You go to the doctor. You’re told the heaviest diagnosis there is, the one every living person secretly fears. You’re facing a long road and you don’t even know where to start.

At first you tell yourself, “Okay, I’ll keep going almost as before.” But after the first or second round of chemotherapy, the nausea hits. Sores appear in your mouth — mucositis. And you ask yourself: how am I supposed to eat now? Is there anything that could help my treatment? Do I need to change how I live, and how exactly?

You ask your oncologist. They don’t have the answers you were hoping for — not in that level of detail. You get some pamphlet and that’s it. You’re left not understood, without direction again.

The truth is, your oncologist isn’t to blame.

What future doctors actually learn

If I’m honest — in medical school, we get a handful of lectures and seminars on nutrition, and that’s the extent of our preparation. It sounds scandalous, but it isn’t an isolated case — this isn’t just true where I study.

A national survey of 105 medical schools found that only 27% cover the recommended minimum of 25 hours of clinical nutrition education — a figure set back in the 1980s by the National Academy of Sciences. Another survey of students found an average of just 1.2 hours of formal nutrition education per year, and most of those who have a dedicated course at all get between 0 and 10 hours total across their entire degree. Among students in their clinical years, the results are just as telling: under 4 hours of training for over half of those surveyed, and only about one in five feel confident enough to perform a nutritional assessment of a patient.

One of the structural differences is this: while dietetics is widely taught as its own specialty around the world, in many countries you first have to complete a full medical degree, and only afterward — if you choose to — specialize in nutrition and dietetics. In practice, the doctor who graduates is left with next to no preparation on the subject. Even if they want to help, they don’t know how — and in medicine, there’s one rule above all others: first, do no harm.

It’s not indifference, it’s a systemic gap

It’s easy to assume the oncologist simply doesn’t care. The data says otherwise.

A survey of oncology fellows found that a full 80% want additional training specifically in nutrition for cancer patients. The main obstacles they themselves cite are a lack of clear guidelines (69%), lack of knowledge (60%), and lack of time (56%). Among practicing oncologists, the picture is similar — lack of time (66.7%), knowledge (54%), and available resources to refer patients to (54.7%).

In other words — your oncologist probably knows your nutrition matters. They simply don’t have the knowledge, the available specialist to refer you to in good conscience, or the 20 free minutes to explain it in detail between two appointments.

What if you do get referred?

Let’s say you’re lucky and your oncologist refers you to a dietitian. The next obstacle is even rougher.

A national survey of outpatient cancer centers in the US found a ratio of roughly one dietitian per 2,308 patients — against a recommended benchmark of around 1 per 120. Picture a waiting room that would need to fit over 2,000 people for a single specialist. Over 90% of cancer patients are treated in exactly these kinds of outpatient settings, where access is weakest.

So even with the best of intentions from the medical team, the realistic scenario looks like this: you ask, you get referred, and on the other end of that referral there may be no one to see you in time — or at all.

Closer to home — the Bulgarian context

International data paints a difficult picture. But in Bulgaria there’s an additional layer of confusion worth addressing separately — because the word “dietitian” itself doesn’t mean the same thing to everyone here.

In Bulgaria, “dietitian” is a medical specialty. Under Ordinance No. 1 of 22 January 2015 issued by the Ministry of Health, the specialty of “Nutrition and Dietetics” can only be obtained by already-licensed physicians — meaning six years of medical school first, and only then another 3-4 years of specialization with colloquiums and a state exam. That means a genuine, medically qualified dietitian is rare — and, unsurprisingly, waiting rooms are just as packed as in the American data above.

Alongside this exists a completely different, parallel path: registering as a practitioner of “dietetics” in the registry of non-physician, unconventional methods kept by the regional health inspectorate — open to people with varying medical or health backgrounds, not necessarily doctors. The two paths sound similar to a patient, but carry fundamentally different levels of clinical expertise. In practice, this goes as far as people with no medical qualification at all — having completed short online courses, or acting purely on personal enthusiasm — presenting themselves as “dietitians” on social media and even opening practices, with no real oversight or registry a patient can easily check.

For you as a patient, this means something concrete: if your doctor does manage to refer you, it’s worth explicitly asking whether the specialist is a physician with the “Nutrition and Dietetics” specialty, or from the second, broader group of practitioners. Both kinds of specialists can be useful in different contexts — but for decisions directly tied to active cancer treatment, medical qualification matters.

It’s also telling that the nutrition guides currently available in Bulgarian for cancer patients are, to a large extent, translations and adaptations of foreign material — for example, American Cancer Society publications adapted by patient organizations like “Dara Help” and the Bulgarian Lymphoma Association — rather than a systematized, officially developed local resource. A good and needed initiative, but at the same time a clear sign that the gap is being filled from outside the system, not from within it.

What you do in the meantime

This is where the gap you already know well, if you’re going through treatment, comes from. A study of cancer patients in active treatment and in remission found strikingly similar themes across their accounts: a sense of missing personalized resources, a perception that oncologists themselves receive weak formal training in nutrition, and — as a natural consequence — turning to informal sources: forums, social media, random articles online, sometimes with contradictory or outright dangerous advice.

It’s not a coincidence that articles like the one on sugar and the ketogenic diet draw so much interest. The gap left by the system gets filled from somewhere — the question is exactly where from, and how reliable that “somewhere” is.

The beauty comes from the synergy

The truth is that treating most illnesses requires an integrative approach — oncologists and dietitians working hand in hand to support the patient’s treatment. Just as the oncologist doesn’t know the details of nutrition regimens (because, honestly, they’re not required to), the dietitian doesn’t know the full detail of every mutation, every variant of chemo-, radio-, immuno-, and targeted therapy.

The beauty of treatment comes precisely from the meeting of the two specialties — not from one replacing the other.

There’s also an encouraging, if small, sign: in recent months, several leading medical organizations in the US have voluntarily committed to increasing clinical nutrition hours in their curricula. Slowly, but the system is moving in the right direction.

What you can do in the meantime

While the system catches up to your needs, a few things are entirely in your hands:

If you only remember one sentence

Your oncologist isn’t silent about food because they don’t care. They’re silent because the system that trained them didn’t give them the tools — and the system they need to refer you to doesn’t have enough people on the other side. Knowing this isn’t a reason for despair, but a reason to ask more specifically and actively look for the right specialist.

This article is for educational purposes and doesn’t replace consultation with your treating physician or dietitian. The data on medical education and access to dietitians relates mostly to studies from the US and the UK — the situation varies between countries, including Bulgaria, but the general trend is similar.

Sources

  1. Nutrition Education in U.S. Medical Schools: Latest Update of a National Survey — pmc.ncbi.nlm.nih.gov/articles/PMC4042309
  2. Duggan, M.P. et al. Survey of Nutrition Education Among Medical Students, Journal of Wellness — ir.library.louisville.edu
  3. Assessing the Nutritional Knowledge Gap: Students’ View of UK Medical School Education — ncbi.nlm.nih.gov/pmc/articles/PMC12681966
  4. The views and practice of oncologists towards nutritional support in patients receiving chemotherapy — ncbi.nlm.nih.gov/pmc/articles/PMC2360668
  5. Oncologists Knowledge and Attitudes Towards Providing Dietary Guidance to Patients With Cancer — ncbi.nlm.nih.gov/pmc/articles/PMC12799481
  6. Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey — pubmed.ncbi.nlm.nih.gov/31885583
  7. Building a Case for Registered Dietitian Nutritionists, ACCC — accc-cancer.org
  8. Cancer Care and Nutrition Counseling: The Role of the Oncologist in Patient Learning and Behavior Change — pmc.ncbi.nlm.nih.gov/articles/PMC11402076
  9. Secretary Kennedy and Secretary McMahon Celebrate Medical School Commitments to Increase Nutrition Training for Future Doctors, HHS.gov — hhs.gov
  10. Bulgarian Ordinance No. 1 of 22.01.2015 on obtaining the “Nutrition and Dietetics” specialty, Ministry of Health — discussed in: “Will We Set a Guinness Record for Most Dietitians,” Standart — standartnews.com
  11. Registration of dietitians in the registry of unconventional methods — Pravatami.bg — pravatami.bg/22789
  12. Bulgarian Ordinance No. 9 of 10.12.2019 on the package of health services guaranteed by the NHIF — nhif.bg
  13. “Nutrition for Cancer Patients” — adaptation of an American Cancer Society guide by Dara Help — darahelp.com
  14. Nutrition advice for patients, Bulgarian Lymphoma Association — limfom.info