A lack of formal training in nutrition could significantly limit how physicians practice, according to an editorial published in JAMA Internal Medicine this month, in some cases leading them to recommend risky treatments to patients in lieu of dietary counseling that might be just as effective.
In JAMA, Neal D. Barnard, MD, an adjunct associate professor at the George Washington University School of Medicine and president of the Physicians Committee for Responsible Medicine, said today’s physicians are failing to grasp the full importance of nutrition in a patient’s care plan—but it’s not entirely their fault. In a 2018 survey, 61% of internal medicine residents reported they’d received little to no training in the area.
Barnard admits he’s been guilty of this “nutritional ignorance,” too, recalling an instance earlier in his career in which his team had recommended a foot amputation to a patient who had presented with a diabetes-related infection. Ready to amputate, Barnard was frustrated the patient declined the recommendation and instead opted for IV antibiotics.
Reflecting on the incident later, Barnard guesses the patient eventually lost the battle with his illness. He’d left the hospital with his foot intact, but Barnard said the patient’s care team had failed to ever speak with him about the underlying cause of his diabetes: his diet.
“Even though the roots of type 2 diabetes are in the everyday food choices that lead to obesity and insulin resistance, we were ready to amputate, but never started a discussion about improving diet,” Barnard wrote.
He said we know that insulin resistance starts with the buildup of lipid particles in muscle and liver cells, pushing blood glucose values up and interfering with insulin signaling. Those intramyocellular and hepatocellular lipids are derived from food, and with sufficient changes diabetics can improve—and in some cases reverse—their condition.
Barnard cited other instances of nutritional ignorance, including one case in which a number of cardiologists recommended a patient for open-heart surgery before discussing dietary changes that might have fixed the problem more easily.
“This is not to suggest that physicians are not interested in nutrition,” Barnard wrote, noting the two most-read articles in JAMA Internal Medicine last year centered around diet. “But the curiosity about nutrition that physicians share with the general public does not equate to clinical competence.”
Barnard suggested mandating nutrition education through CME programs, integrating it into the hours currently required by programs to allow physicians better access to this information. He also said EMS services should include customizable nutrition questionnaires and handouts that could duly educate patients and their physicians.
Physicians are also role models, he said, and should practice what they preach. Still, one study conducted in 2012 found physicians were far less likely to record an obesity diagnosis if their own body weight was higher than their patient’s.
Barnard recommends that all physicians work alongside registered dietitians to recognize the role nutrition plays in disease, especially so they can communicate that information effectively to their patients. Just like seeing a pack of cigarettes in your doctor’s coat pocket would compromise their credibility, so would their inability to answer common questions about diet and nutrition.
“There is no need to argue that medical schools need to teach nutrition—obviously, they do,” Barnard wrote. “Many medical students can do little more than cough up the words ‘scurvy’ or ‘cyanocobalamin’ for a nutrition board examination. Rather than allowing nutritional ignorance to fester like a gangrenous sore, the medical community can take advantage of current knowledge for patient benefit, as well as their own.”