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A Harvard Course Seeks to Put Food on the Table in Medical Education
BOSTON — Doctors often don’t have a lot of time to chat with patients during medical appointments — which means that conversations about nutrition can wind up taking a backseat to other concerns. But during a recent weeklong course at Harvard T.H. Chan School of Public Health, preventive cardiologist Stephen Devries enlisted two dozen students in the mission to integrate nutrition into clinical medicine — changing the way medicine is taught and health care is delivered in the process.
“As a cardiologist, I can attest to the fact that nutrition is vastly underutilized in medical practice,” Devries told STAT. “I saw the end result of disease that in many cases could have been prevented or the severity lessened, had more attention been paid to nutrition and lifestyle.”
In the classroom on this chilly January day in Boston’s Longwood Medical Area, Devries spoke with students about success stories like hospital teaching kitchens, which take a hands-on approach to tailoring meals to patients’ health needs and their access to healthy food, and the Diabetes Prevention Program, which has a combined approach to healthy diet and exercise that demonstrates how effective those interventions can be.
They also reviewed studies showing how two simple queries about food insecurity over the past year, answered by patients before their clinical visits, can identify families in need of referrals to social workers or others who can direct them to solutions. Patients were asked to respond to two statements: “We worried whether our food would run out before we got money to buy more” and “The food we bought just didn’t last and we didn’t have money to get more.”
The winter session course, now in its second year, evolved from discussions in the Harvard school’s Nutrition Education Working Group, whose advocacy has led to more nutrition content in medical board exams and a 2022 U.S. House resolution urging more nutrition education in medical schools. “This new generation of emerging physicians and other health professionals seems to be more engaged and interested in nutrition than any that came before it,” Devries said.
Many of the students in the classroom that day were currently enrolled in medical school or public health programs. Others hoped to be accepted into them, and some had already graduated but wanted to fill gaps in their specialties where they thought nutrition should have been all along. As movements promoting food as medicine — or declaring that food is medicine — gain traction, they all wanted to know more than their advanced degree programs offered them.
That’s a battle Marion Nestle, New York University professor emerita of nutrition, food studies, and public health, has been fighting for decades. “The lack of adequate nutrition education in medical schools has been a big issue since the 1960s, as yet unresolved,” she told STAT. “Nutrition education needs to be integrated into the larger context of health promotion and disease prevention.”
While the students in Devries’ class were searching for a better grounding in the science of nutrition and how to bring it to patients, most medical schools do address the topic already, according to Lisa Howley, senior director, transforming medical education, at the Association of American Medical Colleges. She said that nearly 100% of its 158 medical school members include instruction on the science of nutrition in their curricula, and a growing proportion of them — nearly 50% as of their latest survey in 2019 — also address food insecurity.
That said, Howley noted that there is room for further improvement.
“Improving how we integrate nutrition, diet, preventive care into the curriculum is certainly a priority. Instead of addressing it early on in foundational courses, we’d like to see it threaded throughout the entire continuum of medical education,” she said, with a focus on issues around equity and access to food as a determinant of health.
Before the week of classes started, students got up to speed with an online course from the Gaples Institute, where Devries is the nonprofit’s executive director. A through line of the course was how little time and knowledge it can take to ask a question that brings a nutritional need to the surface, highlighting what Devries called often untapped opportunities to improve health with dietary interventions.
That’s particularly important now that new weight loss drugs might consume doctor-patient conversations, especially after the American Academy of Pediatrics said children with obesity at age 12 or older could be considered for the drugs. “We know the short-term effects, they lose weight. But what are the long-term effects? We don’t know,” Devries said. “We do know the long-term effects of a healthy diet, with so many positive outcomes.”
If pediatricians and other specialists aren’t trained in nutrition, they’re less likely to refer patients to dietitians, surveys have shown.
The students in the class were eager to bridge those gaps.
Harvard M.D.-Ph.D. student Jack Kincaid started his undergraduate education focused on nutrition, but now wants to do more as a physician-scientist. “A really critical message of this course is that dietary and lifestyle changes are really difficult,” he said outside the classroom, noting that enabling patients to make such changes involves not just their individual choices but also addressing the economic, legislative, and political factors that influence food environments. “Nutrition is the number-one modifiable risk factor for mortality and all-cause mortality in the U.S. And that statistic is shocking.”
Marissa Huggins, a student in the master’s program in public health hoping to start medical school in the fall, researched the link between food insecurity and childhood obesity over the summer. She saw children who did not have healthy weight but did have asthma, prediabetes, and developmental lapses. When parents struggle to find food, they sometimes turn to unhealthy choices, sometimes unaware of other options. “It’s like [their children] can’t possibly get better unless there is an intervention, but even better is if you can prevent it from happening in the first place.”
Katherine Erbe, a postdoctoral fellow in nursing research, brought to the class her 17 years of experience as a nurse-midwife and frustration at the small role nutrition plays in her field.
“We, as obstetric providers, don’t have any formal guidelines from any of our professional organizations on how to approach nutrition in pregnancy,” she said. “We are not doing anybody any good with what we’re counseling [our patients]. It’s not individualized.”
Guidance is limited to warning about mercury in fish or potential infections from unpasteurized milk products and deli meat. That’s not going to help vegans or people who don’t eat fish, she said. It would be better to ask patients what their dietary needs are so they can be referred to a place like a teaching kitchen, which Erbe first heard about in the course.
Nestle also cited referrals as a necessary intervention. Given doctors’ limited time with patients, she said, “the best they can — and should — do is refer patients to nutrition professionals who can take the time they need to assess nutritional status and decide on dietary intervention.”
The problem with referrals like these, however, is that insurance doesn’t necessarily pay for the services of a dietitian unless there’s a medical problem.
Still, there are a number of ways that providing more medical education about nutrition could ultimately benefit both health care workers and patients. As Devries urged his students to embrace change from the status quo, he observed that if they themselves combined healthy eating with exercise, they might also ease their own burnout from long hours, endless paperwork, and daily frustrations.
“I’m not here to tell you that diet is the answer to every ill responsible for burnout,” he said, noting studies show health care providers aren’t great at taking care of themselves. But “there are some things you can do for self-care, and one of them is ensuring that your own diet is one that promotes your best well-being.”