Nutrition Education for Cardiologists: The Time Has Come

There and Back Again: A Forty-Year Perspective on Physician Nutrition Education

Medical education faces an urgent need for evidence-based physician nutrition education. Since the publication of the 1985 National Academies report "Nutrition Education in the United States Medical Schools," little has changed. Although several key efforts sought to increase nutrition content in undergraduate medical education over the past 40 y, most medical schools still fail to include the recommended minimum of 25 h of nutrition training. Without foundational concepts of nutrition in undergraduate medical education, graduate medical education unsurprisingly falls short of meeting patient needs for nutritional guidance in clinical practice. Meanwhile, diet-sensitive chronic diseases continue to escalate, although largely preventable and treatable by nutritional therapies and dietary lifestyle changes. Fortunately, recent recognition and adoption of Food is Medicine programs across the country increasingly connect patients with healthy food resources and nutrition education as core to their medical care, and physicians must be equipped to lead these efforts alongside their dietitian colleagues. Filling the gap in nutrition training will require an innovative and interprofessional approach that pairs nutrition with personal wellness, interprofessional practice, and community service learning. The intersectional benefits of connecting these domains will help prepare future physicians to address the social, behavioral, and lifestyle determinants of health in a way that recognizes nourishing food access as a core part of clinical practice. There are numerous strategies to integrate nutrition into education pathways, including didactic and experiential learning. Culinary medicine, an evidence-based field combining the culinary arts with nutritional science and medicine, is 1 promising educational framework with a hands-on, interprofessional approach that emphasizes community engagement. Advancing the critical need for widespread adoption of nutrition education for physicians will require support and engagement across societal stakeholders, including co-leadership from registered dietitian nutritionists, health system and payor reform, and opportunities for clinical innovation that bring this essential field to frontline patient care.

A Place for Plant-Based Nutrition in US Medical School Curriculum: A Survey-Based Study

Purpose. To evaluate medical students' and family medicine residents' perceptions of their current degree of nutrition training in general and regarding a whole-foods, plant-based (WFPB) diet. Methods. An original survey instrument was administered to medical students and family medicine residents. Quantitative and qualitative data were collected to evaluate perceptions of nutrition education in medical training, a WFPB diet, and ideas for nutrition-focused curricular reform. Results. Of the 668 trainees surveyed, 200 responded (response rate = 30%). Of these, 22% agreed that they received sufficient nutrition education in medical school and 41% agreed that a WFPB diet should be a focus. Respondents with personal experiences with a plant-based diet were more willing to recommend it to future patients. Common ideas for curricular reform were instruction on a WFPB diet along with other healthy dietary patterns, patient counseling, a dedicated nutrition course, and electives. Conclusions. Nutrition education in US medical training needs improvement to address the growing burden of obesity-related chronic disease. Proper nutrition and lifestyle modification should therefore play a larger role in the education of future physicians. A focus on plant-predominant diets, such as the WFPB diet, may be an acceptable and effective addition to current medical school curriculum, and deserves further study.

Whole-Foods, Plant-Based Diet Perceptions of Medical Trainees Compared to Their Patients: A Cross-Sectional Pilot Study

Purpose: To evaluate medical trainees' and patients' perceptions of the utility of a whole-foods, plant-based (WFPB) diet for chronic disease management. Methods: A cross-sectional study using two original survey tools was implemented. Quantitative and qualitative data were collected from trainees and patients to evaluate perceived motivations and barriers to WFPB diet implementation. Results: Two hundred trainees and 52 patients responded to the surveys. Nearly half (48%) of patients were willing to try a WFPB diet, expressing a desire for additional information and help with its practical application. Over half (53%) of trainees were willing to recommend a WFPB diet to patients but expressed concern about its acceptability and feasibility. Patients perceived significantly more barriers related to personal enjoyment of animal products while trainees perceived more socioeconomic barriers. Conclusion: Poor diet has been identified as the United States' leading risk factor for mortality from chronic diseases. Plant-predominant diets, such as a WFPB diet, are associated with improved health outcomes and may be an acceptable solution for many patients. WFPB dietary modification could be pursued with a motivational interviewing approach that targets patients' individual goals. Medical providers should address their own assumptions regarding the dietary changes their patients are willing to make.

Heart-Healthy Diets and the Cardiometabolic Jackpot

This review highlights the key components of a heart-healthy diet and presents an evidence-based overview of recent research. Diets that increase plant-based food sources and healthy unsaturated fats consumption and limit foods that are processed and/or high in sodium, refined sugar, and saturated fat are recommended. Dietary modification can be supplemented with lifestyle-based therapies (eg, exercise, time-restricted eating) to maximize clinical benefit and achieve the "cardiometabolic jackpot." Physicians should take into account cultural preferences, affordability and accessibility of foods, and their patients' cultural values or expectations when recommending dietary interventions.

Design and pilot evaluation of an evidence-based worksheet and clinician guide to facilitate nutrition counselling for patients with severe mental illness

BACKGROUND

Schizophrenia spectrum disorders (SSD) are severe, persistent mental illnesses resulting in considerable disability and premature mortality. Emerging evidence suggests that diet may be a modifiable risk factor in mental illness; however, use of nutritional counselling as a component of psychiatric clinical practice is limited. The objective of this project is the design and evaluate a worksheet and clinician guide for use in facilitating nutritional counseling in the context of existing mental health care.

METHODS

The worksheet and clinician guide were developed based on the results of a recent scoping review on the relationship between diet and mental health symptoms among individuals with SSD. A feedback process involved a focus group with psychiatrists and interviews with individuals with lived experience with psychosis. Participants were asked a series of structured and open-ended questions. Interviews were transcribed and data units were allocated to categories from an existing framework. The comments were used to guide modifications to the worksheet and clinician guide. A brief interview with all participants was completed to gather feedback on the final version.

RESULTS

Five psychiatrist participants and six participants with lived experience completed interviews. Participants provided positive comments related to the worksheet design, complexity and inclusion of interactive components. A novel theme emerged relating to the lack of nutritional counselling in psychiatric training and clinical practice. Many constructive comments were provided which resulted in meaningful revisions and improvements to the worksheet and clinician guide design and content. All participants were satisfied with the final versions.

CONCLUSIONS

A worksheet and clinician guide designed to facilitate nutritional counselling with individuals with SSD was found to be acceptable to all participants following a process of feedback and revision. Further research and dissemination efforts aimed at increasing the use of nutritional counselling in psychiatric practice are warranted.

Nutrition from the kitchen: culinary medicine impacts students' counseling confidence

BACKGROUND

Although a poor diet is the number one risk factor for early death in the United States and globally, physicians receive little to no training in dietary interventions and lack confidence counseling patients about lifestyle modifications. Innovative, interprofessional strategies to address these gaps include the emergence of culinary medicine, a hands-on approach to teaching the role of food in health outcomes. We sought to assess the impact of a culinary medicine elective on counseling confidence, awareness of an evidence-based approach to nutrition, and understanding of the role of interprofessional teamwork in dietary lifestyle change among medical students at one undergraduate medical school.

METHODS

We administered pre- and post-course surveys to two cohorts of medical students (n = 64 at pre-test and n = 60 at post-test) participating in a culinary medicine enrichment elective. Chi-square analysis was used to assess the relationship between participation in the course and a positive response to each survey item.

RESULTS

Compared with the baseline, students participating in culinary medicine were more likely to feel confident discussing nutrition with patients (29% vs 92%; p < 0.001), to feel familiar with the Mediterranean diet (54% vs. 97%; p < 0.001), and to understand the role of dietitians in patient care (37% vs. 93%; p < 0.001).

CONCLUSIONS

Culinary medicine shows promise as an impactful educational strategy among first-year medical students for increasing counseling confidence, promoting familiarity with evidence-based nutrition interventions, and augmenting understanding of the role of interprofessional engagement to address lifestyle-related disease.

Rapid Diet Assessment Screening Tools for Cardiovascular Disease Risk Reduction Across Healthcare Settings: A Scientific Statement From the American Heart Association

It is critical that diet quality be assessed and discussed at the point of care with clinicians and other members of the healthcare team to reduce the incidence and improve the management of diet-related chronic disease, especially cardiovascular disease. Dietary screening or counseling is not usually a component of routine medical visits. Moreover, numerous barriers exist to the implementation of screening and counseling, including lack of training and knowledge, lack of time, sense of futility, lack of reimbursement, competing demands during the visit, and absence of validated rapid diet screener tools with coupled clinical decision support to identify actionable modifications for improvement. With more widespread use of electronic health records, there is an enormous unmet opportunity to provide evidence-based clinician-delivered dietary guidance using rapid diet screener tools that must be addressed. In this scientific statement from the American Heart Association, we provide rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.

Medical Student Attitudes on Nutrition Counseling After Implementation of a Novel Curricular Activity

Objective: The aim of this research was to determine the changes in medical student attitudes toward nutrition counseling after implementation of a novel curricular activity during a required third-year clerkship.Method: All third-year medical students completing their required family medicine clerkship were invited to participate in a voluntary survey composed of the Nutrition in Patient Care Survey (NIPS) and demographics before their required curricular clerkship activity consisting of two separate case-based modules focused on nutritional aspects of patient care. Students and faculty facilitators met via web platform at an assigned time to review and discuss questions. All students were invited to complete the postsurvey composed of only the NIPS.Results: Completion rate was 31% for both pre- and postsurveys. Students' intended specialty choice did not lead to a significant difference in scores on any of the five subscales on pre-intervention surveys. Almost half (43.9%) of the students who completed the surveys reported offering nutrition-related counseling despite lack of formal training. The Physician-Patient Relationship score went from 4.29 to 4.37 (p < 0.03) and the Physician Efficacy score went from 3.18 to 3.34 (p < 0.01). The was no significant difference identified pre- versus postintervention for the Clinical Behavior scales.Conclusions: The modules used in this pilot study resulted in positive changes in student attitudes toward counseling patients about nutrition. The inclusion of required case-based modules focused on nutrition is feasible and can positively impact student attitudes regarding their efficacy in counseling patients.

A Clinician's Guide to Healthy Eating for Cardiovascular Disease Prevention

Despite continued advances in health care, the cardiovascular disease (CVD) mortality rate has plateaued in recent years and appears to be trending upward. Poor diet is a leading cause of obesity and type 2 diabetes mellitus, which are leading contributors to CVD morbidity and mortality. Although dietary modification is a cornerstone of CVD prevention, implementation in clinical practice is limited by inadequate formal training in nutrition science. In this report, we review the individual components of a heart-healthy diet, evidence-based dietary recommendations, and the impact of diet on CVD risk factor prevention and management. Furthermore, we examine the unique difficulties of dietary counseling in low-socioeconomic-status environments and provide an evidence-based approach to better serve these populations. We utilized PubMed searches in adults with no date restriction with the following search terms: "carbohydrate," "fat," protein," "DASH," "Mediterranean," "plant-based," "vegetarian," "cardiovascular disease," "obesity," "weight loss," "diabetes," "socioeconomic status," and "race." In this review, we demonstrate that patients should focus on implementing a general diet plan that is high in fruits, whole grains, legumes, and nonstarchy vegetables while low in trans-fats, saturated fats, sodium, red meat, refined carbohydrates, and sugar-sweetened beverages. The Dietary Approaches to Stop Hypertension, Mediterranean, and vegetarian diets have the most evidence for CVD prevention. Clinicians should understand the barriers that patients may face in terms of access to healthy dietary choices. Further research is needed to determine the dietary changes that are most economically, socioculturally, and logistically feasible to reduce these barriers. Improvement in diet is a public health priority that can lead to a significant population-level reduction in CVD morbidity and mortality. It is imperative that clinicians understand current dietary practice guidelines and implement evidence-based dietary counseling in those at high risk for CVD.