Doctors Don't Know How to Talk to People About Nutrition
Doctors Don't Know How to Talk to People About Nutrition
An article breakdown for What's Worth Reading (No. 9) for the week of October 28, 2024
Rather than the usual brief compilation of interesting snippets and insightful stories, I’m taking a closer look at an interesting paper published earlier this year. Get the Who, What, When, How, Why (and why it matters) below!
Be sure to subscribe if you haven’t already, and if this deep dive isn’t your thing, you’ll get a fresh batch of links and recommended reading next week!
Recently, I delivered a keynote on the topic of “Food Is Medicine,” which had me combing through some research about culinary medicine, teaching kitchens, and the current state of nutrition education for physicians. I knew it wasn’t good but um, it’s like, really not good.
I stumbled across an article titled, “Medical Nutrition Education for Health, Not Harm: BMI, Weight Stigma, Eating Disorders, and Social Determinants of Health”. It wasn’t a good fit for the keynote but I wanted to come back to it because I think it makes some important points.
Let’s talk about it!
(But first, a CW for potentially triggering or stigmatizing language, descriptions of ED behaviors, weight stigma)
First, I’ll break down the key features in an easy-to-digest bulleted list. If you’re just here for the highlights, that’s all you need to read! But if you’re like me and want to chew on it a little more, keep scrolling for the extra savory stuff.
OK…here we go…
Article Title: Medical Nutrition Education for Health, Not Harm: BMI, Weight Stigma, Eating Disorders, and Social Determinants of Health
WHO: Researchers from the Augusta University/University of Georgia Medical Partnership, published in “Medical Science Educator,” the Journal of the International Association of Medical Science Educators
WHAT: An open access review project proposing actionable approaches to improve nutrition education. The recommendations provided within are intended to minimize harm and pursue evidence-based, effective, and equitable healthcare (something that should go without saying but is currently the exception rather than the norm in many settings)
WHEN: published April 2, 2024 (no trial or surveying methods included)
HOW: The authors identified “problematic practices in nutrition education from the perspective of both learners and patients”. They formulated a list of six areas of concern and provided a brief description of recommended changes for each.
WHY: Medical education is severely lacking in not only nutrition education but also health-focused, non-stigmatizing training. This contributes to weight stigma and may perpetuate eating disorder behaviors (according to the authors).
What did we learn?
The gaps in nutrition education for physicians are concerning when contextualized with stats in the paper like, “medical schools averaged 14.3 h of nutrition education [in 2012-2013], a number that has been declining” and “72–95% feeling that it is a physician’s responsibility to discuss nutrition with patients”.
In other words, doctors recognize the importance of nutrition and want to include it, but the amount of training they get is egregiously insufficient. And what little education they do get is often flawed and rooted in a weight-centric approach that hurts more than it helps.
That stat about 14.3 hours? That’s over their ENTIRE pre-clinical education. And that’s less than the recommended minimum of 25 hours established 40 years ago.
The authors listed these areas of concern in current education models for physicians:
Limited evidence-based approaches to nutrition
Improper emphasis on body mass index (BMI)
Reinforcement of weight stigma
Omission of eating disorders
Lack of recognition of social determinants of health (SDoH)
Inadequate communication skills coaching
I suggest reading through the tables to see what they recommend doing to address each of these. Table 2 offers specific suggestions to reword or reframe default assumptions about diet, nutrition, and eating habits with an explanation for why. Table 3 is similar, but focuses on BMI and conversations about weight. They’re not perfect but given the limited amount of face time you get with your doctor, I’d take any one of these suggested alternatives any day.
Here’s one of the most insightful statements I pulled from this paper:
Medical students report wanting help learning how to talk to patients about weight; we suggest instead that students need to learn to talk constructively with patients about their goals, behaviors, and health.
It makes me wonder if medical students come into these programs with that weight-focused bias, or if they gradually absorb and internalize it over time. It’s a fair question to ask, considering we see a parallel chicken-or-the-egg situation with dietetic students. Do future dietitians pursue that degree because it masks an underlying eating disorder, or do they develop eating disorder behaviors as they advance through their programs? A 2023 review of 19 studies showed up to 4-32% of nutrition and dietetics students are at high risk for eating disorders, with 23-89% meeting the criteria for orthorexia (an unhealthy obsession with healthy eating).
Regardless of the origins, the fact remains: weight bias is harmful. So is a disregard for the social determinants of health.
Well-intentioned though it may be, this paper shows us that many doctors are stepping out of scope when they bring up nutrition with their patients. They simply don’t have the right training or experience. As the authors put it, this leads doctors to “give bad advice, exacerbate weight stigma, and influence the development of eating disorders, while the omission of social and cultural determinants of diet leads to impractical recommendations that can alienate patients.”
What this means for you
Basically, don’t trust that your doctor knows what they’re talking about when it comes to nutrition…at least not yet. There *might* be changes coming. For instance, another recent paper suggests 36 competencies to add to medical school training to better prepare doctors for their licensing and certification board exams.
But at the end of the day, you don’t need your doctor to be a nutrition expert. You just need them to refer you to one.
Registered dietitians are the true nutrition experts, spending a minimum of six years of education plus a 1200-hour supervised internship learning all kinds of things not covered in medical school or residency programs. That’s recently increased from a 4-year undergraduate degree to a mandatory master’s degree. Many go on to specialize in areas like gut health, sports nutrition, fertility support and family feeding, and more. Odds are high that there’s someone out there who lives and breathes with a focus on precisely the type of nutrition support you want or need.
Our training isn’t perfect either, far from it. It’s still steeped in weight-centric rhetoric and weirdly beholden to the bad science behind the BMI. But if we’re serious about shifting to health-focused approaches, working with a registered dietitian is worlds better than anything you’ll get from a doctor.
(unless that doctor is also a dietitian — rare, but I think there are a few of them out there?)
Hold onto this paper, you might be able to share it with your doctor and point specifically to the recommendations within. But better yet, ask them to refer you to a dietitian. That’s a powerful way to help you connect with a healthcare professional who specializes in nutrition while saving time in your appointment to focus on medical concerns your doctor *is* qualified to cover.
Did you enjoy this format? Academic articles can be dry and boring. But they can also be a great way to advance your knowledge or understanding of the science around a particular topic.
Let me know what you think, or submit an article or study for a future breakdown!