Are You Helping or Hindering? Anti-obesity Bias and Inadequate Nutrition Training in Medical School

By Kelly M. Adams, MPH, RD, LDN, Nutrition in Medicine and Nutrition Education for Practicing Physicians Projects, University of North Carolina at Chapel Hill, Gillings School of Global Public Health

There is an excellent article in the July 2013 issue of Academic Medicine: “Are Medical Students Aware of Their Anti-obesity Bias?” by David P. Miller, Jr. and colleagues at Wake Forest School of Medicine. Because I am on a team of physicians, dietitians, and programmers at the University of North Carolina at Chapel Hill who conduct surveys on nutrition education at U.S. medical schools, I was asked to ponder: Does the lack of nutrition instruction in many medical schools contribute to an obesity bias among medical students? If doctors were better trained in nutrition, if they had a better understanding of the nutritional contributors to health and to disease, would they be less biased against obese patients?

Our most recent survey published in 2010 found that only 27% of the responding medical schools met the minimum benchmark of 25 hours of required nutrition education. Medical students receive, on average, only 19.6 contact hours of nutrition instruction, including the type of basic nutrition science that is covered in biochemistry courses.

Anti-obesity bias is pervasive in American culture, documented in surveys of the general population, physicians, university students, and even children. It doesn’t seem reasonable then to say that inadequate nutrition instruction in medical schools is the cause of this bias in medical students. It is probably already there, even before a student begins medical training. More likely, the lack of nutrition instruction promotes the stereotype that obese patients don’t want to try to change their diets—that lifestyle modification is too burdensome, too complicated, too overwhelming, too mysterious, too futile. The long-term success rate of obesity treatment describes an uphill battle, but many lifestyle changes will successfully treat co-morbidities irrespective of weight loss. We’re not even giving patients a chance to try. Health care providers assume obese patients are noncompliant with a therapy they haven’t even been given!

There are several knowledge-based surveys showing that physicians do not understand many basic nutrition principles and their therapeutic applications. I see this firsthand in my personal and professional life. Friends and family routinely ask me to clarify what their doctors have told them to do when it comes to nutrition. “My total cholesterol was 222. My doctor said to follow a low-cholesterol diet.” “Mine was 204. She said to follow a low-fat diet and increase my exercise.” “My fasting blood sugar was 223. The doctor said no more cake, cookies, and pies–and lose weight.” In none of these cases was the patient referred to a dietitian. As frustrating as it is for me to experience firsthand the need for doctors to provide appropriate nutrition guidance to their patients, at least I have the chance to correct these mistakes (neither a low-fat diet nor a low-cholesterol diet is the first line of treatment for hypercholesterolemia). Physicians are not well-trained when it comes to promoting proper nutrition in their patients, and it is really a shame if the ones that might know what to say don’t give their patients a chance because they have an anti-obesity bias!

I’ve heard it said that the anti-obesity bias is the last socially acceptable prejudice. This important study by Miller and colleagues has identified a critical and unique component of the ideal nutrition curriculum at medical schools, and they have developed a multilevel program to explicitly address implicit weight biases. Effective counseling techniques such as motivational interviewing are taught to some medical students, giving them tools to facilitate behavior change in obese patients. As part of this training, which emphasizes empathy in a patient-centered approach, students could be coached to recognize their own weight biases and examine how it might affect their actions. Understanding the genetic and environmental causes of obesity is a necessary first step. Knowing how to counsel a patient on nutrition and physical activity to prevent or treat obesity is a crucial second step. Actually doing it because you have overcome an anti-fat bias and believe it will make a difference in the patient’s outcome might be the final piece in improving the medical care that obese patients receive.

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5 Comments

  1. Kemi Tomobi
    June 18, 2013 at 3:39 PM

    Thank you for sharing.  I agree that nutrition education is not emphasized enough, and that could be that the average physician-in training is not nutrition conscious.  A good opportunity to address nutrition is when one takes biochemistry in medical school, and certainly in a curriculum that addresses obesity.  I remember a physician counseling a patient with hypertension about every possible thing for blood pressure (medications, etc), except that the patient should lower dietary sodium.  Specific dietary changes for reducing sodium intake were not emphasized, such as limiting processed food intake, increasing consumption of freshly prepared food, use of salt substitutes, etc.,  (especially in African Americans).  It sounds like something similar occurs with dietary counseling for obesity.

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    • Kelly Adams
      June 18, 2013 at 6:41 PM

      You are right…there are many opportunities to address nutrition in medical school, but unfortunately nutrition instruction is getting squeezed by many competing demands, so I fear it is losing ground. Our Nutrition in Medicine project (www.nutritioninmedicine.net) offers a free, online, flexible medical nutrition curriculum that can be used to train physicians, residents, and fellows, as well as medical students. We realized that many doctors were unsure of how to handle dietary counseling in a busy practice setting, so our clinically-oriented modules take only 5-15 minutes to complete. So, for example, they can learn exactly what lifestyle changes are effective in treating hypertension, and immediately apply that information to patient counseling. It sounds like the physician you observed could have benefited from our program!

  2. Jane
    June 18, 2013 at 4:33 PM

    Thank you for the enlightening article. I had also been unaware that “neither a low-fat diet nor a low-cholesterol diet is the first line of treatment for hypercholesterolemia,” so now I’m curious. What is the first line of treatment? Lipid-lowering drugs? (with nutrition/lifestyle changes to follow alongside them?)

  3. Kelly Adams
    June 18, 2013 at 7:12 PM

    Thanks for the chance to elaborate. Your comment and the previous comment zero in on two areas where lifestyle changes, including dietary modifications, can have a clinically significant effect — hypertension and hyperlipidemia. In both areas, dietary changes can be as effective as medication for many patients. The ATP III guidelines for treatment of high cholesterol (http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf or http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf) specify that lifestyle changes should be given a trial of at least 3 months, or at the very least begun alongside drug therapy, according to an algorithm that depends on the patient’s LDL level and risk factors. Calling the recommended diet “low-fat” is inaccurate. It does not need to be fat-restricted overall, but rather reduced in saturated and trans-fats as well as cholesterol. Calling it “low-cholesterol” misses the perhaps more important contribution of these cholesterol-raising fatty acids. Weight loss and increased physical activity should be part of the approach. Our project (www.nutritioninmedicine.net) is working on a simulation that will train physicians how to do a brief dietary assessment and counsel a virtual patient on lipid-lowering, adding to our curriculum that provides physicians with brief, clinically focused nutrition education.

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