GI Docs Nutrition Education Deficit May Shortchange Patients

Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal (GI) symptoms.

In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.

Yevgenia Pashinsky, MD

The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Pashinsky, a gastroenterologist with New York Gastroenterology Associates (NYGA) and affiliated with Mount Sinai Hospital in New York, NY.

“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.

Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.

“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.

As a result, not enough gastroenterologists are giving this topic the attention it needs, some in the industry contend.

One 2022 study based on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.

But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.

Nutrition Overlooked in Procedure-Heavy Specialty

In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in US medical schools.

Octavia Pickett-Blakely, MD, MHS

Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania Perelman School of Medicine and director of the Penn Center for GI Nutrition in Philadelphia.

Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Pashinsky noted.

GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.

The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.

Brandon Sprung, MD

Despite these requirements, the education that fellows receive often falls short for several reasons, said Sprung, an associate professor of medicine at the University of Rochester Medical Center’s Gastroenterology and Hepatology Division in New York.

Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.

Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.

It is possible that some fellowships are just not teaching these core concepts, Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.

Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.

“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.

It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Pickett-Blakely said.

GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.

If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.

Weaving More Nutrition Into Training

To further increase knowledge, Sprung and Newberry, who is an assistant professor and director of GI nutrition at Weill Cornell Medicine’s Innovative Center for Health and Nutrition in Gastroenterology in New York, have created a free online resource covering core nutrition and obesity concepts that is available to GI fellowship programs.

Key components of the curriculum include online pre- and post-learning tests, self-directed reading materials, virtual recorded lectures, and case-based learning modules. It also provides a section on care coordination with a GI dietitian.

“Because the curriculum spans all facets of gastroenterology practice, the information can enhance clinical care experiences on general rotations,” write Newberry and colleagues in their recent analysis in Gastroenterology.

GI fellows can look at the content at their own pace and complete the curriculum as part of a formal elective.

The developers can see who’s taken the tests, and test participation indicates that several GI programs across the country are already using the program, Sprung said.

But it hasn’t been as widely adopted as hoped, he said.

“We’re trying to put some spotlight on it through articles, presentations during Digestive Disease Week, and emails to program directors, things like that,” Sprung said. “So it’s great to spread the word and get the message out there.”

Collaboration in Practice

Ultimately, helping a patient with functional GI problems takes a village, and many practices are now including multidisciplinary teams.

Nancee Jaffe, RD, MS

Having these dietitians available to them, as well as seeing the benefit to their patients first-hand, has helped encourage the attending gastroenterologists’ interest, said Jaffe, who is senior supervisor for the GI Nutrition Program at UCLA Health’s Vatche & Tamar Manoukian Division of Digestive Diseases in Beverly Hills, California.

“We all subspecialize, which allows both doctors and patients access to the best nutrition information for a myriad of GI conditions,” Jaffe said.

In the spirit of teamwork, the university also has an integrative digestive health and wellness program, which is inclusive of doctors, dietitians, and psychologists. These teams meet monthly to discuss cases involving disorders of gut-brain interaction using a multicentered approach, she said.

In New York, one of the first things Newberry, who is also a clinical gastroenterologist with advanced training in nutrition and obesity sciences, did when she accepted her job at Weill Cornell was to advocate for a multidisciplinary team. At the Innovative Center for Health and Nutrition in Gastroenterology, she works with a group of dieticians, a hepatologist, an endocrinologist, and a team of surgeons to take care of patients. The focus is on treating patients’ GI issues while helping them lose weight.

The clinic sees a lot of patients with reflux disease and fatty liver disease. When patients come in, they’ll see the gastroenterologist, the dietician, the endocrinologist, and possibly the bariatric surgeon. The team approach, which calls for constant communication among the physicians, improves outcomes, Newberry said.

It has been shown in the literature that multidisciplinary teams are effective for chronic diseases like nonalcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease) and inflammatory bowel disease, she added.

At the University of Rochester, Sprung and his fellow gastroenterologists coordinate with dieticians and nutrition experts for nutrition support services, as well as liver and transplant nutritional services.

We have nurse practitioners and physician assistants who run our nutritional support services for people who need such specialized care, such as total parenteral nutrition or tube feeds, or for those who need advanced therapies, like for short-gut syndrome, he said.

At NYGA, Pashinsky works with a team of registered dietitians who have specialized in gastroenterology. The dietitians help with identifying which foods in a patient’s diet are problematic and making recommendations to replace them with nutritionally equivalent staples to avoid dietary gaps, she said.

Dietitians inform patient care because they’re trained in food compounds and how foods pass through the GI tract, said Tamara Duker Freuman, RD, MS, CDN, who leads the group of registered dietitians at NYGA. Freuman co-manages many patients with Pashinsky.

Oftentimes, the patient provides insights they never tell the doctor, and the dietitian gets a better idea of the patient’s life and eating habits, she said. “We’re able to spend more time with patients than physicians are, and we ask different questions.”

“Any detective work I do informs any future diagnostics [Pashinsky] does. It’s a team sport,” Freuman said.

Pickett-Blakely has been a consultant for Novo Nordisk and WebMD. Newberry has received a speaking honorarium for Baxter and InBody. Sprung, Pashinsky, Freuman, and Jaffe reported no disclosures.

Jennifer Lubell is a freelance medical writer in the Washington Metropolitan area.

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