Why don’t medical schools teach doctors about nutrition?
HHS Secretary RFK Jr. made waves last week by mandating that medical schools implement nutrition training for physicians-in-training: “RFK Jr. to tell medical schools to teach nutrition or lose federal funding”headlined MSN.com
At an event in North Carolina in April Kennedy laid down his marker:
“There’s almost no medical schools that have nutrition courses, and so [aspiring physicians] are taught how to treat illnesses with drugs but not how to treat them with food or to keep people healthy so they don’t need the drugs . . . One of the things that we’ll do over the next year is to announce that medical schools that don’t have those programs are not going to be eligible for our funding, and that we will withhold funds from those who don’t implement those kinds of courses.”
It’s no secret that doctors receive almost no training in nutrition in medical schools. That was certainly true of my experience 40 years ago at Albert Einstein College of Medicine here in New York. I sought out nutrition training opportunities at other institutions during my elective year, and listened to lectures by nutritional medicine pioneers on cassette tapes in my car while commuting to class.
To address the knowledge gap, I co-founded a Nutrition Study Group where like-minded students could gather and discuss nutrition topics. Sometimes we held tastings of meals prepared with healthy ingredients. As a (then) devout macrobiotic vegetarian, I hosted cooking classes in my Greenwich Village 5th floor walkup for the Learning Annex. I even offered the alternative of soy burgers and “Tofu Pups” at our class graduation BBQ! (I’ve long-since recanted my low-fat vegan zealotry.)
Recent surveys confirm that, despite calls for reform of medical school curriculum, things haven’t gotten much better since then. A 2010 reviewfound:
“Of the 105 schools answering questions about courses and contact hours, only 26 (25%) required a dedicated nutrition course; in 2004, 32 (30%) of 106 schools did. Overall, medical students received 19.6 contact hours of nutrition instruction during their medical school careers (range: 0–70 hours); the average in 2004 was 22.3 hours. Only 28 (27%) of the 105 schools met the minimum 25 required hours set by the National Academy of Sciences.”
A 2023 paper (“Addressing the Gap of Nutrition in Medical Education”) found that in the U.S., 86% of physicians report they feel unqualified to offer nutritional advice to patients.
This despite the fact that, according to the World Health Organization, preventable chronic diseases are responsible for 8 out of 10 deaths, and heart disease remains the number one killer. 30% of cardiac deaths are attributable to poor nutrition. In 2021, 10.6% of global deaths were associated with poor diet. Seven of the 10 leading causes of death in the US are directly affected by diet.
I’d argue that no matter what specialty med students plan to pursue, proper diet and targeted nutrition interventions should be an integral part of their future treatment recommendations.
It’s been argued that, with specialty-trained registered dietitians and certified nutrition specialists already embedded in health care teams, there’s no need for doctors to be qualified in nutrition—they can simply make referrals to experts. But even if they don’t themselves want to dispense nutritional advice—as I do routinely—it’s vital they recognize the role nutrition might play in advancing their patients’ well-being. Because of physician ignorance, there are innumerable missed opportunities to leverage nutrition, not just in primary care, but in fields as diverse as surgery, urology, psychiatry, oncology, ophthalmology, and allergy/immunology.
Knowing some nutrition would help doctors better communicate with patients—many of whom have lost confidence in doctors to provide credible advice about diet and supplements.
It’s not like this hasn’t been in the works for a long time. A 2024 JAMA Network consensus statement notes:
“In 2022, the US House of Representatives passed a bipartisan resolution (House of Representatives Resolution 1118 at the 117th Congress [2021-2022]) calling for meaningful nutrition education for medical trainees. This was prompted by increasing health care spending attributed to the growing prevalence of nutrition-related diseases and the substantial federal funding via Medicare that supports graduate medical education. In March 2023, medical education professional organizations agreed to identify nutrition competencies for medical education.”
Broad agreement was achieved on the following goals:
“A total of 36 panelists (97%) recommended that nutrition education competencies be evaluated through licensing examinations or board certification examinations. In addition, 35 panelists (95%) agreed that institutions should report on their teaching relating to nutrition competencies, and 34 panelists (92%) agreed that surveys of students should be used to assess their competency and confidence in this area.”
So what’s the hangup on implementing these called-for reforms in medical education?
Being a med student is like drinking from a fire hose; there are so many subjects to master over such a limited time span: biochemistry, molecular biology, statistics, pathophysiology, anatomy, histology, immunology, genetics and above all, pharmacology—each jockey for pole positions in the two-year core basic science introduction all medical trainees are expected to know cold.
Departments lobby for face time with students; they’re not likely to cede turf to a new and still controversial discipline, nutrition, often grossly under-represented on med school faculties. Shifting course requirements is like pulling pieces during a game of Jenga. Progress is stymied.
Moreover, programs are accredited on the basis of how well their trainees do on a series of exams students must pass to obtain their MDs. The questions on these exams are heavily skewed to pharmacological solutions. Even if a medical school were to buck the trend and offer extensive nutrition education, it might risk losing its accreditation if students performed less well in regurgitating drug fixes for common medical problems on certification exams.
Less than 1% of questions on the U.S. Medical Licensing Exams pertain to nutrition. So unless the certification and accreditation problem is addressed, there’s little chance for overhauling the focus of medical education.
Pharmaceutical industry influence is pervasive, although often opaque, in medical education. Through grants to researchers who formulate curricula and teach students, provision of educational materials like textbooks and slide decks, and sometimes outright donations for scholarships and infrastructure improvements, the potential for conflicts-of-interest is rife.
Additionally, it’s been argued that there’s too little “settled science” over what constitutes optimal nutrition. Solutions range from a quasi-vegan plant-based paradigm, to a low-carb diet replete with animal protein. And there remains massive skepticism on the part of orthodox medicine over the value of targeted therapy with vitamins, minerals, and botanicals.
But I think there’s a solution. Basic science subjects, and especially biochemistry, molecular biology and pathophysiology, are replete with opportunities for nutrition teaching. When memorizing obscure metabolic pathways, I was animated during med school by the recognition that common vitamins and minerals were integral to their efficiency. Major routes to disease—atherosclerosis, inflammation, insulin resistance, immunosenescence, mitochondrial dysfunction, oxidative stress, dysbiosis—all have significant nutritional concomitants.
Therefore, embed nutrition, not necessarily as a separate and distinct discipline, but as an essential component of basic science study.
And where nutritional science remains controversial—as with divergent diet paradigms for weight loss and cardiovascular prevention—present the contrasting science. Use that as an opportunity to sharpen med students’ analytical skills; they’ll need those as new scientific advances require their discretion in harnessing them for patients.
And finally, bringing nutrition to the forefront in medical education will help equip health professionals to be role models for patients. We need to educate a cadre of not just highly-skilled technicians, but also evangelists for healthy lifestyles of the Americans doctors care for.
Notwithstanding the fact that eating can be catch-as-catch-can during arduous medical training, and doctors’ health often suffers as a result. Equipping them with basic food selection and preparation knowledge—as with some successful Culinary Medicine programs now at progressive medical schools—may help them achieve better productivity and career longevity, and arrest the burnout spiral that is critically depleting the ranks of our health professionals.
For all these reasons, I’m squarely behind RFK Jr.’s nutrition curriculum initiative. It’s high time.