As a preventive cardiologist, AMA member Stephen Devries, MD, saw firsthand the suffering of his patients who had experienced advanced heart disease and how much it changed their lives, often necessitating expensive medications and serial procedures.
That’s because, in the United States, medicine has generally focused on addressing acute problems while paying less attention to underlying issues that caused those problems in the first place. It became clear to Dr. Devries that physicians should learn as much about preventing these conditions as they know about treating their severe manifestation. And that begins with nutrition.
“Patients often ask their physicians about nutrition but unfortunately, most physicians haven’t had the training they need to meaningfully respond,” said Dr. Devries, executive director of the educational nonprofit Gaples Institute in Chicago, and an adjunct associate professor of nutrition at Harvard T.H. Chan School of Public Health.
“Physicians typically don’t receive sufficient training to meaningfully address nutrition questions from patients—an uncomfortable situation for all concerned.”
In an interview with the AMA, Dr. Devries discussed the importance of nutrition, how to keep up with changing information, his invitation to the White House Nutrition Conference and how the Gaples Institute’s podcasts and courses can help.
AMA: How do you keep track of nutrition and diet trends?
Dr. Devries: I stay connected to the growing body of nutrition science research by reviewing hundreds of new nutrition studies every year—it’s a major part of the work we do to prepare the annual update of the Gaples Institute’s nutrition science course. The Gaples Institute is strongly committed to ensuring that the medical students, residents and practicing clinicians who take our course receive the very latest and best evidence available. This is a big reason why six major medical schools now require the course in their curriculum—and why 97% of the more than 4,000 clinicians who have taken the course say that it will change their practice.
I am also on the faculty at the Harvard T.H. Chan School of Public Health where I will be teaching a new course, "Integrating Nutrition into Clinical Medicine: The Role of Health Professionals as Change Agents." I’m fortunate to have the opportunity to work with the outstanding people at the Harvard School of Public Health Department of Nutrition as they have a deep bench of researchers who have long been on the forefront of nutrition discovery.
AMA: How do you find that balance between what works for one person and what works for another?
Dr. Devries: There are foundational principles of nutrition science: avoiding excess sugar, salt and saturated fat and increasing vegetable and fruit intake. But how these principles are applied needs to be individualized based on each patient’s culturally-rooted preferences and personal health goals.
Health care professionals can help emphasize the importance of nutrition with patients, but there has to be authentic bi-directional conversation. That’s the basis of motivational interviewing. Motivational interviewing is strongly emphasized in the Gaples Institute course that includes realistic role-playing clinical scenarios that show how motivational interviewing can be put into practice to develop shared dietary goals.
AMA: You recently took part in the White House Conference on Hunger, Nutrition and Health, and during the meeting the Food and Drug Administration (FDA) released a proposal for a new definition of “healthy” food. What does this mean?
Dr. Devries: The FDA released a new proposal to modify the current criteria for a “healthy” food label. The previous definition was too easy for food manufacturers to game and very much needed to be redefined. The proposal calls for a label of “healthy” to require meaningful amounts of nutrient-dense ingredients and limits the content of salt, added sugar and saturated fat.
The problem the FDA is seeking to address is that, currently, food manufacturers can create heavily processed “Frankenfoods” and label them as “healthy” merely because supplemental vitamins have been added. This new proposal strengthens the meaning of what is healthy to make it more consistent with the science and less prone to industry manipulation.
AMA: How did the White House event elevate the need for physicians to better understand nutrition?
Dr. Devries: I felt honored, in recognition of the work of the Gaples Institute, to be invited to attend the White House Conference on Nutrition. The event, including President Biden’s opening remarks, affirmed high-level recognition of the mounting problems arising from nutrition insecurity and food-related disease. Much of the problem of food and nutrition insecurity is related to skewed distribution—we have plenty of food, but much is wasted, and the more nutritious food is not equitably accessible.
The Conference made clear that government alone can’t do the job and that a whole society response—one that includes community organizations and nonprofits—is needed. The White House agenda also spotlighted the need to enhance nutrition education among physicians and other health professionals. What was clearly acknowledged is that patients trust their physicians and look to them for guidance in all important health matters. But without adequate training in nutrition, how can physicians have the knowledge they need to even begin to help guide their patients?
A good example of how additional physician training in nutrition could make a sizable impact is in screening for food insecurity. More than one in 10 households in the U.S. are food insecure, and those in need are not always readily apparent. A simple solution for identifying patients at risk is a well-validated screening tool that consists of two brief questions and requires about 30 seconds of physician time. But most physicians haven’t received the nutrition education they need and aren’t aware of this rapid screening tool.
Another example of the need for enhanced physician nutrition education relates to the current lack of referrals to the Medicare-funded Diabetes Prevention Program. This program of modest diet and exercise changes has been proven to prevent the development of type 2 diabetes nearly twice as effectively as medication. But enrollment remains poor, in no small part due to lack of physician awareness and knowledge of the benefits. It’s a huge, missed opportunity.
That’s the basis of our work at the nonprofit Gaples Institute—to provide clinically relevant and highly actionable nutrition education. We’re proud that the AMA Ed Hub™ has featured the Gaples Institute’s nonprofit nutrition course since 2017.
And we are definitely making progress. The feedback has been overwhelmingly positive and very gratifying from the six leading medical schools who now require our course. Our nutrition course is not only for medical schools—our nonprofit’s nutrition CME is just as widely embraced by forward-thinking medical practice groups. Some medical practices even require that newly hired physicians take the Gaples Institute course as part of their on-boarding process.
AMA: How did you get started in wanting to share more information about nutrition for physicians with Gaples Institute?
Dr. Devries: Throughout my 25 years of practice as a preventive cardiologist, it became increasingly clear that nowhere is the gap between science and medical practice so wide as with respect to nutrition. One of the main barriers to physicians harnessing the full potential of dietary interventions is the lack of nutrition education in medical training.
The Gaples Institute nutrition course was developed to address this gap in medical training. The course is laser-focused on clinically relevant topics, has no pre-set dietary agenda, and takes learners only two to four hours to complete depending on how many of the 130 clickable references to key literature are explored.
Ninety-seven percent of learners report that the course will change their practice, but the feedback we are equally proud of is that clinicians consistently find the course to be enjoyable—a key feature if we are to make the desired impact. The high level of engagement is made possible by building the course on a sophisticated platform that maximizes interactivity far beyond that possible with the more typical slide show or video format.
There’s another important point to make about the importance of nutrition education—physicians who receive more nutrition training are more likely to refer patients to nutrition and diet specialists. Diet and nutrition specialists are essential to care for patients with more complex dietary needs and to assist in detailed meal planning. And we know that these highly trained diet and nutrition specialists are, sadly, vastly underutilized in practice.
I led a study that showed that physicians who participated in a nutrition-focused continuing medical education program were nearly twice as likely to make a referral to diet and nutrition specialists compared to those who did not. It makes sense that physicians who are better trained in nutrition are more likely to recognize the opportunities to make effective referrals to diet and nutrition professionals.
AMA: Does nutrition education have any other benefits for physicians?
When physicians begin to focus more on nutrition—even by including just one brief nutrition topic each visit—they tell me it strengthens the relationship with their patients and brings them closer to the reason they went into medicine in the first place.
And as we emphasize in the Gaples Institute nutrition course, there is ample evidence that when physicians adopt healthier lifestyle patterns, they not only improve their own care but are also more likely to counsel their patients to do the same.