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Division of Nutrition, Harvard Medical School, Boston, MA 02115
2To whom correspondence should be addressed. E-mail: allan_walker{at}hms.harvard.edu
As American medical care has received more scrutiny over the last decade, principally in the area of cost effectiveness, it is apparent that good health can better be attained by preventing disease rather than providing cutting-edge approaches to its treatment. Nutrition is an important component in establishing a healthy lifestyle and in preventing major causes of diseases that commonly affect Americans today, that is, hypertension, diabetes, cardiovascular disease and cancer (1
). Yet an in-depth analysis of the role of nutrition in medical school and postgraduate education of physicians has reported a large deficit in practical nutrition knowledge in medical care today (2
,3
). Several studies conducted by prestigious medical groups such as the National Academy of Sciences (NAS), the Association of American Medical Colleges and the American Medical Association have strongly recommended that nutrition education be expanded within the medical school curriculum and included in residency training programs (4
). In addition, the National Nutritional Monitoring and Related Research Act of 1990 to implement these recommendations by the U.S. Congress (5
) have mandated nutrition as part of the medical school curriculum. Despite these efforts, very little change in the inclusion of nutrition in medical education has occurred. Accordingly, the National Heart, Lung and Blood Institute (NHLBI) developed a Nutrition Academic Award (NAA) Program in 1997 to "support the development and enhancement of nutrition curricula for medical students, residents and practicing physicians to learn principles and practice skills in nutrition" (6
). This program, cosponsored by the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK), has now funded 21 medical schools for a 5-y period to pursue this goal. This symposium, sponsored by the NAA, provides representative approaches to innovative teaching strategies by selected NAA programs to help creatively to implement this initiative and to improve nutritional education. In this overview, I will attempt to introduce the overall topic by considering three questions: 1) Nutrition in medical education—why?; 2) What is the NAA?; and 3) Why do we need innovative teaching strategies?
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Nutrition in medical education—why? |
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 TOP Nutrition in medical... What is the NAA?Why do we need...LITERATURE CITED |
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). In the last two decades there has been a logarithmic growth in the number of children who are overweight and this is translated into obesity in adulthood. Excessive weight gain resulting in "Syndrome X" has been associated with major diseases affecting the general health of Americans such as type II diabetes, cardiovascular disease, hypertension and various malignancies such as breast and colon cancer (8
). Therefore, early intervention to provide a healthy diet may have an enormous impact in disease prevention. Because disease prevention is more cost effective than treatment, an adequate knowledge of nutritional science as it pertains to medicine is essential for practicing physicians. However, physicians in practice have at best a cursory knowledge of nutrition and, when indicated for medical care, usually defer to hospital dieticians or nutritionists in practice. This lack of emphasis on good nutrition by the practicing physician to their patients diminishes the importance of diet in health care and thereby lessens its impact on patient care.
Because the basis for medical education begins in medical school, a strong emphasis on nutrition needs to be incorporated into all stages of medical education and continued in residencies and postgraduate education. If the patient’s nutritional status becomes an important part of the medical evaluation and treatment plan, a major impact on the prevention of disease should follow. In addition, when asked to evaluate their curricula, medical students consistently requested more teaching hours be devoted to practical aspects of nutrition (9
). In fact, a comprehensive evaluation of medical teaching by the NAS recommended that "medical school students should receive a minimum of 25 hours of nutrition education as part of the standard medical curriculum" (10
). Despite this recommendation, less than 40% of American medical schools complied as late as the mid-1990s. The NAA represents a major step by the National Institutes of Health in attempting to rectify this deficiency.
Another impediment to adding more hours in nutrition to medical school curricula is the sacrosanct nature of teaching within medical schools. Most curriculum committees at medical schools have very little room in their teaching schedule to add additional lectures let alone complete courses to existing teaching programs. Course directors are reluctant to reduce their time with students and excessive additional formal lectures are not in vogue in today’s medical educational philosophy. Accordingly, to provide adequate nutrition education for medical students, residents and practicing physicians, innovative approaches to nutrition education must be used that allow practical nutrition teaching in the minimum time possible and with the least disruption of established programs and courses.
Finally, largely through the use of the Internet, the public is exposed to an increasing array of information, products and programs that involve use of nutrition information, diets and therapeutic modalities to treat or prevent clinical disease or to promote a "healthy lifestyle." The physician and health-care provider must be aware of these sources of information and be able to adequately interpret and evaluate their importance and efficacy within the modern approach to promoting health and treating disease. A cogent example of this evolving health problem is the potential competition or enhancement that functional foods provide today in the setting of a pharmaceutical management of clinical conditions such as heart disease, cancer and allergic reactions. The modern practicing physician must include a comprehensive diet and dietary supplement history in the proper evaluation of the patient’s treatment plans and needs access to information regarding the possible interference or enhancement of a conventional therapy by their use in treated patients.
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What is the NAA? |
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TOPNutrition in medical...What is the NAA?Why do we need...LITERATURE CITED |
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). Twenty-one medical schools were competitively funded after peer review and study section priority scoring between 1998 and 2000 (10 in 1998 and 11 in 2000) to accomplish this goal (Table 1
). A secondary goal of this program was to collectively provide for other interested, but not funded, schools generic teaching materials, including a teaching guide and training modules to help jump-start their nutrition curriculum. The program is well organized and administered by a Steering Committee consisting of principal investigators of award schools and administrators from the NHLBI, which oversees various subcommittees and working groups (Fig. 1
), collectively geared to provide a generic teaching program for medical school undergraduates and for postgraduate education. The group meets annually and has established an accessible website to help support the development of a meaningful nutrition medical education program.
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), the NAA Program attempts to overcome "common barriers to nutrition education for physicians" such as: 1) the lack of a curriculum guide for training physicians; 2) overcoming the misconception that nutrition is not clinically relevant to a proper medical school education; 3) evaluating patients in the absence of standardized nutrition assessment methods, and 4) a general lack of innovative teaching tools. Through the organized component of this program (Fig. 1)
, each of the barriers is addressed and approaches to overcoming them are suggested. This symposium is an attempt to disseminate to the medical and nutrition communities innovative, yet time-efficient, ways to effectively overcome the lack of nutrition teaching tools. It is hoped that the collective input of these geographically and educationally diverse NAA recipients (Table 1)
will establish a network of U.S. schools committed to the development of more effective education and training in human nutrition. Success may lead to further governmental support of additional nutrition education programs in medicine. |
Why do we need innovative teaching strategies? |
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TOPNutrition in medical...What is the NAA?Why do we need...LITERATURE CITED |
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In this symposium, representative NAA recipients provide approaches that have been successful in their environment to help accomplish the objectives of this program. It is the intent of the NAA Steering Committee to assimilate these approaches into generic training modules for access by U.S. medical school communities that wish to avail themselves of these teaching guides.
Three awardees, from Harvard, University of Iowa and Mercer University, have addressed strategies for medical students. In the clinical service rotation usually undertaken in the third and fourth years of medical school, the medical interaction by students with residents is much greater than that of any other physicians and, because of the residents’ closeness in age and experience, they are good role models for the students. Dr. Janet Hafler, an educator at Harvard, has begun a program "to teach residents how to most effectively teach medical students." This approach is applied to the incorporation of nutrition assessment and diet regulation into the overall evaluation of hospitalized patients. First-year medical students are more concerned with their own health than an ethereal patient’s health. Accordingly, Dr. Linda Snetselaar, at the University of Iowa, extensively evaluates the 1st-y students’ nutritional and cardiovascular status at the University Clinical Research Center to underscore its importance in the evaluation of their future assessment of patients. Dr. Brian Tobin (12
) at Mercer University, through a computerized program accessible to students, has facilitated the longitudinal and horizontal incorporation of nutrition science into the medical school curriculum.
In contrast to strategies for medical student education, NAA recipients from the University of Texas Southwestern and from Brown present approaches to the incorporation of nutrition assessment into busy medical practices. Dr. Jo Ann Carson from the University of Texas Southwestern provides evidence why the measurement of the waist circumference is both an excellent tool to estimate body composition and useful for clinical nutrition education. Dr. Kim Gans from Brown University provides new tools (WAVE: weight, activity, variety and excess; and REAP: the rapid eating and activity assessment for patients) "to help physicians and other healthcare providers to conduct nutrition assessment and counseling with their patients in a practical and effective manner" (13
).
Finally, Dr. Charles Eaton from Brown University presents a practical and efficient approach to teaching nutrition skills to primary care practitioners by using a 5A’s behavioral assessment (address the agenda, assess, advise, assist and arrange follow-up) of patient-centered counseling. He has shown that busy primary-care physicians in an office-based–practice setting can effectively help patients overcome nutrition-related maladies such as hypertension and hypercholesteremia.
This symposium underscores a small portion of the progress made thus far by the NAA Program to advance medical education of nutritional science in an appropriate manner for medical students and postgraduate residents and practitioners (14
).
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FOOTNOTES |
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LITERATURE CITED |
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TOPNutrition in medical...What is the NAA?Why do we need...LITERATURE CITED |
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1. Walker, W. A. (2000) Overview. Am. J. Clin. 72(suppl):865S-867S.
2. Zimmerman, N. M. & Kretchmer, N. (1993) Isn’t it time to teach nutrition to medical students?. Am. J. Clin. Nutr. 58:828-829.
3. Committee on Nutrition in Medical Education Food and Nutrition Board, Council on Life Sciences National Research Council (1985) Nutrition Education in the U.S. Medical Schools 1985 National Academy Press Washington, DC.
4. Winick, M. (1993) Nutrition education in medical schools. Am. J. Clin. Nutr. 58:825-827.
5. National Nutritional Monitoring and Related Research Act of 1990. Public Law 1101-445/HR 1608, section 302.
6. Pearson, T. A., Stone, E. J., Grundy, S. M., McBride, P. E., Van Horn, L. & Tobin, B. W. (2001) Translation of nutritional sciences into medical education: the Nutrition Academic Award Program. Am. J. Clin. Nutr 74:164-170.
7. National Heart, Lung, and Blood Institute, Obesity Education Initiative Expert Panel (1998) Clinical guidelines in identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Obes. Res. 282:1458-1465.
8. Willett, W. C. eds. Eat, Drink and Be Healthy 2001 Simon & Schuster New York, NY. .
9. Weinsier, R. L., Boker, J. R. & Brooks, C. M. (1989) Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators. Am. J. Clin. Nutr. 50:707-712.
10. American Medical Student Association Nutrition Curriculum Project (1996) Essentials of nutrition education in medical schools: a national consensus. Acad. Med. 71:969-971.[Medline]
11. Davis, C. H. (1994) The report to Congress on the appropriate federal role in assuring access by medical students, residents and practicing physicians to adequate training in nutrition. Public Health Rep 104:824-826.
12. Tobin, B. W. (1997) Nutrition in the basic medical sciences curriculum: an introduction to generalist physician training through problem-based learning. Nutr. Today 32:54-62.
13. Barner, C., Wylie-Rosette, J. & Gans, K. (2001) WAVE: a pocket guide for a brief nutritional dialogue in primary care. Diabetes Educ. 27:352-362.
14. Halsted, C. H. (1998) Clinical nutrition education—relevance and role models. Am. J. Clin. Nutr. 67:192-196.[Abstract]
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