Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal symptoms.
In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.
The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Dr. Pashinsky, a gastroenterologist with New York Gastroenterology Associates and affiliated with Mount Sinai Hospital in New York.
“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.
Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.
“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.
One 2022 studybased on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.
But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.
Nutrition overlooked in procedure-heavy specialty
In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in U.S. medical schools.
Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Dr. Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania and director of the Penn Center for GI Nutrition, both in Philadelphia.
Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Dr. Pashinsky noted.
GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Dr. Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.
The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.
Despite these requirements, the education that fellows receive often falls short for several reasons, said Dr. Sprung, an associate professor of medicine at the University of Rochester Medical Center’s gastroenterology and hepatology division in New York.
Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.
Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Dr. Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.
It is possible that some fellowships are just not teaching these core concepts, Dr. Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.
Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Dr. Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.
“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.
It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Dr. Pickett-Blakely said.
GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Dr. Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.
If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.