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CRITICAL ISSUES IN NUTRITION EDUCATION AND TRAINING AT THE UNIVERSITY LEVEL Barbara Hansen The lack of nutrition knowledge and of nutrition content in curricula of the health professions has Read's and my combined files (Cardullo, 1982; Hating' and Littlefield, 1982; NRC, 1985~. Nevertheless, despite this continuing identification of this problem, it continues. A recent study (Weinsier et al., 1986) indicated that 85% of senior medical students were dissatisfied with the quantity of their nutrition education, while 60% were dissatisfied with the quality Yet, 59% believed that nutrition training was ''very important" to their careers. Nevertheless, in our own medical school, only about 15% of medical students elect to take a specific nutrition course. This relatively low level of course election is comparable to the 3 to 6% of medical students who elected a nutrition course in the study by Weinsier et al. (1986~. On our second campus, one with 9,000 undergraduates and 1,200 graduate students, I was unable to identify by title any course with nutrition as its focus. To illustrate the unusual situation in which nutrition education is desired and believed in, but neither studied nor internalized, another study, which examined family practice resident nutrition knowledge, found that significant fundamental concepts were not understood (Dapper et al., 1986~. Surprisingly, 56% of the physicians surveyed thought that polyunsaturated fats were less fattening than saturated fats. Furthermore', only 36% of the residents understood that 2 g of sodium was equivalent to 5 g of salt. Thus, even the most practical concepts have, in many cases, not been sufficiently absorbed and utilized (Dapper et al. 205 , 19861.

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In a recently completed study of family medicine residents and faculty, completed by Sobal and his associates on our campus, residents and faculty were surveyed for their respective views of the relative importance of various nutritional topics and their desire to have additional information. This specific needs assessment showed some interesting differences in the areas in which further information was desired by each group (Sobal et al., 1988~. Faculty, interestingly, sought more information on the relationship of nutrition to cardiovascular disease, osteoporosis, cancer, and the elderly. Residents, on the other hand, sought more information about the relationship of nutrition to obesity and weight control, pregnancy, diabetes, parenteral nutrition, and vitamins and minerals. Although not suggested by the investigators, one might suspect some interaction of personalized nutrition issues with those of the clinical setting. Self-perceptions of actual involvement in nutrition teaching of patients may differ from the adequacy of the knowledge base, and perhaps by discipline. For example, 98% of public health nurses indicated that they used nutritional brochures or pamphlets in the education of patients, and 100% stated they included nutrition activities in their maternal health and infant health services (Sabry et al., 1987~. There is clearly no shortage of nutrition education materials available for the instruction of the health professions (Read et al., 1987), as George Bray so well indicated in this symposium. solution might be wrong . . . H.L. Mencken, the ''Bard of Baltimore," has commented that for every problem, there is a solution that is simple, neat--and wrong. I wonder whether our neat ~ ~ . Although it has been suggested that the need is for standardized teaching and performance expectations in the area of nutrition, the above information suggests two additional routes to the enhancement of nutritional knowledge in health professionals. The first is to tailor at least a significant portion of the nutrition information to the personal perceived needs of the learner as related to his or her own health. The second appears to be an apparent need for sophisticated marketing techniques. Although health professionals seem to believe they need nutritional knowledge and verbally indicate they desire it, they are not yet voting with their feet. Perhaps sophisticated marketing techniques aimed at appealing to 206

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their personal desires for better understanding of the impact of nutrition on their own health could produce more active participation and involvement. The American Dietetic Association, in its 1986 House of Delegates Meeting, approved a position statement on the importance of nutrition education to physicians. Aggressive marketing of courses in basic nutrition was mentioned (American Dietetic Association, 1986~. Interestingly, the student participant in the 1984 Conference on Nutrition Teaching in Medical Schools also noted the need for marketing (Shulman, 1984~. Another approach might be through a requirement of active involvement in nutrition research projects. Clearly, the observation of effects of nutrition clinically and of nutrition intervention can be a convincing approach to the internalization of the information. I believe our problem is one of this internalization--like the first time I looked in an ophthalmoscope: I saw, but I didn't perceive. Perhaps it is this aspect of nutrition education which deserves further attention. REFERENCES American Dietetic Association Report. 1986. Position of the American Dietetic Association: Nutrition-- essential component of medical education. (Approved, ADA House of Delegates, October 1986.) J. Am. Diet. Assoc. 87:642,647. Cardullo, A.C. 1982. medical curriculum. Nutrition education in the J. Med. Educ. 57:327-375. Dappen, A., C. Gessert, and J. Walsh. 1985 education for family practice residents. 61:837-839. . . Nutrition J. Med. Educ. Hating, H., and H. Littlefield. 1982. Improving nutrition components in medical and dental school curriculum. J. Am. Diet. Assoc. 85:327-375. NRC (National Research Council). 1985. Nutrition Education in U.S. Medical Schools. A report of a committee of the Food and Nutrition Board. National Academy Press, Washington, D.C. 141 pp. 207 it,

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Read, M., S., Bodner, and H. Sayedi. 1987. Guide to materials for use in teaching clinical nutrition in school of medicine, dentistry, and public health II. Am J. Clin. Nutr. 45:643-660. Sabry, J.H., M.R. Hedley, and M.L. Kirstine. 1987. Nutrition applications in public health nursing: A survey of needs and preferences of public health nurses for continuing education in nutrition. Can. J. Public Health 78:51-56. Shulman, L.P. 1984. Nutrition teaching in medical schools: The student's perspective. In Proceedings, Conference on Nutrition Teaching in Medical Schools. Bull. NY Acad. Med. Vol. 60. Sobal, J., B. White O'Connor, and H.L. Muncie. 1988. The importance of nutrition topics among family medicine residents and faculty. J. Nutr. Educ. 20:20- 22. Weinsier, R.L., J.R. Baker, E.B. Feldman, M.S. Read, and C.M. Brooks. 1986. Nutrition knowledge of senior medical students: A collaborative study of southeastern medical schools. Am. J. Clin. Nutr. 43:959-968. 208