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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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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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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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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.
Representative terms from entire chapter:
nutrition education
