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Supplement: An Evidence-Based Approach to Medical Nutrition Education |
1 From the Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
2 Presented at the symposium "An Evidence-Based Approach to Medical Nutrition Education," held at Experimental Biology 2005 in San Diego, CA, 2 April 2005.
3 Supported by the NHLBI (KO7-HLO3967).
4 Reprints not available. Address correspondence to L Van Horn, Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine, 680 North Lake Shore Drive, Suite 1102, Chicago, IL 60611. E-mail: lvanhorn{at}northwestern.edu.
ABSTRACT
The Nutrition Academic Award (NAA) was developed by the National Heart, Lung, and Blood Institute with additional support from the National Institute of Diabetes and Digestive and Kidney Diseases. The purpose of the NAA was to formally integrate nutrition education within the medical school curriculum. Twenty-one medical schools were funded by the NAA in 2 waves of 5 y each, beginning in 1998 for the 10 vanguard schools and ending in 2005 for the second wave. The organizational structure, goals, objectives, and results of the NAA are summarized. The overall strengths, challenges, and recommendations for future medical nutrition education efforts are also provided.
Key Words: Medical nutrition education • student perception of nutrition education • Nutrition Academic Award
INTRODUCTION
Nutrition is an important contributor to health and can significantly influence the risk of disease (1–3). Despite this association, nutrition education has often been neglected or underrepresented in the medical school curriculum. In 1998 the National Heart, Lung, and Blood Institute (NHLBI) funded the Nutrition Academic Award (NAA) program for the purposes of developing and implementing effective nutrition education as part of the standard medical school curriculum. A comprehensive report of the project design, objectives, rationale, organizational structure, and institutional recipients was published earlier by Pearson et al (4). Funding for the NAA itself concluded in 2005. The purpose of this article is to briefly summarize the background and rationale of the NAA, provide a progress update, and offer recommendations for future medical nutrition efforts.
BACKGROUND
Modeled after the Preventive Cardiology Awards (5, 6), the NAA was intended to provide the faculty support needed to launch a medical nutrition education curriculum in 21 medical schools. The NHLBI funded 19 of these awards, and support for 2 more was provided by the National Institute Diabetes and Digestive and Kidney Diseases. The NAA schools and investigators are listed in Table 1
. The vanguard class of 10 NAA awardees initiated their efforts in 1998. In 2000, the remaining 11 medical schools were funded and their efforts launched. Each award covered a 5-y period; the specific aims of the NAA are shown in Table 2. The NAA followed earlier efforts by the American Medical Association, the National Research Council, and the American Society for Clinical Nutrition (ASCN) to raise awareness regarding the need for medical nutrition education that resulted in the passage of the National Nutrition Monitoring and Related Research Act of 1990 (7). As Pearson et al (4) point out, the ASCN was instrumental in supporting many of these efforts by publishing articles and hosting presentations among the key players at national meetings. Other major advances by the ASCN included the official establishment of the Physician Nutrition Specialist (8) and the Intersociety Professional Nutrition Education Consortium (9). Many of the NAA investigators and co-investigators served in one or both of these capacities as well.
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48% of schools reported offering an elective nutrition course, but an estimated 25% of all medical schools still offered no nutrition instruction (10). Even among schools that were providing nutrition education, the perceived satisfaction among the students was very low. Thus, in 1999 the NAA offered an opportunity to formally address this problem with a primary focus on the prevention and treatment of cardiovascular and other chronic diseases through diet and lifestyle change. ORGANIZATIONAL STRUCTURE OF THE NAA
The organizational structure used by the NAA to accomplish its work is illustrated in Figure 1. The steering committee comprised the principal investigators and the NHLBI program director. An executive committee consisted of a subset of these investigators who developed the agendas for meetings and conference calls and oversaw the various task forces and subgroups. These subgroups addressed various aspects of the medical curriculum and concentrated on specialized offshoots regarding specific topics. Special working groups were formed to address particular topics of interest, including pediatrics, graduate medical education, development of the NHLBI-NAA website, and other related working groups. Particular attention was paid to surveying existing patient materials and outpatient dietary assessment methods. Also, nutrition research and dissemination of publications and materials were addressed by a separate working group.
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When reviewing the accomplishments of the NAA, it is important to remember the original rationale for this project. The NAA was launched for 3 compelling reasons. First, numerous studies and surveys among medical schools showed inadequate nutrition education during the previous 20-y period (10). Second, rapidly growing scientific evidence supported the relation between diet, lifestyle, and risk of chronic diseases, making this an imperative aspect of comprehensive medical education. Landmark studies such as the Dietary Approaches to Stop Hypertension study (11), the Lyon Diet Heart Study (12), and the Diabetes Primary Prevention Trials (13, 14) illustrate more recent examples of the compelling evidence documenting that nonpharmacologic diet intervention can favorably influence risk factors for cardiovascular disease and diabetes. Third, new national dietary guidelines based on this accumulating body of evidence were subsequently developed. These guidelines currently represent the recommended approach for medical care providers to achieve overall public health benefits (1). Physicians and other health care professionals are expected to effectively implement these recommendations, but evidence-based approaches for achieving successful adherence to these guidelines are lacking. Validated methods for assessing ongoing adherence to these guidelines by either the medical profession or the patient population have yet to be reported.
Long-recognized barriers still inhibit progress in establishing routine nutritional assessment and intervention efforts at the clinical level. As summarized by Touger-Decker (10), low reimbursement rates, limited patient contact time, unrecognized importance of nutrition in patient care, and a lack of administrative support are serious limitations. Regardless, the compelling need to address and overcome these barriers deserves further attention until successful solutions can be found.
EVALUATION OF THE IMPORTANCE OF THE NAA
Although each NAA school used its own evaluation system at the local level, 2 outcome measures can help to evaluate the overall impact of the NAA. First, the productivity of the NAA can be assessed by the number and relevance of its publications and the development of patient education and assessment tools available for use. These are addressed elsewhere in this supplement.
Second, the impact of the NAA can also be assessed by comparing the AAMC exit interview data for medical students enrolled in NAA schools with the data for medical students enrolled in non-NAA schools. Is their perception of the adequacy of nutrition education different?
NAA INFLUENCE ON MEDICAL STUDENT PERCEPTION OF NUTRITION INSTRUCTION
Since 1995–1996, the AAMC has reported data on student impressions of their own medical school experiences. Included are data specific to the institution's nutrition curriculum. Since 1995–1996 and 1997–1998 when <50% of the 126 US accredited medical schools offered an elective nutrition course (15), things have improved considerably (Figure 2). In 2000, most (64.4%) students indicated that nutrition training was inadequate. Because of a change in assessment format in 2002 when a Likert scale approach was adopted, direct comparisons across all 5 y are not valid. However, as shown in Figure 3, responses to the new question format were similar between NAA and non-NAA students in the years 2002–2004. Improvements are noted, especially among the vanguard NAA schools, which presumably reflects the 2-y advantage these schools had over the second wave of NAA schools, which did not launch until 2002.
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, the Vanguard NAA schools reported a higher perception of adequate nutrition instruction (32%) than did the non-NAA schools (21%). As further illustrated in Figure 3, the perception by medical students that nutrition-related instruction was adequate improved throughout the time of NAA funding (2003) and was sustained though 2004. About 55% of NAA students perceived adequate nutrition instruction compared with 42% of non-NAA students. The data in Figure 3 also suggest that student perception of nutrition education adequacy among non-NAA schools may have diminished somewhat. Overall, only 30% of the students in the non-NAA schools rated their nutrition education as adequate. Future assessments of this question will better reflect the overall impact of the NAA. Clearly, much more needs to be done before the students themselves feel adequately prepared to provide nutrition-related screening and intervention efforts. ACCOMPLISHMENTS AND CHALLENGES OF THE NAA
The NAA proved to be a highly productive collaboration among multidisciplinary experts in the area of nutrition education and resulted in significant achievements and contributions (Table 3). The NAA legacy is rich in innovation, especially with regard to curricular advances and patient assessment tools (16). Also, members of the NAA developed 2 standardized assessment questionnaires that were applied to the medical school setting. The NAA Knowledge Questionnaire was a pretest to address baseline knowledge and nutrition awareness among entering first-year students (17). Likewise, the NAA Attitude Survey developed by McGaghie et al (18) addressed personal attitudes, behavior, and awareness of entering students as related to patient behavior. A survey of nutrition education efforts was informally conducted among the deans of the NAA medical schools. As the result of the absence of a coordinating center, neither the NAA Knowledge Questionnaire nor the NAA Attitude Survey was universally applied across all NAA schools; instead, individual schools applied these methods locally.
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Some NAA medical schools were more successful than others in launching Graduate Medical Education and Continuing Medical Education efforts in nutrition. This may have been because of previous Graduate Medical Education efforts that were reinforced by the NAA. Most of the NAA schools were not adequately staffed to fully integrate this system throughout their hospital or medical clinics. Regardless, at the undergraduate medical education level, as shown in Figures 2 and 3, improvements were made in the perceived adequacy of nutrition education as documented by graduating medical students who were exposed to the NAA. NAA funding was conditional on a written commitment from a dean or other relevant school administrator that support for medical nutrition education would continue even after the NAA funding had concluded. This challenge remains along with the need to disseminate the relevant NAA materials to all other medical schools.
Fortunately, efforts are ongoing among other medical organizations to adopt and incorporate nutrition education. Recently, a survey was published specifically regarding the state of nutrition education in family practice residencies (19). Since 1982 the Residency Review Committee for Family Practice of the Accreditation Council for Graduate Medical Education has required nutrition education, and the American Academy of Family Practice published Recommended Core Educational Guidelines in Nutrition in 1989, 1995, and 2000 (20). Results of the survey showed great progress in identifying nutrition education coordinators with responsibility for integrating nutrition education and training within the residency, but a low response rate and a nonstandardized approach to the nutrition content, skill set, and qualifications of the faculty make cross-comparisons difficult. As the NAA draws to a close, the importance of these ongoing surveys across Graduate and Continuing Medical Education efforts, including specialty groups such as the ASCN and the American College of Nutrition, becomes even more poignant.
APPLICATIONS AND FUTURE RECOMMENDATIONS
The NAA experience was invaluable and substantially raised awareness in at least 21 of the 126 existing medical schools in the United States. Despite limitations in coordination and data collection, the NAA investigators were committed to sharing and disseminating the materials that were developed for this project. An unanticipated bonus was the opportunity to review nutrition questions on the existing Medical Board exams and suggest more modern, updated, and relevant nutrition topics that can have a long-lasting effect on current and future medical curriculum content and even influence practice patterns. For example, the obesity epidemic that is currently evident in the United States and worldwide was considered underrepresented on previous board exams as a major public health nutrition issue. This and other relevant nutrition-related chronic diseases, as well as new developments in nutritional support, are just a few of the subjects under consideration for future exams.
Finally, the NAA investigators noted the need for standardized nutritional assessment methods for conducting both inpatient and outpatient screening exams that could facilitate quantifiable outcomes. Only when validated, standardized assessment methods become part of routine practice can meaningful evaluation of the effect of medical nutrition education on patient-based outcomes become fully realized. During 1999–2005, >10 000 medical students were in some way affected by the collective NAA efforts. The potential for these NAA-trained students to have a major impact on clinical nutrition efforts in the future is unprecedented and bears watching.
ACKNOWLEDGMENTS
Sincere gratitude is expressed to Claude Lenfant and Elaine Stone formerly with the NHLBI for their willingness and support of this project and to Charolotte Pratt, Project Officer, NHLBI. Deep appreciation is further extended to Jeremiah Stamler and Phillip Greenland, former and current chairs (respectively) of the Department of Preventive Medicine, whose vision and encouragement helped to initiate the NAA, and to Dean Lewis Landsberg, whose ongoing support underlies the current growth and development of medical nutrition education at the Northwestern University Feinberg School of Medicine.
The author had no conflicts of interest.
REFERENCES
This article has been cited by other articles:
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  M. S Edwards Preface. Am. J. Clinical Nutrition, April 1, 2006; 83(4): 933S - 935S. [Full Text] [PDF]
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, vanguard Nutrition Academic Award (NAA) schools (participated in the NAA program from 1998 through 2003); 
, other NAA schools (participated in the NAA program from 2000 through 2005); 
, non-NAA schools.