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RECENT TRENDS AND FUTURE DIRECTIONS Maiden C. Neshelm A biochemist, a human geneticist, a food- scientist, an epidemiologist, a physician/endocrinologist, a human biologist, a public health physician, and a sociologist have discussed aspects of the future of nutritional sciences in this volume. Perhaps it is not surprising, then, that educational institutions are in some confusion as to what to do about nutrition, a field that does not seem to have a neat and tidy academic niche. In this paper I discuss some observations relating to the challenges in nutrition that face educational institutions and raise issues for discussion. Since the great age of discovery of essential dietary factors has been left behind, one could argue that the nutritional sciences have reached a high point in their history, particularly in the United States. The number of individuals in this country who consider themselves to be professionally associated with the field approaches more than 70,000. The memberships of the major professional societies in the United States with a primary interest in nutrition are given in Table 1. The 171

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TABLE 1 Major Professional Nutrition Societies in the United States Society Founded Current Membership American Dietetic Association American Public Health Association Food and Nutrition Section American Institute of Nutrition American Board of Nutrition American College of Nutrition American Society for Clinical Nutrition Society for Nutrition Education American Society for Parenteral and Enteral Nutrition Institute of Food Technologists, Nutrition Division American Association of Cereal Chemists, Nutrition Division Total 1917 1917 1928 1948 1959 1960 1968 1975 1975 1981 56,300 1,085 2,400 400 980 600 3,700 4,450 1,600 300 71,815 largest group, with more than 56,000 members, is the American Dietetic Association (ADA), an association made up primarily of nutrition practitioners. Other individuals associated with various aspects of nutrition research or nutrition and medicine number in the many of thousands, and there have been six major nutrition societies founded in the United States since 1959. The growth of the ADA has been especially striking, with very rapid growth since about 1970 (Figure 1~. 172

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60000 - ~- 2X 1~ f - - - a l9l0 1920 1930 t9 ~lffO 1950 1970 t980 1~0 Year FIGURE 1 Membership of the American Dietetic Association, 1917 to Present. i There has also been a major increase in the number of nutrition science-related journals published both in the United States and worldwide. The number of titles in print began to grow significantly in about 1940, and this growth appears to have accelerated since 1970 (Figure 2~. Journals published outside the United States seem to have increased at a greater rate than those published in the United States. This increase seems to have closely paralleled the rise in funding for nutrition research (Nesheim, 1986~. Prior to 1950, the principal support for human nutrition research was through federal formula funding to state agricultural experimental stations and through industry. 173

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so - ~ : o 40 ~ 20 a' Combined LiLles r tf orsign ULlce of ~u.s ~5185 ,~ 1890 1910 1930 1950 1970 1990 Year FIGURE 2 Major Nutrition-related Journals, U.S. and Foreign Titles in Print, 1890 to Present. SOURCE: Compiled from information in Ulrich's International Periodicals Directory (1987-1988~. The Nutrition Foundation played an important role from 1942 to 1963, providing about $6 million in grants for nutrition research over that period. The National Institutes of Health (NIH) has now become the major source of support, with over $200 million in extramural research related to nutrition. The U.S. Department of Agriculture (USDA) has over $50 million of expenditures in human nutrition research, although these funds are expended largely in support of five major human nutrition research centers. These centers represent a major commitment by the federal government to human nutrition research. The National Cancer Institute (NCI) has recently announced plans to open an intramural nutrition research laboratory to support research relative to diet, nutrition, and cancer. All of these activities--the growth in the number of scientists and practitioners, the level of research funding, and the development of major government research centers--seem to indicate that nutrition science is a growing and robust component of the U.S. scientific community. The growth of the nutrition sciences has also been accompanied by major changes that have affected U.S. educational institutions. Until about 1960, the 174

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principal focus of nutrition research was on the discovery, isolation, and identification of functions of the dietary essentials that are recognized today. It was an extremely exciting period and was clearly the domain of biochemists and physiologists. The practitioners of the nutrition sciences were primarily in the field of home economics, where the emphasis and application of nutrition principals were on the home and family. Today, the research agenda is very different from that of 30 years ago. Nutrition scientists study aspects of metabolic regulation by modern techniques of molecular and cell biology. They are concerned with chronic diseases such as heart disease and cancer, and there are new and rather sophisticated applications of nutrition principles in aspects of clinical medicine. Also, individuals involved in intervention strategies often are concerned with a variety of population-based interventions. The organization of society has made the traditional, family-based approach to nutrition interventions less effective. Thus, in view of the many institutional changes in the field, it is not surprising that we are in a time of uncertainty for nutrition programs at many U.S. universities. Over the years, there has been a waxing and waning of the contributions of various universities to the field of nutrition. Many early researchers traced their lineage to the laboratory of Osborne and Mendel at Yale and that of McCollum at Johns Hopkins. Strong and large programs in nutrition existed for many years at Harvard and the Massachusetts Institute of Technology, and it is fair to say that the nature of those institutions' commitment to nutrition has changed a great deal over the past several years. Much of the institutional difficulties associated with nutrition today involve the nature of research and where it is done. For example, much of the research on nutrition and cancer, or nutrition and heart disease--which has dominated much of our research in the past several years--began in medical schools or in units outside of the traditional nutrition science organizations at universities. Thus, there are universities in which individuals or small laboratories are scattered throughout the institution and in which many research programs significantly related to nutrition 175

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have no institutional connection to units identified with the field. This problem is at the core of the institutional crises that have developed in U.S. universities in terms of nutrition organizations. Perhaps a good illustration of where nutritionists work today can be obtained from examining the sources of papers published in the Journal of Nutrition and the American Journal of Clinical Nutrition (AJCN). The data TABLE 2 Origin of Papers Published in the American Journal of Clinical Nutrition, Vols. 43 and 44, 1986 Origin of Papers No. of Papers Medical schools or hospitals Medical schools and other units (university departments of nutrition, biochemistry, other) Government or private research laboratories University departments of nutrition, food science, or food and nutrition Schools of public health University departments of biochemistry, biophysics, or biomedical sciences Other 92 44 27 25 13 9 5 in Table 2 show that in 1986, for the AJCN, most of the papers came from investigators based in medical schools with a much smaller number coming from traditional nutrition departments. Many came from private or governmental research laboratories and from a large number of other academic centers. Similarly, for the Journal of Nutrition in 1986 (Table 3) researchers based in medical schools represented a major group of contributors, although the more traditional nutrition groups contributed more to this journal than to AJCN. There are papers in both journals from a broad range of 176

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TABLE 3 Origin of Papers Published in the Journal of Nutrition, Vol. 116, 1986 No. of Papers Origin of Papers University departments of nutrition, food science, or food and nutrition Medical schools or hospitals Animal science and veterinary medicine Government or private research laboratories University departments of biochemistry, biophysics, biomedical sciences, and agricultural biochemistry Medical schools and other units (university 19 departments of nutrition, biochemistry, other) Schools of public health Other 76 50 35 31 22 2 organizational entities. The concentration of medical school-based papers is of interest in view of the general lack of identity of nutrition units in many medical schools. Nutrition scientists publish in many other journals; however, the two journals discussed above, which are clearly identified as nutrition journals, probably reflect publications of individuals who wish their work to be clearly identified as nutrition related. It is precisely the lack of focus, definition, and visibility of nutrition research and teaching programs in universities today that led to the development of the Pew National Nutrition Program. This program, funded by the Pew Memorial Trust of Philadelphia, has attempted to help a limited number of institutions develop new strategies for their nutrition programs over the next few years, in light of the modern agenda of the field. When the program was announced in 1986, institutions interested in being considered for an institutional grant of up to $1 million were asked to submit a letter of intent outlining the ideas they wished to develop. Over 70 institutions in the United States responded. The 177

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distribution of these letters of intent was very interesting and provides a useful profile of the distribution of nutrition programs in universities throughout the United States. Some data relative to the letters of intent are given in Table 4. TABLE 4 Nature of Applications to the Pew National Nutrition Program Academic Unit of Principal Investigator No. of Institutions l Medicine Combined medicine and other unites) Public health Human ecology or home economics Agriculture Other Total 29 11 s 11 12 2 70 . . Forty of the applications were submitted by principal investigators based in medical schools. Of those 40, 11 were submitted jointly, that is, by one principal investigator in a medical school and a second principal investigator associated with another organization on campus, most commonly a department of nutrition based in a college of agriculture or home economics (eight applications) or a school of public health or allied health (three applications). Of the medical schools that applied, 23 submitted applications for programs based essentially entirely within the school of medicine. The remaining 17 were collaborative programs between the school of medicine and many other units within the institution, including those related to allied health, agriculture, nursing, dentistry, pharmacy, home economics (human ecology), and even the liberal arts. 178

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Five applications whose principal investigators were within schools of public health were received. The programs proposed in all but one of those applications were collaborative efforts with the school of medicine and in two cases, several other departments ranging from nursing, dentistry, pharmacology, arts and sciences, and education were also involved. . Eleven of the letters-of intent were submitted by schools or colleges of home economics or human ecology. Of these, 10 proposed a collaboration with a large number of other units within the institution. There were 12 applications whose principal investigators were based in a college of agriculture and associated with a variety of departments such as animal science, poultry science, food science, nutritional science, or agricultural chemistry. All of the agriculture-based applications proposed collaborations with multiple departments, ranging, it appeared, across the university. Two of the applications came from university units that did not fall in any of these categories: one was based within a particular department, and the other was a multidepartmental collaboration. Although the original announcement of the Pew National Nutrition Program may have encouraged this multidepartmental approach, it was clear that the applicants were responding to the complex organizational arrangements in which individuals contributing to and interested in nutrition find themselves. proposal outlined a coordination mechanism that would be developed to bring together individuals interested in nutrition, but almost none of the proposals involved substantial -institutional reorganization. In many cases, multiple groups with previous concerns for nutrition were present on the same campus, presumably competing for institutional resources that were allocated to support the subject. Almost every The advisory committee for the Pew National Nutrition Program was somewhat disappointed by the institutional responses, and it is clear that the incentive that would be required to stimulate major organizational changes within institutions is far greater than the funds that were available through the Pew program. Five institutions were identified whose proposals were considered to be innovative and exciting, and the Pew 179

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program intends to work with these institutions over the next 5 years as they attempt to develop aspects of their nutrition programs that will accomplish the objectives of the Pew grants. In response to the general disappointment with the applications, however, some of the funds originally allocated to the program by the Pew Memorial Trust are being redirected into fellowship programs intended to develop skills and leadership in individuals within the nutrition community, as opposed to attempting to promote institutional change. One could respond to the above discussion of the institutional organization of nutrition with the following question: "What difference does it make if the research in nutrition sciences is now scattered throughout institutions and if the focus and identity of nutrition as a subject is becoming lost?" This may be a desirable evolution of subject matter within universities, and there are a number of other areas that have lost identity over the years. As long as the particular research problems important to the field as a whole are being considered with sufficient expertise, perhaps there is no need for strong institutional identities and organizations for the subject within colleges and universities. In contrast to many other fields that have gone in this direction, however, there are some unique factors affecting the field of nutrition that are important for universities to face. Several thousand individuals who are majoring in some aspect of nutrition are graduating from U.S. colleges and universities every year. They are becoming the grass roots nutrition practitioners throughout the United States. In U.S. land-grant colleges, there exists a national network of nutrition educators associated with the cooperative extension system in the United States. This represents one of the principal resources for nutrition education of the public at large. The dissociation of the units or departments that carry out this undergraduate training and nutrition education from the major researchers and research themes now occupying the field represents a long-term problem for the nutritional sciences that should be addressed at the institutional level. Although researchers in human nutrition more often seem to be associated with medical schools, no strong 180

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organizational units associated with nutrition have ~ appeared in many medical schools. Perhaps this is why it has been so difficult to increase the attention given to the teaching of nutrition in medical schools (National Research Council, 19851. Some universities have been coming to grips with this problem and have been making changes in institutional arrangements or in faculty expertise that reflect the changing research agenda of the field. Progress has been rather slow, however, and institutions need to ensure that undergraduates are in contact with the subject matter most important and relevant to nutrition practice today. Care must be taken that professional organizations--which have been so concerned with developing the professionalism that would ensure a niche for practitioners in the field within the health system--do not unintentionally create barriers for institutions that make it difficult to respond to changes that are occurring within the field of nutrition. I have no prescription that can be universally applied for the organization of nutrition in academic institutions. However, universities whose resources in nutrition are scattered throughout several areas of the institution are missing an opportunity to do many interesting and exciting things. Because of the breadth and depth of the subject matter currently making up nutrition, substantial resources are required that are managed in such a way that research, teaching, and public education can be dealt with logically and in concert. This is a challenge that those in the field of nutrition must meet if they are to provide the traditional association between high-quality research, training of graduate students, appropriate undergraduate instruction, and professional education of future nutrition practitioners. REFERENCES National Research Council. 1985. Nutrition Education in U.S. Medical Schools. Committee on Nutrition in Medical Education, Food and Nutrition Board, National Research Council. National Academy Press, Washington, D.C. 181

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Nesheim, M.C. 1986. Human nutrition--changing directions and priorities. Pp. 21-25 in Human Resources Research, 1887-1987, Proceedings. College of Home Economics, Iowa State University, Ames. 182