REVIEW

Clinical Nutrition Education of Doctors and Medical

Students: Solving the Catch 22
Stavia B Blunt1 and Anthony Kafatos2
1 Independent writer and researcher, Richmond, London, United Kingdom; and 2 University of Crete School of Medicine, Department of Social Medicine,
Preventive Medicine and Nutrition Clinic, Heraklion, Greece

ABSTRACT
There is a well-documented pandemic of malnutrition. It has numerous sequelae, including physical and psychological ill health, early death,
and socioeconomic burden. The nutrition landscape and dynamics of the nutrition transition are extremely complex, but one significant factor
in both is the role of medical management. Doctors have a unique position in society from which to influence this scenario at global, public, and
personal levels, but we are failing to do so. There are several reasons for this, including inadequate time; historical educational bias towards disease
and therapeutic intervention—rather than diet, lifestyle, and prevention; actual or perceived incompetency in the field of nutrition; confusion or
deflection within medicine about whose role(s) it is on a medical team to address nutrition; and public confusion about whom to turn to for advice.
But the most fundamental reason is that current doctors (and thus the trainers of medical students) have not received—and future doctors are
thus still not receiving—adequate training to render them confident or competent to take on the role. A small number of important educational
approaches exist aimed at practicing doctors and medical students, but the most effective methods of teaching are still being evaluated. Without
properly trained trainers, we have no one to train the doctors of tomorrow. This is a "catch 22." To break this deadlock, there is an urgent need to make
appropriate nutrition training available, internationally, and at all levels of medical education (medical students, doctors-in-training, and practicing
doctors). Until this is achieved, the current pandemic of nutrition-related disease will continue to grow. Using important illustrative examples of
existing successful nutrition education approaches, we suggest potential approaches to breaking this deadlock. Adv Nutr 2019;10:345–350.

Keywords: nutrition education, nutrition training, global malnutrition, nutrition education of doctors, nutrition education of medical students,
lifestyle education, dietary education, primary prevention, nutrition teachers

Introduction increased to >300 million (3), and today, ∼641 million adults
Malnutrition is one of the biggest health challenges of the worldwide are obese (2, 3). Over 115 million of these people
21st century (1). Globally, obesity- and hunger-malnutrition are in developing countries (approximately one-third of the
underlie most major illnesses and deaths (1–3). global obese population). Globally, 41 million children are
Obesity-malnutrition, smoking, excess alcohol, and insuf- obese, and over one-third of obese children are in developing
ficient exercise underlie 80% of cardiovascular diseases, 90% countries (2). Obesity is thus a global problem likely to get
of type 2 diabetes, and 35–70% of cancers (1, 3). Obesity- worse as the generation of obese children become adults.
malnutrition occurs in a range of economic, political, Obesity-malnutrition may arise from a large array of dis-
educational, and practical settings (2). It affects all ages parate situations, including poor food choice (voluntary and
and socioeconomic groups, and increasingly, all parts of the involuntary), excess food consumption, access constraints to
world. Until the second half of the 20th century, obesity- healthy food, and limited physical activity. Pressures of time,
malnutrition was limited to wealthy countries. In 1995, ∼200 location, finance, education, and social or family support are
million adults and 18 million children aged <5 y were relevant factors (2).
overweight. Five years later, the number of obese adults had At the same time, hunger-malnutrition is growing. Today,
∼815 million people in the world (∼1:9) are hungry—an
The authors reported no funding received for this study. increase from 777 million in 2015 (2). Annually, 10 million
Author disclosures: SBB and AK, no conflicts of interest. children aged <5 y die from malnutrition. One in 3 have
Former address for SBB: Department of Neurology, Section of Clinical Neurosciences, Imperial
College London, London, United Kingdom.
malnutrition-related illness, 155 million children are stunted,
Address correspondence to SBB (e-mail: [email protected]). and poor nutrition causes 45% of their deaths (3.1 million/y).


C 2019 American Society for Nutrition. All rights reserved. Adv Nutr 2019;10:345–350; doi: https://doi.org/10.1093/advances/nmy082. 345
One-third of women of reproductive age are anemic. Most of information from the media; only half trusted their GP (11).
these people live in developing countries, but not all. Food A survey in 2016 revealed that although 85% trusted advice
insecurity is rising in Europe, affecting, in some parts, ∼20% from their GP, 58% equally trusted their personal trainer, 41%
of the population (4). The highest rates are in those regions a “healthy eating blogger” (75% of the 18- to 24-y age group),
where economic pressures are greatest: Lithuania (19.6%), 35% a television chef, and 59% friends or family (16). The
Romania (18.9%), and Greece (17.2%); the lowest rates are Internet, available 24/7 without appointment, is increasingly
in Sweden (3.1%), Germany (4.3%), and Denmark (4.9%). the go-to source for health information. On average, people
However, Great Britain, the sixth largest economy in the spend 2 h/d Internet surfing on their phones; 50% of these
world, ranks in the bottom half of the European scale: ∼8.4 users obtain their nutrition advice online (17).
million people (10% of the population) have insufficient food
and 5% go a whole day without food because of poverty. In Reasons for the Medical Silence in Nutrition
the United States, food insecurity is underdocumented and There are several reasons for the medical silence in the
its health impact underestimated (5). field of nutrition. One reason is time: doctors are too
The medical consequences of hunger-malnutrition were busy fire-fighting the consequences of malnutrition (15, 18).
once primarily low weight and deficiency diseases, but it is Accessibility to GPs, at least in the United Kingdom, is so
no longer so simple. Today, there are also the hungry-obese— poor there has been a recent parliamentary inquiry (19). A
a paradox resulting when food that is cheap and filling second reason is a failure to practice what we (would) preach.
(6) [and possibly “addictive” (7)], but high in energy and One of the best correlates of a doctor offering advice, and
low in nutrients (“empty” calories), is chosen in preference whether he/she will be listened to, is if the doctor practices
to food that is more expensive, possibly less immediately it him- or herself (20, 21). From the patient’s perspective,
filling or tasty, but more nutrient dense (6–8). The obese- “image matters.” Advice from a “slimmer” doctor (20, 21)
malnourished are at double risk of obesity-related conditions or online blogger (17) is given more “weight.” This is a 2-
and deficiency diseases and infections (8). pronged problem: on the one hand, it deters doctors from
Both kinds of malnutrition affect all ages, all socioe- counseling and, on the other, patients from listening. It
conomic groups, and every area of medical practice (1, seems that to effectively give advice—and advice that will be
3). And although their global distribution is uneven, they listened to—doctors must first heal themselves, and lead by
increasingly coexist (2). The medical, surgical, psychological, example. A third reason is “mind set”: medical training and
and socioeconomic repercussions of these dietary-related practice is historically heavily disease, diagnosis, and drug
pandemics are huge. The US bill is $147 billion annually (9). treatment orientated (22), and there is not yet a prevalent-
Furthermore, the trend in most countries is getting worse, enough notion that nutrition is a key part of the doctor’s
not better. responsibility rather than that of other members of the health
This dire situation is of paramount importance to all doc- care system (23). For this to change to a situation where
tors, whatever their specialty and wherever they practice. But preservation of health and prevention of disease are at the
although government and medical education policymakers forefront requires a paradigm shift in how medicine is taught
have recognized the need for increased medical presence in and practiced. But by far the most important reason is that
the field of nutrition for decades, the objectives are elusive: doctors lack the expertise and/or confidence to counsel on
doctors are failing to provide adequate nutrition care (1, 10– dietary patterns and diagnose nutrition deficiencies, because
14). they are not, or do not feel, adequately trained to do so (22–
Only a small percentage of doctors routinely offer nu- 29).
trition care, and methods are haphazard (10–12). In the Ironically, the position of nutrition training in medical
United States, where the role of nutrition in disease has education has actually declined over much the same period
probably received more intense media and research attention as its relevance to health care has surged (8, 22, 28). In the first
than anywhere else in the world, only one-third of obese half of the 20th century, scientific understanding of the role
patients are diagnosed and counseled by their physicians of nutrition in preventing and treating deficiency diseases
(13). In the United Kingdom, general practitioners (GPs) was booming (the Golden Age of nutrition) and nutrition
spend only 16% of clinic time on prevention (14) and few education formed a significant part of the training of all
routinely offer nutrition advice (14, 15). Instead, nutrition doctors (22). In medicine, nutrition was primarily seen for
work is often deferred to nutritionists or dietitians, whose its role in deficiency diseases and medical school curricula
input is invaluable. However, because doctors are usually the matched that emphasis.
first port of call for medical problems, including those that But the world was a different place in the first half of the
are nutrition-related, their inadequate nutrition care lays the 20th century (22, 30). Food was “natural” and unprocessed;
field open for alternative, variably qualified and regulated nu- production had not yet mushroomed through commercial
trition advisers: journalists, bloggers, chiropractors, nutrition farming. It was supply, not demand, driven. This situation
therapists, personal trainers, and celebrity chefs. quickly changed after the Second World War (22, 30). Food
Not surprisingly, the public does not know who to turn shortages resulting from both world wars, economic crises,
to. In 1997, even before the Internet was widespread, a UK and infectious diseases led to international steps to address
survey showed that most people obtained their nutrition global public health. Commercial production methods and

346 Blunt and Kafatos

 fortification of foods brought a better diet to more people. Japan (40), Ghana (41), the United Kingdom and Australia
By the mid-20th century, many classic deficiency diseases (23, 29, 42), and India (43) fare far worse. Five of the 6
had declined in parts of the Western world, although iron medical schools in Greece were contacted by the authors.
deficiency continues to be a major problem (2). But these Two have no nutrition course. Athens University Medical
same changes in food supply coupled with mass marketing, School has a student-selected 28-h lecture course. Ioannina
chain stores, and fast-food outlets, led to an excess and and Patras Medical Schools have a small number of nutrition
easy availability of certain types of food (30). Much of this lectures within the epidemiology-hygiene course. The sixth
food is unhealthy, tastily tempting, quite possibly “addictive,” Greek medical school, at the University of Crete, has had a
and often cheaper than healthier options (6, 7, 30), thus dedicated nutrition course since 1989 (discussed below).
providing additional appeal to the poor (31). In addition,
lifestyle has become increasingly sedentary and indoors How to Reform Nutrition Training
(31–33). At the same time, basic science research shifted There are several obstacles to implementing training in
away from nutrition towards cell and molecular biology nutrition. Putting aside the financial obstacles, 2 of the most
and enzyme and endocrine function (22). Diagnostics and fundamental obstacles are uncertainty about how—and by
therapeutics expanded, shifting the focus of medical training whom—nutrition should be taught.
from physiology, biochemistry, prevention, and holistic care
towards drug treatment (22). From the 1950s onwards, the Training the trainers
importance of nutrition in medical training and clinical A major stumbling block to implementing training in
practice became increasingly obscure; its teaching hung on nutrition for medical students (and thus future doctors) is
precariously in a few medical schools, straddling different that there are few incumbent doctors trained to do this (23,
disciplines (22). 37, 38, 42)—a catch 22. It is clearly impossible to educate
Concurrently, in the last 50 y—the period during which medical students—and thus build up a body of specialists in a
most currently practicing doctors were trained—the global particular field—if there are no appropriately trained teachers
health demographics altered dramatically and quickly. Heart with which to start.
disease, stroke, obesity, and type 2 diabetes increased (32, 33). The United States is the leader in the training of doctors
The links between these “new” diseases and lifestyle and diet in nutrition, with dedicated programs in some schools since
are now well established (32, 33). the 1970s. This has enabled the growth of a body of suitably
The consequences of this combination of events are as trained doctors with specialist nutrition knowledge. Yet, even
follows: in the United States, the acquisition of nutrition training for
practicing doctors who trained before the implementation of
(1) Few practicing doctors worldwide have appropriate nutri- nutrition courses (or who trained in medical schools without
tion knowledge to properly serve the malnutrition-related a nutrition course) is largely self-driven (28). Nevertheless,
ill health of the global population. there are encouraging developments in the formalized
(2) Training in nutrition for future doctors has not adapted nutrition training of medical graduates in the United States.
to changes in disease demographics nor to the scientific Recently the Nutrition in Medicine (NIM) online project
understanding of their nutrition basis. (2010) (44) has extended its program to residents wishing
(3) There are few trained trainers available to train these to study nutrition, while some nonprofit organizations, such
future doctors: a "catch 22." as the Gaples Institute in Illinois (45), now offer nutrition
training for physicians. In addition, graduate fellowships
What Are the Obstacles to Implementing exist for those wishing to specialize (e.g., Arizona integrative
Nutrition Education in Medical Schools? medicine courses; Harvard University Medical School Public
Leaders in medical training and policy have long been Health Fellowship).
aware of the relevance of nutrition in world health. In In other parts of the world, few medical schools have
1985, the US National Academy of Sciences recommended appropriately trained nutrition faculty to teach under-
a minimum of 25 h of nutrition education in medical graduate nutrition programs, and there are no programs
schools (22). In 1989, the WHO made recommendations for for educating practicing doctors (39–43). In the United
schools in Europe and elsewhere (34). In 2009, in Britain, Kingdom, the intercollegiate group on nutrition responded
the General Medical Council emphasized nutrition training to the General Medical Council’s proposals for nutrition
in “tomorrow’s doctors” (35). In 2014, the Association of educational requirements of future doctors with various
American Medical Colleges stipulated required objectives proposals (46, 47) and renewed requirements for newly
(36). qualified doctors in 2013 (48), but there are no avenues
Despite these recommendations, most medical schools governed or provided by any of the royal colleges through
worldwide have neither adequate training in nutrition nor which physicians can obtain approved medical training in
qualified nutrition faculty (37–43). The 2 are obviously nutrition. The University of Surrey offers “the only evidence-
connected. Today, 30 y after the National Academy of based Masters degree of its kind in Europe and is the only
Sciences’ recommendations, only one-quarter of US schools Masters degree in Nutrition Medicine to be accredited by
meet them (38). Medical schools in Western Europe (39), the Association for Nutrition” (49). However, at 5 y, it is

Nutrition education in medicine 347

too long to be practicably useful to practicing doctors. It The NIM online project (2010) (44) provides a free
seems that motivated physicians with an interest in nutrition core nutrition curriculum to medical schools in the United
mostly have to acquire their knowledge voluntarily, through States and abroad. Student-directed learning is intercalated
self-education. Because malnutrition is a global health issue, throughout undergraduate training using Web-based mod-
strategies for tackling the problem should ideally include ules. This enables medical schools to cover the curriculum
internationally standardized training programs in nutrition economically, while circumventing personnel problems.
for medical students and doctors. Nutrition training of
practicing doctors is important for another reason: without The Crete experience
suitably trained faculty, it is challenging to effect a suitable The University of Crete, Greece, has the first and oldest
nutrition course for medical students and future doctors (25, nutrition course for medical students in Europe. In 1989,
27, 28). the university implemented a dedicated course for third-
year students consisting of 6 h of lectures and 25 h of
practical session (52, 53). It was conducted by a team of 8
Approaches to Nutrition Education in Medical Schools (2 physician nutritionists, 2 dietitians, 1 physical activity
Putting aside the immediate obstacle of insufficient faculty expert, 2 nurses, and 1 statistician). Students actively par-
and trainers, there are other uncertainties about how to teach ticipated in the teaching process by performing a health
nutrition in medical schools (31–42). Various approaches to and nutrition assessment on each other supervised by the
teaching nutrition have been used (Text Box 1): required physicians (tools included: dietary history, clinical examina-
or student-selected modules, dedicated or intercalated cross- tion and sociocultural data, anthropometric measurements,
discipline, lecture-based and/or clinical bedside teaching, physical activity—ergometric bicycle—hematological and
online courses, and courses where the students are actively biochemical tests). Students also assessed the health and
involved in the assessments and teaching. nutrition status of pediatric and adult patients. Cases were
presented on the last day of the course, emphasizing nutrition
deficiencies and excesses, and documented changes after the
students’ interventions.
Text Box 1
Approaches to nutrition teaching
United Kingdom
• Student-selected modules
Cambridge University has implemented a “vertical spiral”
• Compulsory modules
nutrition course during the clinically focused years of both
• Dedicated nutrition modules
the undergraduate and graduate medical degrees (54). Its
• Intercalated cross-discipline modules
success is based on 3 factors: leadership and advocacy skills
• Lecture-based teaching
of the teaching team, variability of teaching mode, and
• Clinical/bedside teaching
multidisciplinary review of evaluation tools.
• Online courses
• Students as subjects and mentors
Israel
These different approaches vary in their degree of reliance Students at Hebrew University Medical School have imple-
on faculty-led teaching. Here we present some of the most mented a novel student-led intercalated curriculum that cov-
instructive approaches. ers nutrition, exercise, and lifestyle behaviors at preclinical
and clinical levels (55). The students emerge ready to explore
it both as a coach and in their personal lives.
United States
The United States is the leader in the field of nutrition Conclusions
education of its doctors, and yet even there only 25% Nutrition is at the root of today’s preventative ill health (32,
of medical schools have any kind of nutrition education 33). It follows that doctors must develop a leading role in the
element. Of those, a few have implemented important field of nutrition and, furthermore, one that leads by example.
nutrition education courses and have evaluated the different The key point is the primary and secondary prevention of all
approaches to teaching (50–55). chronic diseases.
Harvard Medical School has recently changed its course Today’s doctors are inadequately trained to fulfil this role.
from a dedicated to integrated curriculum, and this resulted There is an urgent need for training of existing doctors
in no change in medical students’ attitudes or knowledge worldwide in nutrition. This is important not only for the
about nutrition (50). Boston University implemented a provision of appropriate health care but also for the education
student-centered model (51). This team-based approach fo- of future doctors. Without suitably trained doctors, there
cuses on case-based learning in the classroom, practice-based is nobody to teach the doctors of tomorrow. This deadlock
learning in the clinical setting, extracurricular activities, and will continue until the specialty of Physician Nutritionist
a virtual curriculum over 4 y. Despite only 20.5 h of teaching, becomes widely established. Although a Physician Nutrition
the American Academy’s objectives were covered and student Specialist now exists in the United States, it is not widespread
satisfaction was high. or indeed widely known about either within or outside of

348 Blunt and Kafatos

 the medical field. But all trainee doctors need adequate Acknowledgments
basic nutrition knowledge and skills so that they emerge Demetre Labadarios from Stellenbosch University, South
from training with an understanding of nutrition and how Africa, helped initiate the course in Crete. Manolis Linar-
it is part of their role as a doctor, and not solely the dakis and Christos Hatzis helped run the course. The
responsibility of other professionals in the health care team. authors’ responsibilities were as follows—SBB and AK: jointly
Urgent provision of training to both practicing physicians conceived the idea for the manuscript; SBB: was the primary
and doctors-in-training is required, preferably using inter- researcher, with data for Crete University Medical School and
nationally standardized methods, either through approved other Greek medical schools provided and researched by AK;
fellowships and/or online training such as that provided by and both authors: read and approved the final manuscript.
the NIM. The latter is low-cost, requires minimal personnel,
and would result in international uniformity in curriculum,
with obvious advantages when dealing with the global issue
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