As recently as June, 2014, The Bipartisan Policy Center, the Alliance for a Healthier Generation, and the American College of Sports Medicine claimed, “America’s physicians aren’t educating their patients on weight, diet, and physical activity because America’s physicians aren’t themselves educated on weight, diet, and physical activity.” The answer so far? Give doctors in training more nutrition education, provide practicing physicians more continuing education on nutrition and physical activity, and make more specialty boards available to internists, pediatricians and family docs.
I applaud the effort to bring nutrition and physical activity education to medical professionals. They can’t appreciate what they don’t understand, but I doubt a few more hours of education is likely to make much of an impact. The problem can be summed up in two words: time and energy.
HOW WILL DOCTORS EFFECTIVELY COUNSEL PATIENTS ABOUT DIET AND EXERCISE?
In a recent survey, “The majority of physicians — 81 percent — report being either overextended or at full capacity, up from 75 percent in 2012. Just 19 percent of physicians said they have time to see more patients”. This data flies in the face of expectations for physicians to dedicate even more time and energy to counseling patients about nutrition and physical activity.
Overextended or not, most physicians are not likely to have the quality time needed for effective counseling for the growing number of insured patients today, mostly because nutrition education is not just telling someone what to eat. Over the years, simplistic sound bites such as “Eat less and exercise more” or “Fat makes you fat” have done more harm than good. Far too few people appreciate that, “Eating is the most complicated human behavior there is and involves all of human development.”1
IS THE DOCTOR THE BEST SOURCE OF EFFECTIVE NUTRITION COUNSELING?
A recent study looks closely at the time factor. In 2007 study researchers videotaped doctors during office hours. On average clinicians spent 5.3 minutes talking about a major topic and 1.1 minutes discussing minor topics. Patients in an academic setting enjoyed an average of 6.7 minutes to discuss a major issue while patients at an inner city solo practice made due with 3.2 minutes of time. On average the patient talked 2 minutes, the doctor talked 2.3 minutes when discussing a major topic.
With most medical conditions, how often would addressing nutrition be considered a minor topic? In that case, the patients would enjoy a total of 1.1 minute at an academic institution and less than a minute at the inner city solo practice.
Can a doctor accomplish effective nutrition and lifestyle counseling in two minutes? Can a patient adequately address their nutrition questions and concerns? What if a patient struggles with ambivalence or experiences significant barriers to change?
NUTRITION EDUCATION IN MEDICAL SCHOOL: A LONG TERM PROBLEM
Most of my time with clients is spent unwinding the tangle of nutrition tips and advice. Despite the fact that everyone eats, not everyone is an expert in food and nutrition. Too often patients are tripped up by confusing or dated information offered by other health professionals.
Lack of nutrition education in medical school is is an old issue, as Marion Nestle reports her own experience trying to improve nutrition education for physicians over 40 years ago. Most doctors receive just a few hours addressing nutrition science during their years of training despite the escalating cost of treating medical conditions that are significantly influenced by what people eat. Will that change?
This year Congress has stepped into the fray with two bills addressing nutrition education for medical students and practicing physicians. In April of 2014 the The EAT for Health Act and The ENRICH Act were introduced to the House of Representatives, and immediately referred to committee . Both bills are given a 1% chance of passage.
LEAST EFFECTIVE NUTRITION EDUCATION USED MOST OFTEN
We deliver information as if knowledge is enough to change behavior, mostly because telling people what to eat only takes a minute or two. Ironically telling people what to do is often the least effective means of changing behavior.
Telling people what they should be eating mostly ignores the unique needs and challenges of the person who is supposed to be doing all the changing. To make matters worse, most diet instruction materials presume that everyone will benefit from the same information, or that the diagnosis determines the diet. At my own Kaiser facility, my husband was offered nutrition information sent in the mail. If that wasn’t adequate he could attend a cholesterol class taught by a nurse. He signed up despite having a personal dietitian at his disposal, and came home fuming. A nurse taught the course, used out of date materials (published nine years earlier), and she couldn’t answer my husband’s nutrition questions (of which he already knew the answer). My guess is only the most motivated of patients benefit from these rather inadequate efforts.
WHAT EVERY DOCTOR AND HEALTH PROFESSIONAL CAN DO
In the end, I hope medical students and practicing physicians are required to learn more about food and nutrition. But I also hope that we stop fooling ourselves. Nutrition education delivered by well meaning but inadequately educated and overwhelmed physicians is a bizarre use of valuable resources.
Frankly I am baffled that a physician–the most expensive resource in the clinical setting–is expected to address nutrition, diet and weight for a few minutes instead of referring to a nutrition professional. No one expects doctors to take on the role of physical therapist, occupational therapist, speech and language therapist, social worker or psychotherapist. Why the controversial and complex world of food and nutrition?
I see one very good outcome if these bills do pass. Physicians could be educated enough to learn how to effectively refer patients for nutrition counseling by dietitians and other qualified nutritionists. After all, how many of you believe two minutes is enough time to tell your doctor what you need to say? And how may believe your doctor can offer effective nutrition counseling in the little more than 2 minutes left?
1. Kathleen Zelman. Assessing the Picky vs. Problem Eater: A Closer Look at Sensory Processing Disorder. Food & Nutrition. AND. © September/October, 2014.