A physician’s two favorite words: diet and exercise. Patients are constantly told that lifestyle interventions are the most important modifiable risk factors to prevent chronic illnesses like diabetes and hypertension. Even as medical students, we hear these words repeated throughout our lectures, but what do they actually mean? The phrase “healthy eating” is wildly ambiguous and is socially and culturally determined. Western society defines healthy eating as green juices and kale salads, which is not always practical given the varying cultures and resource availability in different communities. This ambiguity becomes particularly problematic during fetal life as changes to the fetal environment caused by maternal diet increase the lifetime risk of various metabolic disorders. Over the past decade, there has been a 95.3% increase in type 2 diabetes rates among children in the United States, an increase that mirrors rates of gestational diabetes. These populations are just two of many impacted by this national problem, and it is clear that the nutrition counseling physicians are providing is not adequate.
The first 1,000 days is a critical period for growth and development that begins at the time of conception through the child’s second birthday. This “window of opportunity” is when 80% of brain development occurs and is either a time to provide the foundation for optimal development or a time of intense vulnerability during which the brain is susceptible to irreversible changes. Therefore, adequate caloric intake as well as specific macro and micronutrient quantities during these first 1,000 days is imperative. Once this critical period has passed, it may not be possible to reverse the developmental changes that resulted from inadequate nutrition. An important protective factor is that pregnant patients generally see their providers regularly, serving as a longitudinal opportunity for counseling and monitoring to prevent these irreversible changes. Physicians must be equipped to provide nutritional information, screen patients for food insecurity and address barriers to accessing high quality nutrition, all while remaining culturally aware of the communities they serve. We see this as a unique opportunity for physicians to intervene given this continuity of care while working alongside dieticians to implement sustainable changes.
Physicians do not feel comfortable providing nutrition counseling to their patients given the overt lack of training in these topics. It is distressing that physicians may be more inclined to prescribe metformin to children with type 2 diabetes because they are uncomfortable counseling them on lifestyle modifications — the first line treatment. The Liaison Committee of Medical Education recommends that US medical schools provide a minimum of 25 hours of nutrition education over the four-year curriculum, however, 71% of medical schools fail to meet that standard and 36% provide less than half of this recommendation. According to the Association of American Medical Colleges (AAMC), medical schools provide about 1,500 hours of lecture time throughout the preclinical curriculum. Why does nutrition education account for less than 1% of this? The average amount of nutrition education taught in medical schools is 14.3 hours in the preclinical period and 4.7 hours during clinical practice. It is therefore no surprise that only 14% of residents feel adequately trained and confident in applying this knowledge during patient encounters. Being further from their medical school education, doctors must feel even less comfortable discussing these topics.
Medical schools must start integrating more comprehensive nutritional education into the preclinical curriculum to allow future physicians to feel equipped to counsel pregnant patients during the first 1,000 days, as well as other patients they may encounter. During our preclinical years, the three hours of lecture we had on nutrition were some of the most memorable and applicable to both our lives and our future careers. Although increased education is imperative, integrating this information into patient encounters is where true change must be made. This change would allow providers at any level of training to interact with and effectively counsel, for example, a pregnant, single mother who lives in a food desert, recently lost her job and has three young kids at home on what she should be eating and feeding her family. Most importantly, she could be educated on how to access these resources while also acknowledging the complexity of her circumstance. And at the end of the day, isn’t providing holistic care the essence of medicine?
A significant barrier to these changes in education is cost, but there have been strides over the last decade to mitigate this. The Expanding Nutrition’s Role in Curricula and Healthcare (ENRICH) Act (H.R. 1413) from 2017 was introduced to expand funding for integrated nutrition curricula to accredited medical schools. While this recognition is a step in the right direction, it has yet to be passed into law while the rate of type 2 diabetes in children continues to rise. This is a ticking time bomb that needs immediate action. The standard of care must be shifted to prevention rather than medication, and this begins with helping medical students develop the tools needed to define healthy eating, however that may look for each of their patients.