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The physician-in-training will be able to:

  1. Correlate direct links between diet and health and disease.
  2. Describe how qualified nutrition professionals such as registered dietitians function in relation to referral and consultation resources for physicians.
  3. Describe nutrition skills and knowledge required for physicians practicing in given medical specialties.

Why should physicians be knowledgeable about nutrition?

  • Direct evidence that links diet to health and disease
  • Patients ask many questions related to nutrition
  • Improve overall patient care in outpatient and institutional settings
  • Understand how other health care professionals such as registered dietitians function in improving nutritional status of patients
  • Reduce potential liability/improve risk management issues
  • Enhanced marketing of medical practice

Here’s a short quiz to test your knowledge about how nutrition is related to health and disease…

  1. Obese people can be malnourished. True or False
  2. Vitamin, mineral and other dietary supplements can take the place of a healthy diet. True or False
  3. Many chronic diseases have etiologies that are directly related to lifestyle issues such as diet. True or False
  4. Most disease prevention and health promotion activities and programs contain nutrition components. True or False
  5. The keys to a healthy diet are moderation, variety, and balance. True or False
  6. Epidemiology has provided much of the evidence of how nutrition modulates the disease process. True or False
  7. Nutrition is mostly considered a curative intervention in medical conditions and diseases. True or False
  8. Immune function is directly related to nutritional status. True or False
  9. There are many non-nutritive compounds in foods that are being investigated in relation to how they influence the prevention and development of many diseases. True or False
  10. An example of new links between the etiology of disease and nutrition is the homocysteine/folic acid/ cardiovascular disease connection. True or False

    1. True. Many times protein malnutrition is overlooked in patients who are obese or not underweight. The common charting of the “well developed, well nourished” patient can be misleading! Nutrition screening and assessment is very important to assure accurate information regarding nutritional status.
    2. False. Supplements may play an important role in the enhancement of dietary intake, notably in terms of folic acid and calcium, in which recommended intakes often exceed what most people consume in foods. Supplements never take the place of a healthy diet because the substrates of a healthy diet are the macronutrients (protein, fat, and carbohydrate) and water. The catalysts (micronutrients and some non-nutritive compounds such as phytoestrogens, flavinoids, and retinoids) need the substrates to act in positive physiologic and biochemical pathways.
    3. True. The development of many chronic diseases, including diabetes mellitus, cardiovascular diseases, hypertension, cancer and osteoporosis, have direct relationships with lifestyle issues such as activity level, diet, stress, and body weight. Body weight alone has strong positive correlations between the incidence of type 2 diabetes mellitus, hypertension, cardiovascular disease and certain types of cancer. The current epidemic of obesity in the United States is strongly correlated with reduced activity level and sedentary lifestyle.
    4. True. Most primary, secondary and tertiary health promotion and disease prevention activities and programs that you will recommend to your patients have a nutrition component. Notably, diabetes education programs consider nutrition education of prime importance, and cardiac rehabilitation programs always include nutrition teaching.
    5. True. Healthy diets consist of a variety of foods as no one food or food type contains all of the essential nutrients people need for achieving or maintaining health. Variety doesn’t mean a Twinkie® today, a chocolate chip cookie tomorrow and a doughnut the next day! Food variety can be categorized into food groupings such as are found in the USDA Food Guide Pyramid. Within categories such as fruits and vegetables, variety should be emphasized to ensure a good mix of nutrient intake. Most people have limited variety in their diets because of a number of factors, including taste preferences, availability, economics, and habit. Moderation is an important key as well. You need to be careful when discussing moderation with patients as it is a very subjective term. The recommended serving sizes of food categories in the Food Guide Pyramid assist in helping people determine appropriate portions of different foods. For example, did you know that a 4 oz. serving of meat, chicken or fish is the size of the palm of your hand? Most people would assume a much larger portion is moderate. Balance regarding healthy diet is assuring that a good variety of foods is consumed in moderation according to the person’s body weight and health status.
    6. True. Evidence based medicine is the standard these days and much of the evidence regarding the relationship between diet and health and disease has been determined through epidemiologic investigations. A classic example of this is the case of pellagra, the clinical manifestation of niacin deficiency. At first thought to be an infectious disease, Joseph Goldberg, an epidemiologic investigator for the US Public Health Service, discovered that the cause of the pellagra epidemic in certain populations in the southern states of the US was nutritional in nature. These individuals lived on a corn-based diet, and the tryptophan in the corn was not treated with alkali, allowing conversion to niacin in the body.
    7. False. The only diseases that nutritional intervention can cure are nutritional deficiency diseases. Much press has been given to “nutritional cures” in the popular literature and people are seeking an easy answer to many complex questions and issues. Cancer is a good example of this. Nutrition is an essential component in health promotion and disease prevention and management but is not considered “curative” therapy per se.
    8. True. Immunonutrition is a term that is frequently used in the scientific literature now and new research is uncovering the mechanisms of how different nutritional factors affect the immune system. This information will be used for both disease prevention and treatment and is an exciting area of study.
    9. True. New compounds found in foods that have bioactivity regarding physiological and biochemical systems in the human body are being discovered on a regular basis. One large pharmaceutical company located in St. Louis, MO has a “nutraceutical” division in which active research groups are conducting studies to identify and classify these compounds that are of interest to the medical community.
    10. True. High blood homocysteine levels have been found to be a significant risk factor for cardiovascular disease and patients with diabetes mellitus tend to have higher levels of homocysteine than individuals who do not have diabetes. Folic acid lowers the blood homocysteine and therefore high intakes of folate reduces risk of morbidity and mortality among these patients.

Family Medicine:

Skills - nutrition screening, assessment, and diagnosis, brief nutrition interventions in office practice, referrals to community nutrition classes or individual counseling with a qualified nutrition professional such as a registered dietitian.
Knowledge - nutrition as it relates to pediatrics, geriatrics, general adult medicine, nutrition in preventive medicine, nutrition in physical diagnosis, drug-nutrient interactions, dietary supplements/nutraceuticals, enteral feeding formulae, primary care in general, nutrition in exercise and sport, eating disorders, weight management.

Community Medicine:

Skills - nutritional epidemiology, referrals to community nutrition resources, research in community nutrition interventions (e.g., Pawtucket Heart Health Program, Five-a-Day Cancer Prevention grants, etc.).
Knowledge - nutritional epidemiology, nutrition in preventive medicine, community and public health nutrition.

General Pediatrics:

Skills - nutrition screening, assessment and diagnosis of infants, children and adolescents, brief interventions in office practice, referrals to community nutrition classes or individual counseling with a qualified nutrition professional such as a registered dietitian.
Knowledge - nutrition and growth, pediatric formulae composition, breast feeding, psychosocial issues in feeding and eating problems in infants, children and adolescents, food allergies, inborn errors of metabolism, dietary supplements, failure to thrive, obesity management in children, nutrition in exercise and sport, eating disorders.

General Internal Medicine:

Skills - nutrition screening, assessment and diagnosis of adults, brief interventions in office practice, referrals to community nutrition classes or individual counseling with a qualified nutrition professional such as a registered dietitian.
Knowledge - nutrition in geriatrics, enteral and parenteral feeding formulae, obesity, nutrition in chronic disease management, nutrition in physical diagnosis, drug-nutrient interactions, dietary supplements/nutraceuticals, primary care in general, nutrition in exercise and sport, eating disorders.

Geriatric Medicine:

Skills - nutrition screening, assessment and diagnosis of older adults, referral to community nutrition programs, nutrition counseling services through home health care, etc.
Knowledge - nutrition in geriatrics, enteral feeding formulae, dietary supplements/nutraceuticals, drug-nutrient interactions, nutrition in chronic disease management, nutrition as it relates to wound healing, nutrition in physical diagnosis, community nutrition resources for the elderly.

Gastroenterology:

Skills - placement of enteral nasogastric, gastric, duodenal, and jejunal feeding tubes, nutritional diagnosis relating to GI problems, referral to individual counseling with a qualified nutrition professional such as a registered dietitian for GI disorders.
Knowledge - nutrition as it relates to GI physiology and pathophysiology, enteral feeding formulae, dietary supplements, food allergies, nutrition in GI disease management, drug-nutrient interactions.

Endocrinology:

Skills - nutrition screening, assessment and diagnosis related to endocrine disorders, referral to diabetes educators and registered dietitians for nutrition education.
Knowledge - nutritional pathophysiology of the endocrine system, nutrition in diabetes management, nutrition and biochemical pathways related to the endocrine system, use of dietary supplements in diabetes, nutrition in exercise and sport.

Oncology and Hemotalogy:

Skills - nutrition screening, assessment and diagnosis related to cancer and blood disorders, referral to qualified nutrition professionals such as registered dietitians for counseling related to nutrition and cancer treatment.
Knowledge - nutritional pathophysiology related to cancer and modulation of tumor development in regard to specific nutrients and food intake, nutrition in cancer prevention and treatment, clinical manifestations of malnutrition in cancer, nutrition in hematologic disorders, e.g., microcytic iron deficiency anemia, macrocytic anemias related to folate and B12 deficiencies, use of dietary supplements in cancer care, enteral feeding formulae, drug-nutrient interactions, side effect management.

Cardiology:

Skills - nutrition screening, assessment and diagnosis related to cardiovascular disease, referral to qualified nutrition professionals such as registered dietitians for counseling related to CVD, referral to community education programs such as cardiac rehabilitation, heart healthy cooking classes, etc.
Knowledge - nutritional pathophysiology related to the cardiovascular system, lipid biochemistry, nutrition in preventive cardiology, dietary management of lipid disorders and other cardiovascular diseases such as congestive heart failure, atherosclerosis, nutrition in exercise and sport, drug-nutrient interactions, weight management.

Nephrology:

Skills - calculation of special diets for patients with renal failure and other nephrologic disorders, referral to qualified nutrition professionals such as registered dietitians for counseling regarding medical nutrition therapy for patients on dialysis, with ESRD, etc., nutrition screening, assessment and diagnosis related to kidney disease, monitoring electrolytes, serum proteins, etc.
Knowledge - nutritional pathophysiology related to kidney diseases, electrolyte and protein biochemistry, medical nutrition therapy in kidney diseases, drug-nutrient interactions.

Rheumatology:

Skills - nutrition screening, assessment and diagnosis related to rheumatologic disorders, referral to qualified nutrition professionals such as registered dietitians for counseling, monitoring of nutritional status of patients on steroids.
Knowledge - drug-nutrient interactions, dietary supplements used for patients with arthritis, nutritional pathophysiology related to collagen diseases, rheumatoid and osteoarthritis.

Pulmonology:

Skills - nutrition screening, assessment and diagnosis related to pulmonary diseases, referral to qualified nutrition professionals such as registered dietitians for counseling, monitoring of nutritional status of patients on steroids.
Knowledge - drug-nutrient interactions, dietary supplements including enteral formulae used for patients with lung disease, nutritional pathophysiology related to pulmonary diseases, use of anabolic agent.

Rehabilitation Medicine:

Skills - nutrition screening, assessment and diagnosis related to patients recovering from cerebral vascular accidents, injuries, major trauma, etc., referral to qualified nutrition professionals such as registered dietitians for counseling and education, home health care nutritionists, etc.
Knowledge - how nutritional status is affected by disability, loss of mobility, etc., nutrition and metabolic stress, nutrition and wound healing, dietary supplements including enteral formulae used for patients recovering from injuries and stroke, relationship between injury and stroke and loss of ability to eat, swallow, loss of taste and smell to nutritional status and intake.

Sports Medicine:

Skills - taking various anthropometric measurements related to body composition, referral to qualified nutrition professionals such as registered dietitians for counseling and education related to sports nutrition.
Knowledge - the relationship between nutrition and physical activity, performance, and endurance in athletes, so called ergogenic aids and dietary supplements popular with athletes (safety and efficacy), nutrition and physical training, eating disorders, weight management.

Dermatology:

Skills - nutrition screening, assessment and diagnosis of dermatological diseases with a nutritional etiology, referral to qualified nutrition professionals such as registered dietitians for counseling related to nutritional deficiencies, excesses that manifest in skin disease (e.g., perifollicular echymoses due to ascorbic deficiency).
Knowledge - the relationship between specific dermatologic disorders and nutrition, e.g., eczema and food allergies, dietary supplements used for skin diseases, e.g., retin A.

Allergy:

Skills - nutrition screening, assessment and diagnosis of allergic disorders that have a food component, referral to qualified nutrition professionals such as registered dietitians for counseling related to food allergies.
Knowledge - food composition, nutrition and immunology, enteral formulae suitable for individuals with specific allergies.

Obstetrics and Gynecology:

Skills - nutrition screening, assessment and diagnosis of gynecological disorders and obstetric complications such as osteoporosis, fibrocystic breast disease, menopause, toxemia of pregnancy, hyperemesis gravidarum, excessive weight gain, and others, referral to qualified nutrition professionals such as registered dietitians for counseling and education related to nutrition and women’s health issues and pregnancy, referral to community nutrition education programs on breastfeeding, infant feeding, etc.
Knowledge - nutrition and embryology, nutrition and fetal growth, dietary supplements used in women’s health and pregnancy, dietary management of complications of pregnancy, gestational diabetes, eating disorders.

General Surgery:

Skills - consultation with registered dietitians familiar with surgical nutrition issues, monitoring of parameters of nutritional status, placement of enteral and parenteral feeding lines nasogastrically, percutaneous endoscopic gastric tube, jejunostomy, subclavian vein, etc.
Knowledge - nutrition and metabolic stress, nutrition and wound healing, enteral and parenteral formulae composition and indications for use, nutritional needs of surgical patients, indications and contraindications of aggressive feeding in surgical patients, use of anabolic agent.

Otolaryngologic Surgery:

Skills - nutrition screening, assessment and diagnosis of head and neck diseases including cancer, loss of sensory perception, consultation with qualified nutrition professionals such as registered dietitians familiar with head and neck surgery.
Knowledge - nutritional pathophysiology of sensory organs, enteral and parenteral formulae suitable for patients undergoing head and neck surgery, nutrition and wound healing, nutrition and surgical/metabolic stress.

Orthopedic Surgery:

Skills - nutrition screening, assessment and diagnosis of bone and joint disorders that have nutrition components, e.g., osteoporosis, osteomalacia, rickets, osteoarthritis, etc., referral to and consultation with qualified nutrition professionals such as registered dietitians for counseling regarding safe methods of weight reduction prior to surgery if indicated, increasing calcium in the diet regarding osteoporosis, etc.
Knowledge - nutrition and bone modeling, nutrition and metabolic/surgical stress, nutrition and wound healing.

Vascular Surgery:

Skills - nutrition screening, assessment and diagnosis of vascular diseases that have nutrition components, e.g., peripheral vascular disease, consultation with qualified nutrition professionals such as registered dietitians for monitoring nutritional status and counseling regarding medical nutrition therapy aimed at lowering blood cholesterol, altering platelet aggregation, etc.
Knowledge - nutrition and metabolic/surgical stress, nutrition and wound healing, nutrition and vascular pathophysiology, enteral and parenteral feeding formulae.

Cardiothoracic Surgery:

Skills - nutrition screening, assessment and diagnosis of cardiovascular and pulmonary diseases that have nutrition components, e.g., coronary artery bypass surgery, lung cancer surgery, etc., consultation with qualified nutrition professionals such as registered dietitians for counseling regarding optimizing preoperative nutritional status, post operative medical nutrition therapy, monitoring post op nutritional status.
Knowledge - nutrition and metabolic/surgical stress, nutrition and wound healing, nutrition and cardiac and pulmonary pathophysiology, enteral and parenteral feeding formulae.

Reconstructive Surgery:

Skills - nutrition screening, assessment and diagnosis of burn or trauma patients requiring plastic or reconstructive surgery, cancer patients, etc., consultation with registered dietitians familiar with trauma, burn, and cancer patients nutritional needs, monitoring nutritional status.
Knowledge - nutrition and wound healing, nutrition and metabolic/surgical stress.

Oncologic Surgery:

Skills - nutrition screening, assessment and diagnosis of cancer patients requiring surgical intervention, consultation with registered dietitians familiar with oncology and surgery patients’ nutritional needs, monitoring nutritional status.
Knowledge - nutrition and metabolic/surgical stress, special nutritional needs of cancer patients, enteral and parenteral feeding formulae, nutrition and wound healing.

Neurosurgery:

Skills - nutrition screening, assessment and diagnosis of patients with neurological diseases requiring surgery, e.g., Parkinson’s disease, brain tumors, etc., consultation with registered dietitians familiar with surgical patients’ nutritional needs, monitor nutritional status.
Knowledge - nutrition and metabolic/surgical stress, enteral and parenteral feeding formulae, nutrition and wound healing.

Nuclear Medicine:

Skills - referral to and consultation with qualified nutrition professionals such as registered dietitians for patients experiencing nutrition related side effects from undergoing whole body irradiation, e.g. thyroid cancer.
Knowledge - radiation effects on nutritional status (on a cellular, e.g. hematologic, and tissue level, e.g., salivary glands).

Radiation Oncology:

Skills - nutrition screening, assessment and diagnosis of patients undergoing radiation treatment for various types of cancer, referral to and consultation with qualified nutrition professionals such as registered dietitians for counseling and recommendations for medical nutrition therapy.
Knowledge - effects of radiation on gastrointestinal system that would affect food intake, digestion and absorption (head and neck radiation, abdominal, pelvic radiation), enteral feeding formulae for nutritional supplementation.

Radiology:

Skills - diagnosis of nutrition-related disorders that can be identified by x-ray, CAT scan, MRI, PET scan, bone densitometry, etc. (e.g., rickets diagnosed through identification of bone deformities, osteoporosis).
Knowledge - nutrition and physical diagnosis, radiologic manifestation of various nutritional disorders.

Pathology:

Skills - diagnosis of nutrition-related disorders that can be identified by gross and cellular pathology identification methods, e.g., protein deficiency.
Knowledge - nutrition and physical diagnosis, nutritional pathophysiology, the role of nutrition in tissue and cellular alteration in disease.

Psychiatry:

Skills - nutrition screening, assessment and diagnosis of patients with psychiatric disorders that have a nutrition component (e.g., depression, anxiety, eating disorders, obsessive-compulsive disorder), referral to and consultation with nutrition professionals such as registered dietitians for counseling and recommendations regarding medical nutrition therapy.
Knowledge - drug-nutrient interactions, nutrition in physical diagnosis, nutritional effects on neurobiological systems.

Neurology:

Skills - nutrition screening, assessment and diagnosis of patients with neurological disorders that have a nutrition component (e.g., neuropathies in diabetes mellitus, vitamin deficiency diseases such as B12 deficiency, Parkinson’s disease).
Knowledge - drug-nutrient interactions, nutrition in physical diagnosis, nutritional effects on neurobiological systems

Laboratory Medicine:

Skills - designing, evaluating and conducting assays to determine alterations in nutritional status regarding sensitivity and specificity, and accuracy and reliability.
Knowledge - nutritional biochemistry, nutrition and microbiology.

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