1) Why include nutrition in medical education
Nutrition is a quintessential integrative topic. It does not belong to any specific medical discipline or specialty. As medical education moves away from fragmented teaching of isolated bodies of knowledge toward a more integrated model of understanding the concepts which reflect how the body works and what creates, causes, and ameliorates deviations from normal function, nutrition can be presented a model for understanding that integration. To understand human nutrition one must simultaneously consider aspects of biochemistry, physiology, food science, and psychology (specifically health behavior). To be effective, a physician must educate patients and help them to change mal-adaptive behaviors. Nutrition can assist us in learning/teaching these skills because it represents a similar challenge for the physician as well as the patient. Nutrition is something we all share. We all eat. Our own struggles to improve our individual diets can serve as a knowledge base for counseling our patients(1). Nutrition can serve as a foundation for preventive medicine discussions. In addition, medicine continues to accumulate evidence demonstrating the correlation between diet and long term health and disease prevention.
A lack of knowledge of nutrition can create malpractice. A background in nutrition is important for clinicians in a variety of specialty areas. Medical students who do not learn to take a diet history will not identify patients following fad or other unhealthy diets and will miss diagnosing eating disorders. Physicians who do not learn nutritional assessment as part of physical diagnosis will fail to recognize nutrition-related medical problems when they present. Surgeons who ignore their patient’s nutritional status will have greater morbidity and mortality and poorer surgical outcomes. Physicians who under-diagnose and under-treat malnutrition in their hospitalized patients will have similar experiences. Physicians’ ignorance of nutrition can lead to greater morbidity and mortality and be costly to the health care system.
Patients are increasingly both curious and knowledgeable about nutritional issues. Inadequately trained physicians are unprepared to guide their patients through the minefield of quackery that today’s health marketplace has become. Unsubstantiated claims abound (many made by physicians with little or no formal nutrition training). Physicians need a good basic understanding of the science of nutrition so that they can keep up with the burgeoning literature to which they (and their patients) are exposed.
Medical practice is currently undergoing great change. None of us knows what the job of a physician will be in 20-30 years (the time frame for which we must prepare our students to practice). Will physicians be in the role of primary care takers whose job description includes obtaining and analyzing dietary information and counseling patients about their diet (some would say we don’t have time to do this now)? Or will increasing technology and encroachments by non-credentialed providers change our roles significantly? If we do not prepare our students to do a good job with counseling patients then we will surely lose that part of the job. Even if physicians are not the ones responsible for delivering the intervention, should they not at least be responsible for making the diagnosis and determining the recommended treatment plan? Nutrition knowledge is essential for this.
2) Efforts to define undergraduate medical curricula
Over the past 25 years, nutrition educators have repeatedly called for improvements in the nutrition education of physicians(2,3). The number of research journals devoted to nutrition has increased significantly (reflecting an ever-expanding knowledge base) while at the same time the number of nutrition-related studies published in major journals has also dramatically increased. Unfortunately, the number of medical schools reporting required courses in nutrition has not changed significantly(4).
Recommendations of specific topics probably date back to the efforts of Gautreau & Monsen(5) and Gallagher & Vivian(6). Young, et. al.(7) later surveyed practicing physicians and medical educators to develop a list of “core competencies.” During the early 1990’s the American Medical Student Association published a list of “essential” topics defined by a group of medical nutrition educators representing the major U.S. professional nutrition organizations(8). The 92 subject areas were distilled from an initial list of over 1,000 topics. The list is not rank-ordered as each of these topics is considered “essential.” Prior to this effort by AMSA, the American Society of Clinical Nutrition’s Committee on Medical/Dental School and Residency Nutrition Education defined “core content” for nutrition in a medical school curriculum(9). Published in 1989, this list of topics evolved as a result of a national consensus workshop review of topics obtained from a national survey of medical school nutrition educators. The topics were rated into 4 priority levels. This list can serve as a valuable tool for curriculum planners who wish to evaluate their current offerings against a “gold-standard” for nutrition curriculum. Attention on the local level then turned to implementation(10) while the professional societies considered program development,(11) evaluation,(12) and standards for graduate training(13).
3) Efforts to define Graduate medical curricula
While specialty societies and their residency review processes serve to standardize graduate medical education curricula, most have not defined the nutrition content which physicians in their specialty should be responsible for. The American Society for Clinical Nutrition has established goals for fellowship-level graduate training in nutrition(14), but to date, the American Board of Medical Specialists has not recognized nutrition as a distinct medical specialty. The American Gastroenterology Association has created a nutrition curriculum for specialists in its field and has recommended (but not required) a specific clinical experience in nutrition. The American Academy of Family Physicians has recommended nutrition training for its primary care graduate programs and has published a set of specific learning objectives(15). The Society of Teachers of Family Medicine has built on these efforts by creating a curriculum in clinical nutrition(16) with suggestions for educational resources that was intended as a “how-to” guide for faculty responsible for teaching nutrition. This curriculum is currently being revised. The Association for Ambulatory Pediatrics in conjunction with the American Academy of Pediatrics has also established curriculum recommendations for undergraduate(17) and graduate training(18) in pediatrics. While there has been an active interest in nutrition by members of the Society of General Internal Medicine, no specific curriculum objectives have been published.
To date, efforts to define the nutrition content needed in medical curricula have suffered from the following deficiencies:
- lack of an implementation strategy: some publications have described implementation efforts at individual schools(19) or regional consortia(20), but clearly local solutions are necessary for implementing curriculum reform(21);
- Other forces also shape medical school curricula: during the 1980’s the Regional Nutrition Center at the New York Academy of Medicine documented(22) an increase in the number of its member medical schools where nutrition courses had been started. After the GPEP report, many of these courses were cut in an effort to reduce lecture hours.
- Any attempt to list content areas is doomed to become rapidly outdated: nutrition knowledge is a rapidly advancing field and even a list of topics which is 5 years old may be useless. There are many examples of areas not included on existing lists (because they did not exist at the times these lists were compiled). The importance of specific B vitamins to reduce homocysteine level in the prevention of atherosclerotic heart disease, and the role of prostaglandin intermediaries as mediators of malnutrition and markers of the metabolic changes of chronic disease are specific examples. Other topics, for example antioxidant nutrients, continue to generate significant controversy among nutrition scientists, and therefore, the perceived importance of these topics may change greatly as we learn more about them.
- Topics not included on the list may be considered to be “marginal” in importance. For example, a basic knowledge of food science is not on any of the published lists but is important in a full understanding of some of the topics which are on the list (e.g. the effects of processing on wheat flour leading to nutrient loss and requirements for enrichment). Such knowledge can also be very helpful in counseling patients (e.g. a knowledge of cooking methods used to preserve taste but reduce fat). Presumably, one should consider food sources of nutrients as one considers those nutrients but this is not clear from existing recommended topics.
- Finally, medical education has advanced significantly since even the most recent of these lists were compiled. They are a valuable resource for our curriculum development efforts but it is now time for us to consider what specific learning objectives we wish to accomplish for the early 20th century and to determine specifically where and how in medical education these objectives should be accomplished.
Recent efforts to improve nutrition education in medical schools have been supported by funds from private sources (Kellogg, Robert Wood Johnson, Heinz Foundation, etc.) as well as the National Institutes of Health. Through NIH support of preventive cardiology grants and cancer education (R25) grants, some schools have been able to create new nutrition curricula. Currently the Nutrition Academic Award (NAA) program jointly sponsored by NHLBI and NIDDK is supporting curriculum development efforts at a number of medical schools. (Ref AJCN nutr educ mtg) The goals of this NAA program are to create nutrition curricula that may serve as models for other institutions. The 10 schools that have already received these awards (another 5 awards are under review) have initiated a process to define nutrition-specific knowledge, attitude, and skill learning objectives for medical students and resident physicians. These efforts are building on a foundation provided by the literature cited here.
- Levine BS, Wigren MM, Chapman DS, Kerner JF, Bergman RL, Rivlin RS. A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of clinical nutrition in medical practice. Am J Clin Nutr 1993;57(2):115-9.
- Council on Foods and Nutrition, American Medical Association: Nutrition Teaching in Medical Schools. JAMA 183:955-56,1963.
- White P, Mahan LK, Moore MD: Proceedings of a Conference on Guidelines for Nutrition Education Programs. Williamsburg, VA., June 25-27, 1972. Chicago, AMA, 1972
- Winick M: Nutrition Education in U.S. Medical Schools. National Academy Press, Wash, D.C. 1985
- Gautreau S, Monsen ER: Priorities of Nutritional Concepts Assigned by Health Professionals and Students. J. Med Ed 54:607-12,1979.
- Gallagher CR, Vivian VM: Nutrition concepts Essential in the Education of the Medical Student. Am J Clin Nutr 32:1330-3,1979.
- Young EA, Weser E, McBride HM, Page CP, Littlefield JH. Development of Core Competencies in Clinical Nutrition. Am J Clin Nutr 1983;38(5):800-10.
- AMSA Nutrition Curriculum Project:Essentials of Nutrition Education in Medical Schools: A National Consensus. Academic Medicine 71(9)969-71,1996.
- Weinsier RL, Boker JR, Brooks CM, Kushner RF, Visek WJ, Mark DA, Lopez-S A, Anderson MS, Block K: Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators. Am J Clin nutr 1989;50:707-12.
- Ritenbaugh CK, Thomson CA, Taren D, Bassford T, Canfield LM, Byers JM, Koff NA, Gall EP: Nutrition Curriculum in Medical Education: An Integrated and Comprehensive Approach. Teaching and Learning in Medicine 1996;8(2):102-10.
- Weinsier RL: Nutrition Education in the Medical School: Factors Critical to the Development of a Successful Program. J Am Col Nutr 1982;1:219-226.
- Weinsier RL, Boker JR, Morgan SL, Feldman EB, Moinuddin JF, Mamel JJ, DiGirolamo M, Borum PR, Read MS, Brooks CM: Cross-sectional study of nutrition knowledge and attitudes of medical students at three points in their medical training at 11 southwestern medical schools. Am J Clin Nutr 1988;48(1):1-6.
- Halsted CH: Toward standardized training of physicians in clinical nutrition. Am J Clin Nutr 1992;56(1):1-3.
- Merritt RJ, Heymsfield SB, Howard L, Rombeau J: Biennial survey of physician clinical nutrition training programs. Am J Clin Nutr 1988;47(5):911-21. Heber D, Halsted CH, Brooks Cm, Chesney RW, DiGirolamo M, Heimburger DC, Hensrud DD, Mark DA, Sitrin MD, Tillman HH, et.al.: Biennial survey of physician clinical-nutrition training programs. Am J Clin Nutr 1993;57(4):463-9. And Boker JR, Weinsier RL, Brooks MC, Olson AK. Components of effective clinical-nutrition training: a national survey of graduate medical education (residency) programs. Am J Clin Nutr 1990;52(3):568-71.
- Recommended Core Educational Guidelines on Nutrition for Family Practice Residents. American Family Physician 1989;40(1):265-6. (revised 7/95)
- Group on Nutrition Education of the Society of Teachers of Family Medicine. Physician’s Curriculum in Clinical Nutrition: a competency-based approach for primary care. 1995 STFM-GNE
- Ambulatory Pediatrics Assoc. & Council on Medical Student Education in Pediatrics. General Pediatric Clerkship Curriculum and Resource Manual.
- Kleinman RE. Pediatric Nutrition Handbook, Fourth Edition. 1998 American Academy of Pediatrics-Committee on Nutrition.
- Young EA: Nutrition Education in U.S. Medical Schools. Am J Clin Nutr 65(5)1558,1997
- Feldman EB: Networks for medical nutrition education-a review of the US experience and future prospects. Am J Clin Nutr 62(3)512-7,1995.
- Rasmann-Nuhlicek DN, Reiter SA, Midtling JE, Holloway RC, Bogenschild EG: Integration of Prioritized Nutrition topics into a Medical School and residency Curriculum: an Aggregate Approach. Am J Clin Nutr 62(1):149-50,1995.
- Shils ME: Conference on Nutrition Teaching in Medical Schools. Bull NY Acad Med 60(6) 539-41,1984