Why Doctors Aren’t Taught Much About Nutrition

Why Doctors Aren’t Taught Much About Nutrition

A UT Southwestern program highlights how physicians can and should be better trained to discuss healthy eating with their patients.

Texas Monthly; Getty

Time is running out, adding to the doctors’ sense of urgency. Four teams of physicians take careful measurements and make precise cuts while conferring in hushed voices about how best to proceed.

Several pounds of chicken need to be sliced, seasoned, and cooked for the fajita bowls. Meanwhile, across the kitchen–several floors up in an office building in Dallas’s Medical District–a medical student takes charge of the sweet potato chili on another stovetop as two family practice interns calmly prepare the garnish.

Nearby, Dr. Emmanuel Enriquez neatly chops cucumber, red onion, and tomato while instructor Milette Siler, dressed in a black chef’s smock, wonders aloud whether the ingredients should be diced into even smaller chunks. That could enhance the flavor of each bite, which would allow the doctors to limit additional salt–making for a healthier dish. Enriquez, a family practice resident dressed in a white apron tied over his black scrubs, considers the idea for a moment, then proceeds to cut the fresh vegetables again, into finer pieces.

Each session of this UT Southwestern Medical School class involves preparing a meal around a given healthcare topic, as well as a lecture on the related nutrition and medical science. The training not only aims to instill an appreciation for nutritious cooking, but also provides young doctors crucial dietary tools that they can share with their patients. It’s part of UT Southwestern’s offerings in the emerging discipline of culinary medicine. For the program’s director, Dr. Jaclyn Albin, the need for this type of education couldn’t be plainer. “Food is the top risk factor for early death,” she says. “What we’re doing isn’t working.”

Indeed, a massive 2018 study published in the Journal of the American Medical Association found that a poor diet–defined as one relatively high in calories but lacking adequate nutrients–was the leading risk factor for premature death in the United States, followed by tobacco use, high blood pressure, and obesity. Diet plays a major role in countless preventable conditions, including cardiovascular disease, the world’s leading cause of death. To confront this problem, the Biden administration has charged the organizations that oversee U.S. medical schools and residencies to convene to evaluate how nutrition is taught to doctors, and Albin will participate in a panel discussion at the summit, in Chicago this March.

For decades, the guidance from the National Academy of Sciences and the accrediting organization for U.S. medical colleges has advised that medical students should receive a minimum of 25 hours of nutrition education–compared to, for example, roughly 100 hours they might typically get of cardiology instruction–but only 29 percent of medical schools met even that modest goal, according to a 2015 study. And as other medical disciplines have grown far more complex thanks to new discoveries and technological advances, some schools have opted to de-emphasize nutrition even further.

At the same time, since the first curriculum was established in 2013, the number of culinary medicine programs has been growing. Based on her team’s research, Albin estimates that out of about 160 medical colleges in the country, roughly 100 offer at least one culinary medicine course, including UT Southwestern, the University of North Texas Health Science Center at Fort Worth, Texas Christian University, UT Houston School of Public Health, and the UT Health Science Center in San Antonio. This instruction has proven popular and effective, but its core message–that nutritional expertise should be a powerful tool taught to physicians–faces significant obstacles.

Two years into Albin’s residency in internal medicine and pediatrics at Baylor College of Medicine in Houston, around 2010, her husband Matthew got very sick. He was eating plenty but losing weight. Multiple doctors couldn’t figure out why. Albin eventually realized that his symptoms aligned with celiac disease, an autoimmune condition in which consuming gluten damages the small intestine. “He was malabsorbing everything he ate for years,” she says.

After a test confirmed his diagnosis, Matthew was advised to adopt a gluten-free diet, but his doctor didn’t offer any guidance beyond that. “No referral to a dietician–we didn’t even get a handout,” Albin, now forty years old, remembers. “It was horrifying that I didn’t know how to help my own family.” In her medical training, Albin had received no guidance on applying nutrition science to clinical scenarios. Shouldn’t someone with her level of expertise, she wondered, know how to adjust a patient’s diet to address a relatively common condition such as celiac disease?

Not long after, in 2012, Timothy Harlan, a chef turned internist in New Orleans who’d likewise noticed a glaring absence of food fluency among physicians, started a class at Tulane University that combined his medical training with what he’d learned working in restaurant kitchens. He called it Health Meets Food, and the next year, UT Southwestern’s Moncrief Cancer Institute, in Fort Worth, became the first to license and begin teaching the class after Moncrief’s director, a Tulane alum, had read about Harlan’s efforts.

About the same time, Albin finished her residency and moved to Dallas to help launch UT Southwestern’s combined internal medicine and pediatrics residency program. She was also asked to teach nutrition to medical students–not because she’d had any specialized training in the subject, but because the director of a student training clerkship had noticed she brought healthy lunches to work every day. “That was my credential before I went back and got training in culinary medicine,” she says.

Eventually Albin and Siler came together, in 2017, to offer culinary medicine classes at UT Southwestern’s main campus. It isn’t alone among medical schools in the state now offering hands-on nutrition education, though some of those efforts have been led by the students rather than administrators or instructors.

About seven years ago, students at the Texas Tech University Health Sciences Center, in Lubbock, won approval of an elective culinary medicine class. Similarly, at Baylor College of Medicine, motivated students launched a popular class called Choosing Healthy, Eating Fresh, that meets once a month to discuss counseling patients on nutrition and to watch presentations both from chefs and the school’s medical faculty.

Albin says that UT Southwestern now requires students to enroll in one nutrition class, but even so, any students who only take that course would graduate with fewer than 25 hours of “meaningful, clinically impactful nutrition education.” At Baylor, students take only one required nutrition course, but Dr. Jerry Clay Goodman, the associate dean for undergraduate medical education, estimates that, with the required course, lectures, and sessions on nutrition in other classes, they spend roughly 80 hours on the subject. Likewise, at Texas Tech, Simon Williams, the senior associate dean for academic affairs, says its students meet or exceed the 25-hour minimum. How these schools define nutrition education varies, of course, which could explain why Baylor and Texas Tech students pushed for culinary medicine courses to supplement their training.

Dr. Martin Kohlmeier, a physician and professor at the University of North Carolina, who coauthored the 2015 study on nutrition education at medical schools, argues that, in order to effectively train the country’s future doctors, nutrition instruction must become part of the core curriculum, not merely electives. “If it’s not a required course, in my metric, it simply does not count,” he says.

But some educators, such as Dr. Craig Jensen, the faculty director of the Choosing Healthy, Eating Fresh course at Baylor, question whether it’s feasible to require every student to study culinary medicine, given all the other important topics that must be taught during the four years of a medical education. “Designing a medical school curriculum is extraordinarily complex,” he says.

Still, UT Southwestern also has seen far more student demand for its culinary medicine program than course offerings can accommodate, and much the same has proven true at Baylor and Texas Tech. So if there’s such significant interest among medical students, and researchers agree that diet is a critical factor in predicting early death, then why aren’t all medical schools requiring their future doctors to learn how to better advise patients on their diets?

It’s a matter of money, according to Wesley McWhorter, a dietician and chef turned public health researcher at UT Health Houston. Doctors and hospitals get paid for treating some immediate, identifiable malady–most often by running tests, performing procedures, or administering drugs. Those are treatments that insurance companies are set up to pay for. There’s little, if any, financial incentive for doctors to keep patients from getting sick in the first place. So why would they invest time in helping patients develop healthier diets? “Nutrition is not really reimbursable,” McWhorter says.

Yet there may be ways to encourage health care providers to take greater interest in nutrition. Dr. Dexter Shurney, the chief health equity, diversity, and inclusion officer at California-based Adventist Health, says that about half of all healthcare costs in the U.S. are covered by companies that offer insurance to their employees through self-funded plans, meaning the companies themselves pay claims. Those employers have an obvious interest in keeping those costs down, and Shurney argues that they could drive the industry to shift from what we have now–a fee-for-service model–to a fee-for-outcome approach, in which providers earn more by keeping patients from getting sick.

“I think the loser in this will be the some of the pharmaceutical companies. If we really get a foothold on lifestyle medicine, there’s just going to be less need for medications,” says Shurney, who is also the former president of the American College of Lifestyle Medicine, a relatively new specialty that promotes “a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection.” There are now 190 Texas clinicians board-certified in lifestyle medicine, including Albin–up from just 17 in 2017, when the certification was first offered.

In addition to the financial obstacles, in a field that prizes unassailable data, nutrition research is sometimes shrugged off as less rigorous than other medical sciences. Indeed, some nutrition guidance has shifted confusingly over time, leading many to question it. Eggs, for example, were once considered bad for heart health because they were believed to contribute to high cholesterol levels, but more recent studies show that eggs have little impact on blood cholesterol levels. And while it’s fairly straightforward to conduct a double-blind, placebo-controlled trial on a pill produced by a drug company, doing that kind of study on how a prescribed diet affects a sample group is far more complicated. “We don’t eat just a single food,” explains Shurney. “We’re eating patterns of food, and so how do you control for all of that?”

Both the University of Texas and Texas A&M have launched nutrition research institutes in recent years. But–just as much research on new medications is funded by the pharmaceutical industry–much nutrition research has been funded by the food industry, and that fact can present conflicts of interest, or at least the appearance thereof. One recent controversy involved Harvard nutritionists who argued that researchers at Texas A&M’s AgriLife were beholden to the beef industry, because the industry provides funding to the agency.

Patrick Stover, a nutrition scientist and the director of the Institute for Advancing Health Through Agriculture at Texas A&M, was party to the AgriLife beef controversy. He argues that the food industry must participate in any “food as medicine” movement. “Agriculture holds the promise to lower health care costs and save lives,” he says, adding that it will require a precise understanding of how individual nutrients affect health. “If we’re going to use food to lower health care costs, we have to understand how food interacts with an individual at that level.”

McWhorter, who is now the director of lifestyle medicine for a Houston-based system of primary-care clinics, agrees that the food industry needs to be part of the solution, but notes that there’s already broad consensus on the fundamentals of a healthy diet. “Folks that eat fiber-rich foods”–fruits, legumes, vegetables, whole grains–“have healthier outcomes,” he says, noting that roughly 90 percent of adults in the U.S. don’t eat enough of these foods. “We shouldn’t focus so much on these individual studies looking at nutrients, but really the overall pattern of eating.”

Since cost and access to nutritious food remains an obstacle to many Americans, culinary-medicine advocates have championed food prescription programs that allow doctors to prescribe fresh fruits, vegetables, and other nutritious foods, which might be covered by the patient’s insurance, much as a pharmaceutical medication would be. At UT Southwestern’s new medical center at RedBird, part of a redeveloped shopping center in southern Dallas, Albin and Siler have developed a consulting service along these lines. Later this year, they will incorporate group cooking classes for which the physician can bill insurance companies for the time they spend in the kitchen instructing members of the community. “We’re hoping to create a long-term sustainable structure that other people can copy,” Albin says.

Back at the UT Southwestern teaching kitchen, the students and residents rush to put the finishing touches on their plates. The team in charge of the quinoa-chickpea salad has finished early, and Albin takes a picture of them posing in front of their cooking station. As each of the other teams finish, they present their dishes to the rest of the class, highlighting how they achieved maximum flavor while reducing the sodium content.

They all then sit down in an adjoining room, with full plates, while Albin delivers a brief lecture. “The narrative has been controlled by people who are trying to make money off of our patients,” she says, before pulling up an analysis of global health data that lists the number of deaths attributed to various poor diets. At the top, right after diets high in sodium, are those lacking nutrients found in whole grains, fruits, nuts, seeds, and vegetables. “We’re dying from what we’re not eating.”

Yet she urges them to consider what she calls “the happier narrative,” that food is the key to healing. “The joy in this story,” she says, “is that you take what’s causing death, and it’s also the solution.”


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