What if your doctor failed to talk to you about the most important threat to your health? Wouldn’t you worry about the quality of your health care? Poor quality diet is a leading cause of death in the United States, but it is unlikely that your doctor has the knowledge to even begin a meaningful conversation about your nutrition or to make an appropriate dietary referral.
Most doctors lack the knowledge necessary to offer nutrition advice to patients; indeed, fewer than 14 percent of physicians report feeling equipped to advise on diet or the connection between food and health. This is unsurprising given that, for example, 90 percent of cardiologists in a recent survey reported receiving minimal or no instruction on nutrition during medical training.
Yet it is also concerning. Obesity, type-2 diabetes, heart disease, cancer, and stroke, which are leading causes of death in the United States, all are closely linked to diet and nutrition.
Nearly 40 percent of adults and 18 percent of children are obese, and these numbers are increasing; almost 10 percent of Americans suffer from diabetes, compared with less than 1 percent just 50 years ago. Even more concerning, more than one-third of Americans have pre-diabetes.
A focus on treatment rather than prevention has led to medical education that ignores the central role that food plays in health. The average U.S. medical school devotes less than 1 percent of total lecture hours to nutrition. Accreditation requirements for medical residencies and fellowships do not include nutrition.
The standardized exams that medical students must pass to become board certified lack questions that test the ability to advise patients on diet. And to date, no state requires continuing medical education in nutrition or diet-related disease as part of the ongoing education for physicians to maintain licensure.
This dangerous gap in their education means that doctors do not learn the basic guidance in the U.S. Dietary Guidelines for Americans, or stay apprised of the latest nutrition science. Accordingly, they fail to recognize, and are unable to convey to patients, the importance of diet to health. This means fewer referrals to nutritionists, even when diet plays a vital role in their patient’s health.
The lack of nutrition education during medical training is also a costly mistake. Health-care spending has skyrocketed — Medicare benefit payments exceeded $730 billion in 2018 and account for nearly 15 percent of all federal spending.
At its current rate, Medicare spending will exceed $1 trillion in the next 10 years. Diet-related diseases account for 5 of the 8 most common conditions among Medicare beneficiaries, so it’s clear that as the prevalence of diet-related diseases increase, health-care spending increases.
Fortunately, we can change this troubling status quo. Opportunities exist for policymakers at the state and federal level, as well as the bodies responsible for testing and accreditation, to make systemic changes to medical training.
For example, state legislatures and Congress can offer grants to medical schools to develop curricular content; the American Council of Graduate Medical Education can amend residency requirements to require competency in diet and nutrition; and testing organizations like the National Board of Medical Examiners and the American Board of Medical Specialties can incorporate nutrition-focused content on step and board examinations, respectively.
Perhaps the most logical and effective solution is to ask Congress to spend our health-care dollars more wisely. Medicare is the single largest source of federal funding for graduate medical education, providing more than $10 billion to eligible programs in fiscal year 2015.
This funding comes with “no strings attached,” i.e. no curricular requirements or performance benchmarks, and certainly no expectation that residents or fellows receive education in nutrition.
Rather than spend a whole lot more on Medicare to treat diet-related diseases down the road, Congress should leverage this funding to require nutrition education for residents and fellows. These policies and others are explored in a recent report from the Harvard Law School Food Law and Policy Clinic.
The education of doctors is a critical issue with universal implications for our national health. When it comes to the care we receive at each doctor’s visit, we reap what we sow. By not insisting that physicians receive at least foundational education in nutrition, we produce a medical system that is focused almost exclusively on drugs and devices, and in which the most costly diseases continue to grow.
Alternatively, by helping physicians understand the connection between food and health, we can produce better individual patient outcomes, improve population health, and change our nation’s health-care landscape for the better.
Emily M. Broad Leib, J.D., is an assistant clinical professor of law at Harvard Law School and the director of the Harvard Law School Food Law and Policy Clinic. Stephen Devries, M.D., is a preventive cardiologist and executive director of the nonprofit Gaples Institute for Integrative Cardiology. Walter Willet, M.D., Ph.D., is a professor of epidemiology and nutrition at Harvard T.H. Chan School of Public Health and a professor of medicine at Harvard Medical School.