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More than Food for Thought: Advancing Nutrition Education in the 21st Century

Disclosure: None
Pub Date: Monday, April 30, 2018
Author: Michael Miller, MD, FAHA
Affiliation: University of Maryland School of Medicine

View the full Science News coverage for Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians

Citation

Aspry KE, Van Horn L, Carson JAS, Wylie-Rosett J, Kushner RF, Lichtenstein AH, Devries S, Freeman AM, Crawford A, Kris-Etherton P; on behalf of the American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; and Stroke Council. Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: a science advisory from the American Heart Association [published online ahead of print April 30, 2018]. Circulation. DOI: 10.1161/CIR.0000000000000563.

Article Text

As a preclinical medical student in the latter part of the 20th Century, emphasis was placed on understanding the biochemical and pathologic basis of America’s most preventable cause of death: cigarette smoking. In effect, the unequivocal evidence linking cigarette smoking to the etiology and promotion of cardiovascular and other diseases enhanced teaching efforts within the medical school curriculum. It also fostered motivation within third and fourth year medical students to seek detailed smoking histories. To this day, when a patient is admitted to our coronary and progressive care units, medical students continue to fluidly recite details relevant to the age of onset of smoking, the number of cigarettes smoked daily, and the total pack year smoked.

The burgeoning rates of type 2 diabetes mellitus (T2DM) and obesity with its associated high disease burden (1) is reminiscent of the smoking epidemic. Yet, it is quite astonishing that the level of enthusiasm devoted to enhancing nutrition education in medical schools has lagged far behind when compared to cigarette smoking.  Moreover, medical students and residents rarely prioritize nutrition during routine patient evaluation and assessment.  This seemingly incongruent view persists despite robust evidence that poor lifestyle choices and dietary habits (e.g., excessive intake of saturated fats) predict the subsequent development of obesity and T2DM (2,3) as well as promotion of cardiovascular disease (CVD) (4,5). 

The new Scientific Advisory from the American Heart Association sheds new insights and provides a blueprint for enhancing nutrition education efforts throughout medical training (6).  Specifically, Aspry and colleagues review established training programs that have successfully navigated nutrition-based education within the medical school and post-graduate medical curriculum. Some nutrition-based modules were developed and implemented during the tenure of the National Heart, Lung, Blood Institute sponsored Nutrition Academic Award (NAA) that was granted to 21 medical schools between 1998-2006 (7).  At our institution, the most highly rated course during the tenure of the grant was a hands-on cooking class taught by a local chef (8).  While some medical school NAA awardees have been able to maintain their nutrition curriculum, only vestiges of original programming remain at other sites.  Overall, the sentiment among NAA awardees was that this project facilitated a number of sustainable nutrition-based initiatives that were not previously made available prior to NAA.  As reviewed in this Advisory Statement, some of these programs have included lectures and problem-based learning modules on cardiovascular nutrition to 2nd year medical students and 1-month nutrition electives to 4th year students aiming to provide 1 on 1 teaching with registered dietitians (RDs) in both inpatient (e.g., renal/dialysis units, medical and surgical intensive care units) and outpatient (e.g., diabetes, hypertension and lipid clinic) units.   

Additional hands-on tools designed to enhance nutrition education for medical students, house officers and fellows, would seemingly require partnership with hospitals and insurers.  To begin with, inpatient and outpatient electronic templates should include a specific section dedicated to “dietary history” akin to “family history” to more firmly cement the medical relevancy of nutrition within the overall evaluation. In this regard, dietary history must include more than catch-all phrases such as “the patient is non-compliant with diet”, or “the patient admits to not watching his/her salt intake” as all too often serve as the primary dietary descriptors presented in patients admitted for congestive heart failure and other chronic disease exacerbations.  Rather, medical students and residents should ask more in depth dietary-based questions as they do when taking a history of tobacco smoking.  This might include asking their patients the specific foods consumed for breakfast, lunch and dinner on an average day, such as the day or two prior to hospital admission.  The amount of time required to collect and record this information is generally less than several minutes in duration.  Fundamentally, its value for therapeutic planning, particularly in older patients (e.g., greater than 60 years old), is far greater than eliciting details related to family history.

To help facilitate nutrition education, RD’s should become integrated within cardiovascular and other inpatient service teams, similar to Doctors of Pharmacy (PharmD’s) who routinely round in cardiac units.  The presence of an RD on medical rounds would not only vastly enhance teaching efforts related to nutrition but also increase its stature and relevancy as part of a well-rounded and comprehensive medical training platform.

Finally, as described above and supported in the Advisory, advancing culinary medicine opportunities is a powerful way to educate as well as reinforce the benefits of healthy nutrition on an affordable scale.  In recent years, partnerships between medical schools, hospitals and various culinary institutes have sprouted up.  In other instances, healthy nutrition is being taught at the community level with medical students welcome to participate.  A prime example is American Heart Association’s first test kitchen in Baltimore, entitled “The AHA Simple Cooking with Heart Kitchen” (9).  For a nominal fee, members of the community learn the basics of healthy food preparation and cooking.   Whether future AHA Heart Kitchens expand to other cities and/or develop collaborative partnerships with University Medical Centers, the objective is clear; teaching medical trainees simple and easy to master techniques for enhancement of cooking skills and fostering healthy eating habits will go a long way toward elevating the critical role that nutrition plays in overall health.  After all, if we subscribe to the Hippocratic Oath, shouldn’t we also acknowledge and subscribe to his suggestion: “let food be thy medicine…”?

References

  1. Health Effects of Overweight and Obesity in 195 Countries over 25 Years. GBD 2015 Obesity Collaborators, Afshin A, Forouzanfar MH, Reitsma MB, et al. N Engl J Med. 2017;377:13-27.
  2. Power C, Parsons T. Nutritional and other influences in childhood as predictors of adult obesity. Proc Nutr Soc. 2000;59:267-72.
  3. Schulze MB, Hoffmann K, Boeing H, Linseisen J, Rohrmann S, Möhlig M, Pfeiffer AF, Spranger J, Thamer C, Häring HU, Fritsche A, Joost HG. An accurate risk score based on anthropometric, dietary, and lifestyle factors to predict the development of type 2 diabetes. Diabetes Care. 2007;30:510-5.
  4. Sacks FM, Lichtenstein AH, Wu JHY, Appel LJ, Creager MA, Kris-Etherton PM, Miller M, Rimm EB, Rudel LL, Robinson JG, Stone NJ, Van Horn LV; American Heart Association.  Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association. Circulation. 2017;136:e1e23.doi:10.1161/CIR.0000000000000510.
  5. Freeman AM, Morris PB, Barnard N, Esselstyn CB, Ros E, Agatston A, Devries S, O'Keefe J, Miller M, Ornish D, Williams K, Kris-Etherton P. Trending Cardiovascular Nutrition Controversies. J Am Coll Cardiol. 2017;69:1172-1187. doi: 10.1016/j.jacc.2016.10.086.
  6. Aspry KE, Van Horn L, Carson JAS, Wylie-Rosett J, Kushner RF, Lichtenstein AH, Devries S, Freeman AM, Crawford A, Kris-Etherton P; on behalf of the American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; and Stroke Council. Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: a science advisory from the American Heart Association [published online ahead of print April 30, 2018]. Circulation. DOI: 10.1161/CIR.0000000000000563.
  7. The Nutrition Academic Award: brief history, overview, and legacy. Van Horn L. Am J Clin Nutr. 2006 83:936S-940S.
  8. Payne D. Medical students learn to cater for healthy appetites. Lancet 2002;359:1212.
  9. https://www.youtube.com/watch?v=dbz4XeZRgLw

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --