A doctor’s two favorite words: diet and exercise. Patients are constantly told that lifestyle interventions are the most important modifiable risk factors to prevent chronic diseases such as diabetes and hypertension. Even as medical students, we hear these words repeated during our lectures, but what do they actually mean? The expression ‘healthy eating’ is extremely ambiguous and socially and culturally determined. Western society defines healthy eating as green juices and kale salads, which is not always practical given the different cultures and availability of resources in different communities. This ambiguity becomes especially problematic during fetal life, because changes in the fetal environment caused by maternal diet increase the lifetime risk of several metabolic disorders. There has been one over the past ten years 95.3% increase in the rate of type 2 diabetes among children in the United States, an increase consistent with the rate of gestational diabetes. These populations are just two of many affected by this national problem, and it is clear that nutritional counseling physicians are inadequate.
The first 1000 days are a crucial period for growth and development, starting from conception through the child’s second birthday. This ‘window of opportunity’ is when 80% Brain development occurs and is either a time of laying the foundation for optimal development, or a time of intense vulnerability when the brain is susceptible to irreversible changes. Therefore, adequate caloric intake and specific amounts of macro and micronutrients during these first 1000 days are imperative. Once this critical period has passed, it may not be possible to reverse the developmental changes resulting from inadequate nutrition. An important protective factor is that pregnant patients generally visit their health care providers regularly, providing a longitudinal opportunity for counseling and monitoring to prevent these irreversible changes. Physicians must be equipped to provide nutrition information, screen patients for food insecurity, and remove barriers to access to quality nutrition, all while remaining culturally aware of the communities they serve. We see this as a unique opportunity for physicians to intervene given this continuity of care, while working with dietitians to implement sustainable changes.
Doctors don’t feel comfortable providing nutritional advice to their patients, given the overt lack of training in these topics. Worryingly, doctors are more likely to prescribe metformin to children with type 2 diabetes because they don’t feel comfortable advising them about lifestyle changes — the first-line treatment. The Medical Education Liaison Committee recommends, however, that US medical schools provide a minimum of 25 hours of nutrition education across the four-year curriculum; 71% of medical schools do not meet that standard and 36% achieve less than half of this recommendation. According to the Association of American Medical Colleges (AAMC), medical schools offer approx 1,500 hours of teaching time throughout the preclinical curriculum. Why is nutrition education responsible for less than 1% of this? The average amount of nutrition education provided in medical schools is 14.3 hours in the preclinical period and 4.7 hours during clinical practice. It is therefore no surprise that only 14% of residents feel adequately trained and confident in applying this knowledge during patient encounters. Being further removed from their medical training, physicians should feel even less comfortable discussing these topics.
Medical schools should begin integrating more comprehensive nutrition education into the preclinical curriculum so that future physicians feel equipped to manage pregnant patients through the first 1,000 days, as well as other patients they may encounter. During our preclinical years, the three-hour lectures we received on nutrition were among the most memorable and applicable to both our lives and our future careers. While more education is imperative, integrating this information into patient encounters is where real change needs to happen. This change would allow providers at any level of training to communicate with and provide effective advice to, for example, a pregnant, single mother living in a food desert who has recently lost her job and has three young children at home about what she should eat and feed her family. Most importantly, she could be taught how to access these resources while recognizing the complexity of her circumstances. And isn’t providing holistic care ultimately the essence of medicine?
A major barrier to these changes in education is cost, but steps have been taken over the past decade to mitigate this. The Expanding the Role of Nutrition in Curricula and Health Care (ENRICH) Act. (HR 1413) of 2017 was introduced to expand funding for integrated nutrition curricula to accredited medical schools. While this recognition is a step in the right direction, it has yet to be translated into law as the number of cases of type 2 diabetes in children continues to rise. This is a ticking time bomb that requires immediate action. The standard of care must shift to prevention rather than medication, and this starts with helping medical students develop the tools needed to define healthy eating, whatever that may look like for each of their patients.
Image credits: “fruit” (CC BY-SA 2.0) by Marcos.Zion”
Shaleen is a third-year medical student at George Washington University School of Medicine and Health Sciences in Washington, DC Class of 2025. She graduated from George Washington University in 2021 with a Bachelor of Science in biology and a minor in economics. Shaleen is passionate about nutrition education, community involvement and culinary medicine.