Expert panel calls for nutrition competencies in US medical education

A professionally-diverse panel of medical and nutrition experts have proposed a set of recommended nutrition competencies for medical students and physician trainees. The study addresses a longstanding concern that most physicians in the U.S. are not equipped to advise patients about nutrition and food choices.

The proposed competencies are a call to action in response to the U.S. House of Representatives’ bipartisan resolution H. Res. 1118, which calls for “meaningful physician and health professional education on nutrition and diet.” The resolution cited concerns about the increasing prevalence of diet-related diseases and Medicare costs, which totaled $800 billion in 2019. Congressional annual financial support for medical trainees in U.S. hospitals was estimated at $16.2 billion in 2020.

“It’s shocking that there are no nationally required nutrition competencies within medical education,” said lead author David Eisenberg, adjunct associate professor of nutrition and director of culinary nutrition at Harvard T.H. Chan School of Public Health.

“This is a surprising and important gap, considering the epidemics of obesity, diabetes, and other diet-related chronic diseases in this country, as well as their ever-increasing financial and societal costs. My guess is that most patients assume their doctors are trained to advise them about nutrition and food choices, but this has simply not been part of their required training.”

The study was published September 30 in JAMA Network Open.

The researchers, Eisenberg, Alexis Cole at Tufts University, and Edward Maile and Matthew Salt, both at U.K.-based consultancy Sprink Ltd, compiled a list of 354 nutrition competencies included in the academic literature and recruited an expert panel made up of 37 medical educators, nutrition scientists, practicing physicians, medical residency directors, and registered dietitian nutritionists from across the country. Over the course of four rounds, the panelists ranked the competencies and provided comments and ideas.

After analyzing the survey results, the researchers identified 36 nutrition competencies on which the panel had reached consensus and recommended for undergraduate and graduate medical school and training. The competencies span six categories:

1. Foundational nutritional knowledge (“Demonstrates knowledge of the nutritional content of foods including the major dietary sources of macronutrients and micronutrients”)
2. Assessment and diagnosis (“Assesses the nutritional status of a patient with a brief diet and food history/questionnaire, anthropometric measurements, and appropriate laboratory tests”)
3. Communication skills (“Listens carefully, compassionately, and non-judgmentally while taking a nutrition history”)
4. Public health (“Demonstrates knowledge of public health nutrition, including the social determinants of health, and how it can reduce the burden of disease and improve access to adequate, healthy food”)
5. Collaborative support and treatment for specific conditions (“Works with other health professionals to deliver a multidisciplinary approach to nutrition care”)
6. Indications for referral (“Makes appropriate referrals to a range of professionals to support the patient to achieve their health goals”)

In addition, 97% of the panelists called for formal nutrition testing on licensing and certification exams for future physicians. Other highlights include:

• 95% of panelists agreed that institutions should report on their teaching relating to nutrition competencies.
• 92% agreed that surveys of students should be used to assess their competency and confidence in this area.
• 73% of panelists recommended a competency related to the environmental and planetary health impact of food choices for inclusion.

The research team also identified 12 possible gaps that were not addressed in the recommended competencies, as these were not identified in a review of the existing medical literature. These included topics such as when and how to discuss glucagon-like peptide 1 (GLP-1) agonists (anti-obesity drugs) with patients and how to responsibly use artificial intelligence to provide patients practical advice about nutrition and food choices.

“The competencies represent the greatest efforts thus far to address H. Res. 1118, and their adoption will undoubtedly significantly enhance public health,” Eisenberg said.

“Ensuring physicians are equipped with the necessary knowledge to advise patients in practical terms about nutrition and food choices will increase referrals to and collaboration with a range of nutrition experts and programs, promote health equity, and improve planetary health.”

The researchers noted that the competencies’ international generalizability may be limited, given that the panel was U.S.-based. However, the consensus-building approach through which the recommended competencies were developed could inform similar efforts by medical educators and regulators worldwide, as nutrition-related health challenges and limited nutrition training for physicians are global problems.