Jennifer Hanes MS, RDN, LD
Have you ever asked your doctor for nutrition advice? They recommend you alter your diet to reduce your cholesterol, and the natural follow-up is to ask how.
The evidence shows, though, that they may not really know how. Short of telling you to eat less, exercise more, and maybe eat more vegetables, MDs and DOs may not know what to say to you.
They simply do not receive adequate nutrition education to be qualified to give nutrition advice for weight loss. Or for any other condition.
My Education to Become a Dietitian
I started grad school at Eastern Michigan University’s Dietetics and Human Nutrition Program, having already completed a Bachelor’s Degree in Nutrition Science.
I spent 2 years (including summers) completing full-time graduate-level coursework, while simultaneously completing clinical rotations.
Other education models have dietetic students complete their hands-on training after they graduate, similar (but shorter) to a doctor’s internship.
Coursework included Nutritional Biochemistry, Macronutrient Metabolism, Micronutrient Metabolism, Integrative Medicine, Statistics for Graduate Students, Research Design and Methods, and many, many more.
I completed 1200 hours of student experiences in hospitals, long-term care, an endocrinology clinic, WIC, a private practice, and 2 healthcare kitchens.
In my long-term care and both acute care rotations, I treated, wrote, and presented a case study to my preceptors.
Actually, in my long-term care rotation, I presented not only to my dietitian preceptor but also to almost every discipline in the facility.
Finally, I wrote a 20-page research-oriented thesis and created a presentation on this as well! I called it “Prevalence of Diabetic Nephropathy in the United States and the Registered Dietitian.”
Just thinking of that process makes me tired all over again!
The Primary Focus of Medical Education
Doctors have a ton to learn, so much so that they require supervised training AFTER they graduate. Their primary training will be to identify problems, diagnose conditions, and treat them using medical management or surgical intervention.
While that list is short to type out, you have to consider the vastly different populations they are treating, regarding age, gender, and ethnicity.
Then, because we can travel so much more easily, they have to be able to think of conditions that may occur on the other side of the world.
They have to know how medications and other treatments interact with each other and with food and what side effects they can cause.
They have to evaluate all types of labs and identify what is abnormal, and if the labs aren’t diagnostic, they have to know what to look for next.
Additionally, they have to know about trends in public health, such as switching from an emphasis on acute conditions such as infections to chronic illnesses and conditions related to an aging population.
And that’s just barely touching on the healthcare part. They also have to learn laws, policies, and insurance management as well!
There’s so much!
All that to say, there’s a reason that there are paraprofessional healthcare professionals who specialize in particular fields, such as nutrition, physical therapy, or speech therapy, to name just a few.
My dietetics education wouldn’t have been as good as it was if I also trained in how to diagnose chronic conditions or how to choose the best asthma medication!
Nutrition Education of the MD
According to the Washington Post, 71% of medical schools don’t even require the recommended 25 hours of nutrition training.
Less than 20% required any sort of nutrition education for medical students at all, which is actually less than 15 years prior, down from 40%.
All this is despite more and more research indicating the importance of nutrition in preventing, treating, and managing chronic diseases.
Furthermore, an MD’s focus is going to be on treating diseases and conditions that have already presented themselves. This means medical management, including potentially preventable conditions.
Other quick facts regarding an MD’s nutrition education:
- On average, MDs received only 2.8 hours of education on weight, nutrition, and physical activity.
- Only 42% of MDs were taught techniques for health behavior counseling.
- In a 2016 study, medical school interns only answered 52% of an 18-question nutrition test correctly.
So who would you want your nutrition advice from? An expert in nutrition, or an MD (though very smart) that did not receive adequate nutrition education?
A doctor who is willing to refer to an expert on a topic they are unsure of is more valuable than one who fumbles and can potentially give bad advice.
Time Constraints in Clinical Practice
There’s another aspect of nutrition that education doesn’t cover at all. And that’s the time we are able to spend with our clients/patients.
Doctors have to see an extraordinary amount of patients per day, and they have to document every encounter.
This generally means very short visits where they have to cover medication management, education on the individual’s conditions, read lab work, answer any questions, and discuss any referrals or other education.
Even if your doctor is highly educated in nutrition, how would they have time to discuss basic nutrition? Let alone any individualized care that a patient needs, such as cultural appropriateness, personal preferences, medical nutrition needs, and more?
How I structure My own Nutrition Counseling Sessions
In contrast, dietitians see (much) fewer patients and clients throughout the day, but we get to spend lots of time with them.
My first session with a client is usually around 90 minutes. And that’s after the person fills out an extensive questionnaire that covers not only their healthcare needs, but also their relationship with food, their body image, physical activity, social wellness, and more.
I then see that person every 2 weeks for 30-60 minutes until they are comfortable spreading out our sessions more.
You can see the major difference in how I am able to determine exactly what would be the best first steps, along with the client. We have time to coach, problem-shoot, and learn behaviors, rather than simply discussing facts.
Personal Experience with MD’s Nutrition Advice
I’ve been in and out of doctor’s offices in the past, trying to figure out some tummy problems and excessive fatigue that seems to come and go.
While talking with one doctor, he mentioned to me that as a vegetarian, I should have a really high B12 intake, because I eat a lot of leafy green veggies.
Note: leafy green veggies do NOT contain vitamin B12.
B12 content in plant-based foods is a big zero. This is why vegans require supplementation.
2nd note: There isn’t really a reason for this particular doctor to know that. He also wasn’t really giving me advice, just communicating with me about a problem.
Another doctor wanted to know why a psych hospital (my primary job at the time) would require a dietitian. There are actually quite a few links between various psychiatric conditions (schizophrenia, depression, bipolar disorder) and malnutrition risk.
That’s not even to mention the number of individuals with addictions or without a home I see who are severely underweight. There are also several nutrition tweaks we can do to help ease the depression and anxiety often seen in psychiatric patients.
But I can guarantee you that if an MD did not learn even basic nutrition concepts in school, they are not aware of more finely nuanced nutrition research.
My clients’ Perspective
I’ve also had clients disclose nutrition advice from their primary care physicians. Some of the worse are:
- Just eat less. (This one happens a lot, with no thought to whether a client has a current or past eating disorder, or is already eating below their expected basal metabolic rate)
- Stop eating tortillas (said to a client of Mexican heritage)
- Everyone should follow the Mediterranean Diet (while this diet is considered very healthful, it is not culturally relevant to a lot of us; it may also be too low in protein for some people and implies that people who don’t eat fish due to allergies or choice cannot eat healthily, and ignores that there are also other dietary patterns that have been found equally beneficial).
- You have XYZ, so stop eating ABC (said about a person’s favorite food – black beans… In reality, no one food exists in a diet alone; dietary pattern, not a specific food is what we should be paying attention to, unless “XYZ” is an allergy).
- You should eat lots of nuts (forgetting, or not knowing, the person is allergic).
- Exercise will help you lose weight (not necessarily! Many people gain weight when exercising because physical activity makes you HUNGRY; and did they even ask the patient if they wanted to talk about weight loss?).
On a Larger Scale…
I was listening to Doctor Radio a while ago. It was a show with a doctor that I really like and like to listen to. She had another guest on, and the theme of the show was weight loss.
She was going on and on about how much she liked the keto diet for weight loss. How there aren’t any notable ill effects of the diet (not true). How it is easy to follow (definitely not true), and other such comments.
She then followed it up by perfectly describing…… the Atkin’s Diet.
She had no clue about the differences between the diets. I was so grateful her co-host was there to gently, but firmly, correct the misinformation that was given.
These examples are all of very smart people who are very good at what they do. It’s just that nutrition and dietetics are not what they do!
We put our doctors and ourselves at a disadvantage when we don’t ask for a referral for the services that we need.
A Disturbing Trend
Celebrity doctors are becoming more and more common. Unfortunately, the ones that maintain their popularity are not the ones that are dispensing good advice. Dr. Oz, Dr. Axe, and Dr. Mercola all come to mind.
Dr. Oz is the most atrocious, in my opinion, and interestingly, the opinion of the United States Congress. Bet he didn’t put that on his show, did he? He has the biggest platform and the biggest name out of all of these doctors.
He had such great potential to help a lot of people and decided to be a snake oil salesman instead…
He has been long maligned for routinely touting “miracle” cures and inviting uncredentialed “specialists” on his show to give health advice. As a result, Dr. Oz was called before Congress to testify regarding complaints of deceptive advertising on his show.
He actually admitted that there is no scientific foundation for the supplements he recommends. Then went on to say he would still recommend them.
He so frequently makes false claims on his show that a group of doctors actually called on Columbia University to relieve Dr. Oz of his position on their faculty. Other celebrity doctors have had similar complaints against them.
More recently Steven Gundry and Paul Saladino have been making atrocious and dangerous claims, very vocally. I have seen these two’s recommendations cause enormous harm to my clients over the last year or so.
I won’t link to them, I refuse to give them any indicator, no matter how small, that they are worth promoting.
There has also been an influx of diet books that have been written by doctors; especially those with no discernible nutrition background. Don’t be sold by the MD or PhD next to their name.
Make sure you know what their background is before reading a book that has ANYTHING to do with your health. I wouldn’t want a cardiologist poking around my GI tract. Or a plumber fixing my car.
What it boils down to is this: The best way for an MD to educate their patients on nutrition is to refer them to a dietitian they trust.
We may not have the TV ratings to back us up, but we do have the education that makes us nutrition experts. We are also required to continue to learn about nutrition topics to maintain our credentials.
However, this is not How Most Physicians Operate
As long as the “health and wellness” and weight loss industry continues to rake in big money, you will have unethical, unqualified individuals who will capitalize on this. This is not limited to the worst-of-the worst doctors either.
But in reality, the vast majority of doctors are genuinely interested in the health and well-being of their patients.
They will not knowingly prescribe harmful diets, but you still run the risk of…
Outdated or inaccurate information and advice, no frequent and ongoing support, help, and question-asking that you would get from a good relationship with a good dietitian.
I should also note here that dietitians often specialize, just like doctors do. For instance, my areas of special interest are vegetarian nutrition and nutritional psychiatry. I also have extensive experience counseling for diabetes.
However, I should not be giving advice to kidney patients, particularly those that require dialysis. I am also not super well versed in herbal supplements, so I should not be the first choice for a patient who wants to use a lot of herbal remedies in their routine.
Make sure the dietitian that has been recommended to you has the experience and continuing education in the condition that you are seeing them for.
Complexities of Dietary Choices
Media, especially social media, often makes us think that our choices are “good” or “bad.” This is usually followed up with “Buy our products!” These are red flags for a reason.
In reality, there are a ton of reasons a person may make a food or meal choice. And their health is not always the determining factor. Here are only a few of the factors that go into choosing what to eat:
- Culture/Heritage – What foods do you grow up with? What do you know how to cook? What was your favorite meal or food as a kid?
- Allergies – seems obvious, but we obviously should be avoiding foods that we are allergic to or intolerant of.
- Religion – many religions restrict what foods can be eaten and how those foods can be raised, prepared, and eaten
- Time – Sure, in a perfect world, I would love to spend a ton of time in the kitchen whipping up gourmet food every night. However, here in reality, sometimes a meal needs to come together in less than 20 minutes, or even 10. My food choices absolutely change based on how much time I have to prep.
- Money – Some foods are cheap, and some are expensive. Sometimes you can afford a “convenience tax” to purchase foods that are difficult to prep, but you really like. You can get a wider variety of fruits and vegetables, try out the latest fad grain, and enjoy all the specialty cheeses you want. However, sometimes you can only buy the cheapest of options.
- Health conditions – specific nutrients may need to be limited or eaten in higher amounts in various medical conditions. When using nutrition as part of your method to manage a chronic condition, you will consider these conditions when making your food choices.
- Preferences – both your own and others you cook for. I’m not making three meals, or cleaning up the kitchen after 3 people cook what they want for dinner. So, the best option is to cook the best you can with everyone’s preferences in mind.
The Importance of Interdisciplinary Collaboration
So What Can You Do?
Take responsibility for your care. Do you really want to learn how to eat for diabetes or lower your cholesterol in your 15-minute appointment?
Or would you rather spend 90 minutes with an expert who is trained to incorporate science, food preferences, and other factors into a healthy eating pattern that you will be able to maintain long-term?
If you feel like your symptoms or lab work results can be improved with nutrition, ask your doctor for a referral to someone who has the expertise to help you.
You wouldn’t ask your doctor to fix your plumbing, don’t ask her to carry out other tasks outside of her area of expertise. And don’t ask me how to fix your car!
For more information:
So, there you have it, the magic behind top-notch healthcare—collaboration!
It’s not about one professional being more important, or educated, than the others; it’s about each specialist contributing their unique specialty and expertise to create holistic care for their patient.
Short answer, yes.
The long answer will take forever but can be summed up by another question. Should doctors give nutrition or diet advice?
There are a lot of good, and bad, answers to be given here. I strongly recommend seeking out the help of a dietitian who works with clients who have the same questions you do.
A dietitian who specializes in kidney disease is fantastic if you want to prevent your kidney disease from progressing to dialysis, but not so great a choice if you want to learn if nutrition can help you manage your PCOS.
There is no good answer to this! The best nutrition advice for one person might be the worst nutrition advice for their neighbor.
As mentioned above, there are enumerable reasons that people make food choices, and enumerable ways that dietary choices might impact health outcomes. When we consider that not everyone has the same health goals, we have to admit that there is no one thing that will apply to everyone.
Jennifer Hanes MS, RDN, LD is a registered dietitian, mom, wife, and vegetarian in North Texas. She has dedicated Dietitian Jenn to be a source of information, ideas, and inspiration for people like her, vegetarians that live with people with different dietary beliefs and/or needs in a multivore household.