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A Deficiency of Nutrition Education and Practice in Cardiology
... Physicians have an opportunity to engage in health promotion in clinical care [33]. However, nutrition and diet are insufficiently incorporated into medical education in medical schools around the world [34][35][36]. In today's complex and time-limited healthcare setting, interactions between doctors and patients are limited. ...
... Due to increasing patient loads, doctors are trained to emphasize one or a few chief complaints. Nutrition counseling is rarely provided, and time spent on it is inadequate to initiate behavior change [35,38,39]. ...
Tools to briefly assess diet among US Spanish-speaking adults are needed to identify individuals at risk for cardiometabolic disease (CMD) related to diet. Two registered dietitian nutritionists (RDNs) recruited bilingual medical students to translate the validated Diet Risk Score (DRS) into Spanish (DRS-S). Participants were recruited from a federally qualified health center. Students administered the DRS-S and one 24-h recall (Automated Self-Administered 24-Hour (ASA24®) Dietary Assessment Tool) on one day; a second recall was administered within 1 week. Recalls were scored using the Healthy Eating Index (HEI)-2015, a measure of adherence to the Dietary Guidelines for Americans. Spearman correlations, weighted kappa, and ANOVA were conducted using SAS 9.4 to assess the relative validity of the DRS-S. Thirty-one Spanish-speaking adults (female: n = 17, 53%; mean age: 58 (42–69)) completed assessments. The mean DRS-S was 9 (SD = 4.2) (max: 27; higher score = higher risk) and the mean HEI-2015 score was 65.7 (SD = 9.7) (max: 100; higher score = lower risk), with significant agreement between measures (r: −0.45 (p = 0.01)), weighted kappa: −0.3 (p = 0.03). The DRS-S can be used in resource-constrained settings to assess diet for intervention and referral to RDNs. The DRS-S should be tested in clinical care to assess the impact of dietary changes to reduce CMD risk.
... In graduate medical education, nutrition education should build upon the foundation established during undergraduate medical education by tailoring the content to the specific needs of each medical specialty [55,56]. Although physicians do not require detailed nutrition training from a registered dietitian, they require a core foundation of evidence-based knowledge and practical skills to provide timely dietary advice and effectively collaborate with nutrition professionals. ...
... Specialties such as cardiology and endocrinology naturally demand advanced nutrition knowledge owing to the dietary sensitivities of their patient populations. However, many cardiologists [55] and endocrinologists [64] have reported insufficient nutritional education during training. Similar gaps exist in gastroenterology fellowship programs, emphasizing the need for more standardized and comprehensive nutrition education across all specialties [65,66]. ...
This review explores the diverse landscape of integrating nutrition and physical activity education into medical school curricula, focusing on the imperative role of physicians in promoting health through lifestyle changes. By examining global medical education structures, we uncovered disparities in nutrition and physical activity training, and highlighted the need for a shared framework to address international and regional challenges. Despite acknowledging the importance of both nutrition and physical activity, studies have consistently uncovered deficiencies in medical school curricula, especially in skills related to providing lifestyle advice and behavioral counseling. Survey studies among medical students have illuminated various perceptions and knowledge gaps, emphasizing the need for more comprehensive and mandatory nutrition and physical activity training. While acknowledging progress, challenges, such as time constraints, resource availability, and faculty expertise, persist. Integrating lifestyle education results in resistance, a demand for strategic communication, and faculty buy-ins. These findings underscore the importance of a holistic approach that balances theoretical knowledge, practical skills, and confidence that medical students need to promote effective nutrition and physical activity in healthcare.
... For example, cardiologists care for patients with many diet-sensitive diseases, such as lipid disorders, coronary artery disease, and heart failure. However, few cardiologists reported receiving nutrition education during training, with their subspecialty fellowship years the least likely to have integrated nutrition education [42]. As such, calls for enhanced education highlight the potential for cardiologists to serve as key team members in the delivery of nutrition interventions, given the broad impact of diet on cardiovascular health [43]. ...
... Lack of testing further contributes to the de-incentivization of nutrition learning, a problem also reinforced by postgraduate board examinations, particularly the case in specialty fields such as gastroenterology, cardiology, and endocrinology [42][43][44]46,79,80]. As previously described, these fields have a preponderance of patients with secondary and tertiary diet-sensitive health problems, including diabetes, heart disease, hypertension, inflammatory bowel diseases, colon cancer, and fatty liver disease. ...
Medical education faces an urgent need for evidence-based physician nutrition education. Since the publication of the 1985 National Academies report “Nutrition Education in the United States Medical Schools,” little has changed. Although several key efforts sought to increase nutrition content in undergraduate medical education over the past 40 y, most medical schools still fail to include the recommended minimum of 25 h of nutrition training. Without foundational concepts of nutrition in undergraduate medical education, graduate medical education unsurprisingly falls short of meeting patient needs for nutritional guidance in clinical practice. Meanwhile, diet-sensitive chronic diseases continue to escalate, although largely preventable and treatable by nutritional therapies and dietary lifestyle changes. Fortunately, recent recognition and adoption of Food is Medicine programs across the country increasingly connect patients with healthy food resources and nutrition education as core to their medical care, and physicians must be equipped to lead these efforts alongside their dietitian colleagues. Filling the gap in nutrition training will require an innovative and interprofessional approach that pairs nutrition with personal wellness, interprofessional practice, and community service learning. The intersectional benefits of connecting these domains will help prepare future physicians to address the social, behavioral, and lifestyle determinants of health in a way that recognizes nourishing food access as a core part of clinical practice. There are numerous strategies to integrate nutrition into education pathways, including didactic and experiential learning. Culinary medicine, an evidence-based field combining the culinary arts with nutritional science and medicine, is 1 promising educational framework with a hands-on, interprofessional approach that emphasizes community engagement. Advancing the critical need for widespread adoption of nutrition education for physicians will require support and engagement across societal stakeholders, including co-leadership from registered dietitian nutritionists, health system and payor reform, and opportunities for clinical innovation that bring this essential field to frontline patient care.
... Physicians who receive more nutrition training provide counseling to more of their patients [36]. However, the majority of physicians report receiving insufficient training to address their patients' nutritional needs [36][37][38][39][40][41], despite 72-95% feeling that it is a physician's responsibility to discuss nutrition with patients [36,37,40,42]. ...
... Physicians who receive more nutrition training provide counseling to more of their patients [36]. However, the majority of physicians report receiving insufficient training to address their patients' nutritional needs [36][37][38][39][40][41], despite 72-95% feeling that it is a physician's responsibility to discuss nutrition with patients [36,37,40,42]. ...
Effective nutrition training is fundamental to medical education. Current training is inadequate and can cause harm to students and patients alike; it leaves physicians unprepared to counsel on nutrition, places undue focus on weight and body mass index (BMI), can exacerbate anti-obesity bias, and increase risk for development of eating disorders, while neglecting social determinants of health and communication skills. Physicians and educators hold positions of influence in society; what we say and how we say it matters. We propose actionable approaches to improve nutrition education to minimize harm and pursue evidence-based, effective, and equitable healthcare.
... Nutrition is one of the modifiable factors of lifestyle and plays an important role in ensuring normal cardiac ejection fraction and maintaining favorable cardiac function (4). However, malnutrition in HF patients has been a common phenomenon partially because fluid and sodium restriction, which is an essential part of HF treatment, often leads to artificial reductions in active feeding and thus causes malnutrition, which is detrimental to patients with HF (5). ...
... Demographic data were obtained through relevant questionnaires including gender, age, race, education, marital status, income, occupation, and type of health insurance. Participants were divided into three groups based on their poverty-to-income ratios: low (≤ 1), midrange (1)(2)(3)(4), and high (≥ 4) (12). Less than a high school diploma, a high school graduate or its equivalent, and a college degree or more were the three categories for education. ...
Background:
The association between dietary energy patterns, calories, and the outcomes of heart failure (HF) is still unclear.
Objectives:
To evaluate the proper energy intake patterns and daily calorie intake in patients with heart failure among US adults.
Methods:
The data were derived from the 2001-2014 National Health and Nutrition Examination Survey (NHANES). A calorie intake pattern variable was created using latent class analysis (LCA) based on the calorie ratio of three major nutrients. Cox proportional hazard regression models were used to evaluate the hazard ratios (HR) and 95% confidence intervals (CI) of the association between calorie intake and energy patterns. The primary endpoint was all-cause mortality.
Results:
Among 991 participants (mean age 67.3 ± 12.9 years; 55.7% men) who suffered from heart failure; the median calorie intake was 1,617 kcal/day [interquartile range (IQR): 1,222-2,154 kcal/day]. In the multivariable-adjusted model, moderate malnutrition was more frequent to death (HR: 2.15; 95% CI: 1.29-3.56). Low-carbohydrate pattern (LCP) and median-carbohydrate pattern (MCP) had lower risks of death compared to high-carbohydrate pattern (HCP) (LCP: HR: 0.76; 95% CI: 0.59-0.97; MCP: HR: 0.77; 95% CI: 0.60-0.98). No association between different amounts of calorie intake and all-cause mortality was found. There was an adjusted significant interaction between calorie intake and energy intake patterns (p = 0.019). There was a linear relationship between energy intake through HCP and all-cause mortality (p for non-linear = 0.557). A non-linear relationship between energy intake through MCP and all-cause mortality (p for non-linear = 0.008) was observed.
Conclusion:
Both LCP and MCP, compared to HCP, were associated with better outcomes in the HF population. The relationship between energy intake and all-cause death may be influenced by energy intake patterns in HF patients.
... Efforts to increase the use of dietary interventions by primary care physicians will require a more robust understanding of physicians' current knowledge, opinions, and perceived barriers to their use (Levine et al., 1993). Several studies have surveyed physicians (cardiologists and internists) to assess objective knowledge and subjective attitudes towards dietary interventions (Harkin et al., 2018, Devries et al., 2017. The current study employs a large regional survey to investigate physicians' knowledge, personal views, and perceived physician-level and systems-level barriers to employing dietary interventions in the context of primary care. ...
... We used a cross-sectional survey of Family Medicine, Internal Medicine, and Pediatric physicians at three Southeast Michigan hospital systems to contextualize the limited use of dietary interventions among primary care providers and to add granularity to previous findings regarding the lack of nutrition knowledge among general practitioners, medical residents, and medical students (Conroy et al., 2004;Vetter et al., 2008). This study adds to the previous work among primary care providers to examine the knowledge and attitudes towards use of dietary interventions (Antognoli et al., 2017, Ball and Leveritt, 2015, Cassidy-Vu and Kirk, 2020, Devries et al., 2017, Smith et al., 2015, Tronieri et al., 2019. ...
Background
Dietary interventions are first-line therapies for the prevention and management of many chronic diseases, yet primary care physicians prescribe these interventions infrequently.
Objectives
This study investigates primary care physicians’ current knowledge and opinions regarding the delivery of dietary interventions. This work aims to identify modifiable barriers to prescribing dietary interventions to prevent and treat diet-related diseases.
Methods
We designed and fielded an anonymous, cross-sectional survey of faculty and resident physicians across the Internal Medicine, Family Medicine, and Pediatrics departments in three academic and community hospitals in lower Michigan. Data were collected between January 15 and April 15, 2019. Self-rated knowledge and attitudes were measured on a 5-point Likert scale. Objective scores were calculated for each question as percentage answered correctly among all respondents. Objective knowledge scores were compared based on participants’ years in practice.
Results
Response rate was 23% (356 responses). The sample was 62.3% female and 75.3% non-Hispanic White, and 56.7% were age 40 or younger. Average objective knowledge score was 70.3% (±17.2) correct. Mean self-rated knowledge score was 2.51 (±0.96) on a scale of 1(Poor) − 5(Excellent). Overall agreement with a statement of importance of dietary interventions was 3.99 (±0.40) on a scale of 1 (strongly disagree) to 5 (strongly agree). A majority (91.7%) of respondents indicated they would like more opportunities to learn about the evidence supporting dietary interventions.
Conclusions
Physicians desire to incorporate dietary interventions into their practice. Findings encourage the development of educational strategies to support dietary intervention use among primary care physicians.
... 71 In another study, 95% of 930 cardiologists surveyed believed nutrition counseling was part of their personal responsibility to their patients, and 90% reported no or minimal nutrition education. 72 In a different study, it was reported that of 40 internal medicine program directors surveyed, less than 50% reported providing "quite a bit/extensive training in dietary counseling" on hypertension, hyperlipidemia, and obesity. 73 The most frequently noted "moderate-to-major barriers" to education were competing curricular demands, lack of physician faculty with expertise in nutrition, inadequate financial resources, and lack of administrative support. ...
The relationship between lifestyle behaviors and common chronic conditions is well established. Lifestyle medicine (LM) interventions to modify health behaviors can dramatically improve the health of individuals and populations. There is an urgent need to meaningfully integrate LM into medical curricula horizontally across the medical domains and vertically in each year of school and training. Including LM content in medical and health professional curricula and training programs has been challenging. Barriers to LM integration include lack of awareness and prioritization of LM, limited time in the curricula, and too few LM-trained faculty to teach and role model the practice of LM. This limits the ability of health care professionals to provide effective LM and precludes the wide-reaching benefits of LM from being fully realized. Early innovators developed novel tools and resources aligned with current evidence for introducing LM into didactic and experiential learning. This review aimed to examine the educational efforts in each LM pillar for undergraduate and graduate medical education. A PubMed-based literature review was undertaken using the following search terms: lifestyle medicine, education, medical school, residency, and healthcare professionals. We map the LM competencies to the core competency domains of the Accreditation Council for Graduate Medical Education. We highlight opportunities to train faculty, residents, and students. Moreover, we identify available evidence-based resources. This article serves as a “call to action” to incorporate LM across the spectrum of medical education curricula and training.
... Nutrition is a cornerstone of cardiovascular guidelines [1], and health professionals should be proficient in basic nutrition knowledge to promote a sustainable pattern of healthful eating for both healthy individuals and those at higher risk [2]. Only a small percentage of cardiologists feel they have "expert" nutrition knowledge due to lack of nutrition education [3]. Yet a recent online survey reported that the Dietary Approach to Stop Hypertension (DASH) diet was commonly recommended to patients with hypertension by health care providers, including physicians, but was not associated with prior nutrition education [4]. ...
The objective of this evaluation was to determine the impact of a pop-up Teaching Kitchen (TK) at a national cardiovascular conference. The 60-minute session was hosted in a hotel conference room and led by two registered dietitians. Participants prepared 12 recipes, enjoyed a family-style meal, and explored nutrition behaviour change strategies for patients. Using Likert-scaled and open-ended questions, pre-/post-online surveys assessed change in perceived nutrition counselling skills, attitudes, and confidence; post-survey also assessed effectiveness of session components and further training needs. Pre-survey response was 72% (18/25). Twenty-one participants attended the event (14 pre-registrants, six from waitlist, and five drop-ins); 81% completed the post-survey. Positive shifts were reported in nutrition competence, particularly attitudes towards using recipes in nutrition counselling, and increased skills and confidence discussing eating on a budget and SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goal setting with patients. Components of the TK session that enhanced nutrition competence were key patient messages and the shared meal. Preparing and eating together in a hands-on format was most enjoyable. Promoting healthy eating behaviours requires understanding the complexity of individual and societal food literacy. With high physician interest, dietitians are well positioned to deliver culinary medicine interventions and support physicians’ confidence in health promotion and chronic disease prevention and management.
... In 2017, a survey of 646 cardiologists revealed that while 95% believed discussing nutrition information to be part of their role, only 10% felt adequately prepared. 31 The application to many other specialties including primary care, 32 gastroenterology, 33 endocrinology, 34 and critical care 35 is clear, demonstrating widespread opportunity for GME nutrition innovation. ...
A poor-quality dietary pattern is a leading risk factor for chronic disease and death in the United States, and the costs of medical care continue to unsustainably rise. Despite this reality, nutrition training for physicians fails to adequately prepare for them to address the complex factors that influence diet-related disease. Expanding nutrition education for physicians-in-training is imperative to equip them for the growing demand of food is medicine services and is also supported by recent policy efforts in the United States as well as the governing bodies of graduate and undergraduate medical education. A multisector approach that links graduate medical education, clinical care delivery innovation, and health and food policy experts provides momentum to advance nutrition education as a core strategy for food is medicine expansion globally.
... Despite the inclusion of evidence on healthy nutrition in (inter-) national guidelines such as ESPEN and ASPEN [11], malnutrition is widespread worldwide, related to this issue being inadequately addressed in health care 12. Nutrition is rarely addressed in the daily routine of doctors [12e14], even though it can have a positive impact on health [15] and patients rely on doctors' advice for their daily nutritional decisions [16]. In fact, physicians often do not feel competent enough to provide nutritional advice [12,17]. ...
Background & aims: Although the risks and opportunities of nutrition in health trajectories are well known, it is rarely addressed in doctors' daily routine. This is partly related to physicians’ lack of confidencein their ability to provide nutritional counselling, possibly due to insufficient training in medical school. Our study aimed at assessing the status quo of nutrition in the German medical curricula and the impact of a recently implemented, student-initiated online teaching initiative on perceived competence, knowledge and attitudes.
Methods: “Eat This!” was the first Germany-wide initiative for online nutritional medicine (NM) education, consisting of 11 digital lectures on nutrition basics, nutrition medicine and public health nutrition. The contact time with NM during studies as well as the effects on students' attitudes towards NM, their self-perceived competence in NM and their nutrition knowledge were assessed from October 2020 to February 2021 in a cross-sectional as well as a prospective study using online questionnaires.
Results: Over 1500 medical students from 42 German faculties participated in the lecture series and the online survey. One hundred and twenty-two students formed a control group. Although considering the topic relevant, students rated their training in NM as insufficient, in terms of both quality and quantity. Initially, they did not feel able to counsel patients and rated their knowledge as low. However, selfratings and the score in a 33-item multiple-choice test knowledge improved by participating in Eat This! as did their attitude towards nutrition and planetary health. No such changes were observed in the control group of 122 students not attending the course.
Conclusion: Our results show that education in NM at German medical schools is perceived insufficient despite high student interest. But even low-threshold educational options like “Eat This!” can improve students' perceived competence, knowledge, and attitudes, and thus be an efficient and cost-effective way to address related deficits.
... The magnitude of total CVD burden was studied utilizing estimates from the Global Burden of Disease (GBD) Study 2019, using records of population-level data source from 1990 to 2019. The trends for years of life lost due to CVD and (DALYs) disability-adjusted life years increased significantly, years lived with disability increased twice from 17.7 million to 34.4 million over that period (6). ...
Introduction: Health authorities particularly World Health Organization emphasize upon the role of nutrition (macronutrients and micronutrients) in prevention of CVD (Cardiovascular Diseases). Objectives: The study aimed to assess knowledge on risk factors of cardiovascular diseases and diverse role of micronutrients in their prevention amongst undergraduate medical students in Pakistan. Methodology: A cross-sectional survey was carried out among students of third, fourth and final year MBBS across various medical colleges in Pakistan. Consecutive non-probability sampling was employed and self-reported questionnaire was used for collection of data. A total of 381 students were recruited and majority (n=213; 55.9%) were females. Largest number of respondents belonged to third year of MBBS (n=160; 42%). Nearly 66% (n=250) medical students had adequate knowledge on cardiovascular diseases’ risk factors. Results: Around 31% (n=117) had adequate while 69% (n=264) had sub-optimal knowledge on benefits of micronutrients in cardiovascular diseases. Chi-square test of association showed statistically significant relationship (P-value <0.05) between demographic variables and knowledge of students. Conclusion: Medical students being the future healthcare professionals can contribute effectively and efficiently to reducing risks of cardiovascular diseases by having an up-to-date knowledge. Future large-scale and in depth studies can further probe the issue.
... Nutrition is a central component of ASCVD guidelines involving risk reduction; however, approximately 9 in 10 cardiovascular specialists report receiving none to minimal nutritional education during fellowship training. 9 While there are several approaches to help address such gaps in training, culinary medicine has emerged as among the most promising. Culinary medicine is a discipline and training modality within clinical and public health education that provides medical trainees (eg, medical students, nursing students, dietetic interns), healthcare professionals and community members with experiential, food-based nutrition knowledge and the culinary skills needed for implementation. ...
Background
Hands-on culinary medicine education for medical trainees has emerged as a promising tool for cardiovascular health promotion.
Purpose
To determine whether virtual culinary medicine programming associates with Mediterranean diet (MedDiet) adherence and lifestyle medicine competencies among medical trainees across the USA.
Method
A total of 1433 medical trainees across 19 sites over a 12-month period were included. The Cooking for Health Optimisation with Patients-Medical Trainees survey composed of 61 questions regarding demographics, nutritional attitudes, dietary habits including MedDiet score and lifestyle medicine counselling competencies. Multivariable logistic regression assessed the association of virtual culinary medicine education with MedDiet intake and nutritional attitudes.
Results
There were 519 medical trainees who participated in virtual culinary medicine education and 914 medical trainees who participated in their standard nutrition curricula. More than one-half of participants were women (n=759) and the mean age was 27 years old. Compared with students enrolled in traditional nutrition curricula, participants in virtual culinary medicine education were 37% more likely to adhere to MedDiet guidelines for fruit intake (OR 1.37, 95% CI 1.03 to 1.83, p=0.03). Virtual culinary medicine education was associated with higher proficiency in lifestyle medicine counselling categories, notably recommendations involving fibre (OR 4.03; 95% CI 3.05 to 5.34), type 2 diabetes prevention (OR 4.69; 95% CI 3.51 to 6.27) and omega fatty acids (OR 5.21; 95% CI 3.87 to 7.02). Virtual culinary medicine education had a similar, although higher magnitude association with MedDiet counselling competency (OR 5.73, 95% CI 4.26 to 7.70) when compared with historical data previously reported using hands-on, in-person culinary medicine courseware (OR 4.97, 95% CI 3.89 to 6.36).
Conclusions
Compared with traditional nutritional educational curricula, virtual culinary medicine education is associated with higher MedDiet adherence and lifestyle medicine counselling competencies among medical trainees. Both virtual and hands-on culinary medicine education may be useful for cardiovascular health promotion.
... This may be because very few, an estimated 10-30% of physicians, get adequate training in delivering nutritional guidance and only 8% feel confident in their delivery (9). This data is available for primary care physicians and cardiologists (9,10); to date, no such data are available for neurologists who deal with CVD risk factors regularly. ...
Background
Poor diet quality has been found to be an independent risk factor for mortality in stroke. However, it is unknown to what extent Neurologists are trained and are comfortable enough to provide dietary counseling to stroke patients.
Objective
To assess the knowledge, attitudes, and practices of neurology residents relating to dietary counseling of stroke patients.
Methods
An online anonymous survey was administered to neurology residents throughout the country between August and November 2019 among a total of 109 (68%) US neurology programs. Self-reported practices and knowledge regarding stroke prevention through nutritional counseling were queried using validated questionnaires.
Results
453 responses out of a potential 672 were received. A minority of residents (12.3%) consistently offered nutritional counseling to stroke patients. 47.7% considered that it was not the neurologist's role to provide nutritional counseling to stroke patients. 83.4% of residents felt that it was the responsibility of the dietician to provide nutritional counseling, yet only 21.4% of residents consistently referred stroke patients to a dietician. 77.9% of respondents felt nutritional counseling is important for stroke patients, yet 65.6% felt they were not adequately trained to provide nutritional counseling.
Conclusion
Neurologists in training believe diet to be an important part of stroke prevention, but practical knowledge and training in nutrition are suboptimal. This study suggests the need to include nutrition as an integral part of neurology training, to ensure neurologists feel empowered to be an important part of the team providing nutritional counseling to stroke patients.
... 84 Furthermore, CR nurses are not required to complete formal training regarding nutrition, 85 and a large proportion of cardiovascular specialists perceive nutrition to be a gap in their medical training. 86 Although qualified dietitians should provide individualized nutrition care to patients undergoing CR with complex co-morbidities, 3,18 it may be the case that other CR staff members have more patient contact and opportunities to support nutrition-related behaviour change than dietitians. These health professionals may benefit from professional development to support dietary optimization for patients who undertake CR. ...
Aims:
Dietary modification is essential for the secondary prevention of cardiovascular disease. However, there are limited published evidence syntheses to guide practice in the cardiac rehabilitation (CR) setting. This systematic review's objective was to assess effectiveness and reporting of nutrition interventions to optimize dietary intake in adults attending CR.
Methods and results:
Randomized controlled trials (RCTs) of nutrition interventions within CR were eligible for inclusion and had to have measured change in dietary intake. MEDLINE, Embase, Emcare, PsycINFO, CINAHL, Scopus, and The Cochrane Library were searched from 2000 to June 2020, limited to publications in English. Evidence from included RCTs was synthesized descriptively. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. This review is registered on PROSPERO; CRD42020188723. Of 13 048 unique articles identified, 11 were eligible. Randomized controlled trials were conducted in 10 different countries, included 1542 participants, and evaluated 29 distinct dietary intake outcomes. Five studies reported statistically significant changes in diet across 13 outcomes. Most nutrition interventions were not reported in a manner that allowed replication in clinical practice or future research.
Conclusion:
There is a gap in research testing high-quality nutrition interventions in CR settings. Findings should be interpreted in the light of limitations, given the overall body of evidence was heterogenous across outcomes and study quality; 6 of 11 studies were conducted more than 10 years old. Future research should investigate strategies to optimize and maintain nutrition improvements for patients attending CR.
Registration:
PROSPERO; CRD42020188723.
... Different publications emphasize the lack of nutrition education in medical degree training generally (Womersley & Ripullone, 2017), in specialties such as cardiology (Devries et al., 2017), and in nursing (Mitchell et al., 2018). A very recent survey with pediatricians from European countries i.e. ...
Review of literature and overview of country-specific information
... 4 In a recent survey of cardiologists, cardiology fellows, and cardiovascular teams, providers reported feeling inadequately trained to provide nutritional support for their patients and saw a benefit to adding an RDN to their health care team. 5 However, few RDNs are integrated in primary care models, despite researchers in the field advocating for an interdisciplinary approach to patient care. 4,6,7 These findings demonstrate the potential for integrated nutritional support in health care, not only for the benefit of the community, but for fellow health professionals as well. ...
There is scant literature available on the Registered Dietitian Nutritionist (RDN) workforce in the United States, but a review of healthcare systems suggests that implementation of RDNs in primary care settings may improve access to care, patient satisfaction, and quality of care. The Area Health Education Center (AHEC), in partnership with the Hawai'i Academy of Nutrition and Dietetics (HAND), investigated 395 providers to evaluate the status of Hawai'i's RDN workforce. The research team utilized all available provider information and direct calling methodology to collect data from August 2019 to February 2020. Microsoft Excel software allowed for data analysis and ArcGIS mapping software was used to visualize provider totals and Full-Time Equivalencies (FTEs) across the state. This study identifies trends in workforce demographics and provider supply. Researchers found 100 RDNs providing direct patient care for a total of 82.4 FTEs. Women account for 94% of survey respondents, and the average age of providers was 48. RDNs who self-identify as being Asian American (41%) or White (47%) were the largest ethnic groups providing direct patient care. Seventy percent of the RDN workforce was located on O'ahu, while RDN FTEs are concentrated in mainly 5 zip codes, 1 on each of O'ahu, Kaua'i, and Maui and 2 on Hawai'i Island. Provider demand trends, increased training and retention efforts, and integration of nutritional services in healthcare teams should be further investigated.
... A survey of medical schools found that on average fewer than 20 h over four years are spent on nutrition education [64]. Accordingly, physicians often lack important nutrition knowledge and the counselling skills required to successfully guide their patients [65][66][67][68][69][70][71][72][73][74][75]. In a survey of resident physicians, only 14% of participants felt physicians were adequately trained to provide nutritional counselling [76]. ...
The coronavirus pandemic has acted as a reset on global economies, providing us with the opportunity to build back greener and ensure global warming does not surpass 1.5 °C. It is time for developed nations to commit to red meat reduction targets and shift to plant-based dietary patterns. Transitioning to plant-based diets (PBDs) has the potential to reduce diet-related land use by 76%, diet-related greenhouse gas emissions by 49%, eutrophication by 49%, and green and blue water use by 21% and 14%, respectively, whilst garnering substantial health co-benefits. An extensive body of data from prospective cohort studies and controlled trials supports the implementation of PBDs for obesity and chronic disease prevention. The consumption of diets high in fruits, vegetables, legumes, whole grains, nuts, fish, and unsaturated vegetable oils, and low in animal products, refined grains, and added sugars are associated with a lower risk of all-cause mortality. Meat appreciation, health concerns, convenience, and expense are prominent barriers to PBDs. Strategic policy action is required to overcome these barriers and promote the implementation of healthy and sustainable PBDs.
... In a survey of 930 cardiovascular specialists, 90% admitted to receiving minimal or no training in nutrition and 95% believed that it is their personal responsibility to teach nutrition to their patients. However, only 20% of cardiologists admitted to eating ≥ 5 servings of fruits and vegetables a day [145]. ...
Despite numerous advances in all areas of cardiovascular care, cardiovascular disease (CVD) is the leading cause of death in the United States (US). There is compelling evidence that interventions to improve diet are effective in cardiovascular disease prevention. This clinical practice statement emphasizes the importance of evidence-based dietary patterns in the prevention of atherosclerotic cardiovascular disease (ASCVD), and ASCVD risk factors, including hyperlipidemia, hypertension, diabetes, and obesity. A diet consisting predominantly of fruits, vegetables, legumes, nuts, seeds, plant protein and fatty fish is optimal for the prevention of ASCVD. Consuming more of these foods, while reducing consumption of foods with saturated fat, dietary cholesterol, salt, refined grain, and ultra-processed food intake are the common components of a healthful dietary pattern. Dietary recommendations for special populations including pediatrics, older persons, and nutrition and social determinants of health for ASCVD prevention are discussed.
Background
Glucagon-like peptide 1 receptor agonists and combination medications (hereafter collectively referred to as GLP-1s) are shifting the treatment landscape for obesity. However, real-world challenges and limited clinician and public knowledge on nutritional and lifestyle interventions can limit GLP-1 efficacy, equitable results, and cost-effectiveness.
Objectives
We aimed to identify pragmatic priorities for nutrition and other lifestyle interventions relevant to GLP-1 treatment of obesity for the practicing clinician.
Methods
An expert group comprising multiple clinical and research disciplines appraised the scientific literature, informed by expert knowledge and clinical experience, to identify and summarize relevant topics, priorities, and emerging directions.
Results
GLP-1s reduce body weight by 5% to 18% in trials, with modestly lower effects in real-world analyses, and multiple demonstrated clinical benefits. Challenges include side effects, especially gastrointestinal; nutritional deficiencies due to calorie reduction; muscle and bone loss; low long-term adherence with subsequent weight regain; and high costs with resulting low cost-effectiveness. Numerous practice guidelines recommend multicomponent, evidence-based nutritional and behavioral therapy for adults with obesity, but use of such therapies with GLP-1s is not widespread. Priorities to address this include: (a) patient-centered initiation of GLP-1s, including goals for weight reduction and health; (b) baseline screening, including usual dietary habits, emotional triggers, disordered eating, and relevant medical conditions; (c) comprehensive exam including muscle strength, function, and body composition assessment; (d) social determinants of health screening; (e) and lifestyle assessment including aerobic activity, strength training, sleep, mental stress, substance use, and social connections. During GLP-1 use, nutritional and medical management of gastrointestinal side effects is critical, as is navigating altered dietary preferences and intakes, preventing nutrient deficiencies, preserving muscle and bone mass through resistance training and appropriate diet and complementary lifestyle interventions. Supportive strategies include group-based visits, registered dietitian nutritionist counseling, telehealth and digital platforms, and Food is Medicine interventions. Drug access, food and nutrition insecurity, and nutrition and culinary knowledge influence equitable obesity management with GLP-1s. Emerging areas for more study include dietary modulation of endogenous GLP-1, strategies to improve compliance, nutritional priorities for weight maintenance post-cessation, combination or staged intensive lifestyle management, and diagnostic criteria for clinical obesity.
Conclusions
Evidence-based nutritional and lifestyle strategies play a pivotal role to address key challenges around GLP-1 treatment of obesity, making clinicians more effective in advancing their patients’ health.
Background
Glucagon‐like peptide 1 receptor agonists and combination medications (hereafter collectively referred to as GLP‐1s) are shifting the treatment landscape for obesity. However, real‐world challenges and limited clinician and public knowledge on nutritional and lifestyle interventions can limit GLP‐1 efficacy, equitable results, and cost‐effectiveness.
Objectives
We aimed to identify pragmatic priorities for nutrition and other lifestyle interventions relevant to GLP‐1 treatment of obesity for the practicing clinician.
Methods
An expert group comprising multiple clinical and research disciplines appraised the scientific literature, informed by expert knowledge and clinical experience, to identify and summarize relevant topics, priorities, and emerging directions.
Results
GLP‐1s reduce body weight by 5% to 18% in trials, with modestly lower effects in real‐world analyses, and multiple demonstrated clinical benefits. Challenges include side effects, especially gastrointestinal; nutritional deficiencies due to calorie reduction; muscle and bone loss; low long‐term adherence with subsequent weight regain; and high costs with resulting low cost‐effectiveness. Numerous practice guidelines recommend multicomponent, evidence‐based nutritional and behavioral therapy for adults with obesity, but use of such therapies with GLP‐1s is not widespread. Priorities to address this include: (a) patient‐centered initiation of GLP‐1s, including goals for weight reduction and health; (b) baseline screening, including usual dietary habits, emotional triggers, disordered eating, and relevant medical conditions; (c) comprehensive exam including muscle strength, function, and body composition assessment; (d) social determinants of health screening; (e) and lifestyle assessment including aerobic activity, strength training, sleep, mental stress, substance use, and social connections. During GLP‐1 use, nutritional and medical management of gastrointestinal side effects is critical, as is navigating altered dietary preferences and intakes, preventing nutrient deficiencies, preserving muscle and bone mass through resistance training and appropriate diet, and complementary lifestyle interventions. Supportive strategies include group‐based visits, registered dietitian nutritionist counseling, telehealth and digital platforms, and Food is Medicine interventions. Drug access, food and nutrition insecurity, and nutrition and culinary knowledge influence equitable obesity management with GLP‐1s. Emerging areas for more study include dietary modulation of endogenous GLP‐1, strategies to improve compliance, nutritional priorities for weight maintenance post‐cessation, combination or staged intensive lifestyle management, and diagnostic criteria for clinical obesity.
Conclusions
Evidence‐based nutritional and lifestyle strategies play a pivotal role to address key challenges around GLP‐1 treatment of obesity, making clinicians more effective in advancing their patients' health.
The focus of this chapter is on the evidence-based landscape describing the impact of two of the most important lifestyle components—healthy eating and physical activity—on chronic kidney disease (CKD) in adults in the stable outpatient setting. The interaction between cardiovascular disease (CVD) and kidney disease is increasingly recognized, particularly with the cardiovascular kidney metabolic health description. Healthy weight is a key element of Life’s Essential 8 because overweight and obesity are at the core of cardiovascular kidney metabolic syndrome. Dysfunctional fat characteristic of visceral or central overweight and obesity are associated with multiple pathologic processes mediated by pro-inflammatory macrophages; adipokines; oxidative stress; insulin resistance; endothelial dysfunction; and in turn, a vicious cycle of T2D, hypertension, dyslipidemia, CVD, and kidney disease. The existing evidence base strongly supports the impact of healthy eating and physically active living on chronic disease prevention, including CKD risk factors, CKD incidence, and CKD progression. Thus, lifestyles that promote cardiovascular health will also universally promote kidney health, with some caveats regarding CKD complications such as hyperkalemia and hyperphosphatemia. Nevertheless, there are still significant research gaps that need to be closed in order to optimize the implementation of lifestyle interventions in the CKD population.
This study aimed to provide an overview of published studies that assess the relationship between nutrition knowledge and dietary intake among university students. A scoping review was undertaken and articles assessing the relationship between nutrition knowledge and dietary intake among university students were identified. EMBASE, PsycINFO and Scopus were searched for peer–reviewed articles reporting primary research. The initial search generated 805 potentially relevant articles. After reviewing titles and abstracts and applying the exclusion criteria, 22 articles were deemed eligible for inclusion. Nutrition knowledge was measured in all studies and information was predominantly collected using adapted General Nutrition Knowledge Questionnaires (GNKQs). Dietary intake measurement methods varied across the studies, with the Food Frequency Questionnaire (FFQ) being commonly used. Findings identified that in most studies a positive relationship was found between nutrition knowledge and dietary intake. The ability to draw strong conclusions about the relationship between nutrition knowledge and dietary intake in university students is limited by the heterogeneity of the study design, the subpopulations considered, and the tools used. Notwithstanding this, findings indicate that the majority of studies reported a positive relationship between nutrition knowledge and dietary intake. Future studies should consider the use of validated assessment tools for both nutrition knowledge and dietary intake and the inclusion of more male student participants.
The importance of nutrition in the development of disease, and in the recovery from illness, is among the most fundamental tenets in human biology and optimal health. Nutrition was fundamental in many traditional forms of medicine until its role in medical care experienced a rapid decline over the last century. We believe a key cause of the decline in nutrition's essential role in healthcare and preventative medicine is the escalating crisis of inadequate nutrition education in medical training. Recent data show 75% of United States medical schools have no required clinical nutrition classes and only 14% of residency programs have a required nutrition curriculum. More troubling, only 14% of current healthcare providers feel comfortable discussing nutrition with their patients. The purpose of this paper is to present the evidence illustrating the distinct lack of nutrition education in medical training. Further, we present key examples of existing formal nutrition curricula to incorporate nutritional science into all healthcare providers’ education and practices. We discuss existing nutrition fellowships and training programs, including the new Duke Online Clinical Nutrition Fellowship. We also cover a physician nutrition certification allowing physicians to pursue clinical nutrition as a career path. Finally, recent financial incentives and quality measures incentivizing healthcare provider nutrition education is discussed. Thus, in conclusion, we advocate the inclusion of nutrition education curricula as a priority in medical schools, graduate medical education, and continuing medical education. Formal clinical nutrition training should be a requirement for hospital leadership and administrators for all Parenteral Nutrition and Nutrition Team Physician Directors in hospitals worldwide, and this key clinical role must become an essential position in all hospitals. In addition, we immediately need to address the critical shortage of physician nutrition specialists who will serve as the next generation of leaders in clinical nutrition care and research.
Importance
In 2022, the US House of Representatives passed a bipartisan resolution (House of Representatives Resolution 1118 at the 117th Congress [2021-2022]) calling for meaningful nutrition education for medical trainees. This was prompted by increasing health care spending attributed to the growing prevalence of nutrition-related diseases and the substantial federal funding via Medicare that supports graduate medical education. In March 2023, medical education professional organizations agreed to identify nutrition competencies for medical education.
Objective
To recommend nutrition competencies for inclusion in medical education to improve patient and population health.
Evidence Review
The research team conducted a rapid literature review to identify existing nutrition-related competencies published between July 2013 and July 2023. Additional competencies were identified from learning objectives in selected nutrition, culinary medicine, and teaching kitchen curricula; dietetic core competencies; and research team–generated de novo competencies. An expert panel of 22 nutrition subject matter experts and 15 residency program directors participated in a modified Delphi process and completed 4 rounds of voting to reach consensus on recommended nutrition competencies, the level of medical education at which they should be included, and recommendations for monitoring implementation and evaluation of these competencies.
Findings
A total of 15 articles met inclusion criteria for competency extraction and yielded 187 competencies. Through review of gray literature and other sources, researchers identified 167 additional competencies for a total of 354 competencies. These competencies were compiled and refined prior to voting. After 4 rounds of voting, 36 competencies were identified for recommendation: 30 at both undergraduate and graduate levels, 2 at the undergraduate level only, and 4 at the graduate level only. Competencies fell into the following nutrition-related themes: foundational nutrition knowledge, assessment and diagnosis, communication skills, public health, collaborative support and treatment for specific conditions, and indications for referral. A total of 36 panelists (97%) recommended nutrition competencies be assessed as part of licensing and board certification examinations.
Conclusions and Relevance
These competencies represent a US-based effort to use a modified Delphi process to establish consensus on nutrition competencies for medical students and physician trainees. These competencies will require an iterative process of institutional prioritization, refinement, and inclusion in current and future educational curricula as well as licensure and certification examinations.
Multiple professional societies recommend the Mediterranean and/or Dietary Approaches to Stop Hypertension dietary patterns in their cardiovascular disease prevention guidelines because these diets can improve cardiometabolic health and reduce the risk of cardiovascular events. Furthermore, low sodium intake can be particularly beneficial for patients with hypertension. Carbohydrate restriction, with an emphasis on including high-quality carbohydrates and limiting refined starches and foods and beverages with added sugars, can promote weight loss and cardiometabolic benefits in the short term, compared with higher carbohydrate intake. Evidence is lacking for sustained, long-term effects of low carbohydrate and very low carbohydrate intake on cardiometabolic risk and cardiovascular outcomes. Time-restricted eating, in the context of an overall healthy dietary pattern, can promote cardiometabolic health by aligning food intake with the circadian rhythm, although its effect on hard clinical outcomes remains to be proven. Although there is no one dietary pattern that is appropriate for all patients, engaging in shared decision-making with patients, utilizing behaviour-change principles and engaging members of the health-care team, such as registered dietitian nutritionists, can lead to substantial improvement in the lifestyle and overall health trajectory of a patient. Emphasizing the similarities, rather than differences, of recommended dietary patterns, which include an emphasis on vegetables, fruits, legumes, nuts, whole grains and minimally processed protein foods, such as fatty fish or plant-based proteins, can simplify the process for both patients and clinicians alike.
There is no longer any serious doubt that daily habits and actions profoundly impact on both short- and long-term health and quality of life. An overwhelming body of scientific and medical literature supports this contention. Thousands of studies support the concept that regular physical activity, healthy nutrition and maintaining a healthy body weight, not smoking cigarettes, obtaining healthy sleep, reducing stress and maintaining positive connections with other individuals all profoundly impact on health. The scientific literature the supports the health impact of these daily habits and actions is underscored by its incorporation into virtually every evidence-based clinical guideline in the area of metabolic diseases. Thus, the scientific basis for lifestyle medicine rests on an enormous body of evidence-based literature. The key issue in lifestyle medicine is to provide an overall framework where these studies, which are often spread over scientific literature in multiple disciplines, can be made accessible to the medical community and to the public at large. This is the essence of the field of lifestyle medicine. The academic basis of lifestyle medicine is robust and needs to be emphasized by all practitioners of lifestyle medicine. This is the key to moving this field forward into the future.
Phenomenon:
Despite the importance of diet in the prevention and management of many common chronic diseases, nutrition training in medicine is largely inadequate in medical school and residency. The emerging field of culinary medicine offers an experiential nutrition learning approach with the potential to address the need for improved nutrition training of physicians. Exploring this innovative nutrition training strategy, this scoping review describes the nature of culinary medicine experiences for medical students and resident physicians, their impact on the medical trainees, and barriers and facilitators to their implementation.
Approach:
This scoping review used the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) checklist as guides. Eligible publications described the nature, impact, facilitators, and/or barriers of nutrition and food preparation learning experiences for medical students and/or residents. Additional inclusion criteria were location (U.S. or Canada), allopathic or osteopathic, English, human subjects, and publication year (2002 or later). The search strategy included 4 electronic databases. Two reviewers independently screened titles/abstracts and a third reviewer resolved discrepancies. The full-text review consisted of 2 independent reviews with discrepancies resolved by a third reviewer or by consensus if needed, and the research team extracted data from the included articles based on the nature, impact, barriers, and facilitators of culinary medicine experiences for medical trainees.
Findings:
The publication search resulted in 100 publications describing 116 experiences from 70 institutions. Thirty-seven publications described pilot experiences. Elective/extracurricular and medical student experiences were more common than required and resident experiences, respectively. Experiences varied in logistics, instruction, and curricula. Common themes of tailored culinary medicine experiences included community engagement/service-based learning, interprofessional education, attention to social determinants of health, trainee well-being, and cultural considerations. Program evaluations commonly reported the outcome of experiences on participant attitudes, knowledge, skills, confidence, and behaviors. Frequent barriers to implementation included time, faculty, cost/funding, kitchen space, and institutional support while common facilitators of experiences included funding/donations, collaboratives and partnerships, teaching kitchen access, faculty and institutional support, and trainee advocacy.
Insights:
Culinary medicine is an innovative approach to address the need and increased demand for improved nutrition training in medicine. The findings from this review can guide medical education stakeholders interested in developing or modifying culinary medicine experiences. Despite barriers to implementation, culinary medicine experiences can be offered in a variety of ways during undergraduate and graduate medical education and can be creatively designed to fulfill some accreditation standards.
Objective: Identify areas of consensus on integrating lifestyle medicine (LM) into primary care to achieve optimal outcomes. Methods: Experts in both LM and primary care followed an a priori protocol for developing consensus statements. Using an iterative, online process, panel members expressed levels of agreement with statements, resulting in classification as consensus, near consensus, or no consensus. Results: The panel identified 124 candidate statements addressing: (1) Integration into Primary Care, (2) Delivery Models, (3) Provider Education, (4) Evidence-base for LM, (5) Vital Signs, (6) Treatment, (7) Resource Referral and Reimbursement, (8) Patient, Family, and Community Involvement; Shared Decision-Making, (9) Social Determinants of Health and Health Equity, and (10) Barriers to LM. After three iterations of an online Delphi survey, statement revisions, and removal of duplicative statements, 65 statements met criteria for consensus, 24 for near consensus, and 35 for no consensus. Consensus was reached on key topics that included LM being recognized as an essential component of primary care in patients of all ages, including LM as a foundational element of health professional education. Conclusion: The practice of LM in primary care can be strengthened by applying these statements to improve quality of care, inform policy, and identify areas for future research.
Objective
The objective of this study was to evaluate the relative validity of the nine-item Diet Risk Score (DRS) among Chinese American adults using Healthy Eating Index (HEI)-2015 scores. We provide insights into the application of the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) for this population, and report on lessons learned from carrying out participant recruitment during the COVID-19 pandemic.
Methods
Thirty-three Chinese American adults (mean age=40; 36% male) were recruited from the community and through ResearchMatch. Participants completed the DRS and two 24-hour food records, which were entered into the ASA 24-Hour Dietary Assessment Tool (ASA24) by community health workers (CHWs). HEI-2015 scores were calculated from each food record and an average score was obtained for each participant. One-way analysis of variance and Spearman correlations were used to compare total and component scores between the DRS and HEI-2015.
Results
Mean HEI-2015 score was 56.7/100 (SD 10.6) and mean DRS score was 11.8/27 (SD 4.7), with higher scores reflecting better and worse diets, respectively. HEI-2015 and DRS scores were inversely correlated (r=−0.43, p<0.05). The strongest correlations were between HEI-2015 Total Vegetables and DRS Vegetables (r=−0.5, p<0.01), HEI-2015 Total Vegetables and Green Vegetables (r=−0.43, p=0.01) and HEI-2015 Seafood/Plant Protein and DRS Fish (r=−0.47, p<0.01). The inability to advertise and recruit for the study in person at community centres due to pandemic restrictions impeded the recruitment of less-acculturated individuals. A lack of cultural food items in the ASA24 database made it difficult to record dietary intake as reported by participants.
Conclusion
The DRS can be a valuable tool for physicians to identify and reach Chinese Americans at risk of cardiometabolic disease.
This paper identifies and examines interpretations of the ontological categories of “food” and “drugs” in allopathic medicine, psychology, and psychiatry. I unearth some implicit interpretive modes in these fields to draw attention to emerging patterns of interpretation. I advance two central claims: First, while practitioners in these fields often interpret food and drugs as existing in a dichotomous relationship with one another, there are demonstrable shifts toward interpretations of food and drugs (in both the “medicinal” and “illicit/detrimental” senses of the term) as categories that overlap with one another. Second, practitioners in these fields ought to recognize these interpretations as interpretations, which both shape and are shaped by our collective experiences, in order to develop a greater understanding and more earnest evaluations of different ontological conceptions of the food-drug relationship.
Purpose: Undergraduate medical education is facing an increasing need to bridge the longstanding gap between basic nutrition knowledge and its application to patient care. In an effort to improve upon knowledge and confidence in this area, the University of Minnesota Medical School Duluth Campus implemented a pilot curriculum to increase content and exposure in the dimensions of food, food systems, nutrition, and clinical application.
Methods: Two classes of outgoing second-year medical students at the University of Minnesota Duluth Campus were surveyed about personal health, knowledge of nutritional topics, and confidence in implementing these topics in patient care. The control group consisted of outgoing second-year medical students (MS2s) during the 2019-2020 academic year (n=28) prior to pilot nutrition curriculum inception. The cohort group (n=29) consisted of outgoing MS2s from the 2020-2021 academic year who received the new pilot curriculum.
Findings: Survey findings did not yield statistically significant differences in control versus cohort responses in students' personal health and knowledge of nutritional concepts. However, over 90% of the cohort group, versus 54% of control, agreed that they were able to discuss and recommend healthy dietary modifications to a patient with a chronic disease. The cohort group also reported higher confidence in talking with patients about dietary patterns (69% vs 39%), whole-food plant-rich diets (90% vs 50%), as well as working inter-professionally with other members of the healthcare team around issues of food and nutrition (97% vs 71%).
Conclusion: Results demonstrate that the pilot curriculum increased medical student confidence in evaluating the multidimensionality of food, food systems, and nutrition content as well as the application of this content to patient care. This pilot curriculum may have relevance to other medical schools who are also wishing to bridge this long-standing gap in medical education.
Diet-related chronic diseases are increasing in prevalence and poised to dominate the future careers of current medical students. While the value of nutritionally-informed care and nutrition-based health interventions is increasingly recognized, nutrition education is inconsistently and often inadequately included in medical school curricula. One obstacle to incorporating nutrition into medical and dental school curricula is the density of existing coursework, with incorporation of new material necessitating removal of other material. One solution is to engage students outside the classroom in immersive education in nutrition and metabolism using health-wearables. We report the Metabolic Health Immersion for Medical Education pilot program, spearheaded and designed by Harvard Medical students centering on use of continuous glucose monitors (CGM). Students reported enjoyment with the study, felt encouraged to improve health behaviors, and shared that the experience enhanced their understanding of nutrition and metabolism, was valuable to their medical education, and would influence their future patient care. This study demonstrates proof-of-principle that metabolic health immersion opportunities for health care trainees provide a means of helping to address the current deficit in medical school nutrition education.
Background and Aims
Human and planetary health are inextricably interconnected through food systems. Food choices account for 50% of all deaths for cardiovascular disease (CVD) – the leading cause of death in Europe – and food systems generate up to 37% of total greenhouse gas (GHG) emissions.
Methods and Results
A dietary pattern able to optimize CVD prevention was identified through a systematic evaluation of the evidence linking the consumption of foods to the risk of CVD in meta-analyses of prospective studies. This dietary pattern was compared to the current diet of the European population. The nutritional adequacy of both diets was evaluated according to the European Food Safety Authority (EFSA) recommended nutrients intake for the adult population, and their environmental impact was evaluated in terms of Carbon footprint (CF).
As compared to the current diet, the desirable diet includes higher intakes of fruit, vegetables, wholegrains, low Glycemic Index (GI) cereals, nuts, legumes and fish, and lower amounts of beef, butter, high GI cereals or potatoes and sugar. The proposed diet provides appropriate intakes of all nutrients and matches better than the current Europeans’ one the EFSA requirements. Furthermore, the CF of the proposed diet is 48.6% lower than that of the current Europeans’ diet.
Conclusion
The transition towards a dietary pattern designed to optimize CVD prevention would improve the nutritional profile of the habitual diet in Europe and, at the same time, contribute to mitigate climate change by reducing the GHG emissions linked to food consumption almost by half.
Purpose:
Lifestyle-related disease substantially impacts health, but physicians lack adequate nutrition education to discuss behavioral change with patients. Many medical schools have developed culinary medicine programs as a nutrition education strategy, but common elements of success have not been defined.
Method:
The authors conducted a scoping review of the literature on culinary medicine programs for medical students. They searched PubMed, Ovid MEDLINE, and MedEdPORTAL databases to identify English-language studies published between January 1, 2012, and October 15, 2021. Multiple search terms were used to identify medical student-focused culinary medicine programs. The authors focused inclusion criteria on medical student learners, curricular description, hands-on cooking components, reflection or application to patient care, and assessment. Additionally, the authors reviewed 2 online databases which list programs delivering culinary medicine education for U.S. medical students.
Results:
Authors identified 251 studies, of which 12 met inclusion criteria. These studies described programs that used a kitchen or similar space adaptable for food preparation to enable hands-on learning, and some programs provided opportunities for practical application. Most programs administered surveys to assess course impact, but the type of survey and cohort size varied. Culinary medicine programs for medical students varied in learner level, number of participants, course length and structure, and instructor background but consistently improved student knowledge in key areas of nutrition application and changed knowledge and attitudes about food and nutrition. Funding was often noted as a barrier to program sustainability. When funding source was provided, it derived from philanthropic or academic sources. When the authors reviewed the 2 online databases, they identified 34 programs offering medical student-focused culinary medicine courses.
Conclusions:
As culinary education programs emerge across academic centers, standardizing programmatic and curricular elements, best practices, and assessment strategies will be vital for quality control, sustainability, and optimal population health impact.
Purpose:
The purpose of this study was to determine physician assistants' (PAs') current level of confidence to engage in nutrition-related tasks and their satisfaction with the nutrition education they received in PA school.
Methods:
To achieve this goal, a mixed-methods approach that consisted of 3 data collection phases (qualitative online discussions, quantitative survey, and qualitative interviews) was used to explore and measure PAs' perceptions of the education they received in PA school and through other sources and how confident they felt addressing nutrition-related issues in clinical practice.
Results:
While 80% of PAs endorse the idea that PAs should be more involved in providing nutritional care to patients, the majority reported basic or no knowledge of the nutritional implications of chronic conditions (69%), inflammatory bowel disease (69%), nutritional needs over the lifespan (67%), and food allergies and intolerances (64%). Barriers to patient care included knowledge-related challenges when selecting lab tests based on patient profile (46%) and identifying needs based on various gastrointestinal diseases (67%) and when using diagnostic data to identify deficiencies (74%). Overall, 59% of PAs reported being slightly or very dissatisfied with the nutrition-related content in the curricula used to formally train PAs.
Conclusions:
The primary goal of every PA program is to prepare its graduates to be competent to enter clinical practice. Regarding nutrition, these data indicate that programs are failing to do so. PAs lack the confidence and ability to provide optimal nutritional care, which is staggering considering that nutrition is the first line of treatment in the prevention and management of numerous chronic diseases.
The field of medicine, despite its prominent influence in society, has invested little to promote healthy lifestyle choices. The consequence of this is reflected in our ever-rising chronic disease statistics, most notably obesity and diabetes rates. This is especially regrettable considering overwhelming evidence confirms most non-communicable disease is preventable by modifying our diets. In light of this critical knowledge that optimizing our nutrition could save innumerable lives, one would naturally assume physicians would be readily practicing its promotion with their patients. Yet, that is far from true. By no fault of their own. Medical schools, entrusted with the responsibility of educating our future healthcare leaders, have managed to largely bypass the topic of nutrition, arguably the most powerful healthcare intervention known to mankind. In fact, on average, medical schools offer an anemic number of hours of nutrition education over 4 years. ¹ What little is offered is focused on biochemistry and nutrient deficiencies, none of which prepares a physician in training for meaningful application in clinical care. This lapse in nutrition education continues throughout post-graduate training; in a recent survey of more than 600 cardiologists, 90% reported they had not received needed nutrition education during training. ² Although we agree that not all physicians must be experts in nutrition, in the very least all should have knowledge of rudimentary and essential facts. We offer this commentary on six vital clinical topics, to increase awareness amongst physicians as to the importance of diet and its role in human health.
The increasingly popular plant-based diet presents a challenging change for many in today’s modern lifestyle – both in terms
of introducing it and maintaining it in the long term. There are several motives for such a diet, usually associated with weight
management and health benefits or ethical reasons. People who decide on changing their diet face many challenges. Some of
these challenges are related to the (i) disapproval of whole-food, plant-based diet by the “profession”, associated with the (ii)
characteristics of a whole-food, plant-based diet, some with the (iii) need for acquiring new skills and some with a (iv) much-needed supportive environment. Here, a comprehensive ongoing support system can play a very important role, since it can offer a personalized and proven process of change for every individual. Such a model makes it easier for an individual to change a dietary behaviour into a new habit, make sense of it and live a healthy and active lifestyle in a tolerant manner to people with different dietary patterns. A well-planned whole-food, plant-based diet enables people an efficient control over their appetite, which is one of the main reasons for unsuccessful weight loss with popular weight-loss diets. Today, a comprehensive approach to a whole-food, plant-based diet is a well-founded and proven model. The majority of energy should be invested in efficient methods of informing and raising awareness about the benefits, potential risks and, consequently, the responsibility for a proper implementation of a plant-based diet and finding sustainable business models that are available to a broader audience.
Many rising issues within the healthcare industry were highlighted due to the COVID-19 pandemic. Burnout among healthcare professionals, increasing rates of lifestyle-related chronic illness, and lack of emphasis on professional self-care have contributed to a continued crisis within healthcare organizations. Numerous organizational and systemic issues have been combined with societal norms to create an unsustainable healthcare system operating on mechanisms of disease management versus of health promotion. This chapter aims to address the factors contributing to the overall health of healthcare professionals and proposed solutions to these issues through an integrative resilience model consisting of lifestyle medicine and positive psychology.
Background:
Poor nutrition is one of the leading risk factors for preventable chronic diseases in the United States. Nutrition counseling has been shown to improve clinical outcomes in the adult primary care setting. Nurse practitioners (NPs) can help fill the critical need for nutrition counseling, yet little is known about their role providing nutrition counseling.
Purpose:
To describe the primary care NP's experience in providing nutrition counseling to adult patients in primary care practice.
Methods:
Qualitative descriptive study design. Data were collected through virtual semi-structured interviews with 18 board-certified primary care NPs. Interviews were audio-recorded, de-identified, transcribed verbatim, and analyzed. Data collection and analysis took place concurrently and continued until data saturation was achieved.
Results:
Five themes emerged from NPs' descriptions of their experiences in providing nutrition counseling to adult patients in primary care practice: (1) role of nutrition counseling in NP primary care practice; (2) developing NP self-efficacy in nutrition counseling; (3) nutrition counseling is more than the provision of information; (4) emotional aspect of nutrition; and (5) barriers to behavior change.
Conclusions:
Findings suggest that although NPs understand the importance of nutrition counseling in primary care practice and provide it in some capacity, its continuance is limited by multiple barriers. Future research should evaluate ways to enhance NPs' preparedness to provide nutrition counseling, assess specific resources and tools to aid in nutrition counseling, and determine best practices for communication when delivering nutrition counseling.
Implications for practice:
Future interventions have the potential to positively affect patients' dietary practices and improve clinical outcomes.
Nutrition is a recognized determinant in 3 (ie, diseases of the heart, malignant neoplasms, cerebrovascular diseases) of the top 4 leading causes of death in the United States. However, many health care providers are not adequately trained to address lifestyle recommendations that include nutrition and physical activity behaviors in a manner that could mitigate disease development or progression. This contributes to a compelling need to markedly improve nutrition education for health care professionals and to establish curricular standards and requisite nutrition and physical activity competencies in the education, training, and continuing education for health care professionals. This article reports the present status of nutrition and physical activity education for health care professionals, evaluates the current pedagogic models, and underscores the urgent need to realign and synergize these models to reflect evidence-based and outcomes-focused education.
To understand predictors of Canadian physicians' prevention counseling practices.
A national mailed survey of a random sample of Canadian physicians conducted November 2007-May 2008.
Primary care physicians (n=3213) responded to the survey (41% response rate); those with better personal health habits, female physicians, and physicians aged 45-64 years old were more likely to report "usually/always" counseling patients than did others, but there were no significant differences by province, origin of one's MD degree, or practice location. There was a clear and consistent relationship between personal and clinical prevention practices: non-smokers were significantly more likely to report counseling patients on smoking cessation; those who drank alcohol less frequently, drank lower quantities or binged less often were more likely to counsel on alcohol; those exercising more to counsel patients more about exercise; those eating more fruits and vegetables to counsel patients more often about nutrition; and those with lower weight were more likely to counsel about nutrition, weight or exercise. Physicians who strongly agreed or agreed that "they will perform better counseling if they have healthy habits" averaged higher rates of counseling (p < 0.001).
Personal characteristics of Canadian physicians help predict prevention counseling. These data suggest that by encouraging physicians to be healthy, we can improve healthy habits among their patients--an innovative, beneficent, evidence-based approach to encouraging physicians to counsel patients about prevention.
Eleven southeastern medical schools cooperated to evaluate nutrition knowledge and attitudes of medical students. This study complements previous reports of an examination of entering freshmen and seniors. Average knowledge scores for 165 students tested after basic sciences (preclinical) training in this study were 67 +/- 7% compared with 53 +/- 6% for freshmen and 69 +/- 8% for seniors. The upperclassmen's scores were higher than the freshmen's (p less than 0.001) and varied with the amount of required nutrition teaching. Only 13% of preclinical students perceived nutrition as important to their careers compared with 74% of entering and 59% of graduating students, suggesting that preclinical teaching reduces their sense of relevance of nutrition to medicine. These findings suggest that nutrition knowledge can be increased through preclinical coursework and that the knowledge level can be maintained through the clinical years. However, the positive attitude of freshmen toward nutrition is lost after preclinical training and is only partially regained after the clinical years.
Importance
Heart disease (HD) and cancer are the 2 leading causes of death in the United States. During the first decade of the 21st century, HD mortality declined at a much greater rate than cancer mortality and it appeared that cancer would overtake HD as the leading cause of death.
Objectives
To determine whether changes in national trends had occurred in recent years in mortality rates due to all cardiovascular disease (CVD), HD, stroke, and cancer and to evaluate the gap between mortality rates from HD and cancer.
Design, Setting, and Participants
The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system was used to determine national trends in age-adjusted mortality rates due to all CVD, HD, stroke, and cancer from January 1, 2000, to December 31, 2011, and January 1, 2011, to December 31, 2014, overall, by sex, and by race/ethnicity. The present study was conducted from December 30, 2105, to January 18, 2016.
Main Outcomes and Measures
Comparison of annual rates of change and trend in gap between HD and cancer mortality rates.
Results
The rate of the decline in all CVD, HD, and stroke mortality decelerated substantially after 2011, and the rate of decline for cancer mortality remained relatively stable. Reported as percentage (95% CI), the annual rates of decline for 2000-2011 were 3.79% (3.61% to 3.97%), 3.69% (3.51% to 3.87%), 4.53% (4.34% to 4.72%), and 1.49% (1.37% to 1.60%) for all CVD, HD, stroke, and cancer mortality, respectively; the rates for 2011-2014 were 0.65% (−0.18% to 1.47%), 0.76% (−0.06% to 1.58%), 0.37% (−0.53% to 1.27%), and 1.55% (1.07% to 2.04%), respectively. Deceleration of the decline in all CVD mortality rates occurred in males, females, and all race/ethnicity groups. For example, the annual rates of decline for total CVD mortality for 2000-2011 were 3.69% (3.48% to 3.89%) for males and 3.98% (3.81% to 4.14%) for females; for 2011-2014, the rates were 0.23% (−0.71% to 1.16%) and 1.17% (0.41% to 1.93%), respectively. The gap between HD and cancer mortality persisted.
Conclusions and Relevance
Deceleration in the decline of all CVD, HD, and stroke mortality rates has occurred since 2011. If this trend continues, strategic goals for lowering the burden of CVD set by the American Heart Association and the Million Hearts Initiative may not be reached.
Purpose:
Plant-based nutrition achieved coronary artery disease (CAD) arrest and reversal in a small study. However, there was skepticism that this approach could succeed in a larger group of patients. The purpose of our follow-up study was to define the degree of adherence and outcomes of 198 consecutive patient volunteers who received counseling to convert from a usual diet to plant-based nutrition.
Methods:
We followed 198 consecutive patients counseled in plant-based nutrition. These patients with established cardiovascular disease (CVD) were interested in transitioning to plant-based nutrition as an adjunct to usual cardiovascular care. We considered participants adherent if they eliminated dairy, fish, and meat, and added oil.
Results:
Of the 198 patients with CVD, 177 (89%) were adherent. Major cardiac events judged to be recurrent disease totaled one stroke in the adherent cardiovascular participants—a recurrent event rate of .6%, significantly less than reported by other studies of plant-based nutrition therapy. Thirteen of 21 (62%) nonadherent participants experienced adverse events.
Conclusion:
Most of the volunteer patients with CVD responded to intensive counseling, and those who sustained plant-based nutrition for a mean of 3.7 years experienced a low rate of subsequent cardiac events. This dietary approach to treatment deserves a wider test to see if adherence can be sustained in broader populations. Plant-based nutrition has the potential for a large effect on the CVD epidemic.
Undergraduate medical education has undergone significant changes in development of new curricula, new pedagogies, and new forms of assessment since the Nutrition Academic Award was launched more than a decade ago. With an emphasis on a competency-based curriculum, integrated learning, longitudinal clinical experiences, and implementation of new technology, nutrition educators have an opportunity to introduce nutrition and diet behavior-related learning experiences across the continuum of medical education. Innovative learning opportunities include bridging personal health and nutrition to community, public and global health concerns, integrating nutrition into lifestyle medicine training, and using nutrition as a model for teaching the continuum of care and promoting interprofessional team-based care. Faculty development and identification of leaders to serve as champions for nutrition education continue to be a challenge.
We evaluated preventive cardiology education in United States cardiology fellowship programs and their adherence to Core Cardiovascular Training Symposium training guidelines, which recommend 1 month of training, faculty with expertise, and clinical experience in cardiac rehabilitation, lipid disorder management, and diabetes management as a part of the prevention curricula. We sent an anonymous survey to United States cardiology program directors and their chief fellow. The survey assessed the program curricula, rotation structure, faculty expertise, obstacles, and recommended improvements. The results revealed that 24% of surveyed programs met the Core Cardiovascular Training Symposium guidelines with a dedicated 1-month rotation in preventive cardiology, 24% had no formalized training in preventive cardiology, and 30% had no faculty with expertise in preventive cardiology, which correlated with fewer rotations in prevention than those with specialized faculty (p = 0.009). Fellows rotated though the following experiences (% of programs): cardiac rehabilitation, 71%; lipid management, 37%; hypertension, 15%; diabetes, 7%; weight management/obesity, 6%; cardiac nutrition, 6%; and smoking cessation, 5%. The program directors cited "lack of time" as the greatest obstacle to providing preventive cardiology training and the chief fellows reported "lack of a developed curriculum" (p = 0.01). The most recommended improvement was for the American College of Cardiology to develop a web-based curriculum/module. In conclusion, most surveyed United States cardiology training programs currently do not adhere to basic preventive cardiovascular medicine Core Cardiovascular Training Symposium recommendations. Additional attention to developing curricular content and structure, including the creation of an American College of Cardiology on-line knowledge module might improve fellowship training in preventive cardiology.
To quantify the number of required hours of nutrition education at U.S. medical schools and the types of courses in which the instruction was offered, and to compare these results with results from previous surveys.
The authors distributed to all 127 accredited U.S. medical schools (that were matriculating students at the time of this study) a two-page online survey devised by the Nutrition in Medicine Project at the University of North Carolina at Chapel Hill. From August 2008 through July 2009, the authors asked their contacts, most of whom were nutrition educators, to report the nutrition contact hours that were required for their medical students and whether those actual hours of nutrition education occurred in a designated nutrition course, within another course, or during clinical rotations.
Respondents from 109 (86%) of the targeted medical schools completed some part of the survey. Most schools (103/109) required some form of nutrition education. Of the 105 schools answering questions about courses and contact hours, only 26 (25%) required a dedicated nutrition course; in 2004, 32 (30%) of 106 schools did. Overall, medical students received 19.6 contact hours of nutrition instruction during their medical school careers (range: 0-70 hours); the average in 2004 was 22.3 hours. Only 28 (27%) of the 105 schools met the minimum 25 required hours set by the National Academy of Sciences; in 2004, 40 (38%) of 104 schools did so.
The amount of nutrition education that medical students receive continues to be inadequate.
In a prospective, randomised, controlled trial to determine whether comprehensive lifestyle changes affect coronary atherosclerosis after 1 year, 28 patients were assigned to an experimental group (low-fat vegetarian diet, stopping smoking, stress management training, and moderate exercise) and 20 to a usual-care control group. 195 coronary artery lesions were analysed by quantitative coronary angiography. The average percentage diameter stenosis regressed from 40.0 (SD 16.9)% to 37.8 (16.5)% in the experimental group yet progressed from 42.7 (15.5)% to 46.1 (18.5)% in the control group. When only lesions greater than 50% stenosed were analysed, the average percentage diameter stenosis regressed from 61.1 (8.8)% to 55.8 (11.0)% in the experimental group and progressed from 61.7 (9.5)% to 64.4 (16.3)% in the control group. Overall, 82% of experimental-group patients had an average change towards regression. Comprehensive lifestyle changes may be able to bring about regression of even severe coronary atherosclerosis after only 1 year, without use of lipid-lowering drugs.
The Lyon Diet Heart Study is a randomized secondary prevention trial aimed at testing whether a Mediterranean-type diet may reduce the rate of recurrence after a first myocardial infarction. An intermediate analysis showed a striking protective effect after 27 months of follow-up. This report presents results of an extended follow-up (with a mean of 46 months per patient) and deals with the relationships of dietary patterns and traditional risk factors with recurrence.
Three composite outcomes (COs) combining either cardiac death and nonfatal myocardial infarction (CO 1), or the preceding plus major secondary end points (unstable angina, stroke, heart failure, pulmonary or peripheral embolism) (CO 2), or the preceding plus minor events requiring hospital admission (CO 3) were studied. In the Mediterranean diet group, CO 1 was reduced (14 events versus 44 in the prudent Western-type diet group, P=0.0001), as were CO 2 (27 events versus 90, P=0.0001) and CO 3 (95 events versus 180, P=0. 0002). Adjusted risk ratios ranged from 0.28 to 0.53. Among the traditional risk factors, total cholesterol (1 mmol/L being associated with an increased risk of 18% to 28%), systolic blood pressure (1 mm Hg being associated with an increased risk of 1% to 2%), leukocyte count (adjusted risk ratios ranging from 1.64 to 2.86 with count >9x10(9)/L), female sex (adjusted risk ratios, 0.27 to 0. 46), and aspirin use (adjusted risk ratios, 0.59 to 0.82) were each significantly and independently associated with recurrence.
The protective effect of the Mediterranean dietary pattern was maintained up to 4 years after the first infarction, confirming previous intermediate analyses. Major traditional risk factors, such as high blood cholesterol and blood pressure, were shown to be independent and joint predictors of recurrence, indicating that the Mediterranean dietary pattern did not alter, at least qualitatively, the usual relationships between major risk factors and recurrence. Thus, a comprehensive strategy to decrease cardiovascular morbidity and mortality should include primarily a cardioprotective diet. It should be associated with other (pharmacological?) means aimed at reducing modifiable risk factors. Further trials combining the 2 approaches are warranted.
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