Nutrition is underrepresented in the medical curriculum; this has always been the case, but recently there has been a focus on trying to change this. A ‘call for action’ by the independent organisation Nutritank CIC and the Nutrition Implementation Coalition has led the way for this. New recommendations for curriculum changes have been proposed, but no mandatory changes are yet in place.
Current situation
The General Medical Council (GMC) publishes guidelines on the competencies expected from UK medical schools, however, there are no set quantities or qualities for nutrition education. Interestingly, a recent study found that 95% of participants (medical students and doctors) believed that doctors play an important role in providing nutrition care, yet 70% reported receiving fewer than two hours of nutrition teaching while at medical school.1 Lack of knowledge has been reported as the most common barrier to providing nutrition advice for patients, but a comprehensive review is required to really understand where the gaps in nutrition education lie.2 The NHS Long Term Plan states that “we will ensure nutrition has a greater place in professional education training”.3 Across many organisations there is an appreciation that nutrition is fundamental for good health, however, this has not been translated into meaningful practices in the education of medical professionals.
Consequences
Malnourished patients see their GP twice as often, have three times the number of hospital admissions and stay in hospital on average around three days longer than non-malnourished patients.4 National Institute for Health and Care Excellence (NICE) guidelines state that “all healthcare professionals who are directly involved in patient care should receive education, and training, relevant to their post, on the importance of providing adequate nutrition”.5 However, we know from the research that the education is not adequate for doctors.
Notably, tobacco smoking has reduced in the UK, however, globally, poor diet and sedentary lifestyle are now the leading modifiable risk factors associated with morbidity and mortality.6 NICE recommends that lifestyle interventions, including dietary modification, are first-line in the prevention and management of common chronic medical conditions, including type 2 diabetes (T2DM), cardiovascular disease, heart failure, and hypertension.7 When trained healthcare professionals advise patients on diet modification this can lead to sustained improved health outcomes in T2DM patients.8
Dietitians and registered nutritionists are paramount in championing this cause. However, with only 9,000 registered dietitians in the UK, they can only be a small voice in the vast healthcare system, and they are also sparsely distributed across the National Health Service (NHS).9 Nonetheless, integrating dietitians into multi-disciplinary teams and on the wards will help to increase the profile of nutrition in healthcare. It is not about educating doctors to the level in which dietitians are then replaced, but as doctors are commonly the gatekeepers of the NHS, it is essential to educate them to recognise when further support is required and generate appropriate onward referrals.
Who are Nutritank?
Nutritank is a non-profit organisation and innovative information hub for food, nutrition and lifestyle medicine. It is on a mission – promoting the need for greater education in medical training around nutrition and lifestyle medicine. It functions as a network and think-tank. Nutritank was created in 2017 by two medical students (now junior doctors) Dr Iain Broadley and Dr Ally Jaffee. They were both frustrated by the lack of nutrition in their curriculum while studying at Bristol University, and decided to take action.
Nutritank now has 22 medical school branches with over 1,500 medical students and junior doctors signed up to support the cause. They aim to provide their network with evidence-based information on nutrition and lifestyle to enable them to advise patients on making sustainable self-care behaviour changes to improve their health. The branches have organised over 300 education events and contributed to two annual conferences in collaboration with the Royal Society of Medicine. Additionally, Nutritank’s junior doctor network aims to implement nutrition and lifestyle medicine education within hospital core training, the food environment, grand rounds and input to research projects such as quality improvement projects (QIPs) and audits. In 2018, Nutritank worked alongside TV chef Jamie Oliver and his campaign team in creating the social media campaign #nutrition4medics, this was instrumental in adding a clause to the NHS Long Term Plan on a commitment to increasing nutrition education for healthcare professionals. Nutritank’s overall mission is to equip healthcare professionals with the knowledge and communicative tools to help reverse the trend in rising diet and lifestyle related chronic disease. Anecdotally, Nutritank medical students and doctors have witnessed that the most common ‘lifestyle’ advice clinicians provide patients with is to ‘lose weight,’ largely, this can be unhelpful, sometimes harmful, and unlikely leads to beneficial behaviour change or improved outcomes. Significantly, patients experience the majority of their weight stigma from medical doctors.10 A more effective approach to clinical management could be self-care activation incorporating advice on nutrition, movement, sleep and stress management, alongside pharmacology. If clinically important, asking permission if the patient is willing to discuss their weight, and if they are motivated to lose weight, the clinician could provide helpful resources on managing their metabolic health or referral to specialist services.
How is Nutritank trying to get more nutrition into medical schools?
In October 2021, after three years of development, the new Association for Nutrition (AfN) Undergraduate Curriculum in Nutrition for Medical Doctors was launched.11 Nutritank was proud to work alongside a wide-ranging inter-professional working group (including medical schools, royal colleges, medical and nutrition organisations, professionals and students). The new curriculum is designed to be incorporated within the core curriculum of undergraduate medical students. Integrating nutrition into current modules, rather than a standalone module, allows students to appreciate the relevance of nutrition and its application across different clinical specialties. This is not mandatory for medical schools to implement, therefore, Nutritank is using its local branches to encourage and advocate this to their individual medical school faculty.
Since its publication, Nutritank has been working alongside the Nutrition Implementation Coalition in organising workshops with faculty members from UK medical schools to advise on how to implement further nutrition teaching into their curricula. To date, 11 medical schools have now sought advice on how to implement further nutrition teaching into their curricula, which is positive progress.
Vision for the future
Nutritank are already driving changes to the curriculum and policy, and hope to be at the forefront of conversations and action around the intersection between food, lifestyle and health, and ultimately become the go-to hub for information and community engagement.
While the new curriculum indicates real progress and potential in pushing nutrition to the forefront, is this going to be enough to get the systemic changes needed? Focusing on medical students is an effective first step, but we need to see top-down changes throughout clinical specialties. Nutrition interventions can prevent chronic disease and manage chronic disease once onset, across the entire life-course. Therefore, it is time for action and to provide medical professionals with sufficient education to address this issue. This needs to start in medical schools, but we should not neglect the need for postgraduate nutrition education throughout medical professionals’ careers.
We call upon the UK cardiology profession to join our campaign for greater nutrition education within medical training for both undergraduate and postgraduate doctors. Being from such a well-regarded profession, your added voice to this educational movement will help innovate medical training, clinical practice and ultimately benefit patients’ health outcomes and society as a whole.
Conflicts of interest
IB and AJ work voluntarily for Nutritank CIC. They are employed by their respective NHS hospital trusts. RW is employed part-time by Nutritank CIC.
Funding
Nutritank CIC has recently received a grant from the AIM Foundation Grant Fund.
Additional resources
https://www.jamieoliver.com/features/medical-students-want-nutrition-education/
https://www.england.nhs.uk/personalisedcare/supported-self-management/
The Nutrition Implementation Coalition is made up of NNEdPro Global Institute for Food, Nutrition and Health https://www.nnedpro.org.uk/, Culinary Medicine UK https://culinarymedicineuk.org/ and Education and Research In Medical Nutrition Network (ERIMNN) https://blogs.brighton.ac.uk/erimn/
References
1. Macaninch E, Buckner L, Amin P et al. Time for nutrition in medical education. BMJ Nutr Prev Health 2020;3:40–8. https://doi.org/10.1136/bmjnph-2019-000049
2. Xie JY, Abramovich N, Burridge J, Jaffee A, Broadley I. Nutrition education in core medical curricula: a call to action from tomorrow’s doctors. Future Healthc J 2021;8:19–21. https://doi.org/10.7861/fhj.2020-0207
3. NHS Digital. The NHS Long Term Plan. London: NHS, 7 January 2019. Available from: https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ [accessed March 2022].
4. Guest JF, Panca M, Baeyens JP et al. Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clin Nutr 2011;30:422–9. https://doi.org/10.1016/j.clnu.2011.02.002
5. National Institute for Health and Care Excellence. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. CG32. London: NICE, 2006. Available from: https://www.nice.org.uk/guidance/cg32
6. Development Initiatives Poverty Research Limited. 2020 global nutrition report: action on equity to end malnutrition. Bristol: Development Initiatives, July 2020. Available from: https://globalnutritionreport.org/documents/566/2020_Global_Nutrition_Report_2hrssKo.pdf
7. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NG28. London: NICE, 2015. Available from: https://www.nice.org.uk/guidance/ng28
8. Taylor R, Ramachandran A, Yancy WS Jr, Forouhi NG. Nutritional basis of type 2 diabetes remission. BMJ 2021;374:n1449. Erratum in: BMJ 2021;374:n1752. https://doi.org/10.1136/bmj.n1449
9. British Dietetic Association. Workforce. Available at: https://www.bda.uk.com/practice-and-education/nutrition-and-dietetic-practice/professional-guidance/workforce.html [accessed April 2022].
10. Brown A, Flint S, Batterham R. Pervasiveness, impact and implications of weight stigma. eClinicalMedicine 2022;47:101408. https://doi.org/10.1016/j.eclinm.2022.101408
11. Association for Nutrition (AfN). AfN UK undergraduate curriculum for medical doctors: October 2021. London: AfN, 2021. Available from: https://www.associationfornutrition.org/wp-content/uploads/2021/10/2021-UK-Undergraduate-Curriculum-in-Nutrition-for-Medical-Doctors-FINAL.pdf
