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Executive Summary Scientific conferences and congressional hearings held during the past two decades have repeatedly drawn atten- tion to the need to upgrade the status of nutrition educa- tion in U.S. medical schools. Several factors convey a sense of urgency in addressing this need. As the general public has become more aware of advances in nutrition, consumer demands for advice on matters of diet and disease have grown. Simultaneously, health care professionals and legislators are becoming aware that strategies for disease prevention are a major hope for the future, that economic and social factors are dictating the development of alter- native health care systems, and consequently, that primary health care providers, whether independent physicians or health maintenance organizations, must be equipped to meet new challenges. One of the challenges is the provision of sound nutritional guidance in the face of myriad forces that compete for the public's attention in the market place. Attention to nutrition education in medical schools is not new. The scientific principles of nutrition were widely taught in U.S. ~ ~ medical schools during the early decades of this century. At that time, mounting evidence for the importance of dietary factors in maintaining health and preventing or curing deficiency diseases pro- vided the primary impetus for emphasizing experimental and clinical nutrition in medical curricula. Toward the middle of the century, however, the period of active identification and isolation of the major vita- mins came to a close; fortified foods, nutrient supple- ments, and a more varied diet became readily available to most Americans; and the classic nutritional deficiency 1

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2 diseases ceased to be a major public health problem in the United States. Partly as a consequence of these achieve- ments, attention in the basic science curriculum of medi- cal schools seemed to turn away from the physiological and biochemical aspects of nutrition to disciplines that encompass the fundamental principles of cellular function, such as cell biology and, more recently, molecular biology. The application of nutrition in clinical prac Lice received less emphasis as the patterns of medical practice shifted from comprehensive care toward speciali- zation and new technology whose association with nutrition was not yet recognized. - In the intervening years, the science of nutrition has advanced far beyond the assumption that overt symptoms of deficiency are the only attributes of malnutrition. Sci- entists now recognize that the functional correlates of poor nutrition may become subtly manifest at all stages of the life cycle--from curtailment of cell division and brain growth prenatally to deficits in learning capacity and behavior during childhood and adolescence and impair- ment in tissue function and metabolism during senescence. Among recent advances, nutrition research has elucidated the function, essentiality, and interaction of several trace minerals, uncovered the intricate role of nutrients in the immune response, and demonstrated that dietary factors, although not the sole determinants, are among lifestyle variables that may significantly influence the outcome of chronic degenerative diseases such as athero- sclerosis and cancer. Has medical education kept pace with the advances in nutrition science? Are medical students being equipped to convey the soundest nutritional advice to their patients and to apply the best therapeutic innovations in treating them? If not, what are the causes for this fail- ure and what strategies are needed to initiate and sustain adequate teaching of nutrition in medical schools? To address these questions, the National Research Council established the Committee on Nutrition in Medical Educa- tion within the Food and Nutrition Board of its Commission on Life Sciences. The scope of the present study was limited to the 4 years of undergraduate medical education. As a conse- quence, the committee was able to conduct a comprehensive study within a short time. The committee recognizes, how

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3 ever, that the incorporation of nutrition education into postgraduate physician training programs and continuing education experiences is exceedingly important, and it supports evaluation efforts in this area. The committee began its task by reviewing the results of many conferences and surveys of medical schools con- ducted during the past 20 years to examine this subject. Among the major deficiencies in nutrition education iden- tified through these efforts were a failure to provide administrative and institutional support for teaching nutrition, a lack of adequately trained faculty, and the absence of a defined place for nutrition in the curricu- lum. Despite repeated recommendations to remedy these shortfalls, a widespread perception persists that nutri- tion is not given the same recognition in the medical curriculum as other scholarly disciplines. Although past surveys were invaluable in providing a qualitative base- line, their quantitative estimates were limited by narrow- ness of scope, questionable sampling techniques, and a failure to validate the results. The committee therefore conducted a new survey of 45 schools--approximately one- third of all U.S. medical schools. The initial selection was random. Additional schools were then selected from underrepresented categories so that the final sample of 45 represented a cross section of an schools. The survey was designed to determine the manner and extent to which nutrition is incorporated into the medical curriculum. (For a more detailed description, see Chapter 4~. To avoid many of the uninterpretable responses that marred the results of previous surveys, the committee directed a series of questions to a faculty member at each school with primary responsibility for teaching nutrition (e.g., a coordinator of nutrition education or a bio- chemistry department faculty member). The questions pertained to the number of hours devoted to nutrition in the required curriculum, the nature and scope of the program, the placement of nutrition in the curriculum, faculty training, and both administrative and financial support for the faculty. The questionnaire was sent to 46 schools, of which 45 responded. Thirty-nine of these replies were followed up by telephone interviews or by asking the respondents to send their curriculum outlines. The survey was followed by detailed telephone interviews with nutrition coordinators at nine of the medical schools

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4 that the committee identified as having discrete nutrition programs. In addition, the committee consulted selected faculty members with primary responsibility for the nutrition curricula at a number of other schools to deter- mine the origin and evolution of their programs. Although much of the information obtained was qualitative, it pro- vided insight into factors that determine the success or failure of nutrition education in medical schools. Recognizing that the National Board of Medical Exami- ners has a profound influence on medical education, prin- cipally through its annual examinations, the committee reviewed the data on student performance and the board's test questions from several recent examinations. In addi- tion, it examined four recent surveys of graduating medi- cal students conducted by the Liaison Committee on Medical Education of the American Medical Association and the Association of American Medical Colleges (AAMC), and it solicited the views of the American Medical Student Association--an organization that represents more than 30,000 medical students in the United States. The committee also examined the funding practices of the National Institutes of Health and other public and private organizations as they relate to nutrition research and training in order to ascertain the emphasis accorded to nutrition and its possible impact on medical school teaching practices. CONCLUSIONS AND RECOMMENDATIONS The committee concluded that nutrition education pro- grams in U.S. medical schools are largely inadequate to meet the present and future demands of the medical profes- sion. This perception, reflecting results of prior sur- veys and conferences, was confirmed by the committee's independent survey and related investigations as outlined above. The committee recommends that medical schools and their accreditation bodies, federal agencies, private founda- tions, and the scientific community make a concerted effort to upgrade the standards as detailed below. The committee recognizes the extraordinary demands placed on the medical education system of today. Nevertheless, it believes these changes could be achieved with minimal

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s disruption of existing curricular and administrative structures although in most cases this upgrading may require a major philosophical adjustment. The committee recommends to medical schools that the basic principles of nutrition be introduced simultaneously with other preclinical sciences as an independent course, and that the precepts of nutrition be reinforced later during clinical training to demonstrate their application to patient care. This recommendation stems from the recognition that the importance of nutrition is not suffi- ciently recognized by the faculty and that its impact is significantly diminished when it is not taught as a dis- crete entity. The present survey demonstrated that most schools teach some nutrition in one form or another; how- it in the first teach nutrition as a ever, only two-thirds of them teach academic year and approximately 20% separate, required course. In medical schools, elective courses are distributed throughout the 4 years of the basic science curriculum and range in duration from less than 4 weeks to more than 10 weeks. Although many schools offer nutrition clerkships or electives, the results of both the committee's and the AAMC's surveys indicated that only a small segment of the student body takes advantage of these options. In contrast, required courses serve as a focal point for a discipline and significantly increase the probability that the student body has a uniform base of knowledge. ~. . . ~ ~__ _ _ 1_ ~ ~^^ _ ~ The committee proposes that the following topics in nutrition become part of the basic curriculum of medical schools and, furthermore, that they be integrated into clinical clerkships: energy balance, role of specific nutrients and dietary components, nutrition in the life cycle, nutritional assessment, protein-energy ~alnutri- tion, the role of nutrition in disease prevention and treatment. and risks from poor dietary practices stemming from individual, social, and cultural diversity. To cover these core concepts adequately, a minimum of 25 to 30 classroom hours should be allocated to them during the preclinical years. At present, only 21 hours, on average, are given to these subjects. According to the committee's survey, there is great variation in the number of nutri- tion hours taught. For example, approximately 60% of the schools surveyed provide less than 20 hours in nutrition instruction and 20% teach less than 10 hours. Only 30%

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6 teach 30 or more hours. The number and distribution of hours devoted to nutrition in clinical settings could not be determined with any degree of confidence. The committee's survey also demonstrated considerable variation in the scope of topics included in nutrition courses. Some subjects, such as energy balance and obesity are covered in almost all schools, whereas others, such as the role of nutrition in health promotion and disease prevention, receive attention in only a few schools. The committee recommends that persons with strong backgrounds in nutrition science, research, and applica- tions to clinical medicine be assigned to lead the development of nutrition programs in medical schools. Physician-nutritionists, well-versed in the clinical application of basic research, would be the ideal candi- dates. Currently, faculty leadership for nutrition pro- grams is shared by M.D.s and Ph.D.s. In the nine schools identified through the survey as having well-established programs, M.D.s play a strong, central role in teaching nutrition and in demonstrating its application to clini- cal medicine. The committee encourages medical schools to involve M.D.s as well as Ph.D.s in the instruction of nutrition. There are variations in the administrative structure of U.S. medical schools and, as a consequence, differences in faculty responsibility. Because authority for nutrition education is often not centralized, the success of a pro- gram often depends heavily on individual initiative. In approximately 80% of the schools that teach nutrition, responsibility is shared by scholars engaged in basic sciences such as biochemistry, physiology, and pharma- cology, or in clinical disciplines such as pediatrics, medicine, surgery, and gastroenterology. Faculty coordi- nators interviewed by the committee on average devoted 40% of their time to nutrition research. The committee deter- mined, however, that although faculty training in nutri- tion science appears to be minimal in schools that place little emphasis on nutrition, renowned nutrition scien- tists in several medical schools do not seem to be engaged in teaching nutrition at their institutions. A strong research program in nutrition enhances the credibility of

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the faculty and provides financial security, but nutrition research per se in medical schools does not guarantee that nutrition will be taught. To ensure permanence of the nutrition programs, the committee recommends that responsibility for the programs be vested in a separate department of nutrition or in a distinct clinical division of the medical school. More- over, it recommends that each institution allocate funds for the support of at least one faculty position in nutrition. At present, faculty positions specifically designated for nutrition are rare. The financial burden attendant on meeting these goals may be partially offset by income generated from nutrition-related clinical sup- port services within the hospital, but in the immediate future will have to be derived predominantly from research support or other sources. The committee supports the concept of diverse approach- es in medical education and recognizes that each school must devise its own curriculum design, implementation strategy, and organizational structure. In its judgment, however, lack of organizational structure and administra- tive and financial support are the prime hindrances to the maintenance of nutrition programs in medical schools. The committee proposes that the National Board of Medical Examiners consider appointing advisors to review the distribution and quality of nutrition-related ques- tions on board examinations and to establish a mechanism for communicating such findings and recommendations to board section chairmen. Such advisors could also identify areas of clinical nutrition that deserve coverage in the examination or provide new questions for consideration by the board committees. Of the approximately 6,000 examina- tion questions reviewed by the committee, 3% to 4% had some relation to nutrition and the distribution of the questions on nutrition among the medical specialties was noticeably uneven. There were no questions on several topics deserving emphasis, e.g., osteoporosis, nutritional requirements of the elderly, total parenteral and enteral feeding techniques, and cancer. and the relationship between nutrition The committee recommends that the federal government and private foundations provide additional financial sup- port for the development of teaching aids and the training

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8 of a cohort of clinical scientists with competence in nutrition. Nutrition coordinators and faculty reported that the resources for teaching nutrition in medical schools are insufficient and that nutrition textbooks and ancillary aids, although plentiful, are unsuited to their needs. Both these deficits place additional demands on medical schools and are a deterrent to the development of nutrition programs. Although the committee encourages institutional sharing of faculty and resources as an interim measure, the long-term survival of nutrition programs is dependent on increases in funds from federal and private sources. To evaluate existing programs more accurately and to assist in planning for the future, the committee recommends that a mechanism be established to monitor periodically changes in the status of nutrition education in medical schools. One device would be to include more exploratory questions on nutrition in the annual survey of medical school curricula conducted by the AAMC. These questions should be directed at persons with primary responsibility for the program. The committee also encourages each medical school to monitor its own program to ensure that it remains abreast of advances in nutrition. Finally, the committee recommends that in approximately 5 years, an authoritative body such as the Food and Nutrition Board of the National Research Council reexamine the status of nutrition in U.S. medical schools. The absence of a reliable surveillance mechanism thus far has severely hampered the ability to define the dimensions of the problem and to characterize progress. * * * * All the elements outlined above--placement of nutrition in the curriculum, scope and duration of courses, finan- cial and administrative support for faculty and research, attention by accreditation bodies that influence medical education, and mechanisms for monitoring progress--are essential to ensure that nutrition programs are initiated and that existing ones are rejuvenated and sustained. The committee recognizes the difficulties that attend any curricular change in undergraduate medical education. Nonetheless, it believes that most medical schools could implement the above recommendations now without major re- allocation of funds or displacement of other disciplines.