Lifestyle Works

By Michael Greger M.D. FACLM on October 6, 2021

Globally, 11 million deaths are attributable to dietary factors each year, “placing poor diet ahead of any other risk factor for death in the world.” Given that diet is our leading killer, you'd think it would be emphasized in medical school, but there is a deficiency of nutrition education in medical training. A systematic review found that despite the centrality of nutrition to healthy lifestyle, graduating medical students are not supported through their education to provide the necessary care.

It could start in undergrad. What's more important—learning about humanity's leading killer, or organic chemistry?

In medical school, students may average only 19 total hours of nutrition out of thousands of hours of instruction, and they're not even being taught what's most useful. How many cases of scurvy or beriberi (diseases of dietary deficiency) will they encounter in clinical practice? In contrast, how many of their future patients will be suffering from dietary excesses—obesity, diabetes, hypertension, and heart disease? Those are probably a little more common. More than nine out of 10 of cardiologists surveyed believe that their role includes personally providing patients with at least basic nutrition information, yet less than one in 10 feel they have an expert grasp on the subject.

If you look at the clinical guidelines for what we should do for our patients with regards to our #1 killer, atherosclerotic cardiovascular disease, all treatment begins with a healthy lifestyle. Yet, how can clinicians put these guidelines into practice without adequate training in nutrition?

Fewer than 50 percent of medical schools reported teaching any nutrition in clinical practice. In fact, they may be effectively teaching anti-nutrition, as students typically begin medical school with a greater appreciation for the role of nutrition in health than when they leave.

The percentage of medical students at different schools indicating that nutrition is important to their careers upon entry into medical school averaged about 75 percent.

Smart bunch. Okay, but then, after two years of instruction in medical school, they were asked the same question. And the numbers plummeted. In fact, at most schools it was zero percent. Instead of being educated, they got de-educated. They had this silly notion that nutrition was important washed right out of their brains. “Preclinical teaching [meaning the first two years of medical school] engenders a loss of a sense of the relevance of the applied discipline of nutrition.”

And following medical school, nutrition education during residency is minimal or, more typically, absent. Major updates were released in 2018 for residency and fellowship training requirements, and there were zero requirements for nutrition. So, you could have an internal medicine graduate who comes out of some prestigious program who has learned nothing—literally nothing—about nutrition.

Why isn't diet routinely addressed already in both medical education and practice, and what should be done about it? One of the reasons for the medical silence in nutrition, sadly, is that nutrition takes a back seat because there are few financial incentives to support it.

What can we do about that? The Food Law and Policy Clinic at Harvard Law School identified a dozen different policy levers at all stages of medical education, and the kinds of policy recommendations there could be for the decision-makers. For instance, the government could require doctors working at the VA, at least, to get some courses in nutrition. Or, we could put questions about nutrition on the board exams so schools would be pressured to teach it. But as we are now, even patients who just had a heart attack aren't changing their diet. Doctors may not be telling them, and hospitals may be actively undermining their future with the food they serve the patients.

The good news is the American Medical Association (AMA) has passed a resolution encouraging healthy food options be available in hospitals. What a concept! The AMA hereby calls on U.S. hospitals to improve the health of patients, staff, and visitors by: (a) providing a variety of healthy food, including plant-based meals, and meals that are low in fat, sodium, and added sugars; (b) eliminating processed meats from menus; and (c) providing and promoting healthy beverages. Nice!

Similarly, in 2018, the state of California mandated the availability of plant-based meals for patients.  And there are hospitals in Gainesville, Florida, the Bronx, Manhattan, Denver, and Tampa all offering 100 percent plant-based meals to their patients on a separate menu, and distributing materials to inpatients to improve their education on the role of diet, especially plant-based diets, in chronic disease.

Let's check out some menus. Mmm…, a little lentil Bolognese. Here's Montefiore's: a little cauliflower scramble with baked hash browns for breakfast, mushroom ragu for lunch, and white bean stew for supper, soup, salad, and fruit for dessert. This is the first time a hospital menu ever made me hungry. It makes me want to get appendicitis and stay for a few days!

The key to these transformations “was having a physician advocate and increasing education of staff and patients on the benefits of eating more plant-based foods.” A single clinician can spark change in a whole system, because science is on their side. Doctors have a unique position in society to influence policy at all levels; it's about time we used it.

Recipe of the Month

Mixed Bean Salad

2 c    cooked mixed beans
2      small onions, diced
2      tomatoes, diced
¾ c   celery, diced
1      yellow capsicum, diced
¼ c    sliced olives
2T     honey    
¼ c    lemon juice
2 T    olive oil  (optional)
salt to taste

In a bowl mix first six ingredients together. Mix honey, lemon juice,
olive oil (if using) and salt together and pour over bean mixture.
For best results, let stand for an hour or two before serving.
Yield: 4-5  cups.

—Ref. What’s Cooking with Natural Foods. Page 98