At almost every single one of my medical school interviews, each interviewer, noting my college major in nutritional science, asked some variation of the question, “What should I be eating to stay healthy?” Each time, I was left unsure of whether or not this question was aimed to gauge my ability to hold a conversation in a stressful environment, articulate my thoughts in a logical manner, or fulfill some other mysterious goal of the infamous medical school interview process. Or, could it be possible that a physician truly did not have an idea about what constitutes healthy eating?
It is predictable that more than one medical school lecture will display the chronological progression of the CDC obesity prevalence maps over the years. The colorful representation of the progression to higher percentages of obesity is familiar but still shocking, with the most recent data from 2013 showing that 34.9% of US adults and 17% of US children and adolescents are obese. We are presented with overwhelming evidence that obesity is a risk factor for type 2 diabetes, hypertension, dyslipidemia, osteoarthritis, and sleep apnea. There is no possible way to go through medical school without understanding that obesity is prevalent and contributes to disease risk. But do we ever really learn how to counsel our patients about this issue?
A 2015 article published in the Lancet about the current status of obesity management emphasizes the scarcity of nutrition medical education in US medical schools . Researchers report that, despite 2007 recommendations by the US Association of Medical Colleges to implement education on overweight and obesity management in undergraduate medical curricula, data from a 2009 survey reveal an average of merely 19.6 hours dedicated to the subject throughout the entirety of medical school, with a range of zero to 70 hours. In fact, only 27% of schools meet the minimum requirement of 25 hours established by the Association . One consequence of this lack of education is well demonstrated by a 2005 study that used a cross-sectional medical record review to identify how frequently internal medicine residents documented obesity as a medical problem and how frequently they managed the issue in an outpatient clinic setting. Data showed that residents identified 7.3% of overweight patients (13/178) and 30.9% of their obese patients (76/246). Even if practitioners identified such patients, it was rare that they intervened: out of the 424 overweight and obese patients in the sample, only 16.5% (70/424) received any form of management for excess weight . Although there was no follow-up as to why, it is likely due to lack of resources, education and confidence in skills.
Another effect of the lack of appropriate education about obesity and its complex etiology is widespread bias among medical students that is likely to impair effective and thorough healthcare delivery. Researchers have identified that medical students in the US are likely to harbor negative biases and stereotypes of obese patients, such as that obese patients are more likely to be noncompliant and less responsive to counseling . However, researchers also demonstrate that, by providing medical students with a more complete education about obesity and associated difficulties, and by providing the opportunity to practice and improve communication skills with educational tools such as standardized patients, biases can be reduced [4, 5]. Other research has shown that, without such focused education, biases are carried through to professional practice, with large samples of practicing physicians across multiple specialties exhibiting implicit and explicit biases against obese patients that have been shown to negatively affect care .
While the solution to the problem of lack of medical school education about nutrition and obesity is undoubtedly complex, a commitment to more thorough education is necessary for the effective management of this widespread problem. Physicians themselves have identified inadequate training in areas such as motivational interviewing and nutritional and exercise counseling. Those who did receive education in such areas felt that it was helpful in their practice . While there are many more areas of educational deficit, these areas could be a good place to start.
After a long morning of rounding on an internal medicine inpatient service, it is typical to see groups of senior physicians, residents , and medical students convening around tables of candy, pizza, and various other less-than-nutritious snacks that adorn the tables of the call rooms. Each time, I can’t help but think back to my medical school interviews and realize that the interviewers probably did not have an alternative agenda for their question about how to eat healthy. They, like many of my contemporaries, probably never learned.
Commentary by Dr. Michelle McMacken
Poor nutrition is a key driver of our leading chronic diseases. Most internists spend their days treating diabetes, hypertension, obesity, fatty liver, and coronary artery disease–all of which have a common root in lifestyle and nutrition. The economic and public health costs are staggering. We rely heavily on pills and procedures in part because we lack the skills or the time to offer nutrition and lifestyle counseling, or because we assume that patients won’t make lifestyle changes. But there is abundant, compelling evidence that when patients do make lifestyle changes, the benefits are tremendous. We owe it to our patients to give them that chance. Core medical education on nutrition and lifestyle medicine is paramount if we want to address the overwhelming burden of chronic disease. After all, pills and procedures will treat symptoms, but only lifestyle change can truly treat the cause.
Elissa Driggin is a 3rd year medical student at NYU School of Medicine
Peer reviewed by Michelle McMacken, MD, internal medicine, NYU Langone Medical Center
Image courtesy of Wikimedia Commons
- Dietz WH, Baur LA, Hall K, et al. Management of obesity: improvement of health-care training and systems for prevention and care. Lancet. 2015;385(9986):2521-2583. http://www.ncbi.nlm.nih.gov/pubmed/25703112
- Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: latest update of a national survey. Acad Med. 2010;85(9):1537–1542. http://www.ncbi.nlm.nih.gov/pubmed/20736683/
- Ruser CB, Sanders L, Brescia GR, et al. Identification and management of overweight and obesity by internal medicine residents. J Gen Intern Med. 2005;20(12):1139–1141. http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2006.00561.x/references
- O’Brien KS, Puhl RM, Latner JD, Mir AS, Hunter JA. Reducing anti-fat prejudice in preservice health students: a randomized trial. Obesity (Silver Spring). 2010;18(11):2138–2144. http://www.ncbi.nlm.nih.gov/pubmed/20395952
- Kushner RF, Zeiss DM, Feinglass JM, Yelen M. An obesity educational intervention for medical students addressing weight bias and communication skills using standardized patients. BMC Med Educ. 2014;14:53. http://www.ncbi.nlm.nih.gov/pubmed/24636594
- Foster GD, Wadden TA, Makris AP, et al. Primary care physicians’ attitudes about obesity and its treatment. Obes Res. 2003;11(10):1168–1177. http://www.ncbi.nlm.nih.gov/pubmed/14569041
- Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open. 2012;2(6). pii:e001871. http://www.ncbi.nlm.nih.gov/pubmed/23257776/