Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians
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Circulation
AHA SCIENCE ADVISORY
Medical Nutrition Education, Training, and
Competencies to Advance Guideline-Based
Diet Counseling by Physicians
A Science Advisory From the American Heart Association
ABSTRACT: Growing scientific evidence of the benefits of heart-healthy Karen E. Aspry, MD, MS,
dietary patterns and of the massive public health and economic burdens Chair
attributed to obesity and poor diet quality have triggered national calls to Linda Van Horn, PhD, RD,
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increase diet counseling in outpatients with atherosclerotic cardiovascular FAHA, Vice Chair
disease or risk factors. However, despite evidence that physicians are Jo Ann S. Carson, PhD,
willing to undertake this task and are viewed as credible sources of diet RD, FAHA
information, they engage patients in diet counseling at less than desirable Judith Wylie-Rosett, EdD,
rates and cite insufficient knowledge and training as barriers. These data RD, FAHA
Robert F. Kushner, MD
align with evidence of large and persistent gaps in medical nutrition
Alice H. Lichtenstein, DSc,
education and training in the United States. Now, major reforms in
FAHA
undergraduate and graduate medical education designed to incorporate Stephen Devries, MD
advances in the science of learning and to better prepare physicians for Andrew M. Freeman, MD
21st century healthcare delivery are providing a new impetus and novel Allison Crawford, MD
ways to expand medical nutrition education and training. This science Penny Kris-Etherton, PhD,
advisory reviews gaps in undergraduate and graduate medical education RD, FAHA
in nutrition in the United States, summarizes reforms that support and On behalf of the American
facilitate more robust nutrition education and training, and outlines new Heart Association Nutri-
opportunities for accomplishing this goal via multidimensional curricula, tion Committee of the
pedagogies, technologies, and competency-based assessments. Real- Council on Lifestyle and
world examples of efforts to improve undergraduate and graduate Cardiometabolic Health;
Council on Cardiovascu-
medical education in nutrition by integrating formal learning with
lar and Stroke Nursing;
practical, experiential, inquiry-driven, interprofessional, and population
Council on Cardiovascu-
health management activities are provided. The authors conclude lar Radiology and
that enhancing physician education and training in nutrition, as well Intervention; and Stroke
as increasing collaborative nutrition care delivery by 21st century Council
health systems, will reduce the health and economic burdens from
atherosclerotic cardiovascular disease to a degree not previously realized.
Key Words: AHA Scientific Statements
◼ diet ◼ nutrition ◼ obesity
© 2018 American Heart Association, Inc.
http://circ.ahajournals.org
Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563 June 5, 2018 e821Aspry et al Guideline-Based Diet Counseling by Physicians
T
here is now abundant scientific evidence docu- nutrition science evidence base related to ASCVD risk
CLINICAL STATEMENTS
menting that adherence to a healthy dietary pat- reduction has grown rapidly, as have other topics justi-
AND GUIDELINES
tern reduces the risk of atherosclerotic cardiovascu- fied for inclusion in medical nutrition education curricula
lar disease (ASCVD) events and can significantly advance (Table 1). Now, major reforms in UME and GME designed
population-wide cardiovascular health, supporting the to incorporate advances in the science of learning and
principal objectives of the American Heart Association’s to better prepare physicians for 21st century healthcare
(AHA’s) Strategic Impact Goals for 2020 and beyond.1 delivery are providing a new impetus and novel op-
Specifically, in large prospective cohort studies and ran- portunities to expand medical nutrition education and
domized trials, higher intakes of fruits, vegetables, leafy training nationwide, as discussed in detail herein.
greens, whole grains, fish, nuts, seeds, and legumes and This science advisory, for medical school curriculum di-
lower intakes of sugar-sweetened beverages, refined rectors, program directors, faculty, trainees, and students,
grains, and red and processed meats are associated with reviews current gaps in medical nutrition education and
reduced ASCVD risk (Figure).2–6 Moreover, the substitu- training in the United States and summarizes reforms in
tion of healthy dietary components for less healthy ver- UME and GME that support and facilitate more robust nu-
sions (eg, liquid vegetable oils for solid fats and whole trition education and training efforts. It also outlines new
grains for refined grains)7–9 and adherence to whole pat- opportunities for accomplishing this goal via new curricu-
terns of healthy eating (eg, the Mediterranean diet, the la, pedagogies, technologies, and competency-based as-
Dietary Approaches to Stop Hypertension [DASH] diet, sessments. Nutrition-related core competencies related to
and others) also reduce the risk of cardiovascular and ASCVD prevention and organized across the 6 domains of
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all-cause mortality.10,11 These effects are now believed the Accreditation Council for Graduate Medical Education
to occur via multiple mechanisms,2–4 and in those with (ACGME) framework are presented. Recommended for
ASCVD, effect sizes are similar to some pharmacological achievement by all residents by graduation, these compe-
interventions.12–14 However, despite the robust nutrition tencies are especially important for those planning careers
science base and wide dissemination of evidence-based in primary care, cardiology, neurology, endocrinology,
dietary guidelines from the AHA/American College of obesity treatment, gastroenterology, oncology, intensive
Cardiology (ACC) in 2013,15 and regularly from the Di- care medicine, and some surgical subspecialties. Although
etary Guidelines for Americans Advisory Committee,16–18 expanded nutrition competencies are needed across all
diet quality remains poor throughout much of the Unit- health professions, those presented herein are limited to
ed States,19–21 especially in ethnically diverse subgroups medical students and trainees and form the basis of the
with low socioeconomic status and in a surprisingly large entrustable professional activities (EPAs) related to nutrition
proportion of individuals with established ASCVD.22–24 that are also presented. Educational resources for building
Numerous factors shape dietary behavior,25 but a large and enhancing medical nutrition education and training
proportion of adults reportedly lack important nutrition curricula, which might be of interest to nutrition educators
knowledge that could negatively impact adherence to from all health professions and to practicing clinicians, are
healthy diet patterns.26–28 listed at the end of this document. A recent AHA scientific
This evidence and the massive public health and eco- statement provides broader guidance on medical educa-
nomic burdens attributed to unhealthy diet behaviors29,30 tion and competencies for lifestyle counseling43 and serves
have triggered national calls to increase the delivery of as a companion to this more specific nutrition competen-
diet counseling in outpatients with ASCVD or risk fac- cies science advisory. Finally, although limitations of time
tors as an evidence-based strategy.31–34 However, despite and resources remain important considerations, current
evidence that physicians are willing to undertake this needs and approaches for strengthening medical nutri-
task and are viewed as credible sources of diet informa- tion education and training, including via new interprofes-
tion,35–37 they engage patients in diet counseling at less sional opportunities,44 are now compelling, urgent, and
than desirable rates and cite insufficient nutrition knowl- abundant. This science advisory represents a roadmap
edge and training as barriers to carrying out this role,38–40 for perpetuating progress toward this educational goal
even during their peak learning years.41 These data align until more robust patient-centered nutrition care deliv-
with ongoing evidence of large and persistent gaps in ery by health systems is achieved nationwide.
medical nutrition education and training in the United
States, discussed in Update on Gaps in Medical Nutrition
Education and Training in the United States. UPDATE ON GAPS IN MEDICAL
Efforts to strengthen undergraduate medical edu- NUTRITION EDUCATION AND
cation (UME) and graduate medical education (GME) TRAINING IN THE UNITED STATES
in nutrition, especially by schools formerly funded by
the National Institutes of Health Nutrition Academic UME in Nutrition
Award,42 have endured for decades, primarily because A 1985 survey of one third of US medical schools by the
of the efforts of dedicated faculty. During this time, the National Academy of Sciences found inadequate expo-
e822 June 5, 2018 Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563Aspry et al Guideline-Based Diet Counseling by Physicians
CLINICAL STATEMENTS
AND GUIDELINES
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Figure. Recent meta-analysis of prospective cohort studies and randomized trials of the effects of specific foods
on the risk of CHD, stroke, and diabetes mellitus.
BMI indicates body mass index; CHD, coronary heart disease; CI, confidence interval; CVD, cardiovascular disease; PC, prospec-
tive cohort; RCT, randomized clinical trial; and RR, relative risk. Reprinted from Mozaffarian et al.2 Copyright © 2016, American
Heart Association, Inc.
Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563 June 5, 2018 e823Aspry et al Guideline-Based Diet Counseling by Physicians
Table 1. Summary of the Clinical Evidence Base Linking Diet to Cardiovascular Health
CLINICAL STATEMENTS
Topic Summary Evidence
AND GUIDELINES
Effects of specific foods and Evidence of significantly reduced ASCVD risk from consumption of fruits, vegetables, Cohort studies, RCTs,
nutrients on ASCVD risk or risk whole grains, beans, legumes, nuts, seeds, low-fat dairy, phytochemicals, and PUFA- reviews, meta-analyses,
factors MUFA vs significantly increased ASCVD risk from sugary foods and beverages, refined statements
carbohydrates, red and processed meats, and saturated fats
Effects of dietary patterns on ASCVD Evidence of significantly reduced ASCVD risk from Mediterranean, DASH, vegetarian, USDA, RCTs, cohort studies, reviews,
risk or risk factors and AHA diet patterns vs significantly increased ASCVD risk from southern US diet pattern guidelines, DGAC reports
Effects of obesity and weight loss on Evidence of significantly increased ASCVD risk from obesity; evidence of significantly RCTs, reviews, guidelines,
ASCVD risk or risk factors; effects of reduced weight and improved ASCVD risk factors from hypocaloric diets; benefits of advisories, NIH supplement
dietary supplements on ASCVD risk omega-3 fatty acid supplementation on reduced ASCVD risk in some groups database
Effects of food environments on Early evidence of improved health outcomes from home cooking and culinary skills Observational studies,
ASCVD-related health outcomes vs ASCVD-related health risks from meals eaten away from home, food deserts, and reviews, USDA website
food insecurity
Effects of behavior modification on Evidence of improved diet outcomes from diet-related cognitive-behavioral RCTs, reviews, websites
diet outcomes interventions
References for all evidence sources listed can be found in the Nutrition Competencies for ASCVD Prevention-Medical Knowledge section.
AHA indicates American Heart Association; ASCVD, atherosclerotic cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; DGAC, Dietary
Guidelines for Americans Advisory Committee; MUFA, monounsaturated fatty acids; NIH, National Institutes of Health; PUFA, polyunsaturated fatty acids; RCTs,
randomized controlled trials; and USDA, US Department of Agriculture.
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sure to nutrition in health and disease, which prompted their ability to counsel patients about diet.41 In contrast,
a recommendation for a minimum of 25 classroom the American Academy of Family Physicians has estab-
hours.45 Four subsequent surveys conducted between lished nutrition education guidelines for family medicine
2000 and 2013 have shown little progress in achieving residents49; however, a recent survey that included family
this goal. The 2013 survey found that 71% of medical medicine trainees also documented low self-efficacy re-
schools provide less than the recommended 25 hours garding nutrition knowledge and diet counseling skills,50
of nutrition education, and 36% provide less than half which suggests that family medicine training gaps also
that amount.46 Of the 30 osteopathic schools surveyed, exist. These data align with a recent survey of 495 pro-
85% reported providing less than the recommended gram directors in internal medicine, family medicine,
25 hours.47 Moreover, despite the growing nutrition sci- surgery, and anesthesiology that reported that only 26%
ence evidence base, the average and median number offered formal GME in nutrition, and 77% believed they
of hours of nutrition instruction at US medical schools were not meeting requirements for GME in nutrition.51
paradoxically declined, to 19 hours and 17 hours, re-
spectively, in the last survey. Also, the survey showed
GME in Nutrition: Cardiovascular
that although some didactic nutrition education is
usually provided, highly valued clinical practice expo- Fellowship Programs
sure and training to build competencies and skills are Gaps in nutrition education delivery also exist during ac-
minimal. However, the latest survey also showed that credited cardiovascular medicine fellowship programs. In
most of the US medical schools that currently exceed a 2010 survey, 44% of cardiology fellowship directors
the minimum 25 hours of nutrition education do so by reported providing a nutrition lecture, but only 27% of
integrating nutrition education across the curriculum their chief fellows recalled a nutrition topic.52 Cardiol-
rather than by providing a single course.46 ogy program directors cited lack of time as the most sig-
nificant barrier to providing more preventive cardiology
training, whereas chief fellows attributed the problem to
GME in Nutrition: Residency Programs lack of a developed curriculum. In a recently updated sur-
Any nutrition education gained during medical school is vey, 56% of senior cardiology fellows reported receiving
likely to be lost if not reinforced and translated into prac- no nutrition education during their training, and 90%
tical how-to knowledge during GME.41 Unfortunately, of >600 practicing cardiologists reported receiving no
evidence suggests that most primary care residencies are or minimal nutrition education during fellowship.53 The
not meeting this need. The ACGME develops program 2015 ACC statement on core competencies for training
requirements for primary care and specialty GME, and in preventive cardiology has recommended that trainees
those for internal medicine training currently include no “know the principles of nutrition and obesity assessment
recommendations for either nutrition-related didactics or and management, including the roles of pharmacothera-
clinical practice exposures.48 This training gap is aligned py and bariatric surgery,” and acquire “skill to implement
with survey data that have shown that only 14% of in- and prescribe lifestyle approaches for the prevention and
ternal medicine trainee respondents are confident in treatment of hypertension, dyslipidemia, tobacco use,
e824 June 5, 2018 Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563Aspry et al Guideline-Based Diet Counseling by Physicians
obesity, and diabetes mellitus,” although specific nutri- vidual and population health, the Association of Ameri-
CLINICAL STATEMENTS
tion knowledge and competencies are not listed.54 can Medical Colleges has also called for greater incor-
AND GUIDELINES
poration of behavioral and social sciences into medical
school and training curricula, as well as for competen-
POPULATION HEALTH NEEDS AND cies related to behavior counseling.61 Finally, a confer-
HEALTH CARE AND CURRICULAR ence of leaders in GME cosponsored by the Josiah Macy
REFORMS ALIGNED WITH EXPANSION Jr. Foundation and the American Association of Aca-
demic Health Centers, has called for specific reforms in
OF MEDICAL NUTRITION EDUCATION residency training, including better alignment with the
AND TRAINING changing healthcare needs of the public; a broaden-
Many factors have contributed to shortcomings in ing of training to include population health, prevention
medical nutrition education and training in the United topics, and interprofessional education; wider adoption
States. Among these are healthcare delivery and pay- of competency-based assessments; and more individu-
ment models that have afforded little incentive or infra- alized training goals and paths.62 Local innovations in
structure for health promotion and disease prevention GME as a result of these reforms have included engage-
and management through diet and lifestyle counsel- ment of residents in activities to improve community
ing.55 However, the national strategy to improve health- health, and interprofessional, team-based care focused
care quality in the United States and stem its rising costs on the social determinants of health.62 Taken togeth-
has led to new payment structures and a reorganization er, the national strategy to improve population health
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of care delivery that will necessitate more robust and and its behavioral determinants, as well as reforms in
better coordinated health promotion and disease pre- UME and GME designed to meet these needs, support
vention efforts by health systems. The national preven- broader integration of nutrition knowledge and skill-
tion strategy calls for these efforts to extend to entire building into medical education and training.
practice-based populations, be focused on the behav-
ioral determinants of health (including healthy eating),
and be better integrated with public health sector ef- NEW OPPORTUNITIES FOR
forts.56 On the basis of some health risk assessment EXPANDING MEDICAL NUTRITION
data, the largest population health needs could be in EDUCATION AND TRAINING
the areas of nutrition and obesity management.57
The need to train clinicians for this new healthcare The reforms in UME discussed herein provide both an
environment and to simultaneously apply advances in impetus and new opportunities to integrate and con-
the science of learning has led to recent calls to reform textually embed nutrition education across all 4 years
UME and GME in the United States. A Carnegie Foun- of learning. This can occur via pedagogical changes to
dation report has called for better integration of formal competency-based curricula, early and longitudinal clini-
learning with early clinical experiences, including inter- cal experiences, and interactive, experiential, and inqui-
professional and team-based activities; a broadening of ry-driven instruction and activities.63 Similarly, reforms in
professional identity to include, among other things, GME provide abundant opportunities to expand nutri-
collaborative care delivery; the development of habits tion-related education and skill building across a broad
of inquiry and quality improvement, including popula- mix of didactic, clinical, experiential, and inquiry-driven
tion health management; and more individualization scholarly activities within a growing number of educa-
of learning processes and standardization of learning tional tracks, including those dedicated to lifestyle medi-
outcomes.58 The authors recognize that all of these will cine. Furthermore, during all phases of UME or GME,
require greater exposure to the social, economic, and Internet-based nutrition instruction can now either sup-
political aspects of healthcare delivery. An international plement or originate nutrition education. Real-world
commission of medical educators also has called for examples of these opportunities are discussed below.
transformative changes in health professions educa-
tion to create a 21st century medical profession that
Integrating Nutrition Education and
“embraces teamwork, upholds a strong service ethic,
and is centered around the interests of patients and Training
populations.”59 A 2017 report by medical educators During UME
from Harvard Medical School echoes these earlier calls As noted, most of the small number of medical schools
and proposes a major restructuring of UME to gradu- that exceed the minimum 25 hours of nutrition edu-
ate “science-minded” and “service-minded” physicians cation do so by horizontally and vertically integrating
with the capacity to advance population health, partic- nutrition content across the learning continuum46;
ularly in poor and underserved areas.60 Recognizing the that is, across organ system didactics, small group ses-
large impact from social and behavioral risks on indi- sions, skill-building clinical exposures, and electives.
Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563 June 5, 2018 e825Aspry et al Guideline-Based Diet Counseling by Physicians
For instance, at Boston University School of Medicine etable intake) or decrease (eg, soda or fried food
CLINICAL STATEMENTS
(through a nutrition Vertical Integration Group), the intake), monitor baseline occurrence, set goals,
AND GUIDELINES
University of Texas Medical School at Houston, and oth- and implement change,70 a learning approach
ers,64–67 nutrition content is now woven into organ sys- that has been shown to improve prevention
tem didactics and case-based and problem-based group care delivery to patients.71,72 At Boston Univer-
sessions to impart formal knowledge and demonstrate sity School of Medicine, an experiential learning
clinical applications. Content might highlight the role of activity in nutrition challenges students to limit
cardioprotective diets in ASCVD risk reduction, dietary their weekly food budgets to the amount pro-
saturated fatty acid restriction in the management of vided by the state’s Supplemental Nutrition As-
blood cholesterol levels, energy balance in obesity and sistance Program.65,66
diabetes mellitus management, and dietary sodium re- • Culinary medicine electives: First offered >100
striction in heart failure and blood pressure manage- years ago,73 the development of culinary skills has
ment.64 In this manner, nutrition becomes a theme recently re-emerged as a way to help medical stu-
that spans multiple organ system blocks instead of a dents translate healthy meal preparation skills to
one-time course with less clinical relevance.63 Although patients.74,75 First taught in the United States at
this approach can make nutrition less recognizable as the State University of New York medical school
a distinct discipline, curriculum directors can electroni- in 2003 and further advanced by a 2013 partner-
cally link nutrition sessions taught across organ system ship between Tulane University School of Medi-
blocks or use nutrition-related Internet-based resources cine and the Johnson & Wales University College
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or textbooks to promote nutrition as a distinct field.63 of Culinary Arts, culinary medicine electives are
New reforms also offer opportunities to develop nu- now offered at a growing number of US medical
trition-related skill building during early clinical experi- schools. At the Tulane campus, culinary skills are
ences now common in the first year of medical school. taught either via classes at Johnson & Wales or
During history-taking and physical assessment activities, in student-led community cooking and nutrition
students learn how to take a diet history, assess body classes at the Goldring Center for Culinary Medi-
mass index and waist circumference, recognize signs of cine,76,77 with a pilot study reporting improved
calorie excess and other cardiometabolic risk factors, blood pressure, cholesterol, and hemoglobin A1c
and assess diet quality and readiness for diet change.64 among a small group of patients with diabetes
In collaborative care settings that pair students with mellitus randomized to a student-led group ver-
other professionals in training (registered nurses, reg- sus usual care.78 Similarly, at Brown University’s
istered dietitian nutritionists [RDNs], behaviorists, social Alpert Medical School, a “Food + Health” elective
workers), students can acquire early nutrition-related pairs second-year medical students with Johnson
practice skills and observe the roles of other nutrition & Wales culinary students at the schools’ Provi-
care team members, satisfying new standards and com- dence campuses in a twice-yearly semester-long
petencies for interprofessional education,68 as outlined class that combines didactics led by medical and
by the Interprofessional Education Collaborative.69 culinary students with 5 themed culinary work-
Applied nutrition knowledge and skill building are shops, including cooking with less salt, healthy
also being integrated into first- and second-year elec- cooking on a budget, and Mediterranean-diet
tives now common in UME, including those that pro- cooking.79 In a separate RDN-designed, 6-week
vide experiential learning, such as the following: community health elective pilot entitled “Food
• Practical nutrition electives: At Albert Einstein Is Medicine,” Brown University medical students
School of Medicine, a popular first-year nutrition and local nursing students lead a community nu-
elective developed in 2009 combines didactics trition cooking class that teaches plant- and olive
with interactive and practical learning experi- oil–based meal preparation to low-income indi-
ences that cover diet assessment, dieting myths, viduals with cardiometabolic risk factors, build-
the science behind the Dietary Guidelines for ing culinary, interprofessional, communication,
Americans, motivational interviewing to effect and community engagement skills. A culinary
diet behavior change, contemporary nutrition medicine experience also has been incorporated
topics, and nutrition label reading, the latter via into the nutrition education curriculum at Boston
an experiential session that also builds community University School of Medicine as part of the stu-
engagement skills.64 dent-formed, faculty-supported Student Nutrition
• Diet behavior electives: At Northwestern Uni- Awareness and Action Council.65,66
versity Feinberg School of Medicine, an elec- Nutrition knowledge and skill building can also be
tive challenges students to complete a 6-week integrated into third-year clerkships in medicine, sur-
behavior change plan in which they self-select gery, pediatrics, psychiatry, and obstetrics/gynecology,
a health behavior to increase (eg, fruit and veg- although these efforts typically require greater coordi-
e826 June 5, 2018 Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563Aspry et al Guideline-Based Diet Counseling by Physicians
nation, and into fourth-year clinical rotations and men- tively new, a recent review reported that these tracks
CLINICAL STATEMENTS
tored inquiry-driven activities.63,64 incorporated within UME improve student knowledge,
AND GUIDELINES
skills, self-care, counseling, and patient outcomes re-
During GME
lated to lifestyle factors.82 The Lifestyle Medicine Edu-
Reforms in GME have resulted in a growing number
cation Collaborative is a newly established partnership
of individualized internal medicine and family medi-
between leaders in LM and medical educators that pro-
cine training tracks and a broader mix of didactic, clini- vides leadership, guidance, and resources to advance
cal, experiential, wellness, and inquiry-driven activities the adoption of LM curricula in medical schools.83 The
within which nutrition knowledge and competencies recently published AHA statement on medical training
can be integrated and assessed. Traditional activities to achieve competency in lifestyle counseling recog-
include noon lectures, conferences and journal clubs, nizes the LM education movement and outlines com-
rotations on inpatient services, and ambulatory experi- petencies needed to educate and train physicians for
ences in advanced primary care and specialty practices, both this career track and LM topics embedded within
such as cardiology, lipid, endocrinology, and bariatric traditional education and training programs.43
surgery clinics. More innovative activities are those that
engage trainees in personal wellness and diet self-care, During GME
nutrition-related community outreach activities, and cu- LM residency programs and tracks provide unique op-
linary skills development via hands-on food workshops portunities to acquire in-depth nutrition expertise and
and cooking demonstrations, the latter now in place at competencies during GME. The American College of
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a reported 10 GME programs through partnerships with Lifestyle Medicine maintains a current and growing list
culinary institutions.80 Together, these educational sites of GME training opportunities in nutrition within LM
and activities offer numerous opportunities to develop programs84 and provides links to nutrition fellowship
and assess nutrition knowledge and competencies and and postdoctoral fellowship programs. GME in LM also
engage residents (and often faculty) in learning related has been linked to improved physician knowledge and
to diet and ASCVD prevention. Finally, although efforts attitudes, practice outcomes, and patient outcomes.82
to enhance GME in nutrition have focused traditionally
on primary care residencies, nutrition educators have Web-Based Nutrition Education
noted that “there is not a single medical specialty or
and Training
subspecialty that would not benefit from an increased
emphasis on nutrition education,” which highlights the During UME
importance of improving nutrition education and train- Medical schools that have not fully integrated nutri-
ing across specialties.64 As an example, at the Montefio- tion science across their 4-year curricula are enhancing
re Medical Center–Albert Einstein College of Medicine, and even originating nutrition education via an Inter-
residents in obstetrics and gynecology now engage in net-based program that can be incorporated into any
self-directed, Internet-based nutrition education focused existing curriculum. The Nutrition in Medicine project
on obesity and diet behavior change during pregnancy, at the University of North Carolina, Chapel Hill,85,86 is
demonstrating improved nutrition knowledge and prac- an online, open-access nutrition education curriculum
tice skills, including increased referral rates to RDNs.64 for medical students established in 1995 by a team of
physicians, nutritionists, and computer scientists. The
50-hour core curriculum covers biochemical, epidemio-
Distinct Lifestyle Medicine Curricula for logical, and clinical aspects of nutrition science. Virtual
Nutrition Education and Training case studies and translational illustrations are abundant
and, although not as effective as self-directed nutrition
During UME
counseling, offer even schools with no or limited qual-
A more focused strategy for incorporating nutrition into
ity nutrition faculty a means of expanding or establish-
UME curricula involves integration into a lifestyle med-
ing nutrition education at a fundamental level. Since its
icine (LM) thread or track, an approach aligned with
inception, >100 (or about one half) of US medical and
calls for more individualization in medical education.
osteopathic schools and dozens of international medical
Rather than offering a distinct course or integration into
schools have accessed the Nutrition in Medicine project’s
standard UME curricula, some medical schools, such as
materials to support their nutrition education efforts.87
Northwestern University Feinberg School of Medicine
and the University of South Carolina–Greenville School During GME
of Medicine, have introduced separate LM tracks that In 2009, the Internet-based Nutrition in Medicine proj-
provide in-depth UME in nutrition alongside other life- ect at the University of North Carolina expanded its in-
style factors, including physical activity, substance and teractive online, open-access medical school nutrition
tobacco use, stress management, sleep hygiene, and education program to include Nutrition Education for
behavioral counseling.81 Although LM curricula are rela- Practicing Physicians. This comprehensive medical nutri-
Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563 June 5, 2018 e827Aspry et al Guideline-Based Diet Counseling by Physicians
tion education program for trainees and physicians in standardize learning outcomes.58,62 Several groups have
CLINICAL STATEMENTS
practice presents a wide range of foundational nutri- proposed content for medical nutrition education and
AND GUIDELINES
tion topics alongside disease-specific clinical vignettes training; however, no consensus on a unified frame-
and is designed specifically for easy incorporation into work has been reached.89–92 The widely adopted AC-
busy clinical schedules.88 GME framework for defining the expected outcomes
of competency-based medical education and training
across 6 domains,93 with or without 2 additional do-
NUTRITION COMPETENCIES FOR mains proposed by medical educators,94 is a suitable
construct for categorizing nutrition competencies that
ASCVD PREVENTION impact ASCVD prevention and should be able to be
Assessing nutrition knowledge and skills imparted by broadly applied across countries.94 The rationale and
the growing list of UME and GME activities discussed content for nutrition competencies within each of the
above is essential for competency-based medical edu- 6 ACGME domains are discussed below and tabulated
cation and training and is aligned with calls to better in Table 2.
Table 2. CVD-Related Nutrition Competencies Categorized by ACGME Domains
Domain Competencies
Patient care: In all patients, uses most long-term care visits to inquire about diet and provide brief, focused diet
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Demonstrate care that is patient centered, recommendations and messages
compassionate, appropriate, and effective In patients with ASCVD or risk factors, demonstrates the ability to
Assess short- and long-term ASCVD risk and criteria for metabolic syndrome via the medical history,
vital signs, waist circumference and BMI, laboratory data, and an ASCVD risk calculator
Take a diet history informally or via a diet assessment tool
Formulate a diet-related diagnosis, intervention, and follow-up plan matched to the level of ASCVD
risk and to specific risk factors
Consider comorbidities and socioeconomic factors that impact diet behavior; assess readiness for diet
change; use evidence-based behavior change techniques, with self-monitoring when appropriate
Recognize patients who will benefit from referral to RDNs for medical nutrition therapy
Record all of the above in an accurate and timely manner
Medical knowledge: Demonstrates knowledge and application of
Demonstrate knowledge of established and Basic principles of nutrition science and food sources of macronutrients and micronutrients
evolving biomedical, clinical, epidemiological,
Basic evidence linking specific foods/nutrients, dietary patterns, and food habits/environments to
and social/behavioral sciences and apply this
increased or decreased ASCVD risk
knowledge to patient care
Diet assessment tools and evidence-based behavior change strategies and techniques
Systems-based practice: Demonstrates the ability to
Demonstrate awareness of the broader health Access national dietary guidelines and Internet-based patient education tools
system and the ability to apply its resources to
Refer patients appropriately to RDNs, lipid specialists, diabetes mellitus care specialists, obesity
individual care
specialists, bariatric surgeons, and behaviorists and to participate in team-based nutrition care delivery
Make appropriate referrals to community, state, and federal programs aimed at improving healthy
food access and education
Practice-based learning and improvement: Demonstrates the ability to
Demonstrate the ability to evaluate one’s care Improve nutrition care delivery by incorporating new nutrition science, guidelines, assessment tools,
and to continually improve it patient education tools, and diet counseling techniques
Monitor and improve patient diet behaviors and outcomes
Monitor and improve one’s progress in achieving nutrition competencies
Interpersonal and communication skills: Demonstrates the ability to
Demonstrate skills that lead to effective exchange Communicate diet and nutrition information to patients based on education and health literacy levels
of information and collaboration to improve
Communicate effectively with dietitians, behaviorists, lipid specialists, and other team members in a
patient care
manner that supports a team approach to health promotion and treatment of disease
Professionalism: Demonstrates
Demonstrate the ability to carry out professional Empathy when counseling patients with alcoholism, obesity, eating disorders, dietary nonadherence,
activities and to adhere to ethical principles and culturally based dietary habits
Professionalism in communications with all care team members and the ability to serve as a role
model to those with less nutrition and medical knowledge
Integrity in the delivery of evidence-based diet information (and avoids financial or other conflicts
related to industry or business entities)
Recognition of personal deficiencies in nutrition competency and the ability to work to rectify these
ACGME indicates Accreditation Council for Graduate Medical Education; ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; CVD, cardiovascular
disease; and RDNs, registered dietitian nutritionists.
e828 June 5, 2018 Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563Aspry et al Guideline-Based Diet Counseling by Physicians
Patient Care • Knowledge of basic nutrition principles pro-
CLINICAL STATEMENTS
vides learners with the foundation needed
The ACGME defines competency in patient care as “the
AND GUIDELINES
to diagnose and treat diet-related disorders.
ability to demonstrate care that is patient-centered,
Students and trainees should demonstrate
compassionate, appropriate and effective.”93 Applied
basic knowledge of the following, summa-
to diet-related patient care for ASCVD prevention, stu-
rized by the Institute of Medicine and National
dents and trainees should demonstrate the ability to
Academy of Sciences in an easily searchable
inquire and provide brief messages about diet at most
online reference111:
chronic care visits, because there is evidence that this
− Macronutrients, their recommended intake
can favorably impact diet outcomes.95 For those with
ranges, and diet composition
ASCVD or risk factors, they should demonstrate the
competencies below, summarized in Table 2, including – Calorie requirements and energy balance
the ability to accomplish the following: – Fatty acids and sterols; carbohydrates and
• Assess short- and long-term ASCVD risk96,97 and fiber; amino acids and proteins
criteria for metabolic syndrome,98 via the medical – Vitamins, minerals, trace elements, and
history, vital signs (including blood pressure, waist electrolytes
circumference, body mass index, or other assess- − The basic roles of all of these in human
ments of adiposity),99,100 and laboratory data, metabolism and homeostasis
including fasting blood glucose and blood lipids. • Knowledge of food sources of nutrients pro-
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• Take a diet history informally or via a diet assess- vides learners with the foundation needed
ment tool.101 to translate nutrition knowledge into practi-
• Formulate a diet-related diagnosis, intervention, and cal guidance. For the purposes of ASCVD risk
follow-up plan that matches short- and long-term reduction, students and trainees should partic-
ASCVD risk; criteria for metabolic syndrome, over- ularly demonstrate knowledge of the following:
weight, or obesity; and the presence of hyperlipid- – Food sources of healthy fats, whole grains,
emia, hypertension, or diabetes mellitus. lean animal and plant proteins, sterols, and
• Consider comorbidities and socioeconomic fac- flavonoid-rich fruits, green leafy and other
tors that impact diet behavior,25 assess readiness vegetables, including those with roles in reg-
for diet change,102 and use evidence-based behav- ulating oxidative stress,112 as tabulated in the
ior change techniques to guide diet change,103–106 US Department of Agriculture’s food compo-
encouraging diet self-monitoring via e-tools,108,109 sition database113
when appropriate. – Food sources of nutrients to be limited based
• Recognize significant nutrition-related diagnoses on the Dietary Guidelines for Americans
to identify patients who will benefit from referral Advisory Committee,16 including added sug-
to RDNs for in-depth counseling and medical nutri- ars, sodium, and saturated and trans fats in
tion therapy based on the Nutrition Care Process processed foods and beverages, including
Model.110 those often mistakenly viewed as “heart
• Record all of the above in an accurate and timely healthy” (ie, sugar-laden cereals, yogurts,
manner. and fruit juices; salt-laden vegetable juices;
and coconut oil), as well as food sources of
nutrients that are underconsumed based
Medical Knowledge on the Dietary Guidelines for Americans
The ACGME defines competency in medical knowl- Advisory Committee,16 such as calcium,
edge as “the ability to demonstrate knowledge of potassium, fiber, and vitamin D, and their
established and evolving biomedical, clinical, epide- roles in disease, particularly in the elderly
miological, and social-behavioral sciences, and to apply – The federally mandated nutrition facts label
this to patient care.”93 Relative to diet and cardiometa- and its application and planned updates114
bolic health, medical knowledge and its applications – The evidence for or against dietary supple-
can be viewed as existing within 3 broad areas, in- ments as outlined by the National Institutes
cluding (1) basic nutrition principles and food sourc- of Health,115 specifically as related to
es of nutrients, (2) evidence linking foods/nutrients, omega-3-fatty acid supplementation, as
diet patterns, and food environments to changes in recently reviewed116
ASCVD risk, and (3) diet assessment tools and behavior 2. Evidence linking foods/nutrients, diet patterns,
change interventions. and food environments to ASCVD risk
1. Basic nutrition principles and food sources of • Knowledge of foods and nutrients associated
nutrients with changes in ASCVD risk or risk factors,
Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563 June 5, 2018 e829Aspry et al Guideline-Based Diet Counseling by Physicians
identified consistently in well-conducted cohort • Knowledge of diet patterns associated with
CLINICAL STATEMENTS
studies and clinical trials, is essential for trans- changes in ASCVD risk, and evidence-based
AND GUIDELINES
lating nutrition science to patients and for rec- guidelines derived from them, is essential for
ognizing diet myths and controversies often and can facilitate diet counseling of patients.
abundant in popular media.117 Trainees should Trainees should demonstrate knowledge of the
demonstrate knowledge of the following: following:
– Specific foods associated with increased or – Healthy dietary patterns and their evidence
decreased ASCVD risk based on prospective bases, including the AHA Dietary Pattern15
studies,2–5 as illustrated in the Figure and the Healthy US Style,16 Mediterranean,10,13
– Individual nutrients associated with increased Dietary Approaches to Stop Hypertension
or decreased ASCVD risk, including: (DASH),126 and vegetarian/vegan diet patterns,
▪ Fats, specifically saturated fatty acids and all reviewed recently127
trans fatty acids, which are associated with – Dietary guidelines and recommendations,
an increase in serum low-density lipopro- including the “2013 AHA/ACC Guideline on
tein cholesterol and the risk of coronary Lifestyle Management to Reduce Cardiovascular
heart disease or all-cause mortality, versus Risk,”15 the 2015 to 2020 Dietary Guidelines
monounsaturated and poly-unsaturated for Americans,16 and dietary recommendations
fatty acids, which reduce serum low- for treating complex dyslipidemias128
density lipoprotein cholesterol and the – The basic process by which diet evidence
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risk of coronary heart disease and total is systematically reviewed, ranked, and
mortality when substituted for saturated incorporated into these guidelines and
fatty acids,7,8,118,119 and which also reduce recommendations129
elevated triglycerides, hyperglycemia, or – The commonalities among current dietary
ASCVD risk when substituted for refined guidelines (including an emphasis on whole
carbohydrates (up to a total fat intake of foods, nutrient density, and energy balance,
35% of calories),120 evidence of which has as well as restriction of added sugars, sodium,
led to calls for policy shifts away from low- and solid fats) that facilitate patient adherence
fat diets121 and coordinated treatment, the latter essen-
▪C arbohydrates in the form of refined tial because many cardiometabolic risk factors
grains and added sugars, especially from overlap and require simultaneous management
sugary beverages, which are associated • Knowledge of weight loss principles that
with obesity, dyslipidemia, insulin resis- impact ASCVD risk factors is essential for treat-
tance, and ASCVD risk,9,122 especially when ing the large numbers of patients with over-
glycemic load is increased,123 versus carbo- weight or obesity encountered in practice.130
hydrates as whole grains, which are asso- Trainees should demonstrate knowledge of the
ciated with reductions in obesity, insulin following:
resistance, ASCVD risk, and total mortal- – The association between obesity and ASCVD
ity when substituted for refined carbohy- risk factors and total mortality131,132 and the
drates,9 and which also reduce coronary favorable effects of weight loss on most of
risk when substituted for total fat in diets these risks133
that are plant-based, fiber-rich, and high in – The evidence that popular hypocaloric diets
fruits, vegetables, beans, and legumes, as appear to induce similar weight loss,134 but
well as whole grains124 those that allow moderate fat are associated
▪ P roteins from plant sources (beans, legumes, with greater reductions in triglycerides and
nuts, and seeds) and fish, which are associ- increases in high-density lipoprotein cho-
ated with reduced ASCVD risk,2–5 versus lesterol and possibly better adherence than
from processed meats (eg, delicatessen those low in fat135
meats, bacon, sausage, hot dogs), which are – Evidence-based guidelines for obesity
associated with increased ASCVD risk2–5 treatment136,137
▪ S terols from plant sources, which are associ- • Knowledge of the effects of food habits and
ated with reductions in serum low-density environments on diet quality and ASCVD risk
lipoprotein cholesterol, versus some animal is essential when engaging patients in diet
sterols (eg, cholesterol in eggs) that raise counseling, especially those with lower socio-
low-density lipoprotein cholesterol and are economic status. Trainees should demonstrate
associated with increased ASCVD risk in knowledge of the prevalence and negative
diabetic patients125 effects on ASCVD risk factors of:
e830 June 5, 2018 Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563Aspry et al Guideline-Based Diet Counseling by Physicians
– Food eaten away from home138–140 and, con- and arrange follow-up and support, includ-
CLINICAL STATEMENTS
versely, of the potentially positive health effects ing referrals to RDNs when needed)
AND GUIDELINES
of culinary skills development and home –
Evidence-based behavior modification
cooking141,142 techniques such as motivational interview-
– Food deserts, defined by the US Department ing, goal setting, and regular feedback,
of Agriculture as “parts of the country vapid which are now Class IA recommendations
of fresh fruit, vegetables and other healthful for diet counseling,103 and particularly the
whole foods, usually found in impoverished 4 basic skills used in motivational inter-
areas”143–146 viewing154 (ie, open questions, affirma-
– Food insecurity in the United States147 tions, reflective listening, and summarizing
3. Diet assessment tools and behavior change theo- [OARS])
ries as applied to diet
• Knowledge of formal diet assessment and
tracking tools that provide an approximation of
Systems-Based Practice
dietary intakes is valuable when assessing diet Competency in systems-based practice is defined by
quality, the need for diet behavior change, and the ACGME as “the ability to demonstrate awareness
the achievement of diet goals. Trainees should of the broader health system and apply its resources
demonstrate familiarity with the following: to individual care.”93 As related to nutrition, trainees
– Rapid Eating and Activity Assessment for should demonstrate the ability to make appropriate
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Patients (REAP), a brief, validated food ques- referrals to RDNs, diabetes mellitus educators, clini-
tionnaire linked to an accompanying physi- cal lipid specialists, and obesity treatment experts; to
cian guide to counseling148,149 local and web-based programs that promote cooking
– Weight, Activity, Variety and Excess (WAVE), skills, weight loss, diabetes mellitus prevention, and
a diet and lifestyle instrument that addresses wellness; and to federal nutrition assistance programs,
calorie balance and healthy eating and incor- including the Women, Infants and Children program,
porates practical tools149–151 Meals on Wheels, and Supplemental Nutrition Assis-
– Food Behavior Checklist, a picture-based food tance Program–Ed.
survey for those with low health literacy152
– New commercial mobile e-health tools for
diet self-monitoring and tracking, for exam-
Practice-Based Learning and
ple, MyFitnessPal,108 Lose It,109 and others, Improvement
and emerging digital platforms with the The ACGME defines competency in practice-based
capability of connecting patient-generated learning and improvement as the “ability to demon-
diet data to electronic health records153 strate evaluation of one’s care and to continually im-
• Knowledge of the many factors that affect diet prove it.”93 Specific to nutrition, competency in prac-
behavior and the evidence supporting specific tice-based learning and improvement includes the
diet behavior change interventions is essential ability to monitor and improve diet-related behaviors
for guiding patients to successful diet change. and outcomes in patients and to hone these skills within
Trainees should specifically demonstrate knowl- complex patient care environments with ever-changing
edge of the following: standards, guidelines, and policies. Therefore, trainees
– The social-ecological model of diet behavior, should demonstrate the ability to access and incorpo-
which recognizes that diet behavior is shaped rate into practice new dietary guidelines, counseling
by individual, social, cultural, and economic techniques, and diet assessment and education tools.
influences; the settings in which foods and Finally, competency in practice-based improvement
beverages are consumed; and system, organi- includes the ability to self-monitor and improve one’s
zational, and industry factors25 own progress in achieving nutrition competencies.
– The trans-theoretical model, which empha-
sizes the need to tailor behavior change
strategies to the stage of readiness (ie, pre- Interpersonal Skills and Communication
contemplation, contemplation, preparation, Competency in interpersonal skills and communication
action, maintenance, or relapse), and of the is defined by the ACGME as the “ability to demonstrate
5A’s steps for applying the trans-theoretical skills that lead to effective exchange of information with
model to diet behavior change102 (ie, assess patients and other providers, and collaboration to improve
diet and readiness to change, advise diet patient care.”93 The latter is especially vital given the in-
changes, agree on diet change goals, assist creasing need for physicians to work within interdisciplin-
to change diet practices or address barriers, ary teams. Trainees should be proficient in communicating
Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563 June 5, 2018 e831Aspry et al Guideline-Based Diet Counseling by Physicians
nutrition guidance across all levels of patient education tional support and academic “homes” for those who
CLINICAL STATEMENTS
and health literacy, in documenting nutrition assessment, do possess these qualifications have contributed to in-
AND GUIDELINES
and in establishing a legal record of nutrition care. adequate UME and GME in nutrition.158–160 However,
multidimensional nutrition curricula that integrate the
expertise of RDNs in particular,44 as well as nurses, be-
Professionalism haviorists, and culinary experts, can greatly enhance the
The ACGME defines competency in professionalism as efforts of even a single faculty member or champion.
the “ability to carry out professional activities and to Nutrition curriculum organizers might also find that
adhere to ethical principles.”93 Compassion, respect medical nutrition education efforts by other faculty,
for others, honesty, and integrity are the foundations RDNs, behaviorists, trainees, and students are already in
of professionalism. In relation to nutrition care deliv- place in other local programs, departments, or practices
ery, trainees should demonstrate professionalism when and can be tapped to help create broader and more in-
counseling patients with eating disorders, alcoholism, tegrated multidisciplinary nutrition education and train-
obesity, dietary nonadherence, and culturally specific ing efforts. The resources discussed above and listed
dietary habits, as well as when interacting with care below can provide faculty with significant support.
team members who might have less medical knowl-
edge. They should demonstrate avoidance of personal
and financial conflicts related to the promotion of diet Curricula Building Guidance
plans, foods, supplements, or other products. Finally, Faculty and curriculum developers seeking to expand
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they should recognize deficiencies in their nutrition their medical nutrition education and training efforts
competencies and work to remedy these. can find valuable information in the following publica-
tions, which provide both general guidance and de-
scriptions of the steps and elements helpful for plan-
EPAs FOR NUTRITION COMPETENCY ning, implementing, evaluating, and sustaining an
Recently the Association of American Medical Colleges integrated nutrition education curriculum:
developed and defined 13 categories of integrated, • “A Novel Method of Increasing Medical Student
observable, and measurable clinical work activities Nutrition Awareness and Education”66
that each graduating medical student should be able • “A Novel Nutrition Medicine Education Model:
to perform in basic fashion without direct supervision The Boston University Experience”65
on the first day of internship and with increasing skill, • “Development of Case-Based Integrated Nutri-
performance, and independence (or “entrustment”) tion Curriculum for Medical Students”161
as he or she progresses along the learning continuum • “Position of the Academy of Nutrition and Dietet-
to graduating senior resident.155–157 As such, EPAs pro- ics: Interprofessional Education in Nutrition as an
vide a clinical context for (and are mapped to one or Essential Component of Medical Education”44
more of) the ACGME/Association of American Medical • “Lessons Learned From Nutrition Curricular En-
Colleges competency domains and are achieved when hancements”162
milestones or “entrustable behaviors” that integrate • “Nutrition Education in Medical School: A Time
patient care, medical knowledge, practice skills, and of Opportunity”63
professional attitudes for that particular activity are • “Comprehensive Integration of Nutrition Into
skillfully demonstrated. As EPAs become adopted, med- Medical Training”163
ical schools must demonstrate their achievement and • The Nutrition Academic Award, funded by the Na-
determine how, when, where, and by whom the EPA is tional Heart, Lung, and Blood Institute between
to be taught, as well as its method of measurement and 1998 and 2005 at 21 medical schools in the
assessment. The 13 core EPAs being advanced by the United States, produced a curriculum guidance
Association of American Medical Colleges and the sug- document, instructional materials, practice tools,
gested entrustable behaviors relevant to nutrition care and publications, available at https://www.nhlbi.
competencies are presented in Table 3. nih.gov/sites/default/files/media/docs/NAA%20
Nutrition%20Curriculum%20Guide.pdf.164
RESOURCES FOR IMPROVING
MEDICAL NUTRITION EDUCATION Educational Content Resources
AND TRAINING CURRICULA Key nutrition science sources and reviews useful for
curriculum developers, faculty, students, trainees, and
Faculty practicing providers are listed in the publications and
Relatively few medical school faculty with training and websites listed below.
expertise in nutrition and the general lack of institu- • Institute of Medicine Dietary Reference Intakes111
e832 June 5, 2018 Circulation. 2018;137:e821–e841. DOI: 10.1161/CIR.0000000000000563You can also read
