welfare (AIHW). Chronic diseases and associated risk factors in Australia, 2006. Canberra: AIHW; 2006.
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  13. Jay M, Chintapalli S, Squires A, Mateo KF, Sherman SE, Kalet AL. Barriers and facilitators to providing primary care-based weight management services in a patient centered medical home for Veterans: a qualitative study. BMC Fam Pract. 2015;16:167.
  14. Keyworth C, Nelson PA, Chisholm A, Griffiths CE, Cordingley L, Bundy C. Providing lifestyle behaviour change support for patients with psoriasis: an assessment of the existing training competencies across medical and nursing health professionals. Br J Dermatol. 2014;171(3):602-8.
  15. Himelhoch S, Ehrenreich M. Psychotherapy by primary-care providers: results of a national sample. Psychosomatics. 2007;48(4):325-30.
  16. Sierpina V, Levine R, Astin J, Tan A. Use of mind-body therapies in psychiatry and family medicine faculty and residents: attitudes, barriers, and gender differences. Explore (NY). 2007;3(2):129-35.
  17. Ampt AJ, Amoroso C, Harris MF, McKenzie SH, Rose VK, Taggart JR. Attitudes, norms and controls influencing lifestyle risk factor management in general practice. BMC Fam Pract. 2009;10:59.
  18. Dickfos M, King D, Parekh S, Boyle FM, Vandelanotte C. General practitioners’ perceptions of and involvement in health behaviour change: can computer-tailored interventions help? Prim Health Care Res Dev. 2015;16(3):316-21.

This article has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.

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