A critic of modern processed foods, a fan of vitamin A supplements and a commentator on the failure of the medical establishment to take nutrition seriously. Surely, I must be referencing RFK Jr, right? Actually, I’m describing Adelle Davis, a Master’s-trained dietitian who was a widely influential post-WWII nutritionist, writing popular books, appearing on Johnny Carson’s show, and influencing the elites of the time. That so few modern self-styled nutrition advocates know of the woman Time Magazine referred to as the ‘High Priestess of Nutrition’ in 1972 says a lot about the durability of pop-nutrition that blurs the line between science and pseudoscience- and offers a lesson for our current era of top-down nutrition fanfare.
Modern medicine – rooted in a self-critical, biological understanding of disease, epidemiology & clinical evidence – took time to take hold and outcompete various alternatives (e.g., homeopathy, osteopathy) gaining broad acceptance by the 1930s or so. Nutrition was slower on the uptake, in part because it is much harder to study, but also because it has not been taken all that seriously. When your science regularly gets diluted with faddism, snake oil sales(wo)men and quackery, the baby (real nutrition science) goes out with the bathwater. This was the central problem with Adelle Davis. Not unlike the modern influencer, she had a nutritional cure-all for everything. While she often trafficked in relatively harmless foodie maxims, her books and teachings were full of inaccurate and misleading statements, misinterpretations of the research, and outright dangerous advice – advice that put children in hospitals with Vitamin A and D poisoning (truly history is so good at repeating itself) and contributed to the death of a colicky child given high doses of potassium chloride. Like a broken clock, Davis had some correct and arguably forward thinking advice about nutrition and chronic disease, but that message suffered under the weight of its extremes. Davis is but one example of many in American history of folks who took enthusiasm for nutrition too far and made it more gimmick than science (see Deutch’s The New Nuts Among the Berries for a full read on this).
Nutrition has come a long way in gaining legitimacy since the time of Davis. Our basic understanding of the components of food and how they interact with our physiology and disease risk factors are much better understood at the molecular level. Large cohort studies assessing diet in relation to disease risk have been established. Seminal controlled trials have shown the potential for food and broader lifestyle interventions to reduce the risk of chronic diseases. Transparent systematic review and certainty of evidence grading norms have (for the most part) taken hold in the field to limit and address bias where possible. There is of course substantial progress to be made, but the promise of evidence-based nutrition is very real and its integration into our biomedical institutions is appropriately beginning to take hold. These gains in legitimacy are, however, fragile, and advocates for nutrition need to be hypervigilant to prevent the juxtaposition of real nutrition science with BS. If nutrition guidance is to be trusted, improve health outcomes, and stand the test of time, it must be clearly separated from the non-evidence-based and pure quackery – a tall order in the era of the profiteering wellness influencers, many of whom are credentialed medical and scientific professionals.
Given all of this, you might think that I’d be happy about the efforts by HHS to require nutrition in the medical school curriculum. I’ve talked before, at a high level about my concerns with overselling the role that physicians will play in nutrition, but I nonetheless remain enthusiastic that physicians who are equipped with legitimate nutrition training will help better catch nutrition-related health issues, refer to Registered Dietitians more and connect patients in need with community resources. They’ll also learn the basics of nutrition science that can help cut through the crap for their patients who want to know what the evidence shows and doesn’t show. But to do that, we need to ensure that the training that they get is legitimate – and that’s where I see some evidence for concern.
Last week, we saw >50 medical schools endorse a federal framework for nutrition education in medical training. The framework contains 71 competencies across 10 domains, from which HHS recommends fortifying existing medical curricula with competencies that contribute at least 40 hours. The framework claims to be ‘informed’ by a 2024 Consensus statement on nutrition competencies for physicians published in JAMA. To be clear, these competencies are not a mandated curriculum and provide substantially more hours than they recommend (191.5 hours total in their competencies)( but they are endorsed by about 25% of medical schools, and they contain some red flags, that won’t be too surprising to anyone following MAHA and the Surgeon General Nomination.
Within the 71 competencies, you see a lot of basic things you might expect – understanding food composition, how disease affects nutrient absorption, nutrition assessment, drug-nutrient interactions, counseling approaches, etc. These concepts are expected and many are listed in the 2024 JAMA consensus statement but the administration slipped in more than a few new eye-brow raising competencies.
Some of the more questionable competencies ..
Readers can review the competencies in full themselves – I’ve binned my thoughts on these competencies in a few categories:
The Preclinical and the Handwavey: If every physician is going to learn nutrition, the priority should be basic assessment, common nutrition interventions, and knowing when to refer to dietitians. Mechanisms matter, but only to the extent that they support a clinical understanding. There’s not a whole lot of reason to focus on epigenetics, microbiome-immune crosstalk, and ‘network’ or ‘systems’ biology concepts – that’s more for a PhD program in nutritional sciences and, given the present state of evidence, provides limited clinical insight. You could argue these are nice to know, but to date, we don’t have any nutritional therapies whose clinical benefits are established through specifically targeting the epigenome and microbiome – you feed high-fiber diets when the clinical evidence indicates it, not because you can handwave that they make butyrate that’s good for leaky gut. Arming physicians with this handwavey mechanistic rationale is exactly how you get entire pseudo-specialties like ‘functional medicine’ that flip the evidence hierarchy upside down, encouraging mechanism over clinical data. When we teach physicians about nutrition, we should be emphasizing nutrition’s link to clinical endpoints, not fueling the fire of more functional medicine physicians invoking epigenetics and methylation to sell genetic tests and expensive supplements to patients.
Supplements, Testing and Wearables: There’s an emphasis across several competencies on assessing panels of biomarkers via testing and wearables that currently no major medical guidelines recommend testing for. CGMs are also enthusiastically mentioned, despite limited evidence that they effectively guide nutrition therapy (and limited evidence they do much out of insulin-managed diabetes). Supplements make their way in with talks of optimizing biomarkers and pursuing nutraceutical interventions. I’m fine with an entry-level physician knowing these topics exist and are being studied, as well as the regulatory and technical issues that they face (e.g., how are supplements regulated and what explains the lack of disease endpoint trials for these as medical interventions? what are the challenges of interpreting real physiology, intra-individual variation and technical variation from each other with a CGM?) – however, it’s pretty clear from the wording in this document that HHS wants physicians to be enthusiastic testing and supplementation pushers. This isn’t too surprising when you peek behind the curtains of MAHA and see how many folks in the MAHA orbit are set up to profit from testing and supplement/nutraceutical interventions.
Odd Specificity/Not a Competency: I’ve written and reviewed competencies for educational curricula before- you tend to focus on broad topics/domains and word things in a neutral manner. You don’t specifically call out your favorite supplements and tests you want physicians to use as ‘first-line’ interventions – you state that practitioners should be familiar with common dietary supplements and their evidence base in relation to chronic disease risk. HHS seems to confuse a competency with a directive, and they seem much more interested in making sure physicians come out with a specific perspective than with an understanding of how to critically think about and holistically understand broad topics within a scope of practice. The competencies listed also commonly have the opposite problem – rather than being hyperspecific, they frequently suffer from saying nothing. Competencies 28 (“Network biology disease assessment: evaluate organ symptoms as downstream manifestations of upstream cellular dysfunction”) and 64 “Personal metabolic optimization: apply systems biology principles to own health data to experience clinical protocols” are great examples of the saying “you can say anything with words, even nothing”. These aren’t competencies that you can assess in a physician and I’m not sure any 2 medical educators reading them would interpret them even remotely similarly. They’re classic buzzword soup coming from functional medicine advocates that might land on certain corners of social media but aren’t what physician educators should be focused on. As you read through these competencies, you’ll find a lot of strange and quite disparate wording – no authors are listed but its clearly more than one person and the authors were pretty clearly not all on the same page.
Outside Scope: There’s quite a bit in these competencies that are just not really in an everyday nutrition practitioner’s scope, particularly the agricultural and farming competencies. I’m all for more nutrition folks getting into agriculture (I’ve encouraged RDs to pursue plant and animal science PhDs, as well as AgEcon) but we only need a small subset of these folks operating at government and industry levels to ensure that nutrition is considered in agriculture. The idea that a dozen hours of the medical education curriculum should have other medical competencies removed so that general physicians can learn about farming is pretty absurd. This, again, is not surprising for anyone who follows the ‘integrative and functional’ medicine brand that surrounds MAHA, as they frequently spread misinformation about supposed benefits of organic food and other farming modalities, overstate fears that modern farming has depleted nutrients from our food, and other viral talking points.
Missing Out: The focus on functional medicine competencies for physicians under the guise of nutrition not only risks integrating pseudoscience into medicine, it distracts from real nutrition competencies. In the competencies, it’s notable that dietitians are mentioned only once in the last competency in relation to billing for nutrition services and culinary medicine consultations with a dietitian. You’d think a huge part of making a physician who can impact on nutrition would be training them to interact with the dietitians that exist all throughout the medical system at the inpatient and outpatient level and functionally do most of the nutrition care that occurs. These competencies literally emphasize working with health coaches and ‘functional nutritionists’ but not RDs – it’s extremely unserious. There’s other major domains where the competencies miss out as well. The entirety of Domain 5 on Public Health Nutrition has essentially no real public health nutrition competencies and mostly lists agricultural and farming competencies. There’s nothing on understanding federal, state and local policies and programs that can help with food insecurity, obtaining medically tailored meals, SNAP/WIC, etc.
All in all, it’s quite concerning to see how much non-evidence-based and pseudoscientific nutrition, largely in the form of ‘integrative’ and ‘functional’ medicine, has taken over huge swaths of modern medicine. We’ve slowly seen the rise of these modalities across medical centers as they’ve realized this is a cash cow. It’s taken a prominent role in dietetics too, with the practice group ‘Dietitians in Integrative and Functional Medicine’ quickly becoming one of the largest and fastest growing practice groups in the society. Now, integrative and functional medicine is being pushed from HHS onto physicians. I am somewhat confident that most medical educators are wise enough to see these recommendations as just that, and will stick to the basics and evidence-based in their limited curriculum time to make more nutrition competent physicians. That said, given how much integrative and functional medicine has spread across academic medicine, I wouldn’t be surprised if there are medical schools out there clamoring to gain favor with this administration and, in trying to appear ‘cutting edge’, adopt some of these more pseudoscientific nutrition practices. This is ripe for creating an unfortunate situation where we have generations of physicians trained with wildly different takes on nutrition, some truly evidence-based and some bunk – not good for patient health outcomes, healthcare spending (if you’re not TrueMed) or public trust.
I hope that evidence-based practitioners across the board who are in and around MedEd make their voices heard that we really do need to be training physicians in the fundamentals of nutrition while empowering dietitians with this new emphasis on nutrition. Now is the time to resist setting nutrition back decades by integrating low-to-no-evidence approaches and pseudocientific modalities and to double down on rigor and research in the field. Let’s hope these standards go the way of Adelle Davis and are largely forgotten.
