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AMA Update

Nutrition education for patient care and physician self-care with Stephen Devries, MD

Oct 3, 2022

In today’s AMA Update, what physicians need to know about nutrition education both for patient care and self-care with Stephen Devries, MD, executive director of the nonprofit Gaples Institute and an adjunct associate professor of nutrition at the Harvard T.H. Chan School of Public Health. AMA Chief Experience Officer Todd Unger hosts.

Access "2022 Update: Nutrition Science for Health and Longevity: What Every Physician Needs to Know" via AMA Ed Hub™. 

Learn more about the Gaples Institute Nutrition and Lifestyle Education.

Speaker

  • Stephen Devries, MD, executive director, Gaples Institute; adjunct associate professor of nutrition, Harvard T.H. Chan School of Public Health

AMA Recovery Plan for America’s Physicians

After fighting for physicians during the pandemic, the AMA is taking on the next extraordinary challenge: Renewing the nation’s commitment to physicians. 

Unger: Hello and welcome to the AMA Update video and podcast, an ongoing series covering a range of health care topics affecting the lives of physicians and patients. Today, we're talking about one of my favorite topics, what physicians need to know about nutrition education for both patient care and self-care. I'm joined by Dr. Stephen Devries, executive director of the nonprofit Gaples Institute and adjunct associate professor of nutrition at the Harvard TH Chan School of Public Health. He's calling in from Deerfield, Illinois. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Devries, it's such a pleasure to have you today.

Dr. Devries: Oh, great to be with you, Todd.

Unger: Well, you were a preventive cardiologist. Is that a big part of what drove you to become focused on educating physicians about nutrition?

Dr. Devries: Absolutely. Early on in my career in cardiology, I used to see patients coming in for an acute cardiac problem and we would patch them up, send them out, and very often, they would come back again. In the old days, there were hard films of cardiac catheterizations, of tests that were done and some patients had 8, 10, 12 of these films lined up from prior hospitalizations. So I figured there had to be a better way. We had to stop this from recurring, rather than just trying to patch people up when they came in sick.

Unger: Well, I'm curious, I think I know the answer to this but I bet people don't immediately link nutrition to that particular problem. And you've said that nutrition education doesn't receive nearly enough attention in physician training. What accounts for this kind of gap? It seems straightforward and simple.

Dr. Devries: It does, but you're absolutely right, nutrition just hasn't been recognized as a priority in medical education, despite the fact that dietary changes are well recognized to be the leading risk factor for premature death and disability in the United States. But still, medical educators often report that they just don't have enough time in the curriculum. And my response is, what deserves more attention than the leading risks for premature death and disability? We just don't have a greater priority.

Unger: I know there's a long list of things that people want to be taught in medical school but I was pretty surprised. I can't remember what the figure is but I think it's a matter of minutes that get spent on nutrition education for physicians. Should that be a required course in medical school, in your book?

Dr. Devries: Oh, absolutely. Absolutely. Nutrition is covered to a small degree. On average, medical students spend about 19 hours over the course of four years in medical school on nutrition. But much of that is related to biochemistry and topics that are important but not directly clinically relevant for patients. So in the absence of meaningful nutrition education, what are medical students to think when they graduate, other than the fact that nutrition must not be very important in their training because they only learned about drugs and procedures?

So we have to change that paradigm because we know, sadly, it's not working, that even with all the new technology ... cardiology that we have, and new drugs and procedures, what is very clear is that what used to be a very rapid decline in mortality rates from cardiovascular disease over the recent decades has now begun to plateau, despite all the new technology. And what is the reason? It's the growing prevalence of overweight and obesity, and with that, type 2 diabetes that comes with it. We just can't out-high-tech poor lifestyle.

Unger: And the numbers on that particular front are pretty discouraging, in terms of obesity rates, overweight percentages. It seems like a lot of what we're doing right now is not necessarily working because the problems continue to get worse.

Dr. Devries: Absolutely.

Unger: You've outlined, on one hand, lack of training. I imagine, on the other hand, that physicians run into a lot of challenges, in terms of educating patients on diet and lifestyle. What do you think there?

Dr. Devries: It's, well, lack of education is one major one but there are others, as you say. One is insufficient reimbursement for prevention services in general, including dietary counseling. And the other one that goes with it is lack of time. And obviously, clinicians are really submerged with work. They've got lots to do and not enough time to do it. So time spent in counseling is a problem.

But what is very possible, imminently doable for clinicians is to at least emphasize to patients that, although taking their medications is a critical part of their health care, that they will never achieve optimal health without, in addition, more attention to nutrition and lifestyle. And making that priority clear by clinicians doesn't take a whole lot of time. And then what physicians who are knowledgeable about nutrition, what they can do is begin to even recognize opportunities to make very empowered referrals to nutrition and diet professionals. And unfortunately now, without adequate education, physicians don't even necessarily recognize great opportunities for making such referrals. And it's very clear that nutrition and diet professionals are vastly underutilized.

Unger: And I'll tell you, from my experience, I think if you're not getting that information from your physician or from an expert like that, there are plenty of other people out there willing to give you information. And a lot of that is not good information. I think my social feeds are filled with products and the latest fad diet, whatever it is. Is this getting worse, or am I just imagining that?

Dr. Devries: No, you're not imagining. It is worse. The threshold for entry into the health advice sphere is very low. So there are some hallmarks of suspicious content to look out for. Of course, when there are claims of miraculous, this is the only diet that has been proven for this or that, those are obviously red flags.

But another one that it's much more common and a little bit more subtle is that there's a tendency for the results of the latest study to be seen as the new truth, which in some people's minds may supersede everything else that they knew before. And that is certainly not necessarily the case. So that's why it requires some background to really get a context to know does this new study, is it a better study than all the ones that came before it or is this surprising result maybe suspect and one that we shouldn't take as the new truth?

Unger: I know exactly what you mean. I mean, we've got kind of a news machine that's working out there. And one day, it's this particular food or ingredient that's identified as either good or bad. And I imagine a lot of people out there are just kind of like—they can't keep up or just kind of give up and throw their hands up. Is that what you find with patients?

Dr. Devries: Oh, absolutely. There's a seesaw. You know, butter is good one day, bad the other. And people feel like no one knows anything about nutrition. But the fact is, if you can get past the media blur, there actually is quite a bit of well established principles of nutrition science. And they can be a little bit more difficult for the public to ferret out but my goal is that physicians and other health care professionals, that they at least be grounded in those well-established principles so they can help teach their patients.

Unger: Well, one thing that you've done and that we at the AMA have been working with you on getting the word out is you've developed a course to help educate physicians and address a lot of these challenges through the Gaples Institute. Why don't you tell us a little bit more about what is the mission of the Gaples Institute and what have you developed, in terms of that course? What are you trying to teach?

Dr. Devries: Yeah, thanks. Well, the mission of the nonprofit Gaples Institute is to advance the role of nutrition and lifestyle in medicine. And we are guided in that mission by national leaders who are on our board, who are leaders in nutrition research and education. And we are, importantly, supported completely through philanthropy. We don't accept corporate support of any type.

So in furtherance of the mission of the Gaples Institute, we have developed a condensed online nutrition course for health professionals. And I'm pleased to say that this course has been evaluated by the AMA and featured on the AMA website since 2017. We update and reaccredit the course every single year, so it always includes the most up-to-date information.

And very importantly, the aim of the course is not to steer physicians or patients toward any one specific type of diet. Our goal is to teach solid, evidence-based principles. And the principles are those of healthy eating. And then we encourage the physician and patient to take that solid evidence base of principles, and then to apply them individually as is appropriate for each patient based on their cultural history and preferences and so forth. So the goal of the Gaples course is to provide the essentials of nutrition clinically.

And the course is used in medical schools, residency programs and used by practicing physicians in all specialties. It includes topics of special relevance that physicians really need to know about, especially now including screening for food insecurity. It talks about the information that helps clinicians understand popular diets. And very importantly, it includes information about self-care for physicians because physicians, obviously, are in the service of caring for their patients but often neglect themselves. And their own diet is one way that can really help to take good care.

So I'm pleased to say the Gaples Institute's course, the one that we're referring to, is the nutrition course that is now required in six medical schools. And it's been taken by over 3,000 medical students and clinicians to date, 97% of whom report that it will change their practice. So we're really proud of the work that we're doing in this nonprofit, proud to have the work that the AMA is doing to help feature the course. And we feel that it's kind of like the missing manual that should have been included in medical education, but up until now has not been.

Unger: And I really encourage everybody out there to check out that course on the AMA Ed Hub, where you can find that. Just such great information. One thing, too, that I want to point out, I think we've learned time and time again, and nothing like the last two and a half years to say it's not just about the information but it is really about communication. And I know your course goes beyond, then, the science part to help physicians communicate. What are physicians going to learn on that front? Why is it so important?

Dr. Devries: It's such a great point, Todd, because in addition to having a background in the science of nutrition, it's really important to be able to make use of that information to help a patient. And that's hard to do. It's a challenge, right, in a busy clinical environment. So one very important topic that we talk about in this single course that it gives four hours of credit for those who need it but many people can do it in two hours or thereabouts, so we include topics in how to do a rapid dietary assessment. And we provide resource tools to help people do just that.

And also, how to use motivational interviewing. Once a goal has been established through the rapid dietary assessment, how can you help patients work with them, not to tell them what to do but to work with them to understand their priorities and to make use of their own internal motivation and to help enhance that through some strategies that we do with clinical scenarios with motivational interviewing? So that's all part and parcel because having the knowledge is not going to be impactful unless you can apply it, and apply it in a very busy clinical setting. And that's what we set out to help clinicians do.

Unger: Couldn't be more important, that combination. You also mentioned earlier this issue around self-care. And I want to dig into that a little bit. We work in a very peculiar environment right now, where burnout was already at a very high level and then induced by the pandemic, we now see physician burnout at an all-time high. I don't think that folks may necessarily make the instant connection between what we're talking about here, which is nutrition education and burnout and self-care. How do those connect?

Dr. Devries: Hm. It's a terrific question. Well, I wouldn't want to say that nutrition and diet are the bulk of the issue relating to burnout but it is a very important part of what we can do to sustain ourselves. And there's a substantial body of knowledge that connects what we eat with cognitive function, with mood and with just a sense of well-being. So if physicians could themselves work toward a healthy diet, they would at least be able to stack that part of the deck way in their favor.

And in fact, residency and fellowship requirements talk about a recommendation that physicians should be eating a healthy diet for self-care. But without detailed knowledge that physicians currently are not receiving about nutrition education, how are physicians in training in a better place to understand what a healthy diet means than any of the general public? So we need to do better with that. So nutrition education for clinicians is not only great for patient care, it's really important for physician self-care.

Unger: Well, an excellent discussion. Such important work that you're doing. And again, you can find the Gaples Institute course on nutrition education on the AMA Ed Hub. Go search it on the AMA site and you'll find that information. Dr. Devries, thank you so much for being here today and your continued work on nutrition education.

That's it for today's episode. We'll be back soon with another AMA Update. You can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.


Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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