Obstetricians and Patients Need Nourishing Knowledge

If a junk-food lover with a French fry habit is ever going to make friends with fruits and vegetables, pregnancy might be when they do it. Growing a new human has been known to be just the thing to jumpstart healthy lifestyle changes.

But what if that person needs guidance about nutrition and fetal growth? Will their OB/GYN have helpful information?

That might depend on whether their doctor is self-educated on the topic. In general, medical schools devote little time to nutrition education. And in a recent survey of 247 OB/GYN programs in the United States, almost half (48%) of respondents reported having had no didactic nutrition education. Forty-nine percent reported having one to two hours, and 3% said they had more than two hours.

The study was published in the Journal of Women’s Health.

Cara Dolin, MD, a maternal-fetal medicine specialist at Cleveland Clinic, was the senior author. The project aligns with her long-held passion for nutrition and wellness.

“My undergraduate degree is in nutrition and food science. I was on the path to become a registered dietitian, and then along the way I found medicine,” says Dr. Dolin. “As a physician, I've always approached my clinical practice with an understanding of the importance of nutrition and food on health – specifically across the course of reproductive health.”

Food and other lifestyle factors play key roles in many common illnesses, including cardiovascular disease, diabetes and obesity, cancer and more. Yet nutrition prevailingly goes unaddressed in medical training.

“Coming into medical school with a lot of knowledge about nutrition, it was kind of shocking to me how little we learned about it,” says Dr. Dolin.

The goal of the survey and resulting article was to expand understanding of what medical education offers OB/GYN residents and trainees in terms of nutrition-related information.

Among the most significant findings: “The majority of residents thought that nutrition was very important, and an important part of prenatal care, but less than a third felt comfortable talking to their patients about it,” says Dr. Dolin.

She has seen evidence of that among peers over the years. At Cleveland Clinic, she says, “Many physicians I know are comfortable discussing nutrition, and counseling patients about nutrition topics. They've sought out information. They've read articles, they've read books, they've taken extra courses. But unfortunately, very little attention is given to nutrition during formal medical training and not all physicians seek to educate themselves about nutrition-related topics.”

For the study, about 4,800 residents in postgraduate years 1 through 4 were contacted by email for the survey; 219 responded and one respondent did not give informed consent. Of the 218 responses analyzed:

• Only 31% said they would feel comfortable counseling their patients on nutrition guidelines.
• 99% agreed or strongly agreed that nutrition plays an important role in maternal and fetal outcomes.
• 92% agreed or strongly agreed didactic education about pregnancy-related nutrition guidelines would be useful to their practice.

Additionally, respondents answered questions related to objective knowledge. Key findings:

1. Overall, the mean percentage of correct answers among all respondents was about 74%.
2. Only 31.2% knew that a patient’s caloric intake should increase specifically during the second and third trimesters.
3. 65.5% knew that people with a history of a fetus with a neural tube defect during a previous pregnancy should supplement with at least 4 mg of folic acid a day beginning at least three months before pregnancy.

Barriers to education

Among barriers to better education is the relative dearth of high-quality nutrition science, says Dr. Dolin.

“It's very hard to study diet and nutrition. Randomized controlled trials, which are the gold standard in research, can be challenging given it is difficult to control what people eat short of having people stay in a research lab and feeding them measured, standardized meals,” she says. “A lot of nutrition research is based on participants trying to recall what they ate. There is recall bias. And unlike some other medical disciplines, there can be a lot of involvement of industry in nutrition studies.”

That said, the links between certain nutrients and pregnancy health are well established.

“The most well-known is the association between insufficient folic acid and neural tube defects, which is why all of our bread, cereals and grains are fortified with folic acid in the United States,” Dr. Dolin says. “It has decreased the rate of neural tube defects. It's also important to get enough calcium for fetal skeletal development. Iron is very important because it’s the building blocks of red blood cells, and anemia is more common in pregnancy.”

Training and partnerships

Solving the problem of too little nutrition education requires a multi-level approach.

“Nutrition needs to be incorporated at all levels of medical training,” says Dr. Dolin. “Starting in medical school, it should be incorporated in our preclinical didactic years. When learning about cardiovascular disease, how does nutrition play a role? When learning about reproductive health, how does nutrition play a role? How does nutrition play a role in childhood development?”

In the clinical environment, multidisciplinary partnerships also can help. Studies show that people are more likely to listen to their physicians than to registered dietitians, says Dr. Dolin, but connecting the two can be powerful.

“Can physicians refer more often to dietitians?” she says. “Can we have them embedded in our clinics, or offer shared medical appointments together with them? Physicians don't necessarily have all the time and skills to counsel, but they can learn how to start the conversation and make appropriate referrals.”

With luck and persistence, those conversations, once begun, can make a difference in patients’ lives.

“Pregnancy is a golden opportunity for lifestyle intervention,” says Dr. Dolin. “It is a time when people who may not otherwise think much about what they're eating suddenly are receptive to this information. Hopefully, if we're able to help them make even small changes in their diet or physical activity during pregnancy, it can continue past pregnancy. And if they're including more vegetables or fruits into their meals, maybe that's spilling over into the rest of the family's meals, too.”