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REVIEW
The Deficit of Nutrition Education of Physicians
a b,c d e f,g
MonicaAggarwal,MD, StephenDevries,MD, AndrewM.Freeman,MD, RobertOstfeld,MD, HannaGaggin,MD,
h i j a
PamTaub,MD, AnneK.Rzeszut,MA, KathleenAllen,BA, RichardC.Conti,MD
a b c
Division of Cardiology, University of Florida, Gainesville, FL; Gaples Institute for Integrative Cardiology, Deerfield, Ill; Northwestern
d
University Feinberg School of Medicine, Chicago, Ill; Division of Cardiology, Department of Medicine, National Jewish Health, Denver,
e f
Colo; Division of Cardiology, Montefiore Medical Center, New York, NY; Division of Cardiology, Massachusetts General Hospital,
g h i
Boston; Baim Institute for Clinical Research, Boston, Mass; Cardiovascular Division, UC San Diego Health System, Calif; Market
j
Intelligence, American College of Cardiology, Washington, DC; Department of Nutrition & Food Studies, New York University, New York,
NY.
ABSTRACT
Globally, death rates from cardiovascular disease are increasing, rising 41% between 1990 and 2013, and
are often attributed, at least in part, to poor diet quality. With urbanization, economic development, and
mass marketing, global dietary patterns have become more Westernized to include more sugar-sweetened
beverages, highly processed foods, animal-based foods, and fewer fruits and vegetables, which has con-
tributed to increasing cardiovascular disease globally. In this paper, we will examine the trends occurring
globally in the realm of nutrition and cardiovascular disease prevention and also present new data that in-
ternational nutrition knowledge amongst cardiovascular disease providers is limited. In turn, this lack of
knowledge has resulted in less patient education and counseling, which is having profound effects on car-
diovascular disease prevention efforts worldwide.
©2018ElsevierInc.All rights reserved. • The American Journal of Medicine (2018) 131, 339–345
KEYWORDS: Cardiovascularnutrition knowledge; Cardiovascular risk; Healthy dietary patterns; International
nutrition; Nutrition; Nutrition education; Unhealthy dietary patterns
INTRODUCTION of cardiovascular disease, both internationally and in the United
Cardiovascular disease is the leading cause of death global- States.6-8 With urbanization, economic development, and mass
1 marketing, global dietary patterns have become more West-
ly, accounting for 31% of all deaths in 2013. In the United
States, recent decreases in cardiovascular disease mortality ernized to include more sugar-sweetened beverages, highly
2-4 processed foods, animal-based foods, and fewer fruits and
appear to have plateaued. However, worldwide death rates
fromcardiovascular disease are increasing, rising 42% between vegetables.9,10 Concurrently, cardiovascular disease rates have
1990and20135(Figure1).Poordietquality is a leading cause increased around the world.10-13 As such, the World Health
Organization and other groups are pursuing initiatives to
improve dietary habits.14-19
Theviewsexpressed in this paper are from theAmerican College of Ca-
rdiology’s Nutrition and Lifestyle Committee as part of the Prevention of
Cardiovascular Disease Council and do not necessarily reflect the position
of the American College of Cardiology. MODIFYINGEATINGHABITSANDRISKFACTORS
Funding: None. Modifying eating habits to decrease cardiovascular risk is a
Conflicts of Interest: AF has done nonpromotional speaking with time-tested approach.20-28 As early as the 1950s, Ancel Keys
Boehringer Ingelheim; all other others have no potential conflicts of inter- with the Seven Countries Study showed that certain dietary
est to report.
Authorship:All authors had access to the data and a role in writing this patterns, especially those with a higher composition of satu-
manuscript. rated fat and cholesterol, were associated with increased risk
Requests for reprints should be addressed to MonicaAggarwal, MD, Di- of cardiovascular disease. In contrast, societies with diets of
vision of Cardiovascular Medicine, Health Science Center, University of <10%saturated fat had a low risk of cardiovascular disease,
Florida, Room M-415, PO Box 100288, 1600 SW Archer Road, Gaines- even after accounting for varying amounts of total fat in the
ville, FL 32610-0277.
29
E-mail address: Monica.aggarwal@medicine.ufl.edu diet, blood pressures, and tobacco use. In the 1980s, the
0002-9343/$ - see front matter © 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.amjmed.2017.11.036
340 The American Journal of Medicine, Vol 131, No 4, April 2018
Lifestyle Heart Study was conducted in which 48 patients with zation recommends at least 5 servings (400 grams) of fruits
moderate-to-severe coronary artery disease were directed to and vegetables daily, as well as daily consumption of legumes,
eat a 10% fat vegetarian diet, do moderate aerobic exercise, nuts, and whole grains.39
undergo stress management training and smoking cessation
counseling, and participate in support groups. Over 1 and 5
years post intervention, plaque regression occurred in the treat- INTERNATIONALEFFORTSFORDIETARY
mentgroup, while progression was MODIFICATION
observed in the control group.30 CLINICAL SIGNIFICANCE Diets vary widely across the globe
(as shown in the Table), as does the
THEMEDITERRANEANAND • Worldwide death rates from cardiovas- extent to which they are consid-
PLANT-BASEDDIETS cular disease (CVD) are rising, and are ered to be good for vascular health.
often due, in part, to poor diet quality. Educating the public in certain
Early studies on the Mediterranean world regions through impactful
diet, which features an abundance of • Newsurvey data of international cardi- policy initiatives has shown signs of
vegetables, fruit, and fiber, as well as ologists shows that nutrition knowledge success.As an example, the multi-
fatty fish and nuts, have also shown andtheability to apply nutrition to ev- faceted North Karelia Project in
that diet modifications can reduce heart eryday care is very limited. Finland reduced smoking and de-
disease risk.25,31 The more recent and creased butter and saturated fat by
pivotal PREDIMEDstudylookedat • Nutrition counseling during patient visits coordinating public policy, indus-
the Mediterranean diet for primary worldwide is very limited, in part due to try, nongovernmental organizations,
prevention of coronary heart disease. knowledge gaps and limited time, health-focused programs at local
In this study, men (55-80 years) and despite the beliefs by most that this community organizations, and
women(60-80years)hadeither di- would improve outcomes. 17,40-42
media messaging. These
abetes mellitus or 3 other • Empowering health care providers with changes were associated with re-
cardiovascular risk factors.AMed- the tools they need in nutrition and life- ducing age-adjusted coronary heart
iterranean diet with olive oil or nuts style medicine could significantly combat disease mortality by 73% among
wascomparedwithastandardlow- CVD worldwide. 35–64-year-old men over a 25-
fat diet. The Mediterranean diet year span.17,40,42 In South Korea,
showed a 30% relative risk reduc- during a period of Westernization
tion of the combined endpoint of and rapid economic development,
myocardial infarction, stroke, or death from cardiovascular a multipronged effort among government, private organiza-
diseases in both the olive oil and walnut groups.31 tions, and health care professionals (emphasizing the traditional
During the early investigations of the Mediterranean diet, South Korean diet high in vegetables, fermented foods, and
the notable DietaryApproach to Stop Hypertension (DASH) low in fat) was associated with slowing the trend toward the
trial was conducted. In this trial, patients with hypertension adoption of a more Westernized diet.43 In Iran, the Isfahan
were given a diet rich in fruits and vegetables, whole grains, Healthy Heart Program improved dietary habits in 2 inter-
andlowinfat,32 and within weeks, without a change in sodium vention counties as compared with a control county by
content, the subjects studied demonstrated a decrease in blood implementing multiple outreaches and community educa-
pressure. Nonrandomized studies of plant-based diets have tional programs.44 In the late 1980s, in response to rising rates
also shown compelling improvements regarding decrease in of cardiovascular disease, the island nation of Mauritius created
blood pressure and rates of cardiovascular events.33-36 a noncommunicable disease outreach program within its Min-
Very recently, a study was done to assess diet quality using istry of Health, which targeted 25–74-year-old individuals.
multiple surveys (Mediterranean, DASH, andAlternate Healthy Using legislation, media, and educational efforts, serum cho-
Eating Index). Notably, a 20% improvement in diet quality lesterol, rates of hypertension, and smoking were reduced.45
wasassociated with an 8%-17% decrease in mortality.37 The Furthermore, the Mexican “soda tax,” which increased the
foundation of each of the diets is the same; namely, whole cost of sugar-sweetened beverages, is projected to lower in-
grains, fruits and vegetables, and fatty fish or a source of cident diabetes and cardiovascular disease.18 There are multiple
omega-3 fatty acids. The study noted that each diet type, as successful paradigms of community, government, and coun-
long as it has this same foundation, was associated with im- trywide efforts leading to health improvements.46 Nevertheless,
proved mortality.37 despite these impressive efforts, additional measures are
These studies have effectively shown that a diet based on needed.
fruits and vegetables, whole grains, and minimally pro-
cessed foods is effective in reducing cardiovascular disease THEROLEOFTHEPHYSICIANINIMPACTING
risk, as compared with the standard Western diet.As a result,
the World Heart Federation has emphasized that a PATIENTS’ DIETS
Mediterranean-type diet emphasizing plant-based foods may Physician investment in patients’ dietary habits is a key in-
reduce cardiovascular disease.38 The World Health Organi- fluence in behavior change but has been described as
Aggarwal et al The Deficit of Nutrition Education 341
Figure 1 Global mortality rates in males due to cardiovascular disease; originally published jointly by the World Health Organization in
collaboration with the World Heart Federation and World Stroke Organization in 2011 as part of the GlobalAtlas On Cardiovascular Disease
Prevention and Control; permission granted by World Heart Federation, November 14, 2017 and World Health Organization, November
23, 2017 (Permission access number 243602).
suboptimal,47 due in part to limited time with the patient,47-51 in educating their patients about nutrition. In the Americas
48,49,51 and Europe, over 70% of physicians felt that it is an essen-
low reimbursement, minimal education, and lack of
comfort in counseling about healthful dietary patterns.48-51 tial part of their role to incorporate detailed nutrition counseling
Given the rising global burden of cardiovascular disease and into their cardiology practice. In Asia and Africa, this per-
the potential for dietary change to positively influence this ception was lower; only 50%-56% of physicians felt that their
trend, physicians are well positioned to help “bend the curve.” role was to include nutrition counseling in their practice. This
Asaresult, the Nutrition and Lifestyle Working Group of the perception of their role in nutrition counseling seems to cor-
American College of Cardiology’s Cardiovascular Disease respond to the amount of actual time spent with patients; that
Prevention Section conducted a survey to assess internation- is, the majority of physicians spent fewer than 3 minutes of
al nutrition education gaps for physicians on a global level patient visit time on nutrition counseling.
with a focus on Southeast Asia.
PHYSICIANANDNUTRITIONALCOUNSELINGOF
STATE OF NUTRITION EDUCATION IN PATIENTS
INTERNATIONALMEDICALTRAINING Evenwhenphysicians did participate in nutritional counsel-
The Nutrition and Lifestyle Working Group of the Ameri- ing, only 57% engaged in a direct discussion, and many
can College of Cardiology’s Cardiovascular Disease Prevention employedother measures such as referring to dietician (64%)
Section developed an online survey that asked primarily car- and providing educational handouts (35%). When physi-
diovascular specialists outside of the United States to describe cians would engage in direct discussion, that discussion would
their nutrition education, as well as knowledge, attitudes, and focus mainly on the disease management and pathophysiol-
practice related to nutrition counseling to understand whether ogy of the illness. Education on nutrition topics was often
this can become an area of focus for undergraduate and grad- limited to the ill effects of high sodium, sugars, and fried foods.
uate medical training. After counseling, physicians (72%) believed that most pa-
In this survey of physicians, 6 of 7 believed that dietary tients understand the role of nutrition and disease. Previous
interventions were likely to provide a substantial additional studies, however, show that while physicians often feel that
benefit to patients with cardiovascular disease. The majori- they have effectively relayed information, only 21% of pa-
ty of physicians also felt that they should play an active role tients feel that they received effective communication from
342
Table Summary of Regional and Global Cuisine
Continent Major Regions Example Countries Predominant Ingredients Example Food Comments
Africa North Africa + Algeria, Morocco, Tunisia, Egypt, Wheat, spices (saffron, nutmeg, Couscous, stewed meats such as Less pork consumption due to
Middle East Israel, Iran, Iraq, Turkey cinnamon, ginger, cloves, lamb tagine, grilled meats such religion – Islam and Judaism
chilies), tomatoes, potatoes, as kebabs, dolma such as stuffed
seafood, goat, lamb, beef, dates, grape leaves
almonds, olives, olive oil,
lemons, peppers, rice,
vegetables, milk, cereal grains,
honey, sesame seeds, meats
Sub-Saharan Africa South Africa, Namibia, Botswana Grains, red meat, dried meats, Braai (barbecued red meat), stewed Also referred to as “rainbow
potatoes, rice, butter, sugar, meats, biltong (dried, cured cuisine” due to a mix of influence
beans, milk, vegetables, corn, meat) from native tribes, Europe and
curry, lemon, rice, fruits and Asia
vegetables, cornmeal
Americas North United States, Canada Meats, wheat Burgers, pasta, “fast food” Immigrant European cuisine The
South and Central Brazil, Ecuador, Belize, Costa Rica Corn, beans, potatoes, less meats Rice and chicken, rice and beans American
Asia East Japan Rice, ginger, garlic sesame, soy and Rice, sushi, pickled and fresh Korea: pickled cabbage (Kimchi)
China tofu, seafood vegetables
Korea Rice, noodles, tofu, pork, beef, Rice/noodles with tofu and meat
mutton, duck, pigeon Journal
South West India, Vietnam, Malaysia Vegetables, coconut milk, Coconut milk-based curries, biryani, Less beef in locations with
chickpeas, lentils, rice, wheat, chapati (flat bread), roti predominant Hinduism, less pork
yogurt, seafood with predominant Islam of
Europe North Norway, Belgium, Germany Wheat, rye, butter, meat, cured Sausages, polenta, smoked salmon Also can be divided as Eastern and Medicine,
meat, rice, pickled food Western Europe
South Italy, Malta, Croatia Olive oil, pasta, vegetables, seafood Pasta dishes, Mediterranean cuisine
Oceania Australia, New Zealand, islands in Sweet potato, taro, fish, fruits Meats, barbecued meats, seafood Immigrant European cuisine as well
the Pacific as native Aboriginal Australian Vol
cuisine 131,
No
4,
April
2018
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