Building the Future Gastroenterologist: Why Nutrition and Lifestyle Medicine Must Be Core Competencies

INTRODUCTION In clinical practice, gastroenterologists often counsel patients with gastroesophageal reflux disease (GERD), inflammatory bowel disease (IBD), or metabolic dysfunction–associated steatotic liver disease to adopt a healthier lifestyle and eating habits; however, most of them were never formally trained in clinical nutrition. In gastroenterology (GI), the field most intertwined with nutrition, formal education on nutrition remains an afterthought. GI fellows often report feeling underprepared to counsel patients on nutrition, even as diet-sensitive chronic diseases continue to rise—conditions that are, in large part, treatable through nutrition and lifestyle interventions. 1 For example, a recent study of GI physicians treating irritable bowel syndrome (IBS) reported that only 56% felt adequately trained to provide nutrition education, whereas 46% reported that they rarely or never offered dietary guidance and 77% reported spending fewer than 10 minutes discussing nutrition with patients. 1 Notably, 91% believed that having access to a dietician would improve their ability to manage IBS. 1 Integrating Nutrition and Lifestyle Medicine into GI fellowship training would help bridge this significant knowledge gap, equipping future gastroenterologists with the skills to translate dietary science into clinical practice and potentially improve patient outcomes. Although nutrition is a central pillar of digestive health, it is only one component of a broader lifestyle framework that profoundly influences disease prevention and management. Core elements of lifestyle medicine—physical activity, sleep hygiene, stress reduction, social connection, and avoidance of risky substances deeply influence disease outcomes. 2 Despite the strong evidence linking daily habits to the prevention and progression of chronic disease, population level adoption of healthy behaviors remains remarkably low. One contributing factor may be that physicians themselves are not routinely incorporating lifestyle counseling into clinical encounters. Studies show that physicians infrequently discuss physical activity, healthy nutrition, weight management, sleep, or other core elements of lifestyle medicine with their patients. 2 This limited engagement not only reinforces the existing gap in patient adoption but also underscores the need for structured training in lifestyle medicine competencies across medical education, including gastroenterology fellowship. CURRENT STATE OF NUTRITION AND LIFESTYLE EDUCATION IN GASTROENTEROLOGY TRAINING Although Nutrition and Lifestyle Medicine are acknowledged in Accreditation Council for Graduate Medical Education milestones, they are neither emphasized nor consistently assessed in GI fellowship training. According to faculty at academic GI programs, institutional priorities, limited faculty expertise, and inadequate nutrition resources contribute to this persistent gap. 1 As Dr. Sprung of the University of Rochester has noted, only a few gastroenterology departments have invested in faculty development for nutrition teaching, which leads to restrictions in training for future clinicians. 1 Numerous studies echo this observation. A study assessing nutrition knowledge and perceived competence among GI fellows found substantial deficiencies across multiple domains. 1 Fellows rated themselves least knowledgeable in obesity and nutrition, and objective test scores averaged approximately 50% in these domains. 3 These findings reinforce that nutrition education within GI fellowship remains fragmented and insufficiently structured. Similarly, a 2013 survey of U. S. GI fellows reported that over one-third had received no formal nutrition education during fellowship, and the majority felt unprepared to counsel patients on dietary or lifestyle modifications. 4 To contextualize these gaps, we compared core nutrition–related training elements in U. S. GI fellowships to curricula from well-established international programs (Table 1). Table 1. - Comparison of nutrition-related training components in gastroenterology fellowships across international programs Country Nutrition training structure Procedural skills (NJ/PEG/PEG-J) TPN/enteral nutrition training Lifestyle medicine components Formal assessment USA Not a dedicated required module; varies by institution Yes, but usually inpatient-focused and without mandatory logbooks Variable/inconsistent Minimal and not standardized; often ad hoc None specific to nutrition UK Dedicated core nutrition training required in accredited units5 Required skill logs for NJ/PEG/PEG-J insertion5 Mandatory competency with supervised training5 Components included under obesity/chronic disease management5 Summated nutrition-related assessment via ESEGH5 Europe (EU) ESBGH standards include nutrition for adult and pediatric tracks6 Competency expected although implementation varies6 Included in advanced luminal/IBD training7, 8 Growing inclusion, especially in IBD and MASLD6, 9 ESEGH provides aligned summative assessment6 Canada Similar to the United States with center-based variability; pediatric programs stronger Common in tertiary training centres Included in patient-care but not always competency tracked Not consistently structured No national standardized exam for nutrition Australia Defined curriculum including nutrition and metabolic diseases across tracks10 Required supervised procedures as part of competency10 Part of official learning and assessment framework10 Increasing inclusion in MASLD/obesity pathways10 Workplace-based evaluation map to nutrition competencies10 ESEGH, european specialty examination in gastroenterology and hepatology; IBD, inflammatory bowel disease; MASLD, metabolic dysfunction–associated steatotic liver disease; NJ, nasojejunal; PEG, percutaneous endoscopic gastrostomy; PEG-J, percutaneous endoscopic gastro-jejunostomy; TPN, total parenteral nutrition. The international comparisons highlight substantial variability in how nutrition and lifestyle education are structured, assessed, and prioritized across gastroenterology training programs. Established models from the United Kingdom, Europe, and Australia demonstrate that clearly defined curricula, competency-based procedural requirements, and formal assessment frameworks are feasible within fellowship training. Although differences in health care systems and accreditation structures may limit direct translatability, these examples offer transferable principles that can inform reform efforts in U. S. programs. Drawing from these global best practices, GI fellowships could move toward more standardized, longitudinal integration of nutrition and lifestyle medicine through defined competencies, supervised clinical exposure, and formal assessment—an approach further elaborated in the following sections. Despite the growing recognition that lifestyle behaviors drive and amplify multiple digestive and metabolic diseases, only a few fellowship programs include structured teaching on weight management, physical activity, or behavioral counseling. Most existing content focuses narrowly on inpatient nutrition support or total parenteral nutrition management, leaving limited exposure to outpatient lifestyle interventions or preventive care. Even where programs express interest in expanding training, the absence of standardized curricula and assessment tools poses a major barrier. WHY INTEGRATION OF NUTRITION AND LIFESTYLE EDUCATION IN GASTROENTEROLOGY TRAINING MATTERS Patients with functional bowel disorders, now classified as disorders of gut-brain interactions, have shown growing interest in dietary interventions. Recent studies have shown that diet modification is the preferred approach among patients with IBS, surpassing interest in therapeutic or psychological therapies. 11 Although disorders of gut-brain interactions most clearly highlight the need for nutrition-focused care, they represent only one part of a broader spectrum. A growing body of evidence states that diet and nutrition play a pivotal role across nearly all major luminal gastrointestinal diseases, including IBD, GERD, and metabolic dysfunction–associated steatotic liver disease. As research has suggested, diet is a major contributor to both development and treatment of IBD. Nutritional interventions have proved to be effective in improving symptoms as well as reducing inflammatory activity in both pediatric as well as adult IBD. Exclusive enteral nutrition (EEN) is recognized as the first-line therapy for inducing remission in mild-to-moderate pediatric Crohn's disease. 12 Clinical trials consistently show that EEN can achieve remission in up to 80% of children, with higher rates of mucosal healing compared with corticosteroid therapy. 13–17 Furthermore, studies by Borrelli et al and Pigneur et al have reported mucosal healing rates approaching 73%–89%, underscoring the therapy's efficacy in pediatric populations. 16, 17 In adults with Crohn's disease, outcomes with EEN have been less robust, likely reflecting challenges with adherence rather than fundamental differences in disease biology. 18 Beyond EEN, partial enteral nutrition (PEN) and structured exclusion diets have also demonstrated efficacy in pediatric Crohn's disease. In a randomized trial, when PEN was combined with the Crohn's Disease Exclusion Diet (CDED), remission rates improved markedly with 75% of children achieving steroid-free remission at 6 weeks, comparable to those receiving EEN, with superior adherence. 19 Similar results have been demonstrated in adults. In a randomized controlled trial of the CDED with or without PEN, 44 adults with mild-to-moderate Crohn's disease were enrolled. By week 6, clinical remission was achieved in 68% of patients receiving CDED plus PEN and 57% of those on CDED alone. Among those who achieved remission at week 6, 80% maintained remission at week 24 comprising 12 of 19 patients (63%) in the CDED plus PEN group and 8 of 21 patients (38%) in the CDED-alone group. In addition, 35% of all participants achieved endoscopic remission by week 24. These findings suggest that dietary therapy can achieve sustained clinical and endoscopic remission in adult Crohn's disease, even in the absence of pharmacologic induction. 20 Although IBD highlights the therapeutic potential of diet in chronic inflammation, GERD highlights the impact of lifestyle modification in symptom control. Evidence from randomized trials and prospective studies demonstrate that modest weight reduction can significantly reduce esophageal acid exposure and reflux symptoms, with reductions in acid contact time from roughly 8% to 5%. 21 Smoking cessation has been shown to lower reflux risk more than fivefold, and simple behavioral adjustments such as avoiding late-night meals and elevating the head of the bed markedly decrease nocturnal acid exposure. 21 Similar benefits have been observed in patients with laryngopharyngeal reflux, where a plant-based Mediterranean-style diet with alkaline water achieved symptom reduction comparable to proton pump inhibitor therapy, with 62. 6% of patients achieving clinically meaningful improvement vs 54. 1% in the proton pump inhibitor group. 22 Beyond clinical outcomes, the implications of limited nutrition training extend to the economic burden of GI diseases. Chronic conditions such as IBD and GERD contribute substantially to health care expenditures—costs that could be mitigated through preventive, nutrition-centered approaches. For example, in a 2023 cost-of-illness analysis from Iran, the mean annual cost per patient was estimated at approximately 1, 600 for Crohn's disease and 1, 100 for ulcerative colitis, with indirect costs, mainly productivity loss, accounting for more than 60% of total expenditures. 23 Medication use represented the largest direct medical expense, highlighting how disease chronicity and disability drive long-term costs in IBD. 23 Early incorporation of these strategies has the potential to reduce long-term disease burden and decrease reliance on costly pharmacologic or procedural interventions. Together, these findings highlight that nutrition and lifestyle interventions are not ancillary but central to the prevention and management of GI disease. Integrating these domains into GI training is, therefore, not an adjunct effort, but an essential step toward building a workforce equipped for preventive, patient-centered care. WHAT INTEGRATION OF NUTRITION AND LIFESTYLE EDUCATION IN GASTROENTEROLOGY TRAINING COULD LOOK LIKE Moving from recognition to reform requires a deliberate rethinking of how GI education prepares future GI physicians. Integrating Nutrition and Lifestyle Medicine into fellowship training does not necessitate a complete curricular overhaul, but rather a thoughtful expansion of existing competencies to reflect modern clinical realities. By embedding structured nutrition teaching and experiential learning into established frameworks, programs can better align training with the evolving needs of patients and the evidence-based demands of practice. Importantly, integration of nutrition and lifestyle medicine within gastroenterology training should not occur in isolation, but rather as part of a longitudinal educational continuum spanning medical school, residency, and subspecialty training. Alignment across these stages would promote progressive skill acquisition, reduce redundancy, and ensure the gastroenterologists enter independent practice with competence and confidence to integrate lifestyle-based interventions into routine patient care. A practical roadmap for integrating lifestyle medicine into GI fellowship training can be drawn from models already implemented in other areas of medical education. Recent curriculum frameworks emphasize competency-based instruction in behavior change counseling, physical activity assessment, sleep hygiene, stress management, and reduction of high-risk behaviors, which are core pillars that closely align with the needs of gastroenterology practice. 24 Beyond these existing models, the updated Lifestyle Medicine Core Competencies provide a detailed framework that can further guide GI fellowship integration. The competencies outline structured training across all pillars of lifestyle medicine, including nutrition assessment and prescription, physical activity evaluation and exercise guidance, sleep health assessment and interventions, stress and emotional health management, reduction of high-risk substance use, and foundational behavior change counseling skills. They also emphasize key clinical processes such as incorporating “lifestyle vital signs” into routine history taking, leveraging interprofessional teams, utilizing team visits and telehealth, and designing quality improvement projects focused on lifestyle interventions. Importantly, the competencies highlight the role of practitioner well-being, modeling healthy behaviors, and community advocacy, reinforcing that effective lifestyle counseling requires both clinical skill and practitioner engagement. 25 Together these competency domains offer a comprehensive, ready to adopt roadmap that GI programs can adapt to build structured, scalable lifestyle medicine training into existing educational pathways. To operationalize these frameworks, GI fellowships may benefit from intentionally developing early adopters—fellows with advanced interest and training who can serve as institutional champions for lifestyle and nutrition medicine. Experience from lifestyle medicine residency training tracks offers a template for cultivating “super fellows” with advanced training in behavior change and nutrition. The lifestyle medicine residency curriculum, now implemented across 380 U. S. residency programs, combines ≥100 hours of didactic lifestyle medicine teaching with ≥400 documented patient encounters and is explicitly designed to prepare trainees for board certification and leadership in lifestyle medicine-focused quality improvement and education initiatives. 26, 27 Similar pathways in undergraduate and graduate medical education use student or resident led lifestyle medicine interest groups and elective tracks to develop local champions who organize teaching, advocacy, and clinical innovation within their institutions. 27, 28 By analogy, GI fellowships could designate a subset of fellows for an advanced nutrition/lifestyle track—with additional clinic time, multidisciplinary rounds, and education projects thus creating a cadre of “super fellows” positioned to champion and sustain broader curricular change. In the United States, even as late as 2023, structured nutrition and obesity education remains largely absent from GI fellowship training, despite overwhelming interest from fellows themselves. The proposed competency-based curriculum by Newberry et al offers a practical framework for integrating nutrition and lifestyle medicine into existing training pathways, aligning education with the realities of modern GI practice. 29 The model emphasizes a competency-based approach built around practical, clinically relevant skills rather than didactic teaching alone. 17 It includes formal instruction on EEN/PEN, nutritional management of common GI and liver disorders, and obesity counseling, paired with hands-on experiences through multidisciplinary rounds and dietitian collaboration. 29 The authors also recommend incorporating nutrition topics into case conferences, quality improvement projects, and board-style assessments, thereby ensuring that fellows graduate with both knowledge and confidence to apply evidence-based dietary strategies in patient care. 29 A similar initiative in pediatric gastroenterology by Shaikhkhalil et al demonstrated that dedicated clinical rotations in nutrition can substantially improve trainee knowledge, confidence, and readiness for clinical application, reinforcing that even brief, structured interventions can have lasting impact on fellow competence and patient care. 30 Although dietary guidance is often reduced to generic “eat less” messages, effective clinical nutrition education must go far beyond caloric restriction. Evidence-based nutrition training for GI fellows should emphasize how to eat and how to construct sustainable, balanced dietary patterns tailored to gastrointestinal disorders. This includes practical skills such as designing meals with adequate protein intake, understanding macro and micronutrient adequacy in conditions like malabsorption and IBD, recognizing role of dietary fiber and fermentable carbohydrates in symptom modulation, and applying principles of culinary medicine to support patient adherence. 31–33 Such competencies equip gastroenterologists to translate nutrition science into actionable, patient-centered recommendations rather than broad, nonspecific dietary advice. These initiatives demonstrate that meaningful nutrition education within GI fellowship training is both achievable and impactful. Structured curricula, even when modest in scope, can substantially improve fellows' competence and confidence in delivering evidence-based dietary and lifestyle guidance. The success of such programs reinforces that integration is not limited by feasibility, but rather by prioritization. By embedding nutrition-focused learning into existing competency frameworks and fostering collaboration between gastroenterologists, dietitians, and lifestyle medicine specialists, training programs can prepare fellows to meet the evolving needs of patients and the health care system alike. BARRIERS TO NUTRITION AND LIFESTYLE EDUCATION AND THE PATH FORWARD Despite growing recognition of its importance, integrating Nutrition and Lifestyle Medicine into GI fellowship training faces persistent barriers. Competing curricular demands, limited faculty expertise, and a lack of institutional prioritization have kept nutrition education peripheral. Many programs rely on informal teaching from dietitians or inpatient teams, often without defined objectives or assessment. Moving forward, incremental changes are both possible and practical. National societies such as the American College of Gastroenterology and the American Gastroenterological Association could play a pivotal role by developing standardized nutrition competencies, offering faculty workshops, and incorporating nutrition-related milestones into accreditation frameworks. 34, 35 Programs might begin by embedding short nutrition modules, interdisciplinary case discussions, or observed counseling sessions within existing rotations. These small, deliberate steps can lay the groundwork for lasting curricular change and a more competent, nutrition-literate gastroenterology workforce. As the of GI must the we its future physicians. The integration of Nutrition and Lifestyle Medicine into fellowship education is no it is a to the realities of modern digestive By equipping fellows with the knowledge and confidence to apply evidence-based nutritional and behavioral interventions, we can potentially bridge the knowledge gap between science and practice. 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