Perspective

Perspective Perspective

History of Nutrition in Medical Training

Kristen Ann ehrenBerger, md phd

Were you required to take a class on nutrition in medical school? Was an started in the post-war period as an artifact of what has been digitized and indexed; if and when I have the time to elective even an option? How many morning reports, noon conferences, or journal clubs in residency were dedicated to perioperative hydration? Have you been offered continuing medical education on the physiology of weight gain and loss? The “triple burden” of undernutrition, overnutrition, and micronutrient deficiencies underlie significant morbidity and mortality around the world today, and many patients trust their doctors to give them dietary advice, yet few physicians feel qualified to give it.

Laments about the poor state of nutrition training fill the medical education literature, going back at least to the late 1950s, when Edward High (1919-1986) at Meharry in Nashville surveyed 66 of the 80 medical schools then in operation. Mid-century angst may reflect the vacuum created when dieticians coalesced as a (largely female and undervalued) profession. Assuming it had been present in curricula earlier, the subject may have been dropped for mostly male medical and surgical trainees destined for increasingly refined and technical (sub)specialties rather than for general practice. Alternatively, the decline in interest may only appear to have search older publications, I would not be surprised to find William Osler or his teachers’ teachers complaining that there are not enough lectures devoted to dietetics. Is there nothing new under the sun? Whenever its nadir, medical training in nutrition may have peaked in the 1980s, when total parenteral nutrition (TPN) was all the rage. Stanley J. Dudrick (1935-2020) had developed this method for intravenously nourishing beagle puppies while a surgical resident at the University of Pennsylvania in the 1960s. The first infant to be fed by vein was a girl born in July 1967 with near-total small bowel atresia; remarkably, she survived for 22 months. For about 15 years, TPN was a panacea, until clinicians realized that the risks of infection, thrombosis, and liver injury might outweigh the benefits in patients who could tolerate enteral feeds. Support for physiciannutritionists waned such that, a decade ago, the average number of hours of undergraduate medical nutrition instruction was 19, and fewer than 20% of North American medical schools required a course on nutrition, much less the 25-30 contact hours recommended by the United States Committee on Nutrition in Medical Education in 1985.

Since then, the pendulum seems to be swinging back in the other direction. Public discussion of the “obesity epidemic” has increased, and clubs or electives in “culinary medicine” have popped up in many medical schools. Unfortunately, first-year students’ interest in the subject tends to wane by graduation, crowded out by sexier topics like point of care ultrasound (POCUS) if not reinforced by clinical preceptors.1

My own effort to remedy this situation locally is an elective for medical students at the University of Pittsburgh called “Medical Nutrition: Past & Present Theories & Practice.” The syllabus reflects my dual training in the history of medicine and in healthcare across the lifespan, with one week each devoted to general (adult) dietary principles, pediatric nutrition, obesity, and surgical or artificial nutrition. I piloted the course in January with 17 fourth-year medical students. We met every day for 2 hours over Zoom to discuss a historical article on why diabetes used to be coded as “a Jewish disease,” listen to a dietician guest lecture on medically supervised weight loss, or practice calculating tube feeds and TPN. The students had three research projects: one to prepare

a meal from a non-grocery store, one to evaluate the evidence behind a fad diet, and one to present on a topic of their choice, such as the effect of BMI on the outcomes of laparoscopic gynecological procedures, or the unbearable whiteness of contemporary nutrition advice from the perspective of a Muslim Ethiopian-American student.

One hundred percent of the students later reported that the course had improved both their clinical skills and their historical knowledge of nutrition, yet only fifty percent thought such a class should be required. Thirty eight percent thought that some of the lessons could be incorporated into the existing curriculum and the rest offered as an elective, but they and the twelve percent who answered “no” to requiring it worried about losing time for career exploration through electives, the dampening effect a mandate would have on enthusiasm, and that nutrition is not relevant to all their classmates. While it is true that a future pathologist or radiologist may not give patients dietary advice, studies have shown that exposure to nutrition content improves medical students’ own knowledge and behaviors.

With so much smoke, you might expect to find some fire. However, the fact that articles continue to be written about insufficient training in nutrition demonstrates the continuing mismatch between what is and what could be taught. This despite the fact that in the 1990s, the National Heart Lung and Blood Institute (NHLBI) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) dispersed 5-year grants to 21 medical schools to develop a Nutrition Curriculum Guide for Training Physicians. At the same time, the National Institutes of Health paid University of North Carolina to develop a standardized Nutrition in Medicine syllabus for undergraduate medical education; around 2010, they added modules for graduate and continuing medical education called Nutritional Education for Practicing Physicians. Although these are all freely available online, medical schools continue to ignore the recommendations for nutrition training or—like I did—reinvent the wheel if they do offer this content.

When I revise the syllabus over the summer, I will make sure it covers what the guidelines suggest while not sacrificing what makes this course unique: the inclusion of historical perspectives. When students wondered why current patient handouts about the benefits of a low-sodium diet specifically target “African-Americans/ blacks [sic],” we discussed the “slavery hypertension hypothesis,” which has no basis in science or historical fact. If a new parent resists the pediatrician’s feeding advice, it may be helpful to recall that professional and advertising agencies only positioned doctors as child-rearing experts 100 years ago; experienced grandmothers and aunties have been keeping babies alive for millennia. And the obesity epidemic was largely born out of the 1998 re-definition of a “normal” body mass index from 27-28kg/m2, a descriptive value reflecting US statistical averages by sex, to <25 kg/m2, a prescriptive value in line with World Health Organization standards. Finally, if you would like a book-length description of how American dietary practices came to carry so much personal weight and public stigma, I highly recommend Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (UNC Press, 2013), by Helen Zoe Veit.

Kristen Ann Ehrenberger is a MedPeds physician who directs the Progressive Evaluation and Referral Center (PERC) at UPMC and serves as secretary of the C.F. Reynolds Medical History Society.

1 Kelly M. Adams, W. Scott Butsch,

Martin Kohlmeier, “The State of Nutrition Education at US

Medical Schools,” Journal of

Biomedical Education vol. 2015 (2015): [7 pages]. 2 Committee on Nutrition in

Medical Education, Nutrition

Education in U.S. Medical Schools (Washington, DC: National

Academies Press, 1985). 3 Curriculum Committee of the

Nutrition Academic Award Program,

“Nutrition curriculum guide for training physician practice behavior skills and attitudes across the curriculum,” (2002): https://www.nhlbi.nih.gov/ sites/default/files/media/docs/

NAA%20Nutrition%20Curriculum%20

Guide.pdf. 4 Nutrition in Medicine can be found at http://www.nutritioninmedicine.org (copyright 2014).