One way to improve nutritional content in the curriculum is to get it in the national requirements for medical training keeping the requirement simple so the medical schools do not feel overwhelmed and providing easy accessible material that can be used without too much effort. If nutrition is seen as a vertical strand through the curriculum along with pathology, infection. physiology and biochemistry it is more likely to be integrated throughout the curriculum rather than a stand alone issue which is learnt and forgotten.

We need clinicians to remember to consider nutrition when seeing/treating a patient rather than being a full nutritional expert. However they should know basics such as basic nutritional needs and guidelines, calculating and interpreting BMI, when to give nutritional support and be aware of the importance of using nutritional screening tools to see if referal to a dietitian is required.

The question is really good food for thought.. Nutrition has to take a majot share of the medical school curriculum.. at times, we think, after teaching them too much about diseases, we make them forget what is health..

As I see it, the tension lies in the amount of material covered by the medical school curriculum (which is enormous) and the perceived relative merit of adding nutrition content to that mountain of material. Medical students are required to understand human biochemistry, but not as it applies to food, diet, culture and eating behavior. Maybe the reasonable compromise is in increasing medical education related to consistently encountered clinical problems (like pediatric eating and feeding issues or adult CVD) and then focusing on improving relations between physicians, nurses, pharmacists, etc. and the nutrition professionals who are strongly equipped to be good partners in nutrition and health promotion content.

Unfortunately, doctors are trained paying the utmost attention to make them become good at recognizing and treating diseases but we forgot that much of the work of doctors must be targeted to maintain healthy population so the doctor becomes healthy lifestyles inductor on the subject before they get sick. We are working hard in our university and on the field with the National S.It.I. to bring this awareness in medical education and in the operation of the National Health Service.

One way to improve nutritional content in the curriculum is to get it in the national requirements for medical training keeping the requirement simple so the medical schools do not feel overwhelmed and providing easy accessible material that can be used without too much effort. If nutrition is seen as a vertical strand through the curriculum along with pathology, infection. physiology and biochemistry it is more likely to be integrated throughout the curriculum rather than a stand alone issue which is learnt and forgotten.

We need clinicians to remember to consider nutrition when seeing/treating a patient rather than being a full nutritional expert. However they should know basics such as basic nutritional needs and guidelines, calculating and interpreting BMI, when to give nutritional support and be aware of the importance of using nutritional screening tools to see if referal to a dietitian is required.

I think epigenetics is coming more to the forefront as time goes on. The interaction between environment and genes are more strongly interrelated than previously thought. Therefore, what we eat and how our body responds to nutrients will gain more interest in future conventional medical school education. Also, with the further understanding of gut flora will strengthen our need to understand nutrition better. Further, how gut flora interact with medications will need further understanding. With an increase in chronic diseases and obesity rates, this will give education systems a push to introduce more nutrition into the curriculum. I think those who understand the importance of nutrition realize that the body should be examined as a whole system and look at the underlying causes of a patient's disease. Hopefully with further understanding of these topics, we will see an increase in the amount of nutritional education taught in schools.

A simple answer, because we have already a nutrition graduation. It's so big as medical school, so if you have interest in nutrition field, should have a specialization or make a new graduation.

I think Jessie Alwerdt Described the problem and the future trends very eloquently.

We dont want MDs to graduate with a double major in Medicine and Nutrition, we just want them to be well informed in Nutrition and its complex relation with all health aspects. True in the developed nations we dont see much of the undernutrition (such as stunting or wasting) problems but we see a lot of the Obesity/Over weight side of malnutrition (which is by the way becoming a problem spreading even among the poorest of the poor in Rural and Urban developing nations).

The Microbiome projects shed some light on the interplay between Gut microbiota and Nutrition and health (you are what you eat is not just a slogan for good helath, it is a fact). With Human Microbiota ecosystem being determined early in life (by age 2 the latsest as some scientific evidence show), it is important to pay a lot of attention to our nutrition from early on in life. Epigentic changes/medictine and gut microbiota play a major role in our brain development, immune system, health over all, nutritional outcomes...etc.

A physcian should not only look at how to treat illness using pharmacological agents, its a wrong approach (let us not forget Our body does not look it that way, and if you dont have a healthy nourished body medication wont do that much good, and the success of the PEPFAR program to fight AIDS was becuase it was a fully integrated program providing nutrition and and-HIV medications)

Med schools, Nursing shcools & pharmacy schools should integrate more nutrition Education in there programs, make it a requirement not an elective class, Studying human physiology, anatomy, pathology all is important but also human nutrition is as important as the other classes. True if you want to become specialized in nutrition and have an advanced degree in nutrition science you need to go back to school and get a graduate degree and do research, but basic human nutrition elements and education should be taught and made part of any Health science program just like anatomy or physiology..etc.

As to why not it is at it is current status right now? I think it is just due to the lack of broad vision on what affect human health and the whole medical/nursing/pharmacy curriculum should be changed and modernized. I am a pahrmacist by training and a Pharmacologist/health sceintist with a research focused on Metabolic syndrome and When I was working in a pharmacy (thanks to the several elective and mandaotry human nutrition classes I took as an undergrad) Everytime I had a pateint walked into my pharmacy I always asked about their nutritional status (what they eat, how much they eat fruit, vegitables, meat...etc), always double checked their histroy, drug-food interaction based on what they eat, and adviced them on better nutritional and eating habits when needed.

If we think about Nutrition as we should it will become obvious that "Nutrition" is the core of any/most successful medical interventions and a well norished body respond better to treatement and therapy..i.e HOW NUTRITION CAN HELP YOU ACHIEVE YOUR GOALS in treating your patients.

The same question can be applied to the promotion of physical activity. Having a healthy diet and engaging in regular physical activity are two means by which the risk of many non-communicable diseases can be reduced. Perhaps one reason why these are not majored on in medical courses is because physicians are trained more in relation to treatment rather than prevention of disease. By the time an ill patient visits their doctor it is too late to tell them that a healthy diet and regular activity will prevent them from becoming diseased.

Robert Elbl: Allow me to disagree with you on a couple of things:

1) Your look at Medicine in the old fashioned way, medicine is far borader than it is as you described it. In fact Physcians Are not the best qualified person to prescribe pharmacological agents, Most of the prescribtions happens on previous obesrvations, best recommended drug, best active...etc and a lot of trail and error to get to the best pharmacological agent at the end. They are the best to make a diagnosis based on lab results...etc , but my own views is that after making a Dx, they should work with a pharmacist to do most of the recommendations for the best drug based on pateint history, other medication he/she is taking, food and diet consumed..etc to look at the whole picture. Most Physcians dont consider other medications the pateint is taking and that is when drug-drug and Drug-food interactions happens (in particular when you are dealing with and elder pateint or those with chronic disease were you will have multiple conditions and multiple drugs used, and some of those drugs have been prescribed to tamper the adverese effects of the other drugs the prescribed for the patients and they add on). When works together an MD and a Pharmacist as a team that is when the best results happens (you have to conisder especilly for drugs with narrow therapeutic window) the TDM, Pharmacokinetics and not only the pharmcodynamics when prescribing a medication to such pateints

2) Diet and many micronutrients have been proven to play a significant role even at the very narrow genetic level in modulating health and genetic experssion and could either aid/impaire drug therapy (refert to many peer reviewed puplications on that topic such as those for Geir Bjørklund et al , Speiglman B et al...etc)

3) Even I agree with you on that Some of the So called "Nutritionist" know not much of the science especially those who never did any actual scientific research, but a well trained and Scientist as a nutritioned is a good team member and aid in providing a lot of support to help in patient therapy.

4) New evidence emerges every day from the Microbiome projects (refer to publications on that and reviews such as the role it plays in Immune system, brain and behavior, nutritional outcomes, ...to mention a few ). Our knowledge and understanding of the factors affecting human health and health outcomes are evolving everyday and science and evdience based interventions in many diesases states are changing faster than you can keep up with them.

5) Not sure about the medical education in Germany and how much nutrition classes are part of the curriculum, but its a worldwide problem not only in one country vs the other.

6) I agree with you on that patients should refrain from going to uneducated and untrained healers for help, this can cause more damage to their health than good and would aggrivate thier conditions sometimes behind repair. But even in any conditions if that superior medical interventions is not accompined by good nutrition and well norished body and mind It wont be of any good and in fact it will harm the body that is malnourished. Remember the body operate as a whole one unit not as for example muslces or skelton alone ...etc, a broken bone need a good orothpeadic surgeon to fix it and a good pain killer to lessen the pain but also good nutrition to help the body heals

Just a thought!

Cheers

Very good question!!!

As a veterinarian I feel nutrition is not well understood in human medicine, as many other preventive medicine issues, except for vaccination. Many effects of nutrition are seen only years later and is hard for people to see the importance.

This discussion is really needed not only in medicine but in many other fields. It affects environment, culture, health...

It should be when of the first ten leading causes of death at least 4 are nutrition related (heart disease, cancers, strokes, and diabetes mellitus). I believe all diseases one way or another are related to nutrition. Maybe we should have MDs graduate with a double major in Medicine and Nutrition!

As you so ably pointed out, Michael, nutrition is indeed the answer in treating most disease, though when we say this we need to point out that synthetic fortification in overprocessed food, or those handy synthetic multiple vitamins that are chewed like Gummie Bears--the main "nutrition" products put out by the pharmaceuticals--are a far stretch from the true meaning of nutrition. Unless a study carefully defines and controls for bioavailability of what is being studied, the results of the study are not reflective of nutrition in general. What the body does with it is ultimately the thing that matters. We have seen subjects who take all the popular vitamin pills who score high on the Gelactin-3 and CRP, only to see their inflammatory response fall to the floor where it belongs by taking their nutrition in organic form. The universe of each nutrient, complete with amino acid chains, enzymes, and uncountable co-factors are what need to be considered instead of the lifeless bare-bones chemical diagram of synthetic nutrition. When these distinctions are made in the course of medical education I believe we will see greater concern for addressing the underlying causes of disease and less for its more superficial symptomology.

Robert, I agree with what you write about titles and mountebanks, but this is an other question. It is important to do more research on the brain-gut axis. You will find relevant articles in PubMed and other databases.

Robert, increasing evidence points to a rather intimate gut-brain axis. Thus in inflammatory bowel disease white matter almost hives like changes could be found using NMR, after a meal (Geissler 1995, Hart et al. 1998). Also in autism, the effect of dietary intervention (Knivsberg et al. 1990, Lucarelli et al. 1995. Knivsberg et al. 1995, Whiteley et al. 1999, Cade et al. 2000, Knivsberg et al. 2002) and AD/HD such a link is probable (Egger et al 1985, Uhlig et al. 1997, Reichelt et al. 2008). If you are interested you can search relevant articles in PubMed and other scientific databases. Personally, I'm at a medical faculty, and I know only physicians who do research in this field.

Geir: To answer your question, I have no idea, but would be a staunch supporter of making nutrition a major field of study in a medical doctors pursuit of their degree. A concern noted by Robert Eibl above would be alleviated if the Drs themselves had a sound foundation in nutrition, or at least made their OWN patient referrals to nutritionists/dieticians) when appropriate

in reaching this perspective, I researched the old-adage, “you are what you eat”. While it still holds true, it apparently has the following caveat “you are what your mother ate and did when she was pregnant with or nursing you.” (Child Health, Developmental Plasticity, and Epigenetic Programming. Hothberg et al April 2011) especially during our childhood

Furthermore, when introducing the concepts behind Dr Ames’ 2010 Triage theory that links cancer risks with insidious deficiencies of micronutrients coupled with Chiang’s et al’s U-shaped dose response curve denoting an optimum range of selenium (and deleterious deficient and surplus levels) a state of equilibrium pattern emerges that shows the need for balance of needed nutrients. I would doubt that similar U-shaped curves don't exist for pretty much every nutrient (ie rare but documented cases of persons dying from drinking too much water - dilutional hyponatremia. ) These papers simultaneously convey that the pervasive society reductionist view that augmenting one vitamin/nutrient without even having a clue if you are deficient in it has been a wrong approach in the pursuit of wellness. One aspect not yet incorporated into this mix is our need as a species to limit consumption of unneeded foods (including excess quantities...there is more then adequate background here if you look at the obesity and/or calorie restriction research) ). Scary in a way that what is looking like the preeminent cause of the negative alterations in our cellular environment has been insidiously self-inflicted, a meal at a time and a personal nutritional practice .

Does nutrition count big-time, uh huh! We just aren't very good at it yet

Excellent remarks, Fleming! Thank you.

Thanks Geir for further details --- now, it really sounds like getting into real science, but the way you asked the question was not totally scientific: it implied that medicine would not be competent for nutrition. I really do not see this to be true - who Else could Measure the effects better??? With what scientific Parameters?

I may just add my brain storming, so it may not help: non-neuronal acetylcholine is present everywhere including the gut; prion proteins get over the gut into leukocytes and are transported into the brain; I always wondered if any -still unrecognized other contagious Proteins so exist, with just Too Long latency periods to be found in Animal experiments for, for example, Alzheimers disease.

Two more thoughts:

1. Medical education is usually for better or best learners, but still is full with a curriculum of 6 years minimum. Nutrition is part of the current curriculum in just so many topics, from biochemistry, physiology to pharmacology, internal medicine and dozens of other disciplines.

2. the real education of a physician just starts after finishing med school, i.e. another 5-20 years of working in a often very, very specialized field, so that only few in the world can perform some operations at its best. This means of course: not every physician needs to know or do everything. Not every physician wants to become the god in medicine, like the best neurosurgeon in the world, but I would not recommend to ask a nutritionist to remove a brain tumor of a patient.

Conclusion: whenever it comes to nutrition, it may be best to look for a specialized person in the field, with a little more than just 2 or three hours of an online university diploma or PhD h.c. not worth the paper its printed on.

Outlook: Any new hypothesis and theory with nutrition and potential benefit needs to be proved - and side-effects determined. That can mean that any new treatment may need 50 years to show any benefit over the side-effects.

Yes, nutrition is an integral part of medicine. I see no reason to disagree here.

"The gut and the brain – with focus on autism spectrum disorders" was the title of a one-day well attended symposium held in May 2012 at the Nobel Forum of the Karolinska Institute in Stockholm. You may find some of these lectures of interest. They are published as articles in the open access journal Microbial Ecology in Health & Disease. You find these articles on the following webpage under "Thematic cluster: Focus on autism spectrum disorders": http://www.microbecolhealthdis.net/index.php/mehd/issue/view/1430

Back to the main issue: Why isn’t nutrition a bigger part of conventional medical school education? Is there more views?

One approach that we are examining in our medical school is to focus on resident education (rather than medical school where the curriculum is so tightly packed and less flexible to immediate changes). Residents have short electives they can choose and also desire online short modules. Our recent strategies include developing self-directed learning opportunities that focus on specific clinical issues (e.g. breast feeding, growth faltering [and nutrition content related to poor growth]). The "relevance" of these modules is evident to the target and the adoption potential (at least from the feedback to date) is quite high. The overall strategy is to identify nutrition topics that are commonly encountered, perceived as valuable and timely by the target and that are flexible with respect to how they can be incorporated into the structure of the program.

Can I suggest those interested have a look at what is happening in UK. Here a working group was instigated to enhance the nutrition education in medical schools some years ago with the support of the Royal Colleges and with clear objectives included in the Tomorrow's Doctors document which prescribes the requirements for medical graduates.

http://www.aomrc.org.uk/committees/intercollegiate-group-on-nutrition/item/undergraduate.html

Both nutrition and pharmacogenetics are being taught at least our University, but one topic I think will come before personalized medicine is gender different doses. We know now that some medications with a small therapeutic window (2-3 fold of therapeutic dose) have up to 33% difference in the bioavailability in the body between males and females. However, prescription writing for the drug is written under one blanket recommendation.

Nutrition has been left behind in the past; however, now it has to be taken into consideration in every patient encounter which has led to the adoption of its own class to learn a survey of nutrition from TPNs, vitamins, and herbal remedies along with that taking the knowledge previously learned while applying it in a therapeutic situation in the rest of our classes.

I think the reason is certainly related to the lack of "preventive medicine" being taught in most medical schools, which are still highly disease-focused and pay scant attention to the social determinants of health and the relationship between community, family, environment and health.

Robert: I see your point of being frustrated with those self proclaimed "Nutritionists" And I totally 100% agree with you on that. I see this kind who write a title of "Nutritionist" after their name everyday and I interact with them on daily bases-which is not my favorite part of my work by the way- The problem as you pointed out is those who call themselves nutrition experts who have done ZERO research in the area and may be got an MPH online, and they may have read a chapter or two on Nutrition, and then they come and try to advice others on what is best for their health or to stop taking their medications and cure their body with food and vitamin supplements. Even some Celebrities will jump into the medical filed and provide some answers to some questions (such as the nut case Tom Cruise being anti-vaccination) .

The point is Who is better to be educated in Nutrition science and provide nutritional advice to the patients? Its bets given to them by their health care provider and not left or referred to an uneducated person.

Cheers, And thanks Geir for posting such a question

Could I pick the brains of those who have written before me. Not every physician needs to know or do everything, in fact it is not possible for one person to know everything. Early in the century our country introduced the concept of Allied Health where the "" health team" is collectively charged with caring for the health of the community and this includes "preventive medicine". This should preclude the need for nutrition . Exercise Physiology .and other allied health professions being taught in medical schools. Till these Allies are encouraged to work together and not overshadowed by the GP or Neurosurgeon our "HEALTH SYSTEM" will bel highly disease-focused and pay scant attention to the social determinants of health and the relationship between community, family, environment and health. Because the Medical fraternity spend 7 years at university we feel they should be consulted about Exercise Physiology and Nutrition which they are exposed to for 15 minutes. I would like to ask pardon for plagiarising the words of my colleagues. Eric

I have talked with previous medical doctors (mostly family practitioners) in the past about incorporating nutrition into their regular routines at their clinic. Although they give out this nutritional information sometimes, they find that the patients have a hard time changing their patients' lifestyles. Therefore, the practitioners see no change in their patients' nutritional habits over time. Although, this is not the case for all. Maybe this is why some medical doctors feel it should be left up to nutritionist? Additionally, since it is not taught extensively in the majority of medical school programs, there is no fast effective way to give that information to the patients without being time consuming. I am sure these past experiences that doctors have had impact what and how curriculum is taught in conventional medical school education. Again, I believe that nutrition should be a large part of the medical school curriculum. With these issues I mention above, I think there is a lot of research still needed to examine what factors can persuade people to obtain a healthier lifestyle in the most effective manner. Again, with the research accumulating on subjects such as epigenetics and the gut-brain axis, medical professionals will see the forthcoming of nutrition to be the utmost importance. Perhaps, an interdisciplinary approach will be the more accepted route where we find the best way to find real change in the human population. This would include working with other professionals, but not leaving just one person to deal with nutrition (only the nutritionist). Instead, every medical professional stresses the importance and is part of the educational route of administering nutrition information along with the other expertise.

Robert

Please look at my post above. In the UK we have debated this in depth at several meetings of those who so teach in Medical Schools and who are experts in evidence based nutrition.

I would also add in the UK we have an Association for Nutrition (AfN) http://www.associationfornutrition.org which accredits Nutrition training at University level and individuals against clear criteria for an evidence based and professional approach, with a code of practice to deal with many of the issues discussed in this forum. Thus we have registered Nutritionists who are not using 'alternative nutrition' approaches but seeking to have excellence in nutritional science and public health nutrition and other professional areas.

Thank you for the update in UK, Christine. In the US, we have similar associations and agencies, but vary widely from state to state as to who may call themselves a "nutritionist". Most states uphold very high standards in this regard. Ahmed ably pointed out that only those who have formally studied science behind nutition and health and who meet the requirements of their respective areas can call themselves such.

My physician students have told me, on the other hand, that in-depth, evidence-based nutrition education, is missing in their medical schools, although that seems to be changing lately. How food interacts in the human body is an important part of psychoneuroimmunology (PNI), so as we see expansion of programs that include PNI we see curriculums that include more nutritional training.

The graver worry today in American medicine, is that it is so tied up in litigation and class action lawsuits re the bad reactions to recently released and to some of the older medicines (statins, SSRIs, neuroleptics, DMII meds, etc.). These pose far greater threats to the public health, especially in today's polypharmacological practice, than nutrition ever has. Just the same, efficacy and safety in all things prescribed or counseled must be foremost in the healthcare arena.

Perhaps it is the reductionist approach of western medicine that is to blame. It would make sense that ALL doctors could (and should) pay attention to the patient's diet in connection with the pills they prescribe. They should also pay attention to patients' genders and ages, their stress and anxiety levels, and their life situations. It is not rocket science to expect doctors, especially generalists, to be aware of the specific situations of their patients. Contemporary western medicine suggests that for every disease/complaint there is a specialist who should be consulted. But what has happened to the common sense of seeing the patient as a whole person who should, and could be treated in a holistic manner? Many generalists serve as gatekeepers who refer their patients to specialists for simple medical issues rather than treating them themselves. Team care with Allied Health professionals is a good solution, but I know from experience that this is difficult due to complex logistics of gathering team members to consult on a single cae, and it is very time-consuming and expensive.

I totally concur with Max and Mariana. Ahmed the problem is that the average healthcare provider is not educated in Nutrition thus not capable of providing in depth advise.

I agree with most of what has been said. I am depressed at the lack of nutritional knowledge in the current generation of medical practitioners.

A knowledge of INFLAMMATION and the connection with prostaglandins, cytokines, eicosaenoids, and the interleukin series etc - and their role in the development of the metabolic syndrome, diabetes, cancers, Alzheimer's and mental illness would , I think, underline the enormous importance of understanding the role of nutrition in generating inflammatory states that lead to the development of these illnesses. I wonder if it could be introduced into the medical curriculum through various channels (painlessly as suggested above) but also in the understanding of the immune system. Prof Robert Lustig has made the point that the NHS and Medicare will go bust by 2020 because of the increase in these illnesses and their complications, which COULD be prevented to a large extent by nutritional means and many eminent people in the field agree with him.

In USA there is a lack of nutrition education in Med Schools. Most medical schools in the United States fail to provide even a bare minimum of nutrition training. I am occasionally in the uncomfortable position of having to tactfully correct well intentioned but erroneous nutrition advice that a physician has given a patient.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430660/pdf/nihms-53396.pdf

Mariana and Dianne hit the nail on the head by introducing into the discussion the reductionist vs open systems debate (which can create the types of situations to which Michael referred) and the inflammatory factor that so often is made worse with medications AND synthetic nutrients. So much chronic disease is rooted in the proinflammatory cytokine cascade, creating over time acute disease episodes. So that if only the symptoms were addressed by the health practitioner and not the underlying causal factors, the patient goes through a revolving door of repeated episodes and, often, multiple medications that only provide temporary relief before crashing into a new level of disease.

But there is also a practical side to the debate on this and that is how does a physician who is expected to see 20 to 30 patients per hour in a clinic address the areas that need careful investigation--often of factors not detected in blood tests or xrays--in a way that is meaningful to the patient's health status? In the US, $100,000 annual liability insurance premiums for a general practitioner is common, as is $300,000/yr and up for surgeons and higher yet for the fast fading numbers of gynecology specialists. This places an unsustainable burden on medicine under wihch not even the most conscientious physicians can fully function.

Few patients in our public clinics and emergency rooms today even see a physician, but instead see nurse practitioners and PAs, who are trying to pick up the slack. These kinds of trends and pressures on an overtaxed and overused healthcare system, and the skyrocketing numbers chronically ill in the population, take us in the wrong direction in matters of nutrition and integrated medicine. Many of these problems are uniquely American, I understand as I travel throughout the world on lecture assignments. But still we see pockets of it occurring elsewhere, as well.

Very interesting discussion, thank you for opening it.

Health is defined as a status of physical, psychological, emotional and social well being. It is a complex mechanism to master, from a professional point of view (I would much like to read that 20 years study of East German dietary habits, see the variables taken into consideration and the statistics employed- on one hand, food should be a very important health factor, but so are many others; on the other, apparently small details -like the amount of dietary salt, even as food conservant,- can make a significant difference).

I think of traditions/philosophies like Ayurveda, or the cinese, that declare as a goal the creation of an entire way of life that would keep healthy and harmonious the individual and the society (and they highly consider nutrition). It is quite a sensible idea, if ever possible. Healthy food is definitely valuable prophylaxy.

Maybe most of todays social contexts, for many reasons, are rather far from being a fertile ground/receptive to very integrated approaches:

- various comercial interests

- different health care systems and politics

- the building of an evidence based medicine, that looks up a long way to walk before really integrating an enormous and growing (and sometimes controversial) quantity of information into a global, reliable perspective.

The lesser attention given to nutrition could reflect this complicated environment and indicate a long and equaly complicated way/travel/battle to do, if the real purpose is to significantly improve public health through healthy nutrition (not even merely study it more).

In spite of the fact that we already know quite a lot.

Because that can reduce the profit of pharmaindustry.

I agree with you . Nutrition is a multi+displinary subject. However, most people are not aware of this subject or field until they are sick.

In part, it has to do with the notion that doctors are to busy to sit down with a patient to go over diets. That role has been delegated to nutritionists. Besides, as medical knowledge expands, teaching hours are dedicated to what is felt adds to the science of medicine.

The cynical response is that med schools still train young doctors too treat patients after they have become sick, or have developed a medical problem. Nutrition, as a subject, falls into the realm of "preventive medicine", which still received scant attention as a subject for teaching. In short, docs are trained to treat illnesses, not to prevent them. That mindset is changing bit by bit, but it is a slow process.

6 August 13:

Further to Max Chartrand’s response, the NHS is going the same way – there is no time for doctor’s to practice the art and science of medicine which is why we cannot understand the need to integrate nutrition into medical training. All tick box and no clinical skill. And money spent on wars and not medicine!

I feel that Pythagoras had the right idea, treatment must concentrate on prevention of disease, the right management of body, mind and spirit. To get the whole picture we need a right and left brain working together (neuroscientist Profs. Ian McGilchrist- Master and his Emissary, - Allan Schore) and for this the brain needs physical and emotional feeding, to facilitate limbic/fronto orbital system functioning to cope with physical and emotional stresses and the ensuing inflammation. Prof Robert Sapolsky writes about stress and excess cortisol and the effects upon the immune system and inflammatory processes which lead to metabolic syndrome, cancers, dementias, cardiovascular disease etc. The Dutch Hunger Winter is a famous and well researched example of how the starving foetuses during WW2 later developed metabolic syndrome and the foetuses children, alarmingly did the same. So the gene expression (failure of gene methylation) persisted into the next generation – as a result of inadequate/wrong nutrition. The imbalance of Omega 3 and 6 fatty acids and arachidonic acid progression to inflammatory prostaglandins and eicosanoids is well documented.

Ronald Smith’s online book is a readable account of the relations between these inflammatory processes and depression with reference to other mental illnesses. (1997) Cytokines and Depression. How your Immune system CAUSES depression. ( And mental illness is worryingly common).

Nutrition has a PROFOUND effect on the development of disease and if teaching medical students about this could prevent 1/10th of the diseases that are killing or disabling people then surely it is essential. And it is primarily a medical matter, not dietetics.

But of course we are in the hands of greedy pharmaceutical companies, food companies and governments. I personally value truth and one has to search around for that.

Sir Michael Rawlin in an Harveian oration put forth a case for observational research- the Scottish Poet and literary critic, Andrew Lang said of a colleague: 'He uses statistics as a drunken man uses lamp-posts... for support rather than illumination.' Not much to do with truth. And of course statistics is left brained and limited and linear – and cannot see the thing-as-as-a-whole.

However, I understand that the Neanderthals lasted longer that our species and now it would appear that we are going down the pan and already rounding the bend! So I don’t think that good common sense can prevail.

Well, I've said many times that organically available nutrition is the BEST nutrition of all. Natural crystalline is a very distant second to organic, and to me synthetic is better than nothing.

People become chronically ill when they smoke, drink alcohol, eat too much sugar (especially GMO high fructose or worse, artificial sweeteners like aspertame), ingest too much caffiene, chronically dehydrate, over eat, lack essential nutrients in their food, etc. (all of the egregious behaviors that bring the majority of disease today).

So, common sense medicine would tell us to address THESE issues as foundational to any meaningful treatment program. But what we typically see instead is these foundational items left unadvised and toxic medicines given to treat the symptoms of these factors. That, to me, is medical malfeasance under the dictum "do no harm". This malfeasance, whether intended or not, is what is bogging down healthcare in our country. The average 2-3 minute face time given most patients in the typical clinic, of course, doesn't allow more than a quick scan of the vitals and a hastily written script without ANY discussion over how much water they are drinking, what their diet consists of, or do they smoke or drink or consume (3) large adrenal-crushing Red Bulls a day.

These days the physicians seem to play the role of "glorified" slaesmen for the pharmaceutical industries. They even collect kickbacks based on how often they have prescribed a pill for cronic diseases. They are trained to treat symptoms rather than the underlying causes of illness. For them in simple words, a headache is due to the "deficiency" of aspirin. The pharmaceutical industries seem to be geared to developing medicines which can be prescribed for life-long use. For example, the blood pressure medications or cholesterol-lowering drugs which must be taken on a daily basis. The old concept of Hipoocrates (400 B.C.) "Let food be thy medicine and thy medicine be food" is no longer sacred for the medical community.

The new concept of free radical damage, inflammation, and roles of antioxidants are not embraced by the physicians. Thus the problem of high blood pressure continues to be due to the deficiency of "amlodipin" or "lisinopril" etc.

Another interesting and equally adverse role is being played by the Food industry. For example, the refined free flowing white salt is devoid of many micronutrients that are normally present in sea salt. Recently a company from Europe introduced strontium ranelate (Protelos ?) as a prescription medicine at a hefty price to prevent osteoporotic fractures. Whereas the same strontium is available through sea salt at a fraction of the cost. In fact, the farmers give sea salt to their cattles and horses which rarely suffer from osteoporosis.

The detrimental effects of high fructose corn syrup through soft drinks and other foods are now well known. There are many such examples of profit-driven practices in both food and pharmaceutical industries.

It's high time for the medical schools to recognize the importance of good nutrition for sound health.

As I tried to say: there is no need to teach any wrong assumptions in med schools. No old or new philosophy or whatever crazy diet can prevent human death; since Most people won't die just "super-healthy", it should be clear there also is not such a super-Important thing as a healthy food - therefore, most of it is just, at its best, a Hypothesis.so definitely no Need to teach that. Unfortunately, some reports tend to indicate that there is a signifikant statistical reduction in lifespan of humans by eating nutrition supplememts. This, if true, should perhaps be better tought at med schools - if it isn't Yet.

I totally disagree with you Dr. Robert Eibl. It's not the matter of dying "super-healthy". It's the quality of life one lives until their death (natural or accidental).

The Issue of Nutritional Illiteracy

The many participants to this important discussion surrounding Geir Bjorklund's excellent (not for the first time) question, have already provided some valuable contributions to the conversation. So I will focus my own attention on the broader fabric and spectrum of an overarching theme, that of nutritional illiteracy, which I will argue through a evidence-based systematic review I have undertaken (a summary of which is presented below - the full review occupies 39+ text pages, not inclusive of over 900 references), is both exceedingly pervasive and of material adverse impact to the provision of optimal patient health, both in terms of QoL and in terms of real clinical outcome, and as such this endemic problem of low nutritional IQ among our health care professionals and most acutely among our physicians (who to their credit as I document frankly acknowledge both their suboptimal literacy and the consequential suboptimal clinical care to patients it entails), represents a global crisis in health care of no small proportion. In a later posting I will outline some of the provisional steps national and international authorities and collaborative initiatives are taking to address this nutritional intelligence quandary, and in still another posting I will share a parallel demonstration of CAM (complimentary and alternative medicine) illiteracy among these same populations. I hasten to note that in neither of these cases should the primary blame to be assigned to the many dedicated and skilled health professionals themselves, who as will be seen are more victims and collateral damage than perpetrators.

Setting the Stage

First, there are certainly multiple barriers to intrinsic integration of nutrition in our medical curricula, many already identified above, which include:

- Lack of trained nutrition experts (NEs) required and available throughout the 4-year curriculum as mentors and as instructors;

- Lack of resources and funding for faculty/teachers with the requisite level of expertise;

- The increasingly crowded curriculum and assorted “territorial jealousies” especially across specializations;

- Student / intern, and more rarely faculty, perceptions that nutrition is more a “soft topic,” not true hard-core science.

Nutritional Illiteracy

Behind these barriers however is a far more vital issue I will address, that of widespread, regressive and endemic nutritional illiteracy. As noted [1], the concept that nutrition should ideally should be integrated vertically and horizontally integrated into core curriculum rather than as adjunct material often relegated to the early preclinical years rather than within clinically real contexts, tends to subverts it as a stand-alone course that often (see below) has been found of little value by faculty and students alike. What needs to be done is both an integrated nutrition curriculum during the basic - not just preclinical - education, and post-graduate education for both physicians and nurses. The Scandinavian Nutrition Group (SNG) study [2] showed improved nutritional practice and competency after implementing nutrition guidelines and standards, supported by additional successful initiatives within the EU and elsewhere to improve the nutritional practices [3]. In these and other studies, it was found that the reason for not properly identifying and treating malnourished patients for example was often triggered by an insufficient knowledge among doctors in such competency [4].

Consistently, insufficient knowledge among doctors and nurses was an identifiable culprit in the inadequate nutritional therapy often seen in different hospital settings [5], supported in other studies [6] (see also below). In agreement, the Council of Europe-Committee of Ministers (ECCEN) [7] cited insufficient nutritional education as another major barrier for the proper nutritional care of patients in both the clinical practice and hospital settings. This dramatic lack of nutritional knowledge helps explain the low priority nutrition has been assigned in medical education and in clinical practice, in accordance with other studies from Europe and the USA [8], a problem in fact acknowledged by physicians themselves: thus half of respondents had difficulties in identifying malnourished patients [9], with this lack of nutritional knowledge cited as the major reason for the poor nutritional services delivered.

In agreement, one study [10] examined the nutrition knowledge of physicians working in general practice in Alberta (Canada), finding poor knowledge of important topics in nutrition that affect the quality of patient care, and patient outcomes (such as the association between excess protein intake and calcium loss; the type of dietary fiber helpful in lowering the blood cholesterol level (physicians answered incorrectly that any type of fiber, soluble or insoluble, when soluble fiber is the effective intervention); the nutrient which helps prevent thrombosis (omega-3 fat); etc.), findings later reconfirmed in dozens of other Canadian studies to date, leading Canadian authorities to call for vitally needed nutritional training for physicians. This has been identical to results in U.S. medical schools as per the latest update of the seminal UNC NIM (Nutrition in Medicine) Project National Survey [11].

But despite many efforts to promote nutritional education, and various strategies to help overcome barriers in training in nutrition [12], a significant number of medical students continue to rate their nutrition preparation as inadequate [13] despite best efforts at remediation [14].

In this context, it is important to note that 80% of the nutrition instruction in medical schools is not specifically identified as such in the curriculum, yet nutrition instruction provided outside of designated courses is often considered diluted in importance, an aside, instead of being given the emphasis it deserves as a core component of current clinical practice. And most of nutritional education, when it does occur in medical schools, in restricted to the preclinical years (first two years of medical training), rather than more beneficially integrated within later clinical years to exemplify the direct correlation between nutrition principles and medical treatment [15].

Recent surveys of residents and practicing physicians support this view [16,17] especially with regard to the growing problem of obesity, an alarming recognition given the importance of nutrition in obesity prevention and the critical role of diet in the energy balance equation, ad this had immediate practical consequences: fewer than half of physicians routinely discuss weight loss with obese patients or provide meaningful dietary counseling or reference, despite acknowledging the critical importance of such counseling both to the individual patient's QoL and health outcomes, and to public health given the pandemic of obesity, diabetes ("diabesity") and metabolic syndrome and the disastrous consequence of this to global health and global health care [18,19], and with at least 62% of physicians reporting real deficits of knowledge about nutrition as major barriers [18]. And internal medicine interns as well as primary care physicians fare comparably poorly, answering only 66% of critical nutritional knowledge questions correctly [20,21].

Global Nutritional Illiteracy

These results are much the same across the world: in Israel [22], gross lack of knowledge towards nutritional therapy in diabetes was found in physicians and nurses (specialists and non-specialists), with an average score upon examination of 48% (in practice-critical critical areas of dietary fat and diabetes, glycemic index and the recognition of food containing carbohydrates/ mono-unsaturated fats), leading to the results that over the majority were providing systematically incorrect nutritional advice to diabetic patients regularly, and prescribing nutritional wrong diets for them. In Iran [23], 100% of all physicians' knowledge of practicing nutrition was tested to be inadequate, either poor (86.9%) or mediocre (13.1%). Indeed, throughout the world, hundreds of studies have established gross nutritional illiteracy sufficient to significantly compromise patient health and outcome of prescribed interventions. In many cases [24], nutritional literacy non-dietitian health professionals was no better than the average patient with eating disorders, despite that level being itself inadequate. Thus we have mean knowledge scores of physicians and medical students in Canada (50%) [25], America (49%) [26], Taiwan (59%) [27], Saudi Arabia (52%) [28], and Turkey (48%) [29], with inter study variability of scores tending to only go down not up.

And these findings were across medical specialties: physicians within the Ontario HIV Treatment Network involved in the care of HIV patients demonstrated suboptimal nutritional knowledge [30]. In the NNFTRI study cited above [23] in which the lower levels of scored nutritional accuracy was 57% among physicians and 47% among nurses, compared to 71% among nutritionists, the authors sensibly concluded with commendable understatement that across the board, these scores "do not inspire confidence in the nutritional advice given" by these medical professionals in whose hands the health of the individual patient and projected global health rests.

Lest one think that specialist are likely to demonstrate a higher nutritional IQ, this has been found to be false: the easy majority thus gastrointestinal (GI) / gastroenterology (GE) fellows acknowledged their insufficient knowledge in obesity and micro/macronutrients, and on a test of key critical competences in relevant nutrition knowledge in the areas of nutrition support, assessment, obesity, micro/macronutrients, and nutrition in GI diseases, the mean total test score was an abysmal 50.04% (and with only a mean score of 40.1% in obesity knowledge [31]. The study demonstrated and concluded therefore that gastroenterology fellows (1) believe their knowledge of nutrition to be suboptimal for the care of their patients, and (2) objective evaluation of nutrition knowledge via testing of vital relevant informational domains showed that they were indeed correct in these beliefs, showing grossly inadequate nutritional knowledge and associated interventional skills.

The endemic lack of nutritional knowledge among Scandinavian doctors and nurses has been well documented: 25% found it difficult to identify patient in need of nutritional therapy, 39% lacked techniques for identifying malnourished patients, and 53% found it difficult to calculate the patients' energy requirement and 66% lacked national guidelines for clinical nutrition. And 28% acknowledged that insufficient nutrition practice could - and in many important cases did - lead to both complications for patients and prolonged hospital stay ("Some of the patients get so little nourishment during admission in my department that this has clinical significance and can leads to complications or prolonged stay"), and note that physicians lacked competency in all three areas of the controlling ESPEN guidelines: screening of patient on admission; assessment of undernourished patient and initiating nutritional treatment.

Insufficient knowledge among doctors and nurses has been one of primary sources of inadequate necessary nutritional therapy observed in different hospital settings [8] and is supported from other studies [6], and note that this was of course not simply a problem of recognition, of the lack of competency to recognize malnutrition in patients but more critically of disastrous failure to provide necessary treatment to these patients. This is cross-confirmed in the Sao Paulo prospective trial [32] which found that implementing a multifaceted nutritional educational intervention improved the quality of nutritional therapy patients received, which was inadequate in the pre-nutrition educational program and decreased intensive care unit length of stay in critically ill patients in the post-nutrition education program. Thus the outcome-compromising impact of inadequate nutrition knowledge of and training for physicians is clear: nutritional therapy (NT) is an important component of care of critically ill patients, and positively impacts clinical outcomes [33-35]; indeed, there are multiple lines of evidence that mortality is decreased significantly from a single nutrient (parenteral L-alanyl-L-glutamine) which improves 6-month outcome in critically ill patients, and its failure to deploy correlatively causing clinically significant increased mortality in the same audience [35].

Finally in this context of the exceedingly direct relevance of nutritional intelligence, or lack thereof, in patient clinical outcomes, I draw your attention to the massive prospective EPIC (European Prospective Investigation into Cancer) GI study [43], including 23 centers in 10 European countries (n=521,457) which found that high intake of dietary antioxidant compounds is an appropriate and effective strategy for the reduction of the risk gastric cancer (GC).

These and additional lines of evidence have established beyond controversy that patients with severe illness who fail to receive adequate nutritional support are prone to complications, including prolonged mechanical ventilation, increased ICU LOS (length of stay), and significantly higher mortality rates [36-38], so it is a professional and moral imperative to provide highly informed evidence-based nutritional support for critically ill patients to correct nutritional deficiencies, improve innate immune responses, reduce adverse oxidative stress, preserve the function and structure of the GI tract, and modulate the inflammatory response, the primary focus of the outcome enhancive of the authoritative SCCM (Society of Critical Care Medicine) and ASPEN guidelines (American Society for Parenteral and Enteral Nutrition) guidelines [36,39] which decisively correlate lack of nutritional knowledge, with its consequent lack of critical nutritional deployment, as patient outcome-compromising. As the nutritional expert investigators of the Sao Paulo prospective trial concluded: "Even if doctors believe that it is important [which is insufficiently common], they lack the knowledge to prescribe appropriate nutritional interventions", inherited ignorance secondary to clinical nutrition not being adequately emphasized during medical school training [40-42]. As experts have oft said in this arena: ignorance kills.

Nutritional Illiteracy: The Case of Fruits & Vegetables (FV)

I will take a practical example as a live demonstration of nutritional illiteracy and drill down to expose broad implications, namely on the consistent misunderstanding by physicians of the importance of fruit and vegetable intake to health and chronic disease (but the same tale could be told about numerous other areas of inadequate nutritional intelligence cited above and elsewhere). Despite the impression of most physicians that such intake is of relatively small or modest importance and impact in health consequence, hundreds of robust studies and prospective trials and dozens of systematic reviews and meta-analyses have decisively demonstrated the contrary, with an exceptionally strong evidentiary base of high-level evidence [44].

Diets rich in fruit and vegetables (FV) are associated with a reduced risk of chronic disease, as concluded by the authoritative German Nutrition Society (DGE: Deutsche Gesellschaft Für Ernährung) evidence-based guidelines group on nutrition in Germany [45], which found high-level (Level I and II) evidentiary support: (Level I (convincing) evidence for benefit to hypertension, CHD, and stroke, and Level II (probable) for benefit to cancer) and therefore increased consumption of FV was strongly recommended as part of a healthy diet [46] (and the isolated East German / Jena studies failed to legitimately contradict or overcome the overwhelming weight of the evidence and contained methodological limitations sufficient to bar their inclusion under meta-analysis criteria).

In addition, the SUN Cohort (Seguimiento University of Navarra) systematic review [47] found that a high F&V consumption is inversely associated with CVD incidence and mortality. And note that even among health-conscious university graduates, low F&V consumption is fairly prevalent: 13 % of participants in the SUN cohort did not meet the goal of consuming at least 400 g/d of F&V and 2·1 % of them did not reach >1 serving/d. And the recent Cochrane Review [48] of 10 trials with a total of 1730 randomized participants concluded that increasing fruit and vegetables has favorable effects on CVD risk factors.

So, despite some to-be-expected small variation in individual studies, meta-analyses of observational studies have consistently shown an association between increased fruit and vegetable intake and reduced risk of coronary heart disease (CHD) [49,50] and stroke [51,52], with a vast body of individual prospective cohort studies published since these meta-analyses tending to strongly confirm this association [53-59]. In addition, the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart [60] study represents the largest prospective analysis of fruit and vegetable intake and CVD risk ever undertaken to date (n=313,074 men and women) in eight European countries followed for an average of 8.4 years. I was found that participants consuming at least eight portions of FV daily had a 22% lower risk of fatal ischemic heart disease (IHD) than those consuming less than three portions daily (relative risk = 0.78), and after calibration of fruit and vegetable intake estimates to account for the different dietary assessment techniques used in participating centers it was, also found that a single portion increment in fruit and vegetables was associated with a 4% lower risk of fatal IHD. Such an observation is in agreement with the previous meta-analysis that demonstrated a similar estimate of difference in risk per portion of daily FV intake increase [50].

In addition, an analysis of the EPIC cohort [61], which included almost 400 000 subject who developed approximately 30,000 cancers at all sites over nearly 9 years of follow-up found a weak but nonetheless statistically significant inverse association, with a 4% reduction in risk of cancer for every 200 grams increase in fruit and vegetable intake.

FV / Diabetes

Another recent systematic review and meta-analysis [62], examined the relationship between fruit and vegetable intake and type 2 diabetes incidence, finding that comparing the highest intake of green leafy vegetables (1.35 portions per day) with the lowest intake (0.2 portions per day) was associated with a statistically significant 14% reduction in the risk of type 2 diabetes (hazard ratio = 0.86). To the same effect, the EPIC-InterAct study [63] found similar associations in relation to green leafy vegetables (relative risk = 0.84), with the EPIC-InterAct data adding an inverse association between root vegetables and diabetes risk (relative risk = 0.87). Therefore, the results of both meta-analyses suggest that an increased consumption of green leafy vegetables is a clinically relevant aid in the reduction of the incidence of diabetes.

FV / ALZ

There is also some evidence of benefit in the neurological context: one systematic review [64] found that nine prospective studies with a follow-up period longer than 6 months, incorporating just over 44,000 participants found that out of the six studies examining fruit and vegetable intake separately, five found that a higher consumption of vegetables (but not fruit) was associated with reduced risk of dementia or cognitive decline, with a similar association for the three further studies that examined fruit and vegetable intake combined.

FV / Chronic Disease

But even studies with hard clinical endpoints, where increased fruit and vegetable intake has been combined with other dietary and lifestyle changes, have also been conducted with positive benefit seen in chronic diseases [65-70]. For example, the Dietary Approaches to Stop Hypertension study [71] demonstrated a beneficial effect of increased fruit and vegetable intake on blood pressure over 8 weeks, while a similar blood pressure lowering effect was demonstrated in a RCT [72] of fruit and vegetable intake in the primary care setting, while again a beneficial effect of increased fruit and vegetable consumption on microvascular function has recently been demonstrated [73]. And there is as we have seen above, robust evidence for the effects of increased FV intake on other cardiovascular risk factors [75-78].

On the broader issue of that nutrition matters to clinical outcomes: macrosimulation modeling carried out by researchers in Oxford [79], using data from the Family Food Survey, has suggested that if the average diet in Wales, Scotland and Northern Ireland was improved to that achieved in England, then the mortality gap in these countries could be considerably reduced (reduction in Wales 81%; Scotland 40%; Northern Ireland 81%). And another estimate the global burden of disease attributable to specifically low consumption of fruit and vegetables [80] suggests that 2.6 million deaths worldwide and 31% of cardiovascular disease (CVD) (and between 2 and 19% of cancers) may be attributed to inadequate fruit and vegetables intake. Finally, a more recent study [81] using World Health Survey data confirmed a low intake of fruit and vegetables worldwide, with approximately 78% of both males and females consuming less than five portions daily.

Conclusions re Fruit and Vegetable Intake

Multiple lines of evidence including systematic reviews and meta-analyses have shown an association between increased fruit and vegetable intake and a reduced risk of cardiovascular disease (CVD) including diabetes, with a high intake also be associated with a slower rate of cognitive decline and risk of mild cognitive impairment and progression to Alzheimer’s disease. Yet despite public health recommendations to increase fruit and vegetable intake, intakes worldwide remain consistently and perniciously lower than even minimal recommended levels.

Methodology of this Review

A search of the PUBMED, Cochrane Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, (WoS) Web of Science, BIOSIS, LILACS and Scirus databases was conducted without language or date restrictions, and updated again current as of date of publication, with systematic reviews and meta-analyses extracted separately. Search was expanded in parallel to include just-in-time (JIT) medical feed sources as returned from Terkko (provided by the National Library of Health Sciences - Terkko at the University of Helsinki). A further "broad-spectrum" science search using Scirus (410+ million entry database) was then deployed for resources not otherwise included. Unpublished studies were located via contextual search, and relevant dissertations were located via NTLTD (Networked Digital Library of Theses and Dissertations) and OpenThesis. Sources in languages foreign to this reviewer were translated by language translation software. I thank several of our leading nutritional experts across the world who have responded to a Request for Comment (RFC) and shared intelligence and insights.

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Constantine Kaniklidis

Director, Medical Research, No Surrender Breast Cancer Foundation (NSBCF) 

European Association for Cancer Research (EACR)

As I have said earlier no one can be an expert in all fields. In a medical system where the specialist is often concerned not only with surgery but a particular part of the anatomy, why try to develop a group of professionals who dabble with a LITTLE of everything. I would also dispute the premise that diet is the single most important preventive measure for healthy aging .As people age they tend to lose muscle mass at an ever increasing rate. Loss of muscle mass reduces the metabolic rate with a resultant increase in fat. and also reduction in insulin sensitivity. Increase in Visceral Fat is the basic cause of a variety of chronic diseases ranging from Diabetes to Cardiovascular problems, depression and also some forms of cancer. Exercise can increase muscle mass, increase bone density and help with a variety Cardiovascular problems. Ro reiterate what I had said in an earlier post maintaining health in Old Age requires a combination of Diet, Exercise Mental relaxation and therefore calls for a team of specialists.

Eric I respecfully disagree, I think one of the problems in Medicine today is the reductionist view. In relation to nutrition which I firmly believe should be part of the medical treatment arsenal there is no excuse in not knowing enough to truly benefit the patients. I concur with you in that maintaining health in Old Age requires a combination of Diet, Exercise Mental relaxation, but we only need a wise physician.

I would agree to disagree. As an Exercise Physiologist I am sure that it takes more than a Wise Physician to get more than a superficial idea of Exercise Physiology

I am very sorry to have to make a negative comment, specially as addressed to a qualified professional as dr. Eibl.

Dear Doctor, the necessity of an appropriate anamnesis is the crucial start point of any medical procedure and has remained a cornerstone of medicine since Hipocrates. It has the purpose to understand all the factors involved in the health status of the pacient.

As we all have to eat several times a day, this is sure one constant, permanent influence to our body's status. It cannot be considered that eating habits and specially the quality of food we eat are of secondary importance. Nature has provided us with a body extremely capable of resisting and adapting to enormous stress factors. But it has limits and these constant damages, together with an increasing lifespan, result in significant increase of morbidity, especially cancer and chronic diseases.

If medicine is still supposed to focus on restoring and maintainig health, nor merely to benefit from disease, the importance of improving the quality of nutrition competence in all medical professionals is essential for the health of individuals and of the society.

If worldwide anti-smoking and anti-drugs campaigns are strongly sustained, why is so difficult to accept that an equally strong attention shall be given to nutrition and its preventive and curing potential (if only to rediscover ancient wisdom)?

Some of the things you point out are right, using dietary supplements without criteria can be damaging and so is the practice of incompetent nutritionists. But this is exactly the point in discussion here, if I'm not mistaken.

This can only be solved by increasing competence and awareness of the medical staff.

The commercial interests (speculating on ignorance and fear, basically) do infest this profession as much as any other potentially lucrative domain.

Can we answer turning our backs to the issue?

For many times I have read nutrition advices on the site of MSKCC, one of the most specialised instiutions in cancer research and treatment. Do you consider them insignificant too?

Pascal compared the knowledge to a sphere, growing it has more and more contact points with the unknown. Understanding fully all biochemical processes of a living organism and its interdependence with the environment may take us one thousand years. Do you think we should wait until then before taking measures and in the meantime disregard the obvious?

Oh, by the way, about listening to your gut.. I would bring in the funny -in that context-(and to my knowledge, scientifically correct) observation of a distinguished researcher, here on RG, dr. Pohl - our brain has essentially nothing to do with the immune response,consciously, the defences of our own body bypass shamelessly this precious tool of rationality. And when you throw away disgusted a bitter piece of food you don't listen to your reason, but to your gut.

However, is the smart brain of a smart guy who sugared well the poisonuos content of a piece of junk food that created the problem. Do you personaly eat this stuff? And if you don't, why?

After taking more serious topics at the university ... you will find out that nutrition is very simple topic you can read it fully alone !!! But yes maybe it needs a bit more care...

Yes, dr. Eibl, I foud it difficult to believe that we cannot find common ground. And sorry to have not explained myself well. I did not mean to say you might disregard the basic role of anamnesis, it would be unthinkable, I was just using that approach in order to make my point indicating the roots of a legitimate interest to and the importance of nutrition in the context of medicine.

Nutrition as a topic is a tip of an ice burg as it encompasses agricultural practices which influence the mineral and nutrient levels of soil and the quality of all foods produced in or on it. Also politics, big business, banking practices, economics... everything in our modern world.

It is said that the fruit and vegetables our grandparents ate as children were many times more nutritional than current fresh produce. Also the quantity of processed food was a fraction of today's accepted daily or weekly diet. Even the current accepted training of a modern nutritionist is heavily influenced by grain and dairy industries placing their products firmly in the food pyramid as staples. This is obvious when you compare their food pyramid with that of naturopaths who put the foods our ancestors ate on the bottom tier.

Nutrition and health is basic chemistry, a cake wont cook if ingredients are missing and a body cant function at full potential if nutrients or minerals are missing. Doctors are not interesting in cure as a rule, treatment is far more lucrative. However this is not a conscious thing rather one needs to look at the relationship between the sponsorship of medical training institutions and big pharma.

A turning point in history was when D Rockefeller shut down 120 existing medical training facilities in the early 1900's in America and replaced them with sponsored wings built onto university buildings. He made sure his own men were on the governing boards yet lived well into his 90's using homeopathy only, as the Queen of England does today. His marketing agents created the culture of charity which made him look benevolent yet steered an endless stream of community generated cash at treatment research. This effectively took the focus off prevention, restoration and cure.

Fifty years ago it was, but now it is not; because, now the habitat, habit and ecology of both patients and doctors has changed drastically.

Now the teachers and students in medical schools find nutrition and nutrient composition in diet and food sources as a tiring and useless course content. The situation is worsened in the form of help by the availability of custom made specific nutritional supplements and substitutes.

The present scenario on the effect of changing nutrition related course in the medical teaching curriculum is that, now a days a medical student or a doctor find it very difficult to name five natural sources of vitamin C, but it is easy to find ten preparations or formulations for supplementation of vitamin C. Interestingly enough, it is also a fact that, at present, all medical students and doctors know much details of metabolic and functional activity of vitamin C for all practical purpose.

The change originates in about 1960's when medical teachers begun giving more importance towards metabolic activities and roles of nutrients rather than the history, sources and dietary contents of nutrients. This was a very good change in teaching habits, but with the bad side effect producing the present scenario.

It is always better to have some old treasure and utilize it too than to depend only on new investments and returns. So it is definitely the time to rethink, reorient and reform the medical curriculum with its nutritional content and composition.

The new generation doctors should be a modern nutritionist with a grand mom's touch.

Fifty years ago it was, but now it is not; because, now the habitat, habit and ecology of both patients and doctors has changed drastically.

Now the teachers and students in medical schools find nutrition and nutrient composition in diet and food sources as a tiring and useless course content. The situation is worsened in the form of help by the availability of custom made specific nutritional supplements and substitutes.

The present scenario on the effect of changing nutrition related course in the medical teaching curriculum is that, now a days a medical student or a doctor find it very difficult to name five natural sources of vitamin C, but it is easy to find ten preparations or formulations for supplementation of vitamin C. Interestingly enough, it is also a fact that, at present, all medical students and doctors know much details of metabolic and functional activity of vitamin C for all practical purpose.

The change originates in about 1960's when medical teachers begun giving more importance towards metabolic activities and roles of nutrients rather than the history, sources and dietary contents of nutrients. This was a very good change in teaching habits, but with the bad side effect producing the present scenario.

It is always better to have some old treasure and utilize it too than to depend only on new investments and returns. So it is definitely the time to rethink, reorient and reform the medical curriculum with its nutritional content and composition.

The new generation doctors should be a modern nutritionist with a grand mom's touch.

Geir: There are many reasons why physicians (and other healthcare providers) are so poorly prepared to recognize their patients nutrition problems and use nutrition interventions in clinical practice. The medical school curriculum is already overburdened as it it and few educators feel the need to reorganize their traditional offerings. Too few physicians include nutrition in their daily practice and very few medical schools and teaching hospitals have string clinical nutrition units. Another major barrier is the lack of medical school instructors with comprehensive training in nutrition. Sometimes a lecture or clinical presentation is outsourced to non-faculty dietitians or nutritionists, but they generally lack the stature of mainstream clinicians. Unfortunately, this becomes a recursive sequence because few budding clinicians feel attracted to a field of such low stature.

The fact is that most US medical schools provide less that the recognized minimum of 25 hours of instruction (as we know from our published surveys) and very little of that time relates to clinical practice. There is renewed interest and you might want to review the presentations at a NYAS symposium a couple of months ago, where a wide range of educators and stakeholders discussed current nutrition education challenges across various health professions http://www.nyas.org/MedicalCurriculumNutrition-eB

To add one additional reality: physicians can't easily bill for nutrition and this puts it in a less than compelling group of subjects that are interesting, but not as highly sought.

Susan hit it again on the head: Reimbursement codes determine practice. No reimbursement code, there will be no assessing and recommending of nutrition. In socialized systems, of which the US is about 70% and increasing under the coming highly regulated system, politics rule medicine. If money is to be saved (read "lost"), fewer patients to see, less money to change hands with each patient contact, the politicians know well the unpopularity of codifying such a scenario into the regulations.

For instance, if there was a cure for cancer at this point in time, millions of people would be thrown out of work, some pharmaceuticals would close down, investors would lose their investments left and right, and whole sectors of government agencies would be adversely affected. Cynical or not, it is the reality of medical politics. So many unneeded surgeries, aggressive treatments when diagnostics are inconclusive, hundreds of thousands of lost lives annually in our country alone each year from overprescribing of drugs instead of search for and addressing underlying causes.

The reality is that consumers of healthcare are likely to be the ones who change the system---as the system is letting them down more and more and keeping them sicker and sicker, they will devise their own ways of avoiding it. Now, that does invite the lesser educated opportunists, but even so they pose a far smaller threat to the public health than a system that would rather spend $80,000 (US) of taxpayer's money on exploratory surgery looking for the sepsis that is actually lurking in a 5-year-old keratosis obturans in the external auditory canal.

The keratosis costs pennies to remove (it is removed the same way as the impacted cerument for which it is often mistaken) compared to laying out the intestines in search for a (non-existent) septic diverticulosis. Food for thought.

We should not lose sight of the fact that nutrition is fundamentally different from taking supplements or medicines because we all have to feed ourselves regularly. We don't have a choice whether we want to do it or not. The only choice we have is what we eat and drink. Considering that nutrition and its consequences affects health very deeply, physicians and other healthcare professionals cannot reasonably ignore the nutritional status and dietary practices of their patients. They fail their patients in more ways than one, if they are not prepared to competently (based on best evidence) advise their patients on prudent lifestyle choices and use nutrition as a powerful medicine.

Wish it were so, Robert. As Constantine so ably pointed out above, utilization of the current knowledge base in medicine is sorely lacking.

Medicine is based on a curative model where specific disease are identified and treated in a specific manner. Nutrition does not fit the model well since its benefits are largely preventative and so often there is no specific disease to be targeted/cured -- i.e. it is not a "magic bullet". If nutrition is to be effectively incorporated into a healthy lifestyle or "treatment" plan, medicine will need a paradigm change towards a more holistic model of human wellness and disease.

I found that interesting - it started with the "multibillion dollar" market of the not so well regulated nutrition supplements. One misconception of the public is, it does not expect a big harm from "nutrition" or supplements, since the public expects they are as potent and regulated by the government.

http://jnci.oxfordjournals.org/content/104/10/732.full

Death induced by high-dose Vitamin C

http://www.ncbi.nlm.nih.gov/pubmed/18714631

I enclose for the discussion a copy of the article mentioned by Dr. Eibl:

McHugh GJ, Graber ML, Freebairn RC. Fatal vitamin C-associated acute renal failure. Anaesth Intensive Care 2008; 36: 585-8.

When it comes to nutrition and good quality supplementation the key term is restoration, to a natural state of homeostasis for an individual based on age, medical history, life circumstances and past self care (or lack of it). This requires a sensible level of a full spectrum so the body can take what it needs to repair, so what if the rest is passed in the urine and why would mega doses been needed?

A goat standing in the paddock next door is manufacturing huge doses of vit C and it makes sense that as a species that has adapted to acquiring it through ingestion, rare in the natural world, we need to consume it daily. Animals heal very much faster than humans, ask any vet. Vit C is found in spinal fluid as this otherwise rather anaerobic area would be unprotected from infection. I would go so far as to say any doctor who does not administer Vit C to a child with meningitis for example should be charged with man slaughter if the child dies.

Eric I agree we need more than a wise physician, no doubt ! The problem is not ignorance but the illusion of knowledge!

The question you pose is also part of the answer Why isn’t nutrition a bigger part of conventional medical school education? Nutrition has for much of our historical lives been synonymous with tasks and issues that were relegated to the home. These had conotations to do with domestic chores, cooking, care, child feeding, nursing and home-making tasks that to this day remain largely to be carried out by women. It is now common to see more female students in medical school than male students (e.g. Sweden). Will this also change the way medical curricula is structured?

Conventional medical schools have never been exemplary of gender equity and suffice to say, nutrition has been a long time coming into the curriculum. And with the discovery of "pills and supplements" this only made it more difficult to create that space for nutrition.

We now have the opportunity to integrate nutrition in medical education BUT we need to keep the messages SSR = Short Simple and Repetitive for students to memorise like all other medical components.

For those that it is hard to imagine any lack of nutrition factors or vitamins with our current diet,here is some literature to brush up.

http://ajcn.nutrition.org/content/75/4/616.full

http://www.pnas.org/content/103/47/17589.full

http://jn.nutrition.org/content/133/5/1544S.full

Geir, I read the case study you cited above. My wife was once the Charge Occupational Therapist in their Rehabilitation Unit and I've lectured there, so we are familiar with the authors of the article. Of course, I don't approve of the way the patient handled his own treatment, but having worked with end stage cases like this I think it is erroneous to extrapolate too much from one case study. It is only conjecture that the fellow died of overdose of Vitamin C when in fact his refusal for dialysis and progression onto transplant were the obvious conclusions. However, occuring much, much more frequently somewhere in the world are people with end-stage dying because, at age 70, their national health service will not provide them with dialysis, and especially, from not having a kidney available or adequate resources for transplant. This has always been a troubling disease for which little progress has been made in conventional medicine.

While we are on the subject of kidneys, someone asked me today what I thought of Protandim, a patented formulation antiodxidant supplement therapy for kidney failure and other disease. Having not analyzed any studies on it, I was astounded by the claims of its manufacturers. Heaven knows we need something positive for stage 4 and 5 kidney failure, but its claims strain credibility by claiming it reverses aging markers back to that of a 20-year-old, etc. (It may hae been referring to caretinoids without using the term). There was quite a list of studies (some already completed and some still in progress); hopefully, it does what it claims. But it does disservice to potential mainstream acceptance to dramatize study results, though I am impressed with the innovation and effort to help fill a serious gap in current medical treatment. Now that it has been brought to my attention, I will be critically reviewing the studies on Protandim to see if it lives up to its billing.

Here is pertinent info on high dose vitamin C safety!

http://www.integratedhealthclinic.com/assets/byTreatment/Vitamin%20C/16-IVAA%20Safety%20-%20Padayatti-10.pdf

http://www.zentrum-der-gesundheit.de/pdf/vitamin-c-bei-krebs-ia_02.pdf

http://orthomolecular.org/library/jom/2002/pdf/2002-v17n02-p117.pdf

http://www.jaoa.org/content/107/6/212.full

http://prhsj.rcm.upr.edu/index.php/prhsj/article/view/340

http://iv.iiarjournals.org/content/25/6/983.full.pdf

Nutrition is an enless topic, you have to tell them the concept and principle of nutrition. Otherwise 5-6 year curriculum will never be enough. Understanding concept and principles will let them acquire more as much as they want. The other day, I read about the absorption of constituents in some the supplementary food and nutrition , they are still unsettled. Nutrition in foods are enormous, even a banana contains more than 100 constituents. Soooo.

I see taking form more that one issue here, correct me if I'm wrong - basically I only present ideas that have been already mentioned, here or by other authors.

- large availability of information to the public, of various quality (internet, publicity...)

- comercial interests, able marketing (creation of demand, sale); related collusion of part of the medical profession

- the magic of a genuine, clean way of living, if only metaphorically suggested

- scarce discerniment of the large public (even professionals have difficulties staying updated)

- education of the public; its quality beyond just supplying data

- socio-economical environment governed by merchantilism and competition (competition prevailing on cooperation at most social levels) in which we all have to make a living after all, because we only live once.

- existence of cases in which social system and conventional medicine failed to give priority to public/individual health/well being

- consequent 'culture' of distrust, confusion - what about the influence of living long in this environment on the quality of decisions made by the individual (The patient in question suggests a certain psychological profile. He was old and sick. What about the younger people that think somehow similarly? Nowadays even a psychological profile can be described biochemicaly and defined ontogeneticaly. Consider also that most phenotipical patterns of behaviour are imprinted on the next generation. What about living a lifetime in a supposedly nonreliable, traumatizing, confusing society context having a chronic and large effect on the decision making to the point that is a sort of pathologic condition? )

- trust in conventional medicine

- availability of good quality, reliable medical assistance

- the profile of various sanitary systems

- the quality and focus of patient-physician relation

They go far beyond the subject in discussion here, but cannot be disregarded, as in a complex system (like the society) so many variables are interrelated that an isolated change may have unpredictabe results or none.

To what degree and how the medical profession should address the complex an worrying context in which we live, considering it has already taken charge of public health long ago?

To the qualified professional, many things tend to be taken for granted. We all know about the toxicity of pesticides and that, if they have to be used, extreme attention must be given to dosage and method of use. I feel is common knowledge and rather reasured by this. Well, for the last months I lived in an agricultural area, considering myself very lucky because here the fruit and vegetables cost a third/half of the price in the city, the air is clean, the peace of nature everywhere. Remainded me of my home, where rich vegetables were grown using the natural fertilizer from our cows that ate the grass and hay from the uncultivated mountain pastures (here is a nostalgic trigger for a decision, if any - right now I remember that forest rangers had the duty to spread mineral fertilizers on these wild pastures, in order to insure sufficient food for the deers and other wild animals; also that DDT was used occasionaly by my parents to kill some damaging insects on potatoes). Until I saw the neighbour calmly spraying disherbant on an uncultivated field, saying that it softens the weeds before cutting them away. Gave me the creeps, knowing also that, as a farmer, he is supposed to make a living, that when he sells in the city is offered extremely low prices by the bulk merchants, that bad weather can wipe away easily his work at any time. What is that we eat and to what consequences? Isn't it a medical problem?

To what degree the entire context (nutrition included), would still interest prevention medicine versus 'therapeutical' measures, the social cost considered?

The following are some recent studies on the importance of vitamin C:

Increase in RDA for Vitamin C Could Help Reduce Heart Disease, Stroke, Cancer. http://www.bjorklundnutrition.net/2012/07/increase-in-rda-for-vitamin-c-could-help-reduce-heart-disease-stroke-cancer/

Big doses of vitamin C may lower blood pressure. http://www.bjorklundnutrition.net/2012/04/vitamin-c-lower-blood-pressure/

Intravenous Vitamin C May be Beneficial in Treatment of Shingles. http://www.bjorklundnutrition.net/2012/04/vitamin-c-shingles/

Vitamin C May Enhance Radiation Therapy for Aggressive Brain Tumours. http://www.bjorklundnutrition.net/2012/02/vitamin-c-for-aggressive-brain-tumours/

Two Vitamin C Tablets Every Day Could Save 200,000 American Lives Every Year. http://www.bjorklundnutrition.net/2011/11/two-vitamin-c-tablets/

Low Vitamin C Levels May Raise Heart Failure Patients’ Risk. http://www.bjorklundnutrition.net/2011/11/vitamin-c-heart-failure/

Vitamin C: A Potential Life-saving Treatment For Sepsis. http://www.bjorklundnutrition.net/2011/07/vitamin-c-a-potential-life-saving-treatment-for-sepsis/

Living Proof: Vitamin C – Miracle Cure? [VIDEO] http://www.bjorklundnutrition.net/2011/09/living-proof-vitamin-c-miracle-cure/

Vitamin C May Be Beneficial For Asthmatic Children. http://www.bjorklundnutrition.net/2011/08/vitamin-c-may-be-beneficial-for-asthmatic-children/

Treatment With Vitamin C Dissolves Toxic Protein Aggregates In Alzheimer’s Disease. http://www.bjorklundnutrition.net/2011/08/treatment-with-vitamin-c-dissolves-toxic-protein-aggregates-in-alzheimers-disease/

I checked only two of your cited Papers shortly. The asthma paper did not include Control. The mouse Model on Alzheimers disease ... Well, i have not really Seen a useful Model for Alzheimer in mouse. I dont See any Need to change medical Education just due to some Wild Spekulations in unproved or not widely accepted results.

From my own view and based on observation (I am not in medical research but a research chemist particularly on rice plant and its growth environment), this is the case because medical doctors in modern practice nowadays are trained not as nutritionists or dietitians for preventing diseases associated with nutrient deficiency but for curing diseases with drugs commonly known as medicines. I go for alternative medicine and I believe with balanced diet and proper nutrition many diseases can be prevented (if not totally prevented, can be somehow delayed). Minerals are essential for protein and carbohydrate metabolism, as co-factors, essential part of biological molecules that when these minerals become deficient in the system, metabolic disorders would occur.

Well, this was only a limited number of studies on a single vitamin ...

One example: The research on epilepsy and ketogenic diet is widely accepted:

High-Fat Ketogenic Diet Effectively Treats Persistent Childhood Seizures. http://www.bjorklundnutrition.net/2011/08/high-fat-ketogenic-diet-effectively-treats-persistent-childhood-seizures/

food is produced under circumstances whereby the nutriënt value is decreased (e.g. apples contain half as much vitamins now than 50 years ago). Animals (cows and catle) are fed with ... fish powder, vegetables are grown on water, etc. The nutritional content of many ingredients has dramatically changed, to the worse, regretfully. The majority of elderly people use unbalaced nutrition, which is cheaper an easier to obtain/prepare! Yes, food supplementation with judicious nutraceuticals makes sense, but high-doses of artificial Vit E (d-alfa-tocopherol succinate, an analog of Vit E), and high doses of Vit C and A are, in fact, not indicated. The high dosis of these viatmins have an opposite effect, they are pro-oxidants, toxic, and probably cancerogenic.

The National Academy of Science of the USA recommends 25 h of nutrition training in medical training, the American Society for Clinical Nutrition even 47 h. Even the NAS target is not reached in any Med School I know of. I teach Biochemistry and give 3 h on Minerals and Vitamins, a 3 h integrated lecture (together with a pharmacologist and a physiologist) on Ca, Mg, Pi and Vitamin D, and a 2 h integrated lecture (with 2 clinicians) on Obesity and Metabolic Syndrome. In addition, we have a Nutritionist who gives 6 h on Nutrition in Life Cycle and in Diseases. That's 17 h total. Of course when I teach other topics like fatty acid or amino acid metabolism, I cover nutritional aspects too. So you get the odd couple of minutes here or there. I hope that students get a little bit of applications during their rotations, but I can't control that. Call it 20 h all together. I'd dare say that this is fairly typical for a Med School curriculum today, which are all suffering from lack of time. This in a world where lack of food in some parts, and over-abundance in others, is the major contributor to both morbidity and mortality.

Let me reinforce what some others have been saying: Any nutrient, when taken in excess, can have negative consequences for health. This is the reason why the Institute of Medicine of the NAS publishes not only RDA-values (the dose that avoids deficiency in 97% of the population), but also Tolerable Upper Limits of Intake (UL) to avoid toxicity.

What may be useful is the basic 4 rules of meal planning we teach our students, for them to pass on to their future patients (many of whom do not have a degree in biomedical sciences):

- Start with a normal size plate

- We eat plains, not mountains

- Leave enough rim that you can carry your plate without the thumps touching the food

- Within the limits above, make your plate as colorful as possible (natural colors, of course).

This should ensure a balanced meal with an appropriate caloric content for most people.

I totally agree that medical schools should incorporate studies nutritional studies to a larger extent in their curriculum. In fact, having them incorporate a rotation with the nutrition department while they are in their clinical years would be an advantage. Working with nutritionist/ dieticians is becoming an importance in the kind of problems we see with patients these days.

To balance the discussion I am in hopes that we discuss the significant dangers of relying upon medications for chronic disesae instead of food and nutrition. The absence of nutrition training of physicians leaves them to become purveyors of medication as if chronic human illness is a medication deficiency.

Nutration is in real sense a greatspecility which as been explored deeply for last hundred yeras or more. the specfic discovery leads to specfic medicine and treatment. thus specility loose its importance in the hands of clinicians. since it is related to good food as natural source most women take it as their right to practice it as nutrationist in many hospitals they can not spare time for further researc. thus specility is suffering.PCG,CLI

This is a great question and has been of interest to me for 40 years. I decided to go to medical school back in the mid-70's after discovering I had lactose intolerance. I was having many typical symptoms and had seen more than a few doctors, but I had to make the diagnosis myself when taking an undergraduate nutrition course. I have spent my career trying to improve nutrition education in medical schools and over my professional career, very little has changed. So, why? Why has this lack of knowledge about a key area of health not been paid more attention to in medical education? Many reasons some of them identified by previous comments, but here's my take on it:

1. Nutrition science is still in its early stages- every time we make a new series of discoveries, we think we understand more than we really do. The vitamins were discovered thru identifying deficiencies & once that was done, we thought we had all the information we needed about nutrition. Then we discovered fiber & the idea that even what we don't absorb is important. Then we discovered phytonutrients & had to accept that vitamins & minerals are not the only things that are important. So, it has been hard to determine what to teach physicians.

2. The generation of physician educators were not taught nutrition, never used it in practice, so have no idea of its therapeutic value.

3. We don't teach any aspect of prevention sufficiently in medical school because no one profits from prevention except the patient. No big pharma money going into preventive studies.

4. Our diets have changed markedly over the years with more processed food, less fresh food (and as mentioned less nutrient-dense even when fresh). The consumer is more interested in taste and convenience and less interested in health effects when eating so most doctors who do try and give dietary advice get frustrated very fast. The add budget for soda in 1 year is more than we spend on education, so students are not learning about healthy food in elementary or high school and only a small fraction of college students take a nutrition course. If our whole society has decided that nutrition is not important, how can physicians be expected to change that?

This is really a very important question which is if answered in Medical Curriculum, more than 50% disease problems will be resolved in no time. But answering this question will have a negative impact on profit margin of the medicine companies and the physicians who are billionaire due to ignorance of peoples about the nutritious and healthy diet.

Good point. Preventive medicine in general is de-emphasized in medical school training. Furthermore, mainstream medicine has been slow to recognize the importance of phytochemicals, other than vitamins, in human health.

The problem of nutrition not only knowledge but also the self control of people to have good habit in eating like prophet by doing fasting.

Yes, Syaefudin, there is a powerful benefit in ocassional fasts, something that seems lost in the modern world today. In fact, those who eat food more frequently than 3 hours between meals risk Pancreatitis and Acid Reflux, because the body needs a period of time to reset the cycle of digestion. Good topic to bring up--

I would argue that nutrition is one of the means for promoting health, whereas modern medical studies are more about managing disease. Altouugh one can say they are the same, I think they are completely different. On that premis, should physicians learn how to perscribe physical activity and training? Should we learn ways for handeling emotional stress?

The general practitioner knows that salt is something that should be avoided in patients with hypertension and ESRD. The same goes with nuts for secondary prevention of CVD, and fish oils. However, the exact knowledge of how many calories should be given to an elderly individual to maintain healthy aging (30-35 Kcal/Kg/day), or how much protein (1 gr/Kg/day) etc - this is probabely for health proffesionals that maintain health, such as dieticians. The fields coincide in many cases, but this is only when physicians have to deal with the nutritional aspects of disease. Diseases such as CVD, Malnutrition, IBD, etc. This is learnt in medical school, but given the fact that nowadays. the physicians are perscribing more medications and invasive treatments, compared to what was available 50 years ago, and that evidence based medicine is strong for pharmaceutical interventions, the nutritional aspects are left behind.

your not a question but a statement should be. Our bad eating habit is the cause of major diseases to which the public is affected. I think it is necessary and mandatory rules on nutrition education in medical courses but I think it lacks the culture and preparation on this topic but I think it necessary to reverse course.

I want to address Robert Eibl's contention that everything physicians need to know about nutrition is already included in the medical curriculum. This is most definitely not the case. Clinical nutrition practice cannot be practiced based on first principles. Medical students learn much about the physiology and biochemistry of vitamins, but they are still as vulnerable to unsupported claims as their patients, sometimes even more so. The problem is very often that they have not learned about the clinical context of both deficiencies and excesses, and what the current scientific and clinical evidence tells us about assessment and effective interventions. Knowing when to suggest a dietary modification or how much of a supplement to use, if any at all, has to be learned, it is hard work and takes time. Physicians do not get such knowledge magically conferred with their medical license. Another example: it is not enough to have memorized the chemical structure of fats when it comes to obesity or to know about all the endocrinological interactions of adipose tissue with the brain and other organs. Physicians have to learn how to provide nutritional guidance based on proven communication techniques and with well-aimed intervention targets if they want to be effective. They also have to be able to do this within the time constraints of their clinical practice, that is, they only have a few minutes per visit. Competent medical nutrition counseling is an acquired skill that they only too often do not learn, neither in medical school nor in their later training. Their resulting failure to help their patients to lose weight loss or to stick to other difficult nutrition prescriptions then leads them to conclude that nothing can be done, anyway, when the problem is really their own skill deficit.

It might be because there is a gap between medicine and nutrition, one from medical field, the other from agriculture and nutrition fields. It is really the time to reform traditional medical education because non-communicable disease becomes the leading cause of death, which is mainly caused by lifestyle risk factors. The way to improve nutrition education is to have it as a common courses in all high education, and have more detail in medical and public health curriculum.

This is a very important question and poses serious questions for the medical fraternity around the training of doctors whose job it is to advise or treat us in regards to our health - and if the levels of iatrogenic deaths worldwide are even half true then there is a lot to be answered.

I asked the question on my account as to whether we should now in fact be teaching our children basic diet and nutrition at elementary and secondary level schooling so that they can be more informed, make better decisions and be more proactive in their health regime as they get older.

The conventional medical profession needs to take heed of the vast amounts of research, clinical trials and anecdotal evidence that supports a much greater input from diet and nutriceuticals in preventative and curative treatments.