Medical schools should be prioritising nutrition and lifestyle educationBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4861 (Published 26 October 2017) Cite this as: BMJ 2017;359:j4861
All rapid responses
Thank you for raising this important issue. Tomorrow’s doctors clearly need to be knowledgeable about nutritional and lifestyle factors affecting disease. This is essential not only for the prevention of obesity and metabolic syndrome, but also for recognizing and managing malnutrition in all patient groups, including people with mental disorders, who are vulnerable to malnutrition. This is particularly true of people with eating disorders, who are often overlooked in medical education. This is probably due to the common misconception that eating disorders are rare and self-limiting disorders, mainly affecting young white women.1 In fact, the cumulative lifetime risk by age 80 of anorexia nervosa, bulimia nervosa, and binge-eating disorder is estimated 4.6%2. According to B-EAT, the leading eating disorder charity, approximately 725,000 people suffer from eating disorders in the UK.3 Moreover, eating disorders have a high rate of mortality and multi-morbidity. Anorexia has one of the highest mortality rates of any psychiatric illness,4 and the mortality rates of bulimia and atypical eating disorders are also elevated.5
The number of eating disorder psychiatrists in the UK is small, and people with eating disorders are often first seen, with severe complications, by other doctors, either in primary care, or in acute hospitals. The physical complications of eating disorders are mainly related to malnutrition,6 include all systems, and account for the majority of the mortality. These deaths should be preventable with timely diagnosis and management. 7 If all doctors were appropriately trained in the recognition and treatment of malnutrition in eating disorders, many lives could be saved.
During the entire medical training structure the assessment of theoretical and clinical knowledge of eating disorders is minimal, not just in the UK, but internationally.8-10 Given that assessment drives learning, it is not surprising that most doctors, including psychiatrists, do not feel confident managing this patient population.11-13 Patient safety is at the centre of the General Medical Council (GMC) standards for undergraduate and postgraduate education and training.14 Severe malnutrition is an acute medical emergency, which is entirely reversible. For the benefit of our patients, we need to make sure that future doctors are confident in managing nutrition related disorders, both in the physically and the mentally ill.
1. Reas DL, Gulliksen KS, Levallius J, et al. Letter to the editor: health professionals' attitudes toward individuals with eating disorders: who do we think they are? J Eat Disord 2017;5:22. doi: 10.1186/s40337-017-0150-6
2. Hudson JI, Hiripi E, Pope HG, Jr., et al. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007;61(3):348-58. doi: 10.1016/j.biopsych.2006.03.040
3. PwC. The cost of eating disorders: Social, health and economic impacts. London, 2015.
4. Schaumberg K, Welch E, Breithaupt L, et al. The Science Behind the Academy for Eating Disorders' Nine Truths About Eating Disorders. Eur Eat Disord Rev 2017;25(6):432-50. doi: 10.1002/erv.2553
5. Arcelus J, Mitchell AJ, Wales J, et al. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011;68(7):724-31. doi: 10.1001/archgenpsychiatry.2011.74
6. Fichter MM, Quadflieg N. Mortality in eating disorders - results of a large prospective clinical longitudinal study. Int J Eat Disord 2016;49(4):391-401. doi: 10.1002/eat.22501
7. RCPsych. MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa CR189. 2014.
8. Anderson K, Accurso EC, Kinasz KR, et al. Residents' and Fellows' Knowledge and Attitudes About Eating Disorders at an Academic Medical Center. Acad Psychiatry 2017;41(3):381-84. doi: 10.1007/s40596-016-0578-z
9. Waller G, D'Souza Walsh K, Wright C. Impact of education on clinicians' attitudes to exposure therapy for eating disorders. Behav Res Ther 2016;76:76-80. doi: 10.1016/j.brat.2015.11.014
10. Mahr F, Farahmand P, Bixler EO, et al. A national survey of eating disorder training. Int J Eat Disord 2015;48(4):443-5. doi: 10.1002/eat.22335
11. Jones WR, Saeidi S, Morgan JF. Knowledge and attitudes of psychiatrists towards eating disorders. Eur Eat Disord Rev 2013;21(1):84-8.
12. Hudson LD, Cumby C, Klaber RE, et al. Low levels of knowledge on the assessment of underweight in children and adolescents among middle-grade doctors in England and Wales. Arch Dis Child 2013;98(4):309-11. doi: 10.1136/archdischild-2012-303357
13. Hudson LD, Court AJ. What paediatricians should know about eating disorders in children and young people. J Paediatr Child Health 2012;48(10):869-75. doi: 10.1111/j.1440-1754.2012.02433.x
14. General Medical Council. Promoting excellence: standards for medical education and training: General Medical Council, 2015.
Competing interests: No competing interests
A subject does not need to be taught in a lecture or tutorial to be covered by the medical school curriculum. Nutrition and exercise are discussed in consultations in General Practice, General Surgery, General Medicine and numerous sub-specialties such as Diabetes, Cardio-vascular, gastroenterology and my own specialty of Breast Surgery. Medical students observe consultations in all these settings and have the opportunity to question and use the discussion as a starting point for private study. Spending time with a nurse on an admissions ward will teach students about nutritional assessment and students are welcome to discuss queries about nutrition with dietitians and exercise with physiotherapists.
Much of my own philosophy on diet and exercise comes from the adage 'moderation in everything'. Next time you see a patient with nutritional issues, ask them to talk you through their day in terms or what they eat and what they do. The solution is often plain to see.
Competing interests: No competing interests