Nutrition Training for Physicians
Mandatory MedEd & CMEs incoming
When I did my clinical rotations in my training to become a Registered Dietitian (RD), meeting the attending physicians felt like rolling the dice. If they were old school, there was a good chance they thought nutrition wasn’t all that relevant or important. If they were too new school, they thought nutrition was damn near close to magic. Occasionally, you’d see physicians who just defaulted to the RD assessment and recommendations but mostly, I saw how much effort it took for the RDs to build up a rapport with the physicians and educate them on standards of care (e.g. definitions of malnutrition, appropriate nutrition support protocols, etc). This varied across specialties and individual physicans’ level of training of course but I think you’d ultimately find few RDs who wouldn’t appreciate physicians with a bit more knowledge about nutrition - a bit of education about nutrition can go a long way in making sure that the appropriate nutrition care for patients is efficiently prioritized and facilitated.
With that said, you’d think I might be super enthusiastic about recent announcements by our HHS secretary that he plans to pull medical schools’ funding if they don’t teach more about nutrition in the medical school curriculum. Similarly, a state-level MAHA bills in Texas is now requiring that physicians and other healthcare practitioners undertake 3 hours of nutrition training in medical school and complete continuing medical education (CME) credits related to nutrition in each renewal of their license (applicable to other healthcare professionals as well). Louisiana is pursuing a similar MAHA Bill with 1 hour of CME every 4 years on nutrition.
What do we make of these efforts? Like any situation these days, there’s nuance and context to consider.
There’s been a push for a while now to add more nutrition into the medical school curriculum. A bipartisan resolution was passed by Congress pushing for more nutrition education of physicians in 2022. Consensus competencies for undergraduate and graduate medical education were introduced in 2023. Textbooks directed towards nutrition education in medical school have been launched (I wrote a chapter on Popular Diets with Deirdre Tobias ScD in this one). Several states have also pushed for physicians to take nutrition continuing education credits, although few have been quite as prescriptive as we’re seeing now. There’s clearly energy for this and we should expect physicians to know more about nutrition than they do.
Simply stating “add more nutrition into medical education!” might sound great - but what does that mean? ‘Nutrition’ refers to an entire degree program worth of courses - think food science, composition and preparation, the digestion and metabolism of all of the nutrients, nutritional status assessment (everything from taking valid anthropometric measures through to biomarkers), understanding the epidemiology and clinical trials supporting various diets to prevent/manage chronic diseases, and being able to counsel patients from various cultures/ethnicities/backgrounds on diet. That’s a lot to consider adding in to physicians’ training across premed undergraduate requirements, current medical school curricula, residency/fellowship training and/or continuing medical education. For reference, we have an entire profession (more on this later) of Registered Dietitians who are trained as nutrition clinicians, and they essentially get ~2yrs of in-classroom didactic training that isn’t found within the pre-med curriculum or medical school curriculum - and that’s before undertaking a 1200hour intern year where they see patients across a range of medical conditions and situations to cement that classroom teaching into legitimate experience. RDs then further do 75 continuing education units every 5 years. 2 years of coursework and 1200hrs to be a competent nutrition practitioner is a lot to fit in to the already packed teaching curriculum and residency/fellowship schedules of physicians.
Of course, physicians don’t need to be dietitians. There is the potential to pair down to a more bare bones curriculum and get some basic competencies. I’d personally advocate for a world where physicians understood the basic concepts of nutrient requirements, appreciate generally how weight status and foods can impact chronic disease risk, understand foorborne illness, understand what the Dietary Guidelines are, and know some basic terminology & diagnostic criteria related to malnutrition and obesity - not to have the average physician become an expert in nutrition, but to facilitate interdisciplinary discussions between nutrition clinicians like RDs (as well as nurses and pharmacists who train in nutrition) and physicians. Having everybody speak the same language is helpful for patients getting the best care and prioritizing nutrition appropriately in the medical process. More physician training in nutrition is useful if we keep our expectations to a reasonable level, that the training ensures that physicians know how nutrition fits into their scope of practice, and that they know that they will need to refer out to other expert nutrition clinicians quite often. At present, the expectations aren’t exactly reasonable or humble.
The Texas MAHA Bill (screenshot below) gives us some idea of what medical education on nutrition might look like - it’s reasonably basic, apart from the performative MAHA’d additives education that wants physicians to also cosplay as regulatory toxicologists (there are 1000s of additives, complex toxicological risk assessments and regulatory systems across the globe to be learned about here, and there’s no way it’ll get adequately done in medschool curricula). One major thing I’d clock about these standards is they focus predominantly on outpatient nutrition education and counseling capacity - this is quite at odds with physician nutrition advocates who are predominantly inpatient, acute care specialists (an area where I am personally much more enthusiastic about physician nutrition education). Overall, the education standards are worded generally enough that they could be actualized in many ways and we’ll still have to wait to see how this gets implemented.
There will be endless debates about how universities can adapt to incorporate nutrition across premed and medical school education, what required courses will be, how many hours are needed, what counts, etc. The real challenge, though, will be training the existing bulk of physicians who are beyond their medical training already and need to learn about nutrition - how do you fit all of the relevant nutrition competencies into 1 hour of CME every few years? You simply won’t.
As much as that seems like a tall challenge, it’s actually one of the tinier hills facing the incorporation of nutrition into medicine. Nutrition knowledge will be particularly useful for inpatient, acute care physicians who are working on a broader team that includes dietitians, nurses, speech language therapists and pharmacists to ensure malnutrition is prevented/treated and nutritional deficiencies are caught. But most of the concern and focus around nutrition that drives the enthusiasm for more physician training in nutrition amongst the MAHA crowd is chronic diseases like obesity, diabetes and cardiometabolic disease which will happen more in outpatient and community practice settings. Expertise aside, the time allotted with patients and economic model don’t lend themselves to nutrition.
Estimates vary for how long physicians get with patients, typically between 10-25 minutes (this will vary by specialty and workplace). In that time, physicians will need to cover all of the medical priorities of the patient, including reviewing labs and medications. Patients and physicians already report that there is not enough time in the rushed, high-volume, reimbursement-driven nature of American healthcare - where will the time for nutrition come from? For reference, an initial visit with a dietitian typically takes 60 minutes - this is essential to capture someones usual and past dietary intake patterns, their supplement usage, where they shop for food, their constraints around eating, their medical goals, providing education on how food impacts their health, and coming up with goals for how to change their diets. Nutrition is highly individualized based on a person’s medical needs, preferences, economic status, culture, etc and you simply can’t fit good nutrition care into 5-10 minutes of an existing appointment. Sorry to say to Mark Hyman but it’s not likely providing nutrition education to physicians will solve 90% of diabetes.
Time is only half the battle - who pays for that time is also a major barrier and the coverage of nutrition services is pretty bad in the United States. Individual private insurance plans are pretty spotty on how many visits are covered for Registered Dietitians but Medicare typically only guarantees coverage for those with a chronic condition like type 2 diabetes or kidney disease - this is antithetical to nutrition as prevention as well as nutrition’s role in supporting health across a number of other disease states. RDs have been battling for decades to expand coverage with limited impact. If RDs, who get compensated anywhere from 5-10X less than most physicians, have struggled to get reimbursement, when there is substantial data from controlled trials showing that RD counseling improves chronic disease risk factors, it begs the question of who is gonna pay the less-well trained physicians to do this? To be clear, it’s not just that physicians are not highly trained in diet assessment and counseling or don’t have the time or that they cost significantly more to provide those services, it’s that there’s an opportunity cost here - they could be doing other reimbursable services instead, likely to pay out more than dietary counseling. The economic model is going to need a massive overhaul to make any nutrition clinician impactful but it’s really unclear to me how physicians will lead the way here when they simply cost so much more and others with more training cost so much less.
You might be thinking to yourself, if RDs are getting substantial training in nutrition and cost less, why aren’t we relying on them more heavily than physicians? That is a super valid thought to have. We have an entire profession that is supposed to be dedicated to nutrition that isn’t empowered - largely due to lack of funding for their services that impede integrating them beyond just the acute care setting. It would be amazing if we trained physicians to better know how to work with and refer to RDs, and then fixed medical reimbursement to ensure that RD services could get covered for both prevention and management of chronic diseases. It’s something of a sticking point in the field that most of the public doesn’t know the difference between a nutritionist (an unregulated term anyone can use) and a registered dietitian (a credentialed practitioner meeting certain education and practical training standards). RDs consistently outperform other providers in the improvement of chronic disease risk factors when they counsel patients and have been the main providers of nutrition interventions in virtually all major lifestyle interventions trials, supporting them as the most evidence-based practitioners to be amplifying during this time of enthusiasm around tackling chronic disease. To be clear, RDs won’t be able to do it all (we don’t even have enough in the country) and comprehensive lifestyle interventions for patients require more than just RDs (we need coverage for exercise physiologists/physical therapists, behavioral and mental health counselors, social work and occupational therapists, etc) — but refocusing some of the excessive enthusiasm around physician nutrition training towards utilizing the heavily underutilized profession of Dietetics would be a great starting point for this administration and states to truly tackle nutrition & chronic disease.
The last point I’ll make here is the potential for harm. Nutrition, fortunately, rarely kills people immediately but it certainly has the potential to harm both physically and mentally. There’s a real question here for me of whether a 1-3hrs of nutrition training for physicians will really improve outcomes and whether it will increase harm (for patients, public health and/or nutrition science communication). To be clear, we have no randomized controlled trials of physicians providing nutrition advice or education showing that they effectively improve outcomes and thus we can’t really assess the degree to which this helps or hurts. There’s reason to doubt the little bit of knowledge, as well as the realities of our healthcare system will result in improved outcomes for patients. Whether harm will come is speculative - but having been a dietitian for a while now and having been in the nutrition media space for over a decade, I do have my concerns. I’ve followed the physician nutrition space for a while and there are legendary clinicians within it who know and respect their scope of practice - but there’s also a lot of junk. Think to yourself the last time you walked through the diet book section of a book store/scrolled the Amazon nutrition book section and saw the preponderance of quick fix, cure-all diet books written by physicians- that kind of junk. There’s also the kind of junk that RDs face on a daily basis - a physician who’s enthusiastic about nutrition gives a patient a BMI and calorie goal and gives them a pamphlet and sends them on their way, leaving the patient feeling a mix of discouraged, shamed and unempowered. The junk has only gotten worse as social media use has increased and we’ve seen branding around ‘integrative’ and ‘functional’ and ‘lifestyle medicine’ rise to prominence in physician spaces - nutrition is all too often the gateway drug that brings physicians in and converts them to fans of dubiously excessive testing, supplements and hyper-prescriptive diets without meaningful evidence (looking at all of the Vegan/Carnivore/Low Carb/GutHealth MDs). Quackery exists in all professions and i’ve been quite critical of RDs going down these rabbit holes but it’s nonetheless concerning when the most influential and powerful medical profession begins to assert itself as having nutrition expertise without solid training or a humble appreciation for its scope of practice - not only does it not likely improve patient health outcomes but it further dilutes trust in nutrition science and evidence-based recommendations, as you can find influential physicians who say wildly contradictory things.
This might sound like I’m advocating for some kind of nutrition scope of practice terf war but I want to emphasize that it’s quite the opposite - I want physicians to start to get a handle on nutrition. Physicians have so much power - to make nutrition a priority in the hospital, to facilitate nutrition interventions in the outpatient/community settings, and to use the massive weight of their social and political capital at the cultural/policy/legislative level to make sure good nutrition is prioritized and adequately reimbur$ed. We need physicians in the nutrition conversation but it’s gotta acknowledge expertise, the realities of medical practice, and uphold evidence-based practice to improve medicine and public health.
Few final notes:
I work with some really amazing nutrition physicians who are well trained (some with undergraduate/master’s level nutrition & dietetic training). I think we need to make a clear pipeline (e.g. MD/RD, MD/MS or MD/PhD in Nutrition) so that we have more physician nutritionists that are extensively trained and there needs to be more effort to create a space in medicine for them. Currently, there are unofficial nutrition fellowships, often for Peds-GI and Endocrinology-fellowship trained individuals, that aren’t recognized nearly enough. These physicians will still run into reimbursement issues when it comes to chronic diseases but particularly in the acute care inpatient setting, they’re amazing leaders in the field — and many will be the first to tell you’re they’re not doing 1 hour diet assessments, have limited understanding of food science/composition/preparation, and meal planning is not their strong suit.
I am a HUGE advocate for Dietitians upping the standards for our scope of practice and making sure the baseline minimum expected knowledge of a RD is higher than it is. I’ve met too many physicians who have had bad experiences with folks who got into Dietetics (mostly in the inpatient setting that’s less relevant to this chronic disease discussion) but hated the science part of it all - we certainly need RDs of all types but shaping up the anatomy & physiology, biochemistry and clinical coursework to ensure that the baseline RD that is graduated operates a high-level, regardless of their final specialty, is something ACEND needs to work on. Having more physicians trained in nutrition and then teaching in Dietetics programs is actually a potential solution to this, doubling down on my rationale to want more doctorally trained clinicians in the nutrition space. I also think Dietetics needs to embrace the clinical doctorate path and invest in it so that it’s a strong career choice and doesn’t break the bank (the move to a Master’s is an economic disaster for the field but doctorate open up so much more, including the potential for training grant funding).
for those physicians who’ve had bad experiences with RDs on some harder science front, I get the frustration. With regard to this conversation though, an RDs knowledge of electrolyte or acid-base balance in the ICU or whatever it was that had you rolling your eyes isn’t super relevant. Most RDs, even those without intense physiology knowledge, are still well-trained in counseling, goal setting and meal planning that facilitates them taking systematic review-informed expert guidelines and turning them into nutrition interventions for chronic disease risk reduction in the outpatient/community setting. And I can almost certainly promise you RDs have more cringe stories about MDs telling patients and families ludicrous nutrition things so this quickly becomes a moot war of anecdotes.
In addition to RDs being more self-critical on our education standards, we’ve got to be doubly as critical about the research the field generates. Expertise starts from the top down and there are too few RDs leading research and ensuring the profession is visible amongst the decision makers in biomedicine and healthcare. We need expert, research competent RDs across NIH, medical societies and in the leadership at major hospitals to ensure that RDs are prioritized and advocated for. Any research excellence we can put out is helpful, but we especially need research that tracks and evaluates the impact and cost-savings of our own services. Analyses indicating our utility exist, moreso than any other nutrition clinician, but data and money talk and we need more to demonstrate our worth in the American medical system. If you’re a RD-to-be or RD reading this, start thinking now about ways you can increase your research/analytical chops, collect data on what you and your colleagues are doing, and publish it - even if its only a case study.
Every time I post about this, I get pretty cagey responses from physicians that someone suggested they’re not an expert, or a few CMEs away from being an expert, in nutrition. This fundamentally devalues expertise and also reveals a deep bias here: if I were to tell physicians that speech language pathology or genetic counseling weren’t their expertise, I highly doubt it would invoke the same response. These are domains where physicians get exposed to similar levels of training - just like medical biochemistry covers some macronutrients and vitamins, anatomy and genetics will cover topics that form the basis of the SLP and GC scope of practice. It is some mix between ego, the cultural value placed on nutrition and its revenue/attention potential that triggers a subset of physicians when they’re told their medical training does not immediately make them a nutrition expert. Physicians have the baseline training that holds a lot of potential for being experts in nutrition (particularly some medical nutrition assessment/intervention in acute care settings) but further substantial training is required.
All of this conversation risks overstating the importance of 1:1 lifestyle interventions, even when intensive - a focus on provider training in nutrition is good, a focus on access to those providers even better, but this needs to be balanced with equal if not more enthusiastic efforts to meaningfully legislate to help ensure the default food options in our environment are those more aligned with dietary recommendations and that social determinants of health are meaningfully addressed. This is an area we could desperately use more physicians - even those without explicit nutrition training - amplifying evidence-based policy proposals. If you’re a physician today looking for a way to improve the population’s nutrition, I encourage you to get to know RDs - everything from the clinical dietitians in your local hospital to the WIC and SNAP RDs (who’s funding is currently being cut). They’ll have lots of ideas about where you can put your time and energy to make an impact and advocate.
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I'm a first year medical student with a strong interest in nutrition, and I worked as a nutrition counselor at WIC before starting school. I can't emphasize your first bullet point enough. I've found it very disappointing that there are few clear, standardized training paths for physicians that want to have evidence based nutrition interventions as a focus in their practice. I think it's worth noting that there likely won't be any large adoption of nutrition ed in the curriculum unless the USMLE exams start testing nutrition concepts. So much of what students choose to focus on is dictated by the board exams, and as far as I know they only really cover a few nutrient deficiencies and a couple of diets like DASH.
I would love if my medical school and others allowed students to take some of the courses in the RD curriculum as electives but thus far that isn't an option. It would give students a better insight to RDs' scope and and make the new generation of physicians more reticent to utilize them (though no major changes until reimbursement schemes are changed, like you said). I'm planning on passing along your article to my dean and the program director for the RD students to encourage more collaboration and hopefully open up some curricular cross-pollination. Keep up the good work!
Great post! Where I live in British Columbia, Canada, anyone can talk to an RD (or exercise physiologist) through the 811 program Mon-Fri, business hours FOR FREE. It's not a perfect program, they can't really do follow-ups or longitudinal care, but I am SO GRATEFUL for this service as a primary care RN. I so deeply value the expertise of RDs and the accessibility of this program has meant I have been able to redirect SO many clients from paying for unregulated, and sometimes unethical, nutrition adivce.