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? Give doctors in training more nutrition education, provide more continuing education to practicing physicians focused 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
LEAST EFFECTIVE NUTRITION EDUCATION USED MOST OFTEN
Ironically, most conventional nutrition education uses the least effective means of changing behavior. We deliver information as if knowledge is enough to change behavior. To make matters worse, most experts presume that everyone will benefit from the same information, or that the diagnosis determines the diet.
We tell people what they should be eating, mostly without considering the unique needs and challenges of the person who is supposed to be doing all the changing. Worksite wellness programs share a similar problem with a dismal outcome. Too often the greatest impact mostly benefits those who need it the least. And if you don’t get with the program, there’s an extra dose of blame and shame waiting for you.
In a 2007 study looking at time allocation, doctors were videotaped during office hours. On average clinicians spent 5.3 minutes talking about a major topic and 1.1 minutes discussing minor topics. In that five minutes the patient talked 2 minutes, the doctor talked 2.3. Can a doctor accomplish effective nutrition and lifestyle counseling in two minutes? What if a patient struggles with ambivalence or experiences significant barriers to change? When it comes to prevention, clinicians will need to dedicate even more time.
IS THE DOCTOR THE BEST SOURCE OF EFFECTIVE NUTRITION COUNSELING?
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.
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 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.