In a study completed in 2016, more Americans demonstrated risk factors and died from causes related to poor diet than from tobacco use. Dietary risks accounted for nearly 530,000 U.S. deaths that year, about 10% more than died from cigarette smoking. About 11 million people globally died due to dietary factors, making it the world-leading risk factor for death.

The risks associated with poor diet are at least as well known as those associated with smoking. Dietary risk factors include diets low in fruits, vegetables, legumes, whole grains and nuts and seeds for fiber, as well as seafood’s omega-3 fatty acids, polyunsaturated fatty acids, and calcium from milk. Risk factors also include diets high in red meat, processed meat, sugar-sweetened beverages, trans fatty acids and sodium.

According to a recent article in the Journal of the American Medical Association’s JAMA Network, more than one in five deaths worldwide could be prevented if people improved their diets. Why, then, do more Americans, citizens of a wealthy country, die from poor diet than from smoking? Perhaps it is due, in part, to what doctors learn in medical school. The risks from smoking probably get a lot more attention in medical training than do the risks of not eating enough fruit.

A study published in September in the U.K. medical journal The Lancet reviewed 24 studies on nutrition curricula in medical schools in the United States, Europe, the Middle East, Africa and Australasia. The authors concluded that “nutrition is insufficiently incorporated into medical education, regardless of country, setting, or year of medical education. Deficits in nutrition education affect students’ knowledge, skills, and confidence to implement nutrition care into patient care.”

In a study published in 2010, researchers surveyed students at nine Canadian medical schools and concluded: “Students were comfortable in their ability to counsel patients regarding basic nutrition concepts and the role of nutrition in prevention of disease, but were much less comfortable discussing the role of nutrition in the treatment of disease and nutrient requirements across the lifecycle, and in identifying credible sources of nutrition information.” Some 87% of those students wanted more education about nutrition.

In poor countries, poor diets that contribute to obesity and other chronic diseases are often accompanied by malnutrition affecting large parts of the population. A World Health Organization study found that while stunted growth fell from 39.3% in 1990 in children younger than five to 21.9% in 2018, obesity increased from 5.0% to 5.9% in the same period.

Jennifer Abasi, writing at JAMA Online observed: “No study objectively measured whether medical students were competent in nutrition care, but future physicians themselves said that their training left a lot to be desired. They reported little priority given to nutrition education, an absence of scientific rigor in the curriculum, and a lack of faculty devoted to the subject. They also said they witnessed little or no nutrition counseling in clinical practice while shadowing physicians.”

While most people probably know that comfort foods as well as fast food are often not particularly healthy, not as many are aware just how bad they are — here are the unhealthiest items in every fast-food chain in the U.S.

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