During my dietetic internship at Massachusetts General Hospital, I was inspired by the wonderful model of nutrition and culinary education provided to clinicians and patients alike at the nearby Boston Medical Center (BMC). As the largest safety-net hospital in New England, it is also the primary teaching hospital for Boston University's School of Medicine. With a teaching kitchen offering free classes by a registered dietitian and other team members, a rooftop garden providing greens and other foods to its cafeteria and a "preventive food pantry" distributing healthy food to patients in need, BMC seeks to address the barriers to good health posed by poor nutrition. It also offers extensive programming to educate medical students about nutrition, behavior change and opportunities to address food insecurity in the local community. By doing so, it serves as inspiration to other providers around the country.
The need to elevate nutrition in healthcare
Food insecurity, obesity and lifestyle-related diseases are big contributors to the $4.1 trillion in annual healthcare-related costs in the US. Compared to most other high-income countries, the US has the highest adult obesity and infant mortality rates and the lowest life expectancy.
Here are a few statistics that indicate the need for improved nutrition in healthcare:
Heart disease and stroke account for almost one-third of deaths in America and cost $216 billion per year in healthcare costs.
More than one-third of Americans have prediabetes (caused by insulin resistance and a precursor to type 2 diabetes) and various forms of heart disease.
Nearly ninety percent of American adults fail to consume the daily amounts of fruits and vegetables recommended by the Dietary Guidelines for Americans.
Since the 1960s, Americans have decreased both the amount of food they prepare at home and the time they spend preparing it. However, foods prepared at home tend to be more nutritious than foods prepared away from home.
Many health professionals have been calling for expanded incorporation of nutrition curricula into medical education and training to address these problems. While registered dietitians (RDs) ultimately hold this expertise, doctors and other allied health professionals should have at least a basic understanding to be able to answer their patients' questions, address their nutritional needs and know when to refer them to RDs for counseling or more acute interventions in an inpatient setting.
The most recent nationwide survey indicates that only 29% of American medical students receive the National Academy of Sciences' recommended minimum of 25 hours of nutrition education and only 29% of schools require what they consider to be a full nutrition course (which typically translates to at least five hours during the entire program). According to a series of surveys by Adams et al. in 2015, the number of medical schools with a required nutrition course has declined since 2000, and the percentage of schools meeting the 25-hour recommendation fell by two percent. Over this time, rates of diabetes, heart and kidney transplants and many other conditions often attributed to poor diet have continued to rise.
And yet, a 2008 survey showed that more than 80% of physicians believed they lacked enough training in nutrition to be able to offer helpful information to patients. In a 2017 survey of cardiologists—who so often treat and manage lifestyle-related diseases—90% reported receiving no or minimal nutrition education during fellowship training. Lacking both knowledge of the field and the skills required to educate and counsel patients, these providers are inadequately prepared to effectively address the nutrition issues that contribute significantly to the current burden of poor health in the US. A 2019 systematic review amalgamated these individual findings, leading the authors to call for institutional commitments to make nutrition education compulsory, establishing nutrition competencies and funding innovative curriculum initiatives.
Medical schools making progress
Indeed, some medical schools are starting to catch on. In 2018, UCLA launched a new pediatric public health elective course (led by a dietitian and public health professional) to teach physicians about pediatric nutrition and basic cooking skills. They also work on counseling skills to better work with patients to improve their dietary behaviors. Stanford Medical Center physicians (who are also chefs) teach basic cooking and nutrition elective classes to medical and physician assistant students.
The Teaching Kitchen @ Stanford
National networks are working together to enhance basic cooking skills and nutrition education to improve health. The Teaching Kitchen Collaborative, co-led by the Harvard TH Chan School of Public Health and the Culinary Institute of America, was formed in 2016 to share resources and best practices to propel this movement forward. The group compiles research to build an evidence base showing that basic culinary education can improve health in various settings and has begun an NIH-funded, multi-site trial. The goal of these efforts is to expand similar opportunities around the country by removing barriers to implementation.
The Bipartisan Policy Center, the American College of Sports Medicine and the Alliance for a Healthier Generation also launched a joint effort in 2016 that helped lay the groundwork for teaching health professionals how to work effectively with patients to prevent or treat obesity. Their efforts resulted in "Provider Competencies for the Prevention and Management of Obesity" to help standardize curricula, an "Innovation Award for Health Care Provider Training and Education" and advocacy to improve reimbursement for health services that target lifestyle factors (as opposed to the more traditional fee-for-service payments that encourage additional treatments).
Other experts (Adams et al.) suggest additional tactics, such as a greater emphasis on nutrition in clinical rotations to avoid overburdening classroom curricula and teaching nutrition interventions alongside the options for medicine or surgery (when appropriate) to prevent the need for the latter. While it will always be important to refer patients to RDs for the most comprehensive nutrition interventions, doctors have tremendous potential to improve health and reduce expensive medical treatments with a greater emphasis on what is known as lifestyle medicine.
Recent actions from the federal government also offer promise. The White House Conference on Hunger, Nutrition and Health coincided with the release of the administration's national strategy on nutrition and health. Its second pillar, "Integrate Nutrition and Health," includes the tactic to "strengthen and diversify the nutrition workforce," which aims to increase the workforce of RDs and enhance nutrition education for medical professionals through graduate medical education curriculums, board exams and postgraduate training. Earlier in 2022, the House of Representatives passed a resolution to call on these same entities to provide "meaningful physician and health professional education on nutrition and diet."
What should patients do with this information?
To answer nutrition-related questions and provide counseling, always consult with an RD. Check your insurance plan's coverage before making an appointment. Ask your primary care or specialty physician for a referral if they don't automatically suggest it.
Educate yourself using sources written by public health and nutrition experts, such as the Academy of Nutrition and Dietetics, The Nutrition Source from the Harvard TH Chan School of Public Health and Berkeley Wellness Newsletter from the UC Berkeley School of Public Health.
Remember that a healthy and adequate diet, physical activity and quality sleep are some of the most important steps you can take to maintain good health, prevent disease and even optimize outcomes during most types of medical treatment.
Resources
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Christina Badaracco, MPH, RD
Christina is a registered dietitian and author who aims to improve access to healthy and sustainable food and educate Americans about the connections between food and health. She loves to experiment with healthy recipes in the kitchen and share her creations to inspire others to cook.
Christina completed her dietetic internship at Massachusetts General Hospital and earned her Master of Public Health degree from the University of California, Berkeley. Previously, she graduated with a degree in Ecology and Evolutionary Biology from Princeton University, after conducting her thesis on sustainable agriculture and energy in Kenya. She has done clinical nutrition research at the National Institutes of Health, menu planning and nutrition education at the Oakland Unified School District and communications at the Environmental Protection Agency's Office of Water. She has also enjoyed contributing to children’s gardens, farmers markets and a number of organic farms.