HHS Nutrition Competencies for Physicians
A Trojan Horse for Pseudoscience & COI Galore
A critic of modern processed foods, a fan of vitamin A supplements and a commentator on the failure of the medical establishment to take nutrition seriously. Surely, I must be referencing RFK Jr, right? Actually, I’m describing Adelle Davis, a Master’s-trained dietitian who was a widely influential post-WWII nutritionist, writing popular books, appearing on Johnny Carson’s show, and influencing the elites of the time. That so few modern self-styled nutrition advocates know of the woman Time Magazine referred to as the ‘High Priestess of Nutrition’ in 1972 says a lot about the durability of pop-nutrition that blurs the line between science and pseudoscience- and offers a lesson for our current era of top-down nutrition fanfare.
Modern medicine - rooted in a self-critical, biological understanding of disease, epidemiology & clinical evidence - took time to take hold and outcompete various alternatives (e.g., homeopathy, osteopathy) gaining broad acceptance by the 1930s or so. Nutrition was slower on the uptake, in part because it is much harder to study, but also because it has not been taken all that seriously. When your science regularly gets diluted with faddism, snake oil sales(wo)men and quackery, the baby (real nutrition science) goes out with the bathwater. This was the central problem with Adelle Davis. Not unlike the modern influencer, she had a nutritional cure-all for everything. While she often trafficked in relatively harmless foodie maxims, her books and teachings were full of inaccurate and misleading statements, misinterpretations of the research, and outright dangerous advice - advice that put children in hospitals with Vitamin A and D poisoning (truly history is so good at repeating itself) and contributed to the death of a colicky child given high doses of potassium chloride. Like a broken clock, Davis had some correct and arguably forward thinking advice about nutrition and chronic disease, but that message suffered under the weight of its extremes. Davis is but one example of many in American history of folks who took enthusiasm for nutrition too far and made it more gimmick than science (see Deutch’s The New Nuts Among the Berries for a full read on this).
Nutrition has come a long way in gaining legitimacy since the time of Davis. Our basic understanding of the components of food and how they interact with our physiology and disease risk factors are much better understood at the molecular level. Large cohort studies assessing diet in relation to disease risk have been established. Seminal controlled trials have shown the potential for food and broader lifestyle interventions to reduce the risk of chronic diseases. Transparent systematic review and certainty of evidence grading norms have (for the most part) taken hold in the field to limit and address bias where possible. There is of course substantial progress to be made, but the promise of evidence-based nutrition is very real and its integration into our biomedical institutions is appropriately beginning to take hold. These gains in legitimacy are, however, fragile, and advocates for nutrition need to be hypervigilant to prevent the juxtaposition of real nutrition science with BS. If nutrition guidance is to be trusted, improve health outcomes, and stand the test of time, it must be clearly separated from the non-evidence-based and pure quackery - a tall order in the era of the profiteering wellness influencers, many of whom are credentialed medical and scientific professionals.
Given all of this, you might think that I’d be happy about the efforts by HHS to require nutrition in the medical school curriculum. I’ve talked before, at a high level about my concerns with overselling the role that physicians will play in nutrition, but I nonetheless remain enthusiastic that physicians who are equipped with legitimate nutrition training will help better catch nutrition-related health issues, refer to Registered Dietitians more and connect patients in need with community resources. They’ll also learn the basics of nutrition science that can help cut through the crap for their patients who want to know what the evidence shows and doesn’t show. But to do that, we need to ensure that the training that they get is legitimate - and that’s where I see some evidence for concern.
Last week, we saw >50 medical schools endorse a federal framework for nutrition education in medical training. The framework contains 71 competencies across 10 domains, from which HHS recommends fortifying existing medical curricula with competencies that contribute at least 40 hours. The framework claims to be ‘informed’ by a 2024 Consensus statement on nutrition competencies for physicians published in JAMA. To be clear, these competencies are not a mandated curriculum and provide substantially more hours than they recommend (191.5 hours total in their competencies)( but they are endorsed by about 25% of medical schools, and they contain some red flags, that won’t be too surprising to anyone following MAHA, its many allies and the Surgeon General Nomination.
Within the 71 competencies, you see a lot of basic things you might expect - understanding food composition, how disease affects nutrient absorption, nutrition assessment, drug-nutrient interactions, counseling approaches, etc. These concepts are expected and many are listed in the 2024 JAMA consensus statement but the administration slipped in more than a few new eye-brow raising competencies that reveal the involvement of vested functional medicine interests in the compiling of this list.
Readers can review the competencies in full themselves - I’ve binned my thoughts on these competencies in a few categories: