Nutrition training

The National Academy of Sciences recommends 25 h of nutrition education be provided during medical school in the USA^{(Reference Danek, Berlin and Waite5)}. However, it has been shown that 71 % failed to provide this recommended 25 h^{(Reference Adams, Butsch and Kohlmeier6)}. Moreover, the small amount of nutrition education is largely provided in the early years of medical school and has little connection to common diseases^{(Reference Devries, Dalen and Eisenberg7)}. The issue of meagre nutrition education within medical school curricula is not a new one. The National Nutrition Monitoring and Related Research Act of 1990 noted the inconsistency between national public health goals and attention to nutrition-related matters in medical school curricula in the USA⁽⁸⁾, and some sources suggest this issue dates as far back as 1950^{(Reference Frantz, Munroe and McClave9)}. Poor nutrition education in medical school curricula extends beyond US medical schools. When medical schools in the USA, the Middle East, Australia, Europe and Africa were assessed, nutrition education in medical school curricula was lacking in each country^{(Reference Crowley, Ball and Hiddink10)}. Not only was nutrition education lacking but also it appeared to have a direct negative impact on medical student’s nutrition knowledge and confidence to address nutrition with their patient population^{(Reference Crowley, Ball and Hiddink10)}.

According to Aggarwal et al., when practicing physicians were surveyed, 22 % remembered receiving zero nutrition education throughout medical school^{(Reference Aggarwal, Devries and Freeman11)}. Moreover, among the same physicians who did recall receiving nutrition education in medical school, 35 % reported that nutrition education was limited to a single lecture^{(Reference Aggarwal, Devries and Freeman11)}. Medical students’ perceptions of nutrition education curricula in medical school reflect the sparse amount of nutrition training offered. Medical students felt as though nutrition was only mildly incorporated into their coursework, and they felt the nutrition education provided in medical school was inadequate^{(Reference Danek, Berlin and Waite5)}. Survey data from internal medicine residents reported that only 14 % felt prepared to address nutrition-related issues with their patients^{(Reference Vetter, Herring and Sood12)}. Additionally, 94 % felt obligated to discuss nutrition with their patients^{(Reference Vetter, Herring and Sood12)}. Feelings of unpreparedness among medical residents are likely due to an overall lack of nutrition training in medical schools in the USA, which is a repercussion from little to no accreditation standards focussed on nutrition^{(Reference Lepre, Mansfield and Ray13)}.

In contrast, registered dietitian nutritionists (RDN) in the USA undergo rigorous, standardised, didactic training in the field of nutrition and dietetics and are well-equipped to address obesity and obesity-related illnesses with patients^{(Reference Raynor and Champagne14)}. Moreover, RDN are educated in behaviour change theories and motivational interviewing, both of which help the RDN establish how best to help the patient achieve their nutrition goals^{(Reference Cunningham15)}. Healthy lifestyle approaches effectively reduce BMI among individuals with obesity^{(Reference Apovian16)}. However, the implementation of these lifestyle interventions is the main barrier for most individuals^{(Reference Apovian16)}. While 14 % of physicians feel prepared to address nutritionally pertinent topics with their patients^{(Reference Vetter, Herring and Sood12)}, 92 % of RDN feel they are the most qualified professionals to assist patients with weight loss^{(Reference Bleich, Bandara and Bennett17)}. These data suggest that if patients with obesity or obesity-related illnesses were appropriately referred to an RDN, their chances of clinical success would improve greatly.

Considering the seriousness of obesity and obesity-related illness prevalence in the USA, it is problematic that resident physicians feel relatively unprepared to provide nutrition counselling to their patients^{(Reference Vetter, Herring and Sood12)}. Hicks et al. highlight the discrepancy in medical school nutrition education and consumer confidence in physician nutrition knowledge^{(Reference Hicks, Howard and Murano18)}. According to the Centers for Disease Control and Prevention, 51·2 % of all healthcare visits in the USA are with a PCP⁽¹⁹⁾. Moreover, 64 % of Americans feel physicians are well-equipped to provide nutrition recommendations⁽²⁰⁾. These data suggest primary care physicians (PCP) have an unique opportunity to direct patients with nutritionally pertinent health ailments towards a healthcare professional trained in nutrition (e.g. a RDN).

Current interprofessional collaboration

The fact that physicians receive minimal nutrition education^{(Reference Adams, Butsch and Kohlmeier6)}, and consequently feel ill-equipped to provide patients with nutrition recommendations^{(Reference Vetter, Herring and Sood12)} suggests physicians might rely heavily on RDN referrals. Yet, data on patient access to RDN services appear extremely limited. Moreover, physicians feel obligated to address nutrition^{(Reference Vetter, Herring and Sood12)} and feel as though clinical outcomes would improve greatly by incorporating nutrition into patient care^{(Reference Aggarwal, Devries and Freeman11)}. These data suggest insight into the referral process between PCP and US RDN is warranted.

The confidence RDN feel to address obesity and obesity-related illnesses is justified. When RDN were incorporated into the offices of PCP, they effectively improved clinical outcomes related to nutrition^{(Reference Crustolo, Kates and Ackerman21)}. However, PCP referrals to nutrition services are lacking in some settings. For example, RDN currently provide weight loss counselling through a Veterans Health Administration weight loss programme^{(Reference Jay, Chintapalli and Squires22)}. Less than 10 % of eligible patients are referred to the programme. When referring PCP were interviewed, poor anticipated clinical outcomes were identified as a major referral barrier^{(Reference Jay, Chintapalli and Squires22)}. The results of this study suggest PCP may have poor insight into the RDN knowledge base and scope of practice.

A recent study conducted by Fitzpatrick et al. assessed whether an alert in the medical record prompted physicians to refer patients with a BMI indicative of obesity to an RDN^{(Reference Fitzpatrick, Dickins and Avery23)}. The researchers concluded the medical record alert did not effectively improve RDN referrals^{(Reference Fitzpatrick, Dickins and Avery23)}. These data suggest the intervention to improve physician referrals to RDN must be more involved. A study assessing referrals to RDN by physicians working in the primary care setting found that a misunderstanding of the role nutrition education plays in chronic disease management was the foremost reason PCP did not refer their patients to a RDN^{(Reference Barnes, Weiss-Kennedy and Schaefer24)}. Therefore, it appears the lack of nutrition education offered in medical school is not only having a negative impact on the amount of nutrition education physicians are offering to their patients, but also is having a negative impact on referrals to RDNs as well. A lack of PCP knowledge about the knowledge base and scope of practice of the RDN appears to be barrier to RDN referrals^{(Reference Jones25)}.

Improving interprofessional collaboration: possible solutions

Improving nutrition education for physicians might facilitate interprofessional collaboration between PCP and RDN. Interventions to bolster medical school nutrition curricula have a positive impact on the nutrition knowledge of medical students and physicians^{(Reference Baute, Carr and Blackwell26)}, which is translating to positive clinical outcomes^{(Reference Baute, Carr and Blackwell26)}. RDN are qualified educators in this context and should play an integral role in educating physicians throughout their training and practice^{(Reference Hark and Deen27)}. Not only are RDN qualified educators in this context but also exposure to an RDN in medical school or through continuing education might increase physicians’ knowledge about the RDN scope of practice and knowledge base, and therefore has the potential to improve physician referrals to RDN.

Several medical schools in the USA have recognised the lack of nutrition education in their curricula and have attempted to ameliorate the issue. For example, the University of Nevada School of Medicine integrated nutrition-based curricula into their medical school^{(Reference St Jeor, Krenkel and Plodkowski28)}. Upon review of these curricula, they found that they were unique among medical schools in the USA and felt that positivity and being proactive facilitated nutrition education integration^{(Reference St Jeor, Krenkel and Plodkowski28)}. The University of Pennsylvania also attempted to independently integrate nutrition information into their medical school curricula with success^{(Reference Cooksey, Kohlmeier and Plaisted29)}. Prior to the integration of nutrition curricula, 80 % of medical students at the University of Pennsylvania thought nutrition education was inadequate. After the nutrition curricula had been integrated, only 10 % of medical students felt that way^{(Reference Cooksey, Kohlmeier and Plaisted29)}. When integrating nutrition into medical school curricula, foreseen issues include limited faculty time and ‘issues of control and inertia’^{(Reference Gans, Ross and Barner30)}. Effective strategies include a ‘forward-thinking attitude’ of the institution and ‘creativity and innovative strategies’ used by nutrition faculty and administrative staff^{(Reference Touger-Decker31)}.

Although nutrition education within medical school curricula appears to be an effective way to improve the nutrition knowledge of physicians, continuing medical education initiatives should also be considered to support physician nutrition acumen. A recent study by Hicks and Murano assessed whether an online continuing medical education course created by an RDN and physician PCP effectively improved nutrition knowledge relating to type 2 diabetes among practicing physicians. This course effectively improved nutrition knowledge relating to type 2 diabetes management among physicians and awareness of the role of the RDN^{(Reference Hicks and Murano32)}. Virtual seminars may be an effective tool to disseminate nutrition information to medical students as well^{(Reference Kolasa, Jobe and Daugherty33)}. However, in the context of medical school and continuing medical educations, challenges exist with virtual learning, such as a lack of audience engagement^{(Reference Dimaria-Ghalili, Edwards and Friedman34)}.