Doctors’ Orders
Why physicians don’t talk about diet and exercise—but should

When Dr. Michael Jon Zackin, N82, N86, quizzes his patients about what they had for breakfast yesterday, he is not testing their memories. In his pediatric practice in Weston, Mass., he sometimes asks his patients or their parents to do 72-hour nutrition recalls (writing down everything they’ve eaten for three days) to evaluate their diets. If one of his teenage patients is seriously overweight, Zackin may encourage the youth to meet with him monthly.

Dr. Michael Jon Zackin, N82, N86, emphasizes nutrition in his medical practice, but he the exception, not the rule. Photo: Steven Vote

“I personally spend an inordinate amount of time talking about nutrition right from the start, at every well-visit,” said Zackin, who earned his doctorate from the Friedman School before going on to get his medical degree at the University of Massachusetts Medical School. “I try to get families eating well, and talking about eating behaviors.”

As a physician, Zackin is an exception, and not just because of a lifelong interest in fitness that prompted him to read nutrition books, for fun, at age 12. Studies show that while most physicians are comfortable writing a prescription for a cholesterol-lowering pill or a diabetes drug, telling a patient how many servings of greens to eat or how many minutes of exercise to get is rarely part of doctors’ orders. This is despite the bevy of medical literature that says diet and exercise can be just as effective as medication in treating—and especially preventing—illnesses such as cardiovascular disease, diabetes and high blood pressure.

“Most consumers say while they get their initial info from the web and blogs and mainstream media, when it comes to the information they trust, the sources they trust, the physician is number one,” said Sylvia Rowe, an adjunct professor at the Friedman School and former president and chief executive of the International Food Information Council (IFIC).

The recent and alarming reports on obesity-related diseases have spurred some doctors to make lifestyle modification part of their exam-room agenda. But while nutrition advocates have long wanted to see physicians act a little more like Zackin, it has been a long, uphill battle, often waged against the American health-care system itself.

Second Fiddle in the Examination Room
Why does nutrition get such short shrift? Physicians point to the brevity of the average office visit, which lasts about 18 minutes, according to The New England Journal of Medicine. “The basic reality is physicians have limited time with patients to convey what they consider to be the critical medical facts. Rarely will they get into lifestyle issues like nutrition and physical activity,” Rowe said. “The exception is if you have an overweight or obese patient, but even that is somewhat ducked unless the patient brings it up.”

Money is also an issue. Insurance companies don’t readily reimburse physicians for preventative nutrition counseling. Then there are physicians’ attitudes toward nutrition itself, which they may rank anywhere between alternative and hippy-dippy. Rowe will never forget when the IFIC surveyed physicians about their views on functional foods. One respondent was impressed with the medical research on foods naturally rich in antioxidants. But he wasn’t about to tell his patients to go eat nuts and berries. “They will think I’m some sort of quack and go elsewhere,” he said.

In general, medical schools do little to dissuade aspiring doctors from the perception of nutrition as a “soft” science. As recently as a decade ago, fewer than 26 percent of medical schools required that students take a nutrition course, while another 25 percent offered no nutrition course at all, even as an elective. Fresh from his studies at the Friedman School, Zackin was unimpressed by the brief nutrition class he and his classmates took in medical school, and wonders how it affected the others’ practices. “I think most physicians don’t know enough about nutrition, and if you don’t know enough, you don’t want to talk about it enough,” he said.

Margo Woods, an associate professor at Tufts School of Medicine as well as the Friedman School, has fought to keep nutrition in the medical school, where it has been a required first-year course since 1991. To integrate even more nutrition into the curriculum, she applied for and won a grant, called the Nutrition Academic Award, from the National Heart, Lung and Blood Institute in 1998. Tufts was one of 10 pilot schools to receive the award, which helped Woods and her colleagues teach diet evaluation and intervention strategies. They developed case studies and brought in trained patient actors with whom the third- and fourth-year students could practice doing nutrition reviews. This “standardized patient experience” is still part of Tufts’ family medicine rotation, which all medical students go through.

The goal is to know enough to take the right first steps. “You have to be able to evaluate a person’s diet by looking at it,” Woods said. “Count up the serving of fruits and vegetables and animal products. Are they having beans and nuts every day? Are half the carbs high in fiber? Even if you refer them to the dietitian, you make the first contact. It’s the physician’s responsibility to motivate them, to educate them, evaluate what they are currently doing and then negotiate with them what they think they can change.”

Dietetic interns learn they sometimes have to prove the value of nutrition to their physician colleagues. Photo: Steven Vote

That last part can be difficult, because it takes a certain kind of personality to work with patients on lifestyle modification. “Doctors like to tell people what to do, but here, they have to ask, ‘What do you think you can do and succeed at?’” Woods said.

The good news is that she has seen medical students become more and more interested in nutrition each year. “What really captures them most is that they have to keep a three-day food record and compare it to some standards,” she said. “They click into that because it’s personal.” This may have an added benefit, because some studies have reported that doctors who have made improvements in their own diets are more likely to give advice to their patients about good eating habits.

Last year, the Friedman School and Tufts Medical School have created another nutrition education opportunity for future physicians. Alice Lichtenstein, the Stanley N. Gershoff Professor of Nutrition Science and Policy, and Dr. Edward Saltzman, both scientists at the Jean Mayer USDA Human Nutrition Research Center on Aging (HNRCA), have partnered to teach a nutrition course for Tufts medical school’s new M.S. in biomedical sciences degree program, which is designed specifically for students aiming to become stronger applicants to medical school.

Lifestyle Medicine
Dr. James Rippe, a cardiologist and associate professor of medicine at Tufts Medical School, is a longtime proponent of preventative medicine in the doctor’s office. He edits a textbook, Lifestyle Medicine, that teaches physicians about the impact of lifestyle decisions on wellness, with an emphasis on cardiovascular heath. He knows the barriers that physicians face, but said it is up to the medical community to overcome them.

“If we really want patients to do the best they can for their health, we’ve got to figure out a way to do this stuff,” he said. By not bringing up diet and exercise with patients, he said, “we send them the subtle message that it is not important.”

Earlier this year, he launched the American Journal of Lifestyle Medicine, a compendium of prevention-focused, peer-reviewed research that reaches 20,000 physicians every other month.

“Most people go into medicine with the desire to take the best possible care of patients they can,” he said. “To deny the existence of this very exuberant, wonderful literature … is a very nihilistic point of view.”

In the journal’s inaugural editorial, he conceded that change will mean bucking the system: “Our mandate is nothing short of changing the way we practice medicine and provide health care in the United States and the rest of the industrialized world.”

For his part, Zackin is on a task force that is looking at ways to deal with obesity in the office setting. If physicians are going to take up the lifestyle modification banner, the ones who work with children may be standard-bearers.

“Pediatrics is one of the best specialties in which to use nutrition,” Zackin said. “We’re getting kids from day one, and we can really make a difference in their long-term health and lifestyles right from the beginning.”

In fact, that is partly why he went into pediatrics, and may be one reason other physicians find lifestyle modification a lost cause. “If you have a 40- or 50-year-old person coming in with all these poor habits,” Zackin said, “I found it difficult and frustrating to try to change them.”

In the end, the call for preventative medicine may come from patients themselves. “For some time now, but more so recently, patients have been pushing their doctors to know more about nutrition,” said Dr. Robert Russell, a physician who directs the HNRCA and is a Friedman School professor. “Many more doctors are contacting me to ask how to counsel patients who come in with questions about specific diets and specific nutrients, or substances such as green tea. Even though the medical schools are falling behind on teaching preventative medicine, including nutrition, I think doctors are becoming more informed on the job. Patients are demanding it.”

Julie Flaherty is editor of Tufts Nutrition magazine, where a longer version of this article first appeared in the fall 2007 issue. She can be reached at