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Supplement: An Evidence-Based Approach to Medical Nutrition Education |
1 From the Department of Pediatrics, University of Colorado School of Medicine, Denver
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 NIH grants K07 DK02976-01 (Nutrition Academic Award) and K24 RR018357-01. 4 Reprints not available. Address correspondence to NF Krebs, Department of Pediatrics, 4200 East Ninth Avenue, Box C225, Denver, CO 80262. E-mail: nancy.krebs{at}uchsc.edu.
ABSTRACT
Nutrition must be integrated into the medical school curriculum to train physicians who can effectively provide nutrition care for the prevention and management of chronic diseases. This article describes the comprehensive nutrition curriculum developed at the University of Colorado School of Medicine. Two fundamental principles have guided the school's approach to medical nutrition education: 1) nutrition content must be broad in nature and be vertically integrated across the preclinical and clinical years and continued through postgraduate training, and 2) active adult learning (eg, "learning by doing") should be practiced whenever possible. From our experience, we have identified several key elements important for the successful integration of nutrition into the curriculum. First, identifying a core group of committed faculty to advocate for nutrition and serve as role models and having a physician nutrition specialist at the helm provides constant momentum for the advancement of nutrition education. Second, establishing a network of linkages with other elements of the existing curriculum creates the opportunity to add nutrition content without necessarily adding time. The third key element is an emphasis on incorporating nutrition in clinical training. Students must be routinely exposed to physicians practicing nutrition for nutrition to become part of standard patient care. This can be accomplished through multiple exposures to nutrition throughout the curriculum (ie, vertical integration). Finally, a coordinator is needed to monitor the many "fronts" of the integrated nutrition curriculum and to continue networking and program implementation.
Key Words: Medical school curriculum • nutrition education • postgraduate education • faculty role models • clinical training • health behavior change
INTRODUCTION
As more and more Americans are afflicted with chronic diseases in which nutrition plays a key role, the need for improved nutrition training of physicians has never been more evident. These chronic diseases include conditions such as obesity, type 2 diabetes, hypertension, and cardiovascular disease, and health care costs related to these conditions escalate yearly. Obesity and type 2 diabetes are at epidemic proportions and are being diagnosed in growing numbers of pediatric patients. Even though medical technology continues to make advances in the pharmacologic and surgical management of these chronic diseases, the cumulative evidence is that much of the morbidity and mortality associated with these conditions may be preventable through dietary and lifestyle modifications (1). However, achieving improved dietary choices and increased physical activity by Americans remains a monumental challenge, especially in a climate in which quick fixes are routinely sought and dietary supplements and weight-loss products constitute a multi-billion-dollar industry. To address the health concerns of our nation, public health goals call for increased physician counseling about diet and exercise (2). Doctors are viewed as among the most reliable and trusted sources of information on diet and nutrition (3–5). But, despite the tremendous need for physician-directed nutrition care and the trust the public places with physicians, many physicians do not routinely assess or address nutrition issues (6–9). Students routinely report inadequate training in nutrition during medical school (10), and practicing physicians report less confidence in discussing diet issues with their patients than in discussing tobacco cessation, for example (11). Thus, nutrition training in medical schools and residency programs has been identified as an essential component of medical education by numerous organizations, including the American Society for Clinical Nutrition, the American Medical Student Association, the National Academy of Sciences, the American Academy of Family Physicians, the Society for Teachers of Family Medicine, and the US Congress, which passed the National Nutritional Monitoring and Related Research Act of 1990 mandating nutrition as a part of the medical school curriculum (12–17).
The integration of nutrition into the medical curriculum at the University of Colorado School of Medicine (UCSOM) has been guided by 2 fundamental principles. The first is that the nutrition content taught must be broad in nature and be vertically integrated across the preclinical and clinical years of medical school training, and that efforts be continued through postgraduate training (Figure 1
). We have thus sought to tailor nutrition content to the students at different stages of training throughout the 4 y of medical school by building on a sound knowledge base and on emerging general clinical assessment and diagnostic skills and by offering opportunities to develop and solidify nutrition-related clinical skills through interactions with faculty who are knowledgeable in and committed to nutrition. Emphasis on active, adult learning is the second guiding principle for integrating nutrition into the medical school curriculum, with the ideal of "learning by doing" whenever possible. This has historically been a challenge for nutrition because of a paucity of faculty physicians who routinely practice nutrition in patient care. Identifying medical school faculty who are willing and able to function in the role of nutrition mentors outside of the lecture hall is a key aspect of making medical nutrition education successful, as is the identification of a variety of reliable nutrition resources to foster guided but self-directed learning.
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FIRST-YEAR CURRICULUM
Knowledge
A core 20-h nutrition course has been required for first-year medical students for >15 y. This has been an excellent avenue for introducing basic concepts in nutrition, but it is too early in the curriculum to spend significant amounts of time on nutrition and disease because the students have had limited exposure to pathophysiology and clinical medicine. The core content of the course includes all nutritional (versus biochemical) aspects of macro- and micronutrients and issues of broad public health importance, such as cardiovascular disease and hyperlipidemia, cancer, breastfeeding, osteoporosis and geriatric nutrition, and the Dietary Guidelines and Food Guide Pyramid. The content is thus a combination of emphasis on preventive and primary care and primary nutritional disorders. Recognizing that first-year medical students have been found to respond well to a curriculum that is focused on their own personal nutrition and health habits (18–20), students complete a written assignment that requires them to track food intake and activity for 24 h and then analyze their intake with the use of nutrient analysis software. They calculate their estimated energy expenditure and compare this with energy consumed; compare their intake patterns with national recommendations; and interpret their intake into clinical recommendations for one of several common conditions, such as pregnancy, hypertension, osteoporosis, and others. Students consistently rate the assignment positively, likely in part because they can relate broad topics such as public health recommendations for a healthy diet to their own eating and lifestyle patterns.
Skills and introduction to clinical medicine
Also in the first year, medical students are exposed to general nutrition assessment concepts through the Foundations of Doctoring (FOD) curriculum. Diet and activity histories, body mass index calculation and interpretation, and general physical exam are introduced in FOD. These basic topics are easily added to the existing curricula without adding to overall time. Nutrition faculty developed the material and provided it to the FOD faculty, who incorporated it into existing lecture and small group exercises.
SECOND-YEAR CURRICULUM
Knowledge
For second-year medical students, the role of nutrition in disease was introduced within the pathophysiology course, which had an existing structure of lectures plus faculty-facilitated, case-based small groups. As part of the course for each organ system, a faculty instructor led small group sessions with discussions centered on case workbooks. Nutrition content was added to existing cases for the sections on cardiology, endocrinology and diabetes, gastrointestinal disease, pulmonary disease, and renal disease. In each case, the nutrition faculty developed the nutrition content (both questions for students and answers and explanations for faculty) for existing case materials, and individual subspecialty faculty delivered the nutrition material and facilitated student discussions. No additional time was necessary to teach this nutrition material because it was integrated into existing cases, and nutrition faculty time was not required for the small groups.
Skills and introduction to clinical medicine
Nutrition has been integrated into the FOD advanced cardiovascular disease physical exam session as "Nutrition and Cardiovascular Disease Risk Factors." This session is facilitated by nutrition faculty and focuses on nutrition physical exam findings related to cardiovascular disease, obesity, and metabolic syndrome and reinforces relevant diet and activity histories and general nutrition assessment skills. Use of a standardized patient allows the students to practice active learning with assessment skills, such as measuring waist circumference, taking a diet history, and considering a differential diagnosis.
THIRD-YEAR CURRICULUM
Nutrition integration into the third-year curriculum focuses on the clerkships in internal medicine and pediatrics. A physician nutrition specialist facilitates core interactive sessions during the pediatric clerkship, with emphasis on normal nutrition for infants and children. The internal medicine clerkship requires that students complete a clinical workbook (brief text and short answer questions) covering common adult medicine cases. The students are required to complete the workbook on the basis of either live cases they have seen or reading; the material is then reviewed with a physician preceptor. Nutrition content was added to cases on coronary artery disease, hyperlipidemia, health maintenance and disease prevention, type 2 diabetes, hypertension, and dementia. The basic content incorporated into the cases included key aspects of disease-related nutrition history, physical exam findings, and how this information relates to assessment and therapeutic options. This approach was a relatively invisible way of adding nutrition material to the students' learning, with no nutrition faculty time required after material development and no additional time in the curriculum.
FOURTH-YEAR CURRICULUM
Students spend most of their final year choosing from a variety of electives. The clinical nutrition elective (CNE) was created to provide students with one-on-one contact with a variety of nutrition specialists. The 2-wk long CNE provides students with active learning experiences with physicians who practice routine nutrition assessment and care as part of their practice. Students spend time in physician-directed clinics in the areas of adult obesity, pediatric obesity, childhood diabetes, adult diabetes, metabolic syndrome, hyperlipidemia, bariatric surgery, pediatric growth failure and undernutrition, pediatric gastrointestinal and liver disease, adult metabolic bone disease, or geriatric medicine. Students also spend time with registered dietitians, diabetes nurse educators, nutrition support pharmacists, and the in-patient nutrition support team (pediatric or adult medicine, depending on student interest). Active learning experiences in patient care are complemented by CD-ROM learning modules (21), optional participation in clinical research facilities (indirect calorimetry, dual-energy X-ray absorptiometry scanning, and metabolic testing), and self-directed, small research projects. Common learning objectives and both required and selective activities provide a structured learning approach. The specific CNE activities are flexible and can be tailored to the learning needs of each student on the basis of anticipated type of residency and individual learning goals. Experiences have been provided for students planning residencies in internal medicine, family medicine, surgery (nutrition support focus), pediatrics, and obstetrics and gynecology. Since the CNE was begun in 2001, 64 students have participated in this opportunity for hands-on nutrition training.
A second 2-wk elective, Introduction to Breastfeeding Management, is also available to fourth-year medical students. This elective also emphasizes active learning as students work with lactation consultants in the community and learn about managing a plethora of issues relating to the breastfeeding dyad. Learning objectives address knowledge and skills related to maternal medical and nutritional needs and assessment of nutritional adequacy of the breastfeeding infant. Patient care experiences are balanced with the use of multimedia learning resources including a Web-based educational program, videos, and CD-ROMs. Students are also required to complete a written short-answer, case-based exam. Fifty-six students have taken this elective since 2001.
RESIDENCIES AND POSTGRADUATE TRAINING
Residents represent a unique group in the scheme of medical education; they are learners who also are frequently in the role of teachers, both of their peers and of medical students (Figure 1
). Increasing the nutrition knowledge and skills of residents has great potential trickle-down effects, in that the residents convey not only knowledge but also values of importance to students (22, 23). Residents can serve as peer role models in the area of nutrition if given adequate opportunities for training that emphasize practical clinical nutrition skills.
With this uniquely influential position in mind, several interventions were implemented to increase the nutrition training of residents. For internal medicine residents, nutrition faculty facilitate several small group sessions per year on topics such as obesity assessment and counseling, nutrition intervention for diabetes, and dietary and lifestyle management of hypertension. The emphasis is on practical skills and knowledge that can be used by the residents immediately in patient care. Patient-friendly handouts were developed and provided as a resource to residents, and role-playing with the nutrition faculty allows the opportunity to practice behavior change and counseling approaches (eg, transtheoretical model). Because the group sessions are small (
10–12 residents per session plus clinic attendings), candid discussions about barriers to health behavior change for patients occur, with constructive strategies offered by the nutrition faculty. The sessions with the nutrition faculty also expose the residents to positive peer role models: other physicians who practice and excel in nutrition-related clinical subspecialties.
Following the model of the CNE for medical students, and on the basis of interest expressed by the residents for more in-depth time with nutrition-related clinics and faculty, the resident CNE was established. Thirty-four residents have taken the elective since it began in 2002. The residents' time is split approximately evenly between inpatient care with the nutrition support service and outpatient care in various physician-directed subspecialty clinics. Although there is not a separate family medicine CNE, arrangements are made on a regular basis to accommodate family medicine residents who want a nutrition elective experience. The nutrition rotation for them generally focuses on outpatient nutrition training in the areas of pediatric, adolescent, and adult medicine.
In pediatrics, the strong presence of the physician nutrition specialist provides nutrition expertise as well as role modeling. All pediatric residents rotate through the physician nutrition specialist–directed nutrition referral clinic, where learning by doing consists of residents interviewing patients and parents to assess diet and activity (in the context of a complete medical history), assessing growth and performing a physical exam in relation to nutritional status, and participating in the development of individualized nutrition care plans. For residents who seek more in-depth nutrition training, a pediatric resident CNE is available that has an organizational structure similar to that of the medicine elective. Finally, core lectures are provided annually to all pediatric housestaff on parenteral nutrition and growth failure, and, in alternating years, on obesity, micronutrients, and other topics.
FACULTY ATTENDINGS
In the hierarchy of medical training, the faculty attending physicians are at the top of the pyramid, and as such are influential role models for residents and students (Figure 1). Thus, ideally they would promote the incorporation of nutrition into routine clinical practice. The legacy of the omission of nutrition from the training of several generations of physicians, however, is that the role modeling by many faculty preceptors may in fact be to ignore or downplay the importance of nutrition to patient care because of their lack of confidence in discussing diet and lifestyle issues with patients. Focus group discussions conducted with faculty preceptors reinforced what others have reported (24). Practicing physicians reported less confidence in discussing diet and lifestyle change with patients than other health behaviors such as tobacco cessation (11). Students in the preclinical years not infrequently report that their preceptors recognize them (the students) as the nutrition experts, and the students get called on to provide the nutrition expertise in the practice. This represents a heartening reversal of roles and further dissemination of nutrition applications. Hence, although this was a group for whom we were unable to target as many interventions, they are critically important allies in the overall nutrition training of physicians.
EVALUATION
With all the efforts at integrating nutrition into the UCSOM curriculum, we are left with the question, "Is this making a difference in student and resident attitudes about nutrition, confidence in their ability to assess nutrition issues, and likelihood of practicing nutrition care as physicians?" To address this primary evaluation question, we administered self-report surveys to medical students and residents at baseline and again after they had taken various components of the nutrition curriculum to determine whether they reported significant changes in their knowledge, attitudes, and behaviors after exposure to nutrition-related training activities. We have collected >900 surveys from medical students and residents, and the final phase of data collection was recently completed. Exploratory analyses to date suggest that those medical students who were exposed to the new integrated curriculum seem more knowledgeable, comfortable, and able to address the nutritional needs of their patients.
Enrollment in the nutrition electives is also one marker of success. The number of students taking the electives has steadily increased over the course of the Nutrition Academic Award (NAA), and has surpassed our goal of 25% of the student class (Figure 2). For 2005–2006, the number of students registered for the CNE actually exceeded the initial capacity (33 versus 24), and efforts are underway to expand its opportunities for a greater number of students without compromising the integrity of the learning experience. Similarly, the number of residents choosing the nutrition elective has steadily increased since its inception and now accounts for 20% of the residents in internal medicine.
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The concept of what we have termed a vertically integrated nutrition curriculum across all 4 y of medical school is not new (24–26), nor is the recognition that residents and faculty are critical to the successful incorporation of nutrition into medical trainees' clinical practices (24, 27, 28). Full implementation of such a comprehensive model, however, has not been widely reported. The NAA provided the critical support needed to expand the nutrition curriculum at our institution, which has had a free-standing required nutrition course for several years. The brief descriptions above of the various layers of nutrition integrated into the training of medical students and residents highlight the multiple opportunities found in our institution. Presumably, comparable opportunities will exist in many medical schools and training programs, although specifics will differ for each setting, depending on curricular structure and expertise available.
Several key elements from the UCSOM experience should be considered when developing a nutrition curriculum for medical training (Table 1). The first critical factor is faculty leaders, including especially physicians, to advocate for nutrition in the medical school curriculum and resident training programs. Physicians are critical not only as advocates but also as role models. The value of a physician nutrition specialist has been proposed (29), and in our experience, has been realized, to be a key resource for the institution and for initiating partnerships and networking among colleagues and programs. Involvement by other interested and qualified faculty has also been essential to extend both our credibility and the manpower for taking advantage of the opportunities identified. These faculty have included endocrinologists, primary care specialists, geriatricians, nutritionists, epidemiologists, and others.
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Our proposed third key element, incorporation of nutrition into settings of clinical training, is listed as a separate item to emphasize the importance of trainees experiencing nutrition as a routine part of their clinical practice skill set. In our institution, this has been met through the FOD course, the third-year clerkships, and the CNEs. A laudable quest for nutrition as a recognizable, separate subspecialty must not allow it to become marginalized to the point of irrelevance. Rather, positive role modeling, not only by subspecialist nutrition faculty but also by other primary care faculty and community preceptors, of the application of nutrition to routine clinical care is critical (32). Students exposed to physicians practicing nutrition are more likely to emulate this behavior and have opportunities to do so with guidance and feedback. Thus, targeting nutrition education efforts toward residents and attending physicians who are active clinicians is essential to reinforce lifelong clinical habits by medical students.
Vertical integration offers the benefit of repeated doses of nutrition education and presumes that cumulative exposure will enhance knowledge and skills as students and resident trainees continually develop their own clinical competencies. The popularity of the CNEs, for students and residents, illustrates the benefits of offering varied and flexible opportunities for learning to best meet the interests of the learners. With the provision of modest structured learning support, such as learning objectives and a range of required and potential educational activities, trainee interest is endorsed and self-directed learning is fostered. The flexibility and individualization of the elective experience requires coordination of scheduling, which could be a barrier to full implementation.
The last key element we propose is support for a coordinator, ideally one who can provide both content and administrative support, such as a clinically experienced registered dietitian. This role is essential for ongoing networking and program implementation, especially the more comprehensive the curriculum. Our experience suggests that the more nutrition content is successfully integrated into the curriculum, the more challenging it is to manage the content and keep it current, because there are many "fronts" to monitor. Although this position at UCSOM was initially supported by the NAA, the institution has committed partial ongoing salary support, because of the recognition by the institution's education leaders that nutrition has become integral to the UCSOM curriculum. The long-term sustainability of this position is unknown but will undoubtedly require ongoing vigilance and advocacy for nutrition's place in the curriculum.
Consideration of future directions for nutrition education leads to a gap in training that is not unique to nutrition. As management of chronic illnesses becomes a major part of medical care, new models of training and practice are required. The chronic care model is one such example and emphasizes the importance of involving the individual patient in his or her own care plan (33). Initiating health behavior change is integral to successful management of many chronic conditions, such as obesity, hyperlipidemia, hypertension, and diabetes. We submit that knowledge of and positive attitudes toward nutrition will not be enough to effectively influence patients' behaviors involving diet and physical activity. The next generation of nutrition training for health care professionals will ideally incorporate principles of health behavior change, such as motivational interviewing (34) and the transtheoretical model (readiness to change) (35, 36). Until physicians can confidently and effectively encourage patients' behavior change, discussions about lifestyle changes including diet and activity will be avoided. This is an area gradually being addressed in medical school curricula and offers another critical opportunity for nutrition experts to take a leadership role.
SUMMARY
We have briefly described a comprehensive nutrition curriculum that includes integrated components for all 4 y of medical school and for residency training. Key elements of a successful integrated nutrition curriculum include identification of a core group of committed faculty; a network of linkages with other elements of the existing curriculum; an emphasis on the incorporation of nutrition in clinical training; the provision of multiple exposures throughout the medical school curriculum, with reinforcement by training all levels of learners and teachers (ie, residents and faculty); and coordination and administrative support of the programming, in our case, by a registered dietitian with extensive clinical experience. New directions for nutrition education must include an emphasis on patient health behavior change. Such empowerment of future physicians to effectively practice nutrition will go a long way toward meeting public health goals and improving the health of individual patients.
ACKNOWLEDGMENTS
This article was jointly written by the 2 authors. Neither author had any conflicts of interest.
REFERENCES
This article has been cited by other articles:
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  M. L. Vetter, S. J. Herring, M. Sood, N. R. Shah, and A. L. Kalet What Do Resident Physicians Know about Nutrition? An Evaluation of Attitudes, Self-Perceived Proficiency and Knowledge J. Am. Coll. Nutr., April 1, 2008; 27(2): 287 - 298. [Abstract] [Full Text] [PDF]
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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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