Diet-related diseases, including hypertension, diabetes, and obesity, comprise a large portion of primary care visits in the U.S. But nutrition can be an overlooked component of care in a 15-minute visit.
“Dietary interventions, despite being first-line therapies for a lot of these conditions, are very seldom prescribed by physicians,” said Megan McLeod, a fourth-year medical student at the University of Michigan in Ann Arbor. A lack of focus on nutrition during medical training, time and compensation constraints, and a potential perceived inefficacy of nutritional interventions all factor in, she said.
To get a better understanding of primary care physicians' baseline knowledge of and attitudes about dietary interventions, Ms. McLeod conducted a study of about 350 internal medicine physicians, family medicine physicians, and pediatricians across the state of Michigan. She presented the results at the American Public Health Association's 2019 annual meeting, held last November in Philadelphia.
Through a 50-item online survey, physicians rated their self-perceived knowledge and tested their objective knowledge base about dietary interventions. Interventions included the Dietary Approaches to Stop Hypertension (DASH) diet, the Mediterranean diet, the ketogenic diet, carbohydrate counting for patients with diabetes, and fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) and elimination diets for irritable bowel syndrome.
The respondents' overall objective knowledge score was 70.3% and was positively associated with number of years in practice. Self-rated knowledge score and self-rated efficacy in counseling patients were also positively associated with their objective knowledge score, Ms. McLeod reported. “So physicians are doing a reasonable job of guessing their overall knowledge base pertaining to these topics, and it's not great,” she said. Nonetheless, overall agreement with the importance of dietary interventions was 3.95 on a scale of 1 (strongly disagree) to 5 (strongly agree).
Despite being able to accurately predict their overall knowledge base, physicians were less apt at accurately rating their knowledge about specific nutrition topics, such as the DASH diet and portion control, Ms. McLeod said.
“I think [the study] speaks to the breadth of misunderstanding within the topic of nutrition that physicians are facing … and it does help inform future efforts to improve nutrition education, which we have seen and will continue to see,” she concluded.
Two other presentations at the session focused on efforts to increase nutrition education and awareness, both among practicing clinicians and among medical students.
Medical nutrition for the busy clinician
Increasing nutrition knowledge and performance among primary care physicians is included in the U.S. Department of Health and Human Services' Healthy People 2020 objectives.
Within nutrition and weight status objectives, there are two broad workforce training objectives: increasing the proportion of primary care physicians who regularly measure body mass index, and increasing the proportion of physician office visits that include counseling or education related to nutrition and weight.
To help support these objectives, the Institute of Human Nutrition at Columbia University in New York City launched a medical nutrition certification program for health professionals in 2013.
The program enrolled students from a variety of health professions, including dental professionals, nurse practitioners, physicians, physician assistants, and registered dietitians, said Kim Hekimian, PhD, an assistant professor of nutrition in pediatrics at the Institute of Human Nutrition at Columbia. Classes were held one full weekend a month for a year, with some online modules.
In one of their first assignments, the students were asked to review their own professional society's guidelines on nutrition, she said. “Most had never seen their own nutrition guidelines before and certainly felt that they were not trained in those guidelines,” Dr. Hekimian said. “So this lack of awareness confirms the literature and confirms the need for further workforce training.”
The overall aim of the program was to improve clinicians' understanding of the etiology, prevention, and treatment of nutrition-related diseases, she said. “We really hoped to develop content that we could give on the weekends that the practicing health professionals could apply to their clinical practice on Monday morning,” said Dr. Hekimian.
The program aimed to emphasize educational components that were relevant to clinical practice and also covered the biochemical basics of nutrition and metabolic disease, she said. While some clinicians were initially apprehensive about taking biochem again, “We felt that it was very important for clinicians to be able to assess future nutrition claims by understanding the fundamental science behind them,” Dr. Hekimian said, adding that there was also much emphasis on evidence-based nutritional counseling, particularly motivational interviewing.
Another core component was teaching cooking skills, which students were also a bit hesitant about initially, she said. But the cooking sessions were soon a very popular component of the program.
“So not only were they learning quick, easy recipes that they could share with their patients, but … if we talked about a particular nutrient or metabolic pathway that day, we could show them with food what the relation was,” Dr. Hekimian said.
The program led to changes in three components of students' clinical practice, according to focus-group data and in-depth interviews.
First, all participants who were interviewed reported more frequently offering nutritional counseling, and many gave examples of using their clinic appointments to focus specifically on nutrition, Dr. Hekimian said. She quoted a primary care cardiologist, who said, “I do more intense counseling, more frequent follow-up visits, [and] I've learned that motivational interviewing is a valuable technique in getting patients to acknowledge their problematic food choices.”
Second, some participants reported changing their professional focus or seeking out professional opportunities where nutrition was their focus. “As a component of that practice, some are now developing training modules for other residents [at] Columbia about nutrition, and some are developing surveys on nutrition within their practice,” Dr. Hekimian said.
Third, an unexpected area of change was that participants reported shifts in their own habits. “Many students … utilized the recipes and the cooking skills that they had [learned] to change their own eating habits, and they felt that they could then utilize those changes to express more confidently to their patients that their patients could do this too,” she said.
Overall, the impact on clinical practice was significant, but the program was labor-intensive and unsustainable in its current format, Dr. Hekimian said. The next step for Columbia is to develop similar workforce training modules in nutrition that are online only.
Cooking up a new rotation
At West Virginia University in Morgantown, nutrition education is starting even earlier.
From mid-February through March 2019, fourth-year medical students were recruited to join a two-week culinary medicine elective rotation. Culinary medicine, which combines the art of food and cooking with the science of medicine, often uses a hands-on curriculum to strengthen nutrition and culinary skills (see “Setting a Course for Food as Medicine,” ACP Internist, June 2018).
As part of the rotation, students participated in lectures, hands-on learning, and cooking activities that were held in the lifestyle intervention research lab, which has a teaching kitchen, said Rachel Wattick, a nutritional and food science master's student and graduate research assistant at West Virginia University. The research team measured changes in the students' nutritional knowledge and attitudes with a pre- and post-survey.
A total of 15 students were included, four on the first two rotations and seven on the third, she said. “Because of space limitations, as well as the need for that one-on-one interaction, we did have relatively small groups,” Ms. Wattick said.
The curriculum included lecture topics such as behavior change theories, basic food groups, food safety, culinary techniques, macronutrients, biochemistry, nutrition counseling, and fad versus evidence-based diets, she said. Students also had to create cost-conscious meals, going to the grocery store with a specific budget for ingredients and returning to the lab to cook them. For example, an assignment to feed a family of four where the parents were watching their blood pressure yielded a healthy, plant-based meal of chickpeas, quinoa, and four different types of vegetables for less than $10.
“We are in West Virginia, which is a very health-disparate, low-socioeconomic-status state,” Ms. Wattick said. “So we thought it was really important to talk about cooking healthy on a budget so they could have the knowledge to recommend low-cost, healthy options to their patients.”
Before and after the rotations, students took surveys that measured nutrition knowledge, attitudes, and self-efficacy. Overall, there were statistically significant increases in nutrition knowledge and self-efficacy. However, the increase in attitude scores trended toward but did not reach significance. “We do think it's because attitudes are already rather high coming in,” Ms. Wattick said. Students also completed an elective evaluation to provide feedback on the course. Overall, they rated the course highly and rated the hands-on cooking sessions and presentations as most helpful, she said.
Based on student feedback, the school will continue to refine and test the curriculum with a new cohort of students this coming spring, Ms. Wattick said. As for the students who took the elective and have since moved into residency, “It'd be interesting to see how it has impacted what they've been exposed to so far in practice,” she said.