During my third-year neurology rotation, I had several elderly patients present to the clinic with concerns about “pins and needles” sensations affecting their mobility. Each time these patients came, my resident physician would ask me what labs we should request. Checking their vitamin B12 level was high on the list.
Vitamin B12 deficiency is one of the most common causes of peripheral neuropathy, particularly in elderly patients, which affects their balance and ability to walk. This is a nutritional fact I, and almost every medical student in America, learned in pre-clinical nutrition courses.
One of health secretary Robert F. Kennedy Jr.’s refrains has been that doctors don’t learn enough about nutrition in medical school. In a recent op-ed in The Wall Street Journal, he called for “rigorous, measurable nutrition education at every stage of medical training.”
Contrary to what Kennedy might have you believe, medical schools do teach students about nutrition. However, most of our nutritional education centers on dietary deficiencies that have life-threatening and potentially irreversible consequences. These frequently require medical intervention, which requires a prescription or can only be administered in inpatient settings by a health care professional.
For example, a patient with subacute combined degeneration, a severe neurological condition that comes from prolonged vitamin B12 deficiency, will need a prescription for an intramuscular B12 shot.
We also learn about how vitamin K deficiencies can lead to bleeding disorders in newborns, or how vitamin B9 and B12 deficiencies can cause anemias, or how protein deficiencies can lead to kwashiorkor, a life-threatening form of malnutrition that can kill children.
Medical schools certainly could offer more robust education on the impact of vitamin and mineral deficiencies on chronic conditions, which affect many Americans.
However, adding a few nutrition classes to the medical school curriculum is unlikely to produce widespread improvement of American nutrition on a broader scale. To truly improve nutritional education, access, and application for the average American, the Department of Health and Human Services should focus on increasing educational opportunities for registered dietitians, improving access to evidence-based nutritional experts, and encouraging medical schools to offer interprofessional education.
Kennedy’s impulse to start with medical student nutritional education underscores an unhelpful myth: that medical doctors should be leaders in all parts of a person’s health. Registered dietitians spend two years intensely studying and completing more than 1,000 hours of clinical work in the field of nutrition. They, not medical doctors, should be respected as the primary health care providers for patients who would like to improve their nutrition.
Even if medical schools bolster their nutritional courses, they simply cannot offer a nutritional education that rivals that of R.D.s. Nor should they. Instead of pressuring medical schools to change their curriculum, Kennedy should focus on helping more people become registered dietitians and giving patients more access to their expertise. (Why do people like Kennedy overlook the value of registered dietitians? I can’t help but notice that women account for approximately 94% of the field.)
Increasing scholarships would enable more students to afford to become registered dietitians, thereby increasing the number of people deeply versed in the nuances of nutrition and its integration into a person’s overall health. I used to work at a federally qualified health center and would regularly see patients on Medicaid get denied access to R.D.s. Even when Medicaid or insurance does permit an appointment with an R.D., it’s often too brief. Nutrition — which is to say food — is a complex, emotional topic, and it frequently cannot be squeezed into the short chunks of time that most insurance companies will allow. Instead, many Americans end up looking for unlicensed nutrition coaches or try to find their own, sometimes inaccurate information.
With the proper amount of time, R.D.s and licensed nutritionists (who are required to have a master’s degree) can offer medical nutrition therapy, which involves individualized nutrition information and counseling based on someone’s specific mosaic of diseases. Many people have more than one chronic condition, which requires careful diet management.
For example, 33% of people with type 2 diabetes (a condition that Kennedy has taken an interest in), also have chronic kidney disease. When you eat protein, it gets broken down into amino acids and waste products. Your kidneys filter out the waste. Eating more protein means your kidneys work harder. In people with CKD who have reduced kidney filtering function, too much protein is harmful for their kidney health. So an ideal diet for a diabetic with kidney disease is usually a low or moderate protein diet. The high-protein caveman diet that RFK follows and endorses would not be suitable for this population he focuses on so much. Individualized nutrition counseling is necessary because many people’s health and diet needs are not going to be one size fits all. Increasing insurance reimbursements for registered dietitians or licensed nutritionists would enable more people to access the highest quality nutritional information from evidence–based experts for their specific health needs. Expanding access for Americans would be of great help.
It could also happen more quickly than revamping the medical school curriculum, which is tightly regulated. Between the biochem, physiology, clinical medicine rotations, and more, it would be impossible to fit in a nutrition course that could even begin to rival that of an R.D. student. Furthermore, it would take a few years for there to be widespread standardized change in nutrition in medical schools.
Any discussion about medical school and nutrition should be spearheaded by those who have already found successful ways to do so.
Some medical schools — such as the University of Minnesota Medical School, which I attend — offer interdisciplinary education. This means that medical students participate in coursework and meetings with students from other schools. For example, med students, physical therapy students, and R.D. students could work together in an interprofessional educational activity. These opportunities offer students a deeper understanding of the importance of interprofessional collaboration. Having medical students and registered dietitian students collaborate, or having medical students take courses taught by registered dietitians, is a tangible way to increase education rapidly.
Additionally, many medical school student groups strive to promote healthy food options. For example, in Minneapolis, Urban Roots Kitchen collaborates with medical students and residents to teach culturally sensitive, health-conscious cooking classes to help members of the local Ethiopian and Somali communities learn how to prepare their native foods in more nutrition-dense ways. Again, solutions are already available; we just need funding to expand nutritional education.
Lastly, it’s worthwhile to remember that medical school is the beginning of a long journey to become a physician. Students who enter fields such as pathology and radiology may not frequently discuss health concerns with their patients.
A more effective use of time would be to focus education efforts during residency, particularly for those in primary care and internal medicine, who often interact with patients managing chronic conditions. Offering residents paid training sessions on nutrition, where they can apply their knowledge in real time with their patients, would be a much faster and wiser choice to help Americans as a whole.
As I continue my medical career, I will likely encounter more people with vitamin and mineral deficiencies. While I hope to help prescribe a healthy diet to meet their needs, I also want to consult with nutritional experts to provide patients with detailed information. If we want to improve American health care on a massive scale, we need to remember that it’s a team sport.
Tiffany Onyejiaka is a writer, a medical student at the University of Minnesota Medical School and a graduate of the Johns Hopkins School of Public Health.
