Nutrition Competency: A Crucial yet Overlooked Domain in Gastroenterology

Despite the central role of nutrition in gastrointestinal (GI) disease management, structured nutrition education remains one of the most underemphasized components of gastroenterology fellowship training worldwide. This educational gap persists even as evidence increasingly shows that nutrition interventions are integral to effective, high-quality care. A recent study published in the Journal of Gastroenterology and Hepatology examined the impact of a dietitian-led celiac disease clinic (DLCC) in improving timely access to diagnosis and treatment for adults newly diagnosed with celiac disease [1]. The clinic shortened waiting times by more than a year, reduced unnecessary gastroenterology referrals, and provided earlier and more comprehensive nutritional counseling. This scheme is important and improves patient outcomes. This model demonstrates the value of embedding dietitian expertise into care pathways. Yet it also raises an important issue: Are gastroenterologists themselves adequately equipped to address the nutritional needs of their patients? Multiple studies from various regions point to a common issue—nutrition training for gastroenterologists is still insufficient [2]. Research consistently shows that GI trainees have limited knowledge and lack confidence in both the fundamentals of clinical nutrition and the disease-specific application of nutrition science to patient care. In the United Kingdom, a survey by Sartain et al. found that although GI trainees valued nutrition training, only 39.5% had completed advanced nutrition training [3]. Even among this subset, just over half (52.9%) felt reasonably confident managing nutrition in certain GI disorders. Reported barriers included limited structured education, few training opportunities, and the absence of dedicated nutrition rotations. In the United States, Halegoua-De Marzio found that 86% of GI trainees rated their nutrition knowledge as suboptimal, with most expressing a strong desire for more structured training. Fellows identified their weakest areas as understanding micro- and macronutrients and providing nutritional support [4]. Canadian data reveal similar trends. In a survey by Singh and Duerksen, while 65% of gastroenterologists were involved in nutrition support or feeding tube placement, most felt that nutrition training during fellowship was underemphasized [5]. Importantly, 95% agreed that nutrition education should be standardized across fellowship programs. The consequences are clear and far-reaching. Nutrition plays a pivotal role in the management of many gastrointestinal conditions, including celiac disease, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), chronic liver disease, short bowel syndrome, and other functional GI disorders. Evidence-based, disease-specific algorithms for nutrition care in these conditions are increasingly available. However, their successful implementation application hinges on clinician competence. For instance, in celiac disease, strict dietary adherence is the only effective treatment, requiring clinicians to provide clear guidance, identify hidden sources of gluten, and monitor nutritional status. For IBS, evidence supports the use of a low FODMAP diet to reduce symptoms, yet its success depends on careful patient selection, education, and monitoring to prevent nutritional deficiencies. In IBD, malnutrition can exacerbate disease activity, impair immune function, and worsen surgical outcomes. In cirrhosis, targeted nutrition interventions have been shown to reduce complications, improve muscle mass, and enhance survival. Without sufficient nutrition expertise, gastroenterologists risk missing critical risk factors, delaying timely interventions, and failing to integrate dietitians effectively into the care team—ultimately leading to gaps in patient care. Addressing this gap requires action on several levels (Figure 1). First, structured nutrition curricula must be integrated into gastroenterology training. This should extend beyond traditional lectures, incorporating case-based discussions, joint clinics with dietitians, and hands-on exposure to specialized nutrition services. Training should cover both the basics—such as macronutrient and micronutrient metabolism—and condition-specific approaches, from dietary therapy in eosinophilic esophagitis to nutritional optimization before liver transplantation. Second, interprofessional collaboration should be encouraged from training to practice. The DLCC model is a good example, combining medical expertise with dietitian counseling to speed up diagnosis, improve patient understanding, and ensure dietary adherence [1]. When gastroenterologists work closely with dietitians, care is more cohesive and patient outcomes improve. Nutrition support teams (NSTs), which often include gastroenterologists, dietitians, pharmacists, and nurses, set high standards for nutrition care and serve as powerful teaching partners [6]. Third, opportunities for sub-specialization in GI nutrition should be expanded. Dedicated fellowships, short courses, and regional initiatives can cultivate physician-leaders who integrate nutrition into research, education, and clinical care [7]. Training opportunities include programs endorsed by the American Society for Parenteral and Enteral Nutrition (ASPEN) or the European Society for Clinical Nutrition and Metabolism and (ESPEN), some of which offer travel fellowships. Regionally, initiatives such as GastroDIET—an international meeting on food, diet, and gastrointestinal health, most recently held in Kuala Lumpur in 2024—offer valuable platforms for learning and networking [8]. Clinical rotations with hospital-based NSTs and mentorship from functional GI specialists, who often have strong nutrition backgrounds, should be incorporated into training pathways. Finally, nutrition competence should be assessed and continuously reinforced. Fellowship programs can adopt formal assessments to establish baseline competency, while professional societies should provide continuing medical education modules and conference tracks focused on nutrition in GI practice. Ongoing assessment ensures that knowledge remains current and that nutrition care is consistently considered in clinical decision-making. The recent JGH study on a dietitian-led celiac disease clinic illustrates how embedding nutrition into GI care can accelerate diagnosis, streamline treatment, and improve patient outcomes [1]. But it also highlights a broader imperative: gastroenterologists must be active participants in nutrition care, not passive referrers. By embedding robust nutrition education into fellowship curricula, fostering interprofessional collaboration, expanding sub-specialty pathways, and committing to lifelong learning, the specialty can close the training gap and meet patients' nutritional needs with confidence. In doing so, the specialty will not only enhance patient outcomes but also reaffirm its commitment to comprehensive, patient-centered care. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.