Capacity Building in Nutrition Science: Revisiting the Curricula for Medical Professionals
Posted August 01, 2013
On June 6, 2013, a group of physicians, nurses, dietitians, and other health care professionals met at the New York Academy of Sciences to discuss reforming nutrition science curricula throughout medicine. With an ongoing global pandemic of obesity, metabolic syndrome, and other nutrition-related diseases, patients increasingly turn to clinicians for advice on diet, exercise, and related topics. However, clinical training programs have not kept pace, leaving many health care providers unprepared to discuss these critical topics.
The Capacity Building in Nutrition Science: Revisiting the Curricula for Medical Professionals conference was presented by the Josiah Macy Jr. Foundation and the Academy's Sackler Institute for Nutrition Science. Speakers discussed the current landscape of nutrition education, including specific efforts that have helped individual schools to improve curricula. Presentations also covered the challenges involved in expanding these successful efforts, the need for clearer assessments of student knowledge, and the strategies schools are developing to integrate additional teaching into already-full programs. A series of panel discussions and wide-ranging question periods explored related subjects, such as the need for more qualified dietitians, the chronic difficulty of maintaining funding for curricula reforms, and the importance of equipping health care workers with simple, practical strategies to help patients.
Use the tabs above to find a meeting report and multimedia from this event.
Presentations available from:
Sharon R. Akabas, PhD (Columbia University)
Darwin Deen, MD, MS (The City College of New York)
Rose Ann DiMaria-Ghalili, PhD, RN (Drexel University)
Eugene Dinkevich, MD (SUNY Downstate Medical Center)
Marilyn S. Edwards, PhD, RD (University of Texas Medical School at Houston)
Gerald Friedman, MD, PhD (The Icahn School of Medicine at Mount Sinai)
Penny M. Kris-Etherton, PhD, RD (Pennsylvania State University)
Martin Kohlmeier, MD, PhD (University of North Carolina at Chapel Hill)
Ellen J. Landsberger, MD, MS (Albert Einstein College of Medicine)
Carine M. Lenders, MD, MS, ScD (Boston University School of Medicine)
Matthew D. Levy, MD, MPH (Georgetown University School of Medicine; Bipartisan Policy Center)
Carole A. Palmer, EdD, RD, LDN (Tufts University School of Dental Medicine)
Kathy West, MS, RD, LD (Abbott Nutrition Health Institute)
Panel facilitator: Judith Wylie-Rosett, EdD (Albert Einstein College of Medicine)
- 00:011. Introduction; Presentation by Gerald Friedman
- 04:352. Presentation by Nancie Herbold
- 09:193. Presentation by Yasmin Mossavar-Rahmani
- 15:014. Presentation by Christina Stark
- 19:335. Presentation by Riva Touger-Decker
- 24:326. Presentation by Judith Wylie-Rosett; Elective and required courses
- 30:237. The example of New Jersey Medical School; Measuring success; Conclusio
Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: nutrition education for medical students and residents. Nutr Clin Pract. 2010;25(5):471-80.
Benson L, Baer HJ, Kaelber DC. Trends in the diagnosis of overweight and obesity in children and adolescents: 1999–2007. Pediatrics. 2009;123(1):e153-8.
Bligh J, Prideaux D, Parsell G. PRISMS: new educational strategies for medical education. Med Educ. 2001;35(6):520-1.
Christmas C, Park E, Schmaltz H, et al. A model intensive course in geriatric teaching for non-geriatrician educators. J Gen Intern Med. 2008;23(7):1048-52.
Deckelbaum RJ, Fisher EA, Winston M, et al. Summary of a scientific conference on preventive nutrition: pediatrics to geriatrics. Circulation. 1999;100(4):450-6.
Deen D. How can nutrition education contribute to competency-based resident evaluation? Am J Clin Nutr. 2006;83(4):976S-980S.
Englert DM, Crocker KS, Stotts NA. Nutrition education in schools of nursing in the United States. Part 1. The evolution of nutrition education in schools of nursing. JPEN J Parenter Enteral Nutr. 1986;10(5):522-7.
Harden RM, Sowden S, Dunn WR. Educational strategies in curriculum development: the SPICES model. Med Educ. 1984;18(4):284-97.
Kulick D, Deen D. Specialized nutrition support. Am Fam Physician. 2011;83(2):173-83.
Lenders C, Gorman K, Milch H, et al. A novel nutrition medicine education model: the Boston University experience. Adv Nutr. 2013;4(1):1-7.
Martins D, Maia J, Seabra A, et al. Correlates of changes in BMI of children from the Azores islands. Int J Obes (Lond). 2010;34(10):1487-93.
McKee MD, Maher S, Deen D, Blank AE. Counseling to prevent obesity among preschool children: acceptability of a pilot urban primary care intervention. Ann Fam Med. 2010;8(3):249-55.
McMahon MM, Hurley DL, Mechanick JI, Handelsman Y. American Association of Clinical Endocrinologists' position statement on clinical nutrition and health promotion in endocrinology. Endocr Pract. 2012;18(5):633-41.
Pan L, Blanck HM, Sherry B, et al. Trends in the prevalence of extreme obesity among US preschool-aged children living in low-income families, 1998–2010. JAMA. 2012;308(24):2563-5.
Touger-Decker R. Preparing dietetic professionals for practice in the 21st century: how can educational programs respond to changes in health care? Nutrition. 1998;14(6):535-9.
Van Horn L. The Nutrition Academic Award: brief history, overview, and legacy. Am J Clin Nutr. 2006;83(4):936S-940S.
White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-8.
Websites, Reports, and Books
Association of American Medical Colleges. Health Educators, Foundations Announce Competencies and Action Strategies for Interprofessional Education. 2011.
American Dental Education Association. ADEA Survey of Dental School Seniors, 2011 Graduating Class.
Bipartisan Policy Center. Lots to Lose: How America's Health and Obesity Crisis Threatens Our Economic Future. 2012.
Bray GA. Contemporary Diagnosis and Management of Obesity. Newtown, PA: Handbooks in Health Care; 1998.
Centers for Disease Control and Prevention. The Power to Prevent, The Call to Control: At A Glance 2009.
Cooke M, Irby DM, O'Brien BC, Shulman LS. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA: Jossey-Bass; 2010.
Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. 2010.
John A. Hartford Foundation. Grants and Strategy: Nursing Education.
National Heart, Lung, and Blood Institute. National Institutes of Health. Nutrition Academic Award.
National Heart, Lung, and Blood Institute. National Institutes of Health. Working Group on Future Directions for Implementing Nutrition Across the Continuum of Medical and Health Professions Education and Training, and Research. 2012.
Plotkin F. Eating Healthy for a Healthy Baby: A Month-by-month Guide to Nutrition During Pregnancy. New York, NY: Three Rivers Press; 1994.
Sharon R. Akabas, PhD
Sharon R. Akabas is associate director of the Institute of Human Nutrition at Columbia University and director of the institute's MS in Nutrition program. Her primary research interests are in the education of health professionals about the importance of nutrition in disease prevention. She works with professionals from almost all health care sectors to develop programs and curricula that focus on childhood obesity. This work includes organizing symposia for practicing health care professionals and collaborating with community groups to develop obesity prevention programs and to identify, understand, and lessen bias towards overweight children and adults. Akabas has served as a member of the institute faculty since 1995, developing many courses and training programs. She holds a PhD from Columbia University.
Gerald Friedman, MD, PhD
Gerald Friedman is a clinical professor of medicine specializing in gastroenterology and the director of nutritional medical undergraduate education at Mount Sinai School of Medicine. He holds a PhD in pharmacology from Syracuse University Graduate School and an MD from SUNY Buffalo. He completed residencies in internal medicine at Mount Sinai Hospital and Montefiore Medical Center and a fellowship in gastroenterology at Mount Sinai Hospital. He is president of the New York Gastroenterological Society. Friedman’s research is focused on the role of nutrition in gastroenterology. He studies the influence of diet on diseases of the digestive system such as irritable bowel syndrome, antibiotic-associated diarrhea, and Clostridium difficile colitis. He is also interested in nutritional factors that affect gastroenterology diagnoses and therapies. Friedman is conducting research on potential applications of probiotics-based nutritional therapy.
Martin Kohlmeier, MD, PhD
Martin Kohlmeier is a research professor in Department of Nutrition at the University of North Carolina at Chapel Hill. He holds an MD from the University of Heidelberg, Germany. Kohlmeier’s research has focused on the influence of genetic variation as a modulator of nutrient disposition and on the assessment of nutritional status in normal populations, as well as the impact of nutritional status on health. He has developed novel biochemical methods for the assessment of dietary intake and nutrient adequacy. He is the author of a comprehensive textbook on nutrient metabolism and is the lead author and developer of numerous online nutrition courses for medical students and health care professionals. He is the founding chief science officer of PogoHealth Inc., which uses online technology to help the public make rational dietary supplement choices. Kohlmeier is the project director of Nutrition in Medicine (NIM) and Nutrition Education for Practicing Physicians (NEPP) projects. The NIM materials are used by more than a hundred U.S. medical schools and many international institutions and are accredited for continuing education by the American Society for Nutrition and the American Dietetic Association.
Charlotte A. Pratt, PhD, RD
Charlotte A. Pratt is a program director in the Prevention and Population Sciences program in the Division of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health. She previously served as the program director for the Nutrition Academic Award program, which supported 21 medical schools to incorporate nutrition into their curricula. Before joining NHLBI, she held faculty positions at Virginia Tech, Michigan State University, the University of Malawi (as a senior Fulbright Scholar), and Eastern Michigan University. She was the director for the Resource Center for Cardiovascular Health at Michigan Public Health Institute and a research nutritionist at the United States Department of Agriculture. She is the program director for the ongoing Childhood Obesity Prevention and Treatment Research Consortium. Pratt holds a PhD from the University of Minnesota. Her research interests include obesity in youth and adults, health disparities, nutrition, physical activity, and global health.
Gwen Twillman is the managing director of education and professional development at the American Society for Nutrition. She has more than 23 years of experience in nonprofit program development, management, and evaluation. The focus of her work has been implementing educational programs targeted to clinicians, researchers, young investigators, students, and patients. She has worked with multidisciplinary volunteer committees to plan and execute successful education and professional development activities targeted to professionals in health care and research fields. These programs have ranged from large, international scientific conferences to small, professional development events. Before joining the American Society for Nutrition, Twillman was executive director at the Peripheral Arterial Disease Coalition and held various positions at the American Diabetes Association.
Mandana Arabi, MD, PhD
The Sackler Institute for Nutrition Science
Brooke Grindlinger, PhD
The New York Academy of Sciences
Matthew D. Levy, MD, MPH
Matthew D. Levy is an associate professor of clinical pediatrics at Georgetown University School of Medicine. He is also medical director of community pediatrics, director of the fellowships in community pediatrics and children’s advocacy, director of the community pediatrics component of the pediatric residency program, director of the third- and fourth-year medical student community electives, and co-director of the social justice and health advocacy curriculum. He has worked to strengthen the electronic medical records systems across the medical campus and has served as a board member of the DC chapter of the American Academy of Pediatrics, receiving its distinguished service award in both 2006 and 2008 for work to promote better access to care for adolescents and for the development of a web-based resource guide for providers in DC. Levy has developed and implemented multiple programs to improve access to health care for high-risk children. He holds an MD from New York Medical College and an MPH from the Johns Hopkins School of Public Health.
Martin Kohlmeier, MD, PhD
Sharon R. Akabas, PhD
Darwin Deen, MD, MS
Darwin Deen is a professor of community health and social medicine at the City College of New York. He holds an MD from Albert Einstein College of Medicine and completed a residency in family medicine at Montefiore Medical Center. Deen has 30 years of experience working with underserved communities in the Bronx and has devoted his career to training urban primary care clinicians. He was the director of medical student education for the Department of Family and Social Medicine at Albert Einstein College of Medicine before joining City College, where he teaches medical interviewing and primary care. He edited the Complete Guide to Nutrition in Primary Care and has written several nutrition books for lay audiences. His other interests include integrative medicine, physician–patient communication, stress management for patients and professionals, and medical student resiliency.
Rose Ann DiMaria-Ghalili, PhD, RN
Rose Ann DiMaria-Ghalili is an associate professor in the Department of Doctoral Nursing and in the Department of Nutrition Sciences at Drexel University. She holds BSN and MSN degrees from Hunter College and a PhD from New York University. Her research focuses on nutrition and surgical recovery to improve the care of older adults undergoing surgery. Her other interests include nutrition assessment, inflammation, sarcopenia, and health outcomes. During a John A. Hartford Foundation post-doctoral fellowship, she collaborated with interdisciplinary experts to incorporate biomarkers of nutrition and inflammation into her research model. DiMaria-Ghalili is an associate editor for the Journal of Parenteral and Enteral Nutrition and is on the editorial board for Biological Research for Nursing.
Eugene Dinkevich, MD
Eugene Dinkevich is a pediatrician and the director of the Downstate Healthy Lifestyles program at SUNY Downstate Medical Center.
Marilyn S. Edwards, PhD, RD
Marilyn S. Edwards is a professor of nutrition at the University of Texas Medical School at Houston. She holds a PhD in human nutrition from Colorado State University. She was a principal investigator for the National Heart, Lung, and Blood Institute’s Nutrition Academic Award program and a fellow at the American College of Nutrition. Her research focuses on clinical nutrition studies, with an emphasis on lipid disorders in humans, animal models of such human disease, and metabolic feeding studies in malnourished patient populations.
Penny M. Kris-Etherton, PhD, RD
Penny M. Kris-Etherton is a distinguished professor of nutrition in the College of Health and Human Development at Pennsylvania State University. She holds a PhD in nutrition from the University of Minnesota and is a fellow of the American Heart Association. Her research expertise is cardiovascular nutrition. For over 20 years, she has conducted controlled clinical nutrition studies designed to evaluate the role of diet on risk factors for cardiovascular disease. Kris-Etherton is on the board of WomenHeart and the National Lipid Association, and serves as president of Shaping America's Health and the Northeast Lipid Association. She has held editorial board appointments on journals such as the Journal of Clinical Lipidology; Lipids; Current Atherosclerosis Reports; the American Journal of Clinical Nutrition; and others.
Ellen J. Landsberger, MD, MS
Ellen J. Landsberger is an associate professor of clinical obstetrics and gynecology and women's health at Albert Einstein College of Medicine’s Montefiore Medical Center. She holds an MD from George Washington University School of Medicine and completed residency training at New York University, Albert Einstein College of Medicine, and Planned Parenthood of Westchester, as well as a fellowship at George Washington University Medical Center. Landsberger performs clinical research on women’s health with a focus on prevention, screening, and treatment of gestational diabetes.
Carine M. Lenders, MD, MS, ScD
Carine M. Lenders is a pediatric gastroenterologist and physician nutrition specialist with training and experience in obesity medicine and global health. She holds an MD and a Master’s degree in Global Health from the State University of Liege and the Institute of Tropical Medicine in Belgium. After several years of service in Africa and Asia, she completed a pediatric nutrition fellowship at the University of Pennsylvania, followed by a pediatric residency and fellowship in pediatric gastroenterology at Harvard Medical School and a doctorate in nutrition at the Harvard School of Public Health. She directs a pediatric weight management program and a nutrition support service at Boston University Medical center and is an associate professor of pediatrics at Boston University School of Medicine.
Carole A. Palmer, EdD, RD, LDN
Carole A. Palmer is a professor in the School of Nutrition, an adjunct professor in the School of Medicine, and the program director for the MS Dietetic Internship at Tufts University. She is also a professor and the head of the Division of Nutrition and Oral Health Promotion at Tufts University School of Dental Medicine and a staff nutritionist at the Frances Stern Nutrition Center of New England Medical Center Hospital. She holds an EdD in educational policy, planning, and administration from Boston University and an MEd in nutrition education from Tufts University. Her primary research emphasis has been the study of relationships between diet and nutrition and oral conditions. She is a leader in developing models for implementing nutrition care in clinical dental settings. She is known internationally for the innovative nutrition video training programs she has developed for national research studies, the government, voluntary agencies, professionals, and the public.
Kathy West, MS, RD, LD
Kathy West is a manager for the Healthcare Education program at Abbott Nutrition Health Institute.
Judith Wylie-Rosett, EdD
Judith Wylie-Rosett is a professor in the Department of Epidemiology and Population Health and in the Department of Medicine in Endocrinology at Albert Einstein College of Medicine. She holds EdD and MEd degrees from Teacher's College of Columbia University. Her research has focused on the role of nutrition in chronic disease prevention and control. She has collaborated in multicenter clinical trials and other studies aimed to integrate care recommendations into health care for people with diabetes, heart disease, cancer, and obesity. She is an investigator in the Diabetes Control and Complications Trial, the Diabetes Prevention Program, and the Women’s Health Initiative. Her current research includes a clinical trial to compare low-fat and low-carbohydrate diets in diabetes management; an evaluation of telephone support to reinforce medical nutrition therapy for overweight adolescents at risk for diabetes and cardiovascular disease; and an evaluation of simplified tools to promote the inclusion of nutrition information in primary care.
Darwin Deen, MD, MS
Gerald Friedman, MD, PhD
Nancie H. Herbold, EdD, RD
Nancie H. Herbold is the Ruby Winslow Linn Professor and chair of the department of nutrition, co-director of the Center for Hygiene and Health in Home and Community, and Dietetic Internship director at Simmons School of Nursing and Health Sciences. She holds an EdD from Boston University and serves on the Massachusetts Nutrition Board, an advisory board to Massachusetts Governor Deval Patrick. She is a registered dietitian and has worked in hospitals and as a consultant to home health agencies, corporations, and individuals. At Simmons, she teaches advanced community nutrition, nutrition proposal development, nutrition research projects, and classes for the dietetic internship. She also consults on grants and is the co-editor of two books. Herbold holds a Master's in Health Science in nutrition and a PhD in educational technology from Boston University. She completed a dietetic internship at Brigham and Women's Hospital.
Yasmin Mossavar-Rahmani, PhD, RD, CDN
Yasmin Mossavar-Rahmani is an associate professor in the Department of Epidemiology and Population Health at Albert Einstein College of Medicine. She holds PhD and MS degrees in nutritional sciences from the University of Connecticut and an MA in Regional Studies: Middle East from Harvard University. Her expertise is in dietary assessment and intervention. She was a co-investigator and lead nutritionist for the Women’s Health Initiative Dietary Modification Trial at the New York City Clinical Center. She serves as the nationwide principal investigator for the Study of Latinos: Nutrition and Physical Activity Assessment Study, which is designed to investigate the measurement error of diet and physical activity assessment instruments in a Hispanic cohort in four U.S. cities. She is also the Bronx principal investigator for the Study of Latinos Sleep Study.
Christina M. Stark, MS, RD, CDN
Christina M. Stark is the program leader for Cornell NutritionWorks, an online professional development program for nutrition and health practitioners. She oversees the content and structure of the website and develops marketing and evaluation strategies. For over 32 years she has been responsible for interpreting and communicating research-based information on food and nutrition issues to educators and other professionals, consumers, and the media. Her interests include providing continuing professional education through distance-learning technology, primarily in the areas of childhood obesity prevention and global health, including infant- and young-child feeding. She is also interested in consumer-food and nutrition issues, such as dietary guidelines and food safety. Her work focuses on enhancing the link between nutrition research and practice. She is a registered dietitian and holds an MS in foods and nutrition from Oregon State University.
Riva Touger-Decker, RD, PhD
Riva Touger-Decker is a professor of nutritional sciences and diagnostic sciences and is chair of nutritional sciences at the Rutgers School of Dental Medicine, Rutgers University. She holds a PhD from New York University. Her research interests include nutrition and oral medicine, advanced practice in dietetics, dietetics education and credentials, nutrition and oral health outcomes, orofacial pain and nutrition, international dietetics, and nutrition terminology.
Alan Dove is a science writer and reporter for Nature Medicine, Nature Biotechnology, and Bioscience Technology. He also teaches at the NYU School of Journalism and blogs at http://dovdox.com.
As the world faces a rising tide of obesity, metabolic syndrome, diabetes, and other nutrition-related chronic diseases, patients increasingly turn to health care workers for advice. Unfortunately, most practitioners are not well prepared to provide nutrition information.
In medical, nursing, dental, and other professional schools, a packed curriculum leaves little room for practical discussions of nutrition, and continuing education standards often give the subject short shrift as well. As a result, few health care workers have the knowledge and confidence to advise patients about such basic subjects as losing weight and planning a balanced diet.
To address this education gap, the New York Academy of Sciences hosted Capacity Building in Nutrition Science: Revisiting the Curricula for Medical Professionals on June 6, 2013, drawing faculty, administrators, and curriculum developers from medical, dental, and nursing schools, as well as professional educators, nutritionists, and dietitians. The conference was presented by the Josiah Macy Jr. Foundation and the Academy's Sackler Institute for Nutrition Science.
An opening address and two keynote talks defined the scope of the problem, surveying both the mushrooming obesity pandemic and the shortage of clinically useful nutrition training. The first session reviewed how nutrition is currently taught in medical, dental, and nursing schools; while all clinical curricula purport to cover nutrition, the focus is usually on basic biochemistry rather than on clinically applicable guidelines.
Many reform efforts have struggled to establish sustainable funding. The Nutrition Academic Awards sponsored by the National Heart, Lung, and Blood Institute, for example, aimed to foster new collaborations between clinical training programs and to establish guidelines for nutrition education, but funding ended in 2005. However, some student-led projects that began as elective courses and seminars have led to sustained improvements, often becoming part of the main curriculum after a few years.
The second session covered how to integrate nutrition education into medical curricula. Speakers argued that linking nutrition to other topics, such as women's health, pediatric obesity, and aging, could help course developers to present the subject in realistic contexts.
The third session focused on how to assess nutrition training. Schools traditionally emphasize material that appears on licensing exams, but many of these tests use multiple-choice questions and favor memorization of scientific facts rather than application of practical knowledge. Improving the quality of the test questions could help drive changes in curricula.
The final session featured a series of case studies. Three speakers discussed their work to develop elective courses and independent study programs in nutrition. Students in these courses often agitate for changes throughout the curriculum. Other programs focus on collaborative training for different kinds of health professionals and on the use of web-based classes to reach students in remote locations or outside normal classroom hours.
The conference also featured question sessions and other opportunities for participants to interact. Although the discussions highlighted the inherent challenges of adding more information to already-full course loads, successful efforts show that improvements are possible.
Gerald Friedman, The Icahn School of Medicine at Mount Sinai
Matthew D. Levy, Georgetown University School of Medicine; Bipartisan Policy Center
Martin Kohlmeier, University of North Carolina at Chapel Hill
- Health care workers are often unable to provide the nutrition information patients need.
- A new emphasis on preventive medicine requires clinical training programs to re-evaluate their nutrition courses.
- The federally-funded Nutrition Academic Award created several new tools for nutrition curricula reform before its funding ended in 2005.
- Web-based training programs can supplement clinical curricula.
An appetite for change: what do medical professionals need to know?
What should doctors, nurses, and other health care professionals know about nutrition, and how should it be taught? With a global obesity pandemic overloading health care systems everywhere, it's an urgent question. To define the problem, the opening speakers discussed how nutrition education is currently structured and highlighted several recent reform initiatives. Change is needed; as Gerald Friedman from the Icahn School of Medicine at Mount Sinai explained in his opening address, "medical schools teach very little clinically applicable nutrition information; as a result, physicians remain unable to deliver critical nutrition advice to their patients."
Federal agencies have looked for solutions. Prompted by a recommendation from the Institute of Medicine, the U.S. National Heart, Lung, and Blood Institute established the Nutrition Academic Award (NAA) in 1998, which sought to foster collaborations between medical schools, to develop new guidelines, and to create educational and clinical tools to evaluate nutrition teaching. Friedman reported that the program accomplished these goals before its funding ended in 2005.
One significant NAA achievement was the completion of a comprehensive curriculum guide for physician training, broken into different sections for teaching medical students, residents, and clinical faculty. The guide is freely available online, but Friedman said that it is underutilized. With up to 80% of chronic diseases believed to have at least some nutritional component, he considers this neglect unacceptable: "We need ... a national core nutrition curriculum in every medical school," he said, adding that such a curriculum would include measures to increase collaboration among physicians and other health care professionals. New initiatives with sustained federal funding would help, but Friedman urged conference attendees not to wait; instead, he advocated using online materials from the NAA to implement reforms immediately.
Policy makers prescribe prevention: be the change you want to see in health
Matthew D. Levy from Georgetown University School of Medicine gave the first keynote presentation, outlining the magnitude of the obesity epidemic in the U.S. and the consequent need to improve nutrition training for health care workers. Levy described work by the Bipartisan Policy Center to address these intertwined issues.
Two-thirds of Americans are overweight or obese, and fewer than 20% meet recommended levels of physical activity. The nation's children have tripled in weight over the last 30 years. This national binge is a favorite topic of late-night comedians, but its impact is no laughing matter. Health care spending skyrockets for patients with diabetes, hypertension, and other complications of obesity, and overweight children face a lifetime of medical problems. "Our economic security and our future prosperity are in jeopardy ... we are in a health care crisis," Levy said.
Policy makers have noticed: the landmark Affordable Care Act of 2010 places a heavy emphasis on preventive health care, new standards for electronic health records require routine assessments of body mass index and nutritional status, and insurers are beginning to provide reimbursement for obesity screening and prevention. But these efforts face a limited supply of adequately trained health care workers.
The Bipartisan Policy Center recommends including training on nutrition and physical activity in all phases of medical education. The American Association of Medical Colleges, American Medical Association, and other medical organizations have agreed to similar recommendations. Levy recommends emphasizing practical results and developing curricula that provide the knowledge and skills health care workers need to be able to change patient behavior, such as encouraging healthier eating and regular exercise.
Starving for knowledge: nutrition education in the medical school curriculum
Martin Kohlmeier from the University of North Carolina at Chapel Hill delivered the second keynote presentation, which described nutrition education in medical schools. The news isn't good.
In a 2008 survey of medical interns in New York, less than a third felt prepared to assess a patient's nutritional status; a majority could not calculate body mass index, the standard measure for overweight and obesity screening; and fewer than 60% felt knowledgeable about how saturated fat acts in the bloodstream. Most interns wanted to be able to discuss nutrition with their patients but did not feel ready to do so. "Clearly, whatever is happening in medical schools, we are failing," Kohlmeier said.
Correcting that failure will not be simple. Medical school curricula are packed with subjects ranging from basic biology to pain management. The NAA recommended 25 contact hours of nutrition education across the four-year program, but the national average is only about 20 hours. Only a small portion covers clinically applicable information. As Kohlmeier pointed out, "basic biochemistry that talks about vitamins and nutrients in a biochemical sense is not really nutrition, but just the biochemical foundations of nutrition."
The NAA also surveys medical schools; their comments are disheartening. One school reported that they had replaced nutrition education with a module on "knowledge and discovery"; another had replaced it with a class on interpreting electrocardiograms; another said that the Dean did not recognize obesity as a core knowledge topic for medical education.
To help cover these gaps, Kohlmeier and his colleagues have developed a web-based training program called Nutrition in Medicine. The site has over 40 modules, each between 15 and 60 minutes long, with a combination of text, animations, and videos and interactive patient simulations to help students gauge their performance.
Rose Ann DiMaria-Ghalili, Drexel University
Carole A. Palmer, Tufts University School of Dental Medicine
Carine M. Lenders, Boston University School of Medicine
Martin Kohlmeier, University of North Carolina at Chapel Hill
- Nurses are the largest group of health care workers, but it is unclear whether their nutrition training is adequate.
- Dental hygienists may receive better dietary training than dentists.
- Past reforms in geriatric nursing training provide a model for improving nutrition curricula.
- Student-driven programs help increase schools' interest in nutrition.
Learning from the past: integrating nutrition into nursing education
Rose Ann DiMaria-Ghalili from Drexel University opened the first session with a discussion of nursing education. Nursing and food have been closely connected since the days of Florence Nightingale; the three million registered nurses in the U.S provide a crucial interface between health care and nutrition. However, it is difficult to determine how well prepared they are for this role.
DiMaria-Ghalili found a single survey of nurse-training programs in the literature, from 1987. All Bachelor of Science in Nursing curricula required nutrition training, but not all nurses earn a BSN and different accreditation bodies may set different standards. DiMaria-Ghalili called for a new, more comprehensive survey of nursing curricula and for the establishment of clear standards based on its results.
Clinical educators could turn to a strategy developed in the late 1980s, when nurse training received a major overhaul in anticipation of the "silver tsunami" of aging baby-boomers. At that time, the American Association of Colleges of Nurses collaborated with the Hartford Institute to develop a set of standards for teaching geriatric care. Those standards are now part of undergraduate nursing programs nationwide. Recently, the program also produced web-based continuing education training modules for nurses.
DiMaria-Ghalili advocated following a similar procedure to help the nursing profession adapt to the obesity epidemic. She argued that institutions should define new standards for interdisciplinary training on obesity assessment and other nutrition topics and should incorporate those standards into nurse training.
Something to sink your teeth into: nutrition education for dental professionals
Carole A. Palmer from Tufts University School of Dental Medicine described nutrition education in dental schools. Dentists may not be an obvious source of nutrition information, but dental caries, periodontal disease, and oral infections all have dietary implications for patients. As Palmer pointed out, "the mouth is the pathway to the rest of the body; anything that happens in the mouth can have a trickle-down effect [on health]."
Acknowledging the close connection between oral health and food, dental schools have long taught about nutrition. Like medical schools, however, dental schools face demand to cover ever more topics, resulting in an erosion of nutrition training. A 2001 survey showed that only 28% of dental schools had a registered dietitian on the faculty and that the number of hours students spent on nutrition ranged widely, from 7 to 40. A survey from 2011 found that dental hygienists receive a robust education in nutrition—surpassing that of dental students—with an average of 47 hours of learning.
Efforts to promote inter-professional education may help dentists and other clinicians to brush up on nutrition. Palmer cited the program at Tufts as a model; she said it is unique in providing inter-professional education, pairing dental students with nutritionists for part of their training.
The breakfast club: a student-centered model
Carine M. Lenders and her colleagues at Boston University School of Medicine are taking another approach to curriculum reform, beginning by training the students who are most interested in learning about nutrition. With a 2006 grant to evaluate and improve nutrition training, the researchers assessed program needs and implemented a novel student-led effort to fill gaps.
One result is a voluntary student group that meets to present papers, mentors peers, and promote networking to highlight nutrition topics. Lenders reported that the group is very active and student interest has grown—there is now a waiting list to join.
These efforts led to the creation of a new nutrition course that is scheduled to begin this fall. In addition, all students now receive an orientation tour of inner-city communities in Boston, which includes visiting grocery stores and clinics to learn about the area's nutritional and medical landscape. Students also perform dietary self-assessments and attend a lecture on nutrition and cancer by a registered dietitian.
Although these changes sound promising, it has been difficult to evaluate the impact of the project. Boston University's medical students now receive 26 hours of nutrition education, but Lenders argued that this is not necessarily the best guide to a program's success; a better measure is the quality of the training.
The session concluded with a panel discussion and question period moderated by Martin Kohlmeier. The panelists observed that teaching students to work with other health professionals in interdisciplinary teams is difficult. The Affordable Care Act places a new emphasis on collaborative care to reduce costs and errors, but the faculty who teach this care model are themselves poorly trained in collaboration. Lenders argued that earlier efforts to reform the geriatric care curriculum faced similar problems, so the strategies that worked in those efforts could serve as a model for nutrition.
The health care reform act also emphasizes preventive care, which should increase interest in nutrition. However, many clinicians worry that reimbursement limits will make nutrition counseling a losing proposition. Panelists also talked about the problem of certification exams, which often emphasize biochemical aspects of nutrition rather than practical knowledge.
Finally, the group discussed the problem of funding. Many of the current curriculum reforms have been funded by short-term grants and will be unsustainable once the money runs out. Lenders suggested that corporate funding could change this sitaution, but universities fear that companies could exert undue influence over their curriculum.
Ellen J. Landsberger, Albert Einstein College of Medicine
Eugene Dinkevich, SUNY Downstate Medical Center
Marilyn S. Edwards, University of Texas Medical School at Houston
Charlotte A. Pratt, National Institutes of Health
- Linking dietary training to women's health can help multiple generations of patients.
- Simple nutrition advice from pediatricians can help prevent obesity in children.
- Integrated courses can cover nutrition across the entire human life cycle.
A menu of options: nutrition education in women's health
There are many opportunities to integrate information about diet, exercise, and nutritional needs into clinical training. Increasing pressure from insurers, government agencies, and medical associations to do more to combat the burgeoning obesity epidemic is helping to push curricula reform forward.
Ellen J. Landsberger from Albert Einstein College of Medicine opened the second session with a presentation about the importance of nutrition in women's health. Everyone needs good information about diet and exercise, but the impact of poor nutrition on women can be particularly profound. Gynecological complications of obesity can include infertility, cancer, and surgical complications, and women are also at risk for osteoporosis and cardiovascular disease. Women's health care provides unique opportunities for nutritional interventions; for example, during pregnancy, when women are particularly receptive to information about nutrition.
As earlier speakers noted, most physicians finish medical school without the necessary nutrition training to confidently advise patients; obstetricians and gynecologists are no exception. Landsberger suggested approaching this training through adult education, focusing on self-directed learning for providers who are already in practice. A web-based training program she and her colleagues developed significantly improved obstetricians' and gynecologists' understanding of weight and diet. Landsberger teaches residents and physicians to focus on practical, simple advice on topics such as "portion control, healthy foods, and ... avoiding sugary drinks and juice."
An ounce of prevention: nutrition science in clinical pediatrics
Eugene Dinkevich from SUNY Downstate Medical Center also thinks dietary advice should be simple, especially for new parents. As a pediatrician, he runs a counseling and behavior-modification program for children diagnosed with obesity. He reported that many physicians wait too long to refer patients and recommended teaching pediatricians to intervene much earlier, rather than waiting until a child is obese. That's a tall order. A 2009 study found that pediatricians missed half of all cases of obesity, and most failed to recognize overweight at all.
Part of the problem is that the standard measure for overweight and obesity, the body mass index, provides only a coarse guide for children. BMI is calculated by dividing body weight by the square of height. Small errors in height measurement can cause large errors in BMI and the index does not distinguish between fat and muscle weight.
Nonetheless, Dinkevich argued that BMI is useful if used correctly. He favors tracking a child's BMI over time and graphing the results, giving parents a strong visual indication when a child begins to gain excessive weight.
The life cycle approach: nutrition education for aging
Marilyn S. Edwards from the University of Texas Medical School at Houston spoke about health across the age spectrum and the importance of nutrition in every branch of medicine, from neonatology to gerontology. The university teaches nutrition in this context.
Like most medical schools, UT Houston has rearranged traditional classes into integrated courses; students now learn nutrition and other topics as part of courses on the complete human life cycle, from infancy to old age. The school integrates nutrition into all four years of medical training, offering elements such as dietary and physical activity self-assessments and a fourth-year elective in nutrition. Edwards's team has built a website devoted to nutrition and has prepared a clinical handbook on nutrition in preventive medicine.
Students complete additional nutrition training in preparation for residency, which includes learning how to refer patients to dietitians. Edwards said that it is important for students to understand that they play a key role in directing patients to these providers.
The session ended with a panel discussion and audience questions moderated by Charlotte A. Pratt from the National Institutes of Health. By 2030, 20% of Americans will be over age 65; speakers and attendees agreed that this demographic shift will increase the importance of nutrition in medicine. The chronic diseases that accompany old age overlap with those that accompany obesity, and elderly patients commonly develop other nutrition-related problems as well.
The increasing focus on the role of nutrition in health will encourage clinicians to refer more patients to dietitians. However, the panelists agreed that the demand for dietitians already outstrips the supply, at least in part because these specialists often find it difficult to earn a living wage.
Penny M. Kris-Etherton, Pennsylvania State University
Sharon R. Akabas, Columbia University
Darwin Deen, The City College of New York
Kathy West, Abbott Nutrition Health Institute
Judith Wylie-Rosett, Albert Einstein College of Medicine
Darwin Deen, The City College of New York
Gerald Friedman, The Icahn School of Medicine at Mount Sinai
Nancie H. Herbold, Simmons College
Yasmin Mossovar-Rahmani, Albert Einstein College of Medicine
Christina M. Stark, Cornell University
Riva Touger-Decker, Rutgers School of Dental Medicine, Rutgers University
- This meeting was part of a broader push for nutrition curriculum reform, and follow-up meetings are planned.
- Multiple-choice tests are not the best way to assess students' understanding of practical topics.
- Online continuing education courses can supplement health care workers' nutritional knowledge.
- Nutrition counseling should be more effectively tailored to different patient populations.
The appetizer course: summary of an NHLBI workshop
Penny M. Kris-Etherton from Pennsylvania State University opened the third session with a summary of a workshop held at the National Heart, Lung, and Blood Institute (NHLBI) in September 2012. This Academy conference was a sequel to that meeting, so the two events covered similar material.
These discussions are part of a broad push by health care workers to improve training on diet, exercise, and other nutrition-related subjects. Participants in the NHLBI workshop discussed the old NAA program, reviewed options for improving nutrition training for all health care workers, recommended standards for interprofessional collaboration, and developed priorities for evaluating new training methods.
The workshop also framed overarching goals, which Kris-Etherton said should "[focus on] the quality of patient care: how can we improve patient outcomes, population health, and health care costs?" Participants also talked about the need for specific, quantifiable treatment standards, such as lowering body weight and cholesterol levels.
Nutritional literacy: competencies in the health professions
Sharon R. Akabas from Columbia University also supports defining clear standards, but cautioned against setting unrealistically lofty goals. The value of curricula change is not based solely on improvements in patient outcomes; thus, rather than focusing exclusively on outcomes, she suggested testing students' general competency in nutrition. Competency is a complex measure to define, but she presented a working definition based on the ability to use communication, knowledge, skills, reasoning, and values to solve practical problems.
Achieving cooperation among different types of health care workers should be easy; all the major clinical societies agree on the general messages patients should receive about nutrition topics such as diet, exercise, and vitamins. Unfortunately, the information patients actually receive is often inadequate. Akabas said that nutrition information materials need to be tailored to the literacy level of consumers. She suggested that clinicians should collaborate with public health groups, many of which have experience overcoming literacy barriers.
All of the above: assessing testing standards
Darwin Deen from the City College of New York also tackled the thorny problem of assessing clinicians' understanding. Like other educational institutions, medical schools must balance testing efficiency with assessing knowledge. Multiple-choice exams are easy to grade but do not test understanding well, while practical tests often yield results that are difficult to quantify. In addition, most testing regimes only tell students how well or poorly they did, not how to improve.
Deen and his colleagues reviewed medical board exams, finding inadequate coverage of nutrition and a focus on basic biochemistry rather than on clinically useful knowledge. They lobbied exam developers and have been invited to develop new questions with a more practical focus.
An endless buffet: continuing education in nutrition
Kathy West and her colleagues at the Abbott Nutrition Health Institute create continuing education courses to train health care workers, particularly nurses, on nutrition. The institute offers online courses about many topics, from pediatric nutrition to adult dietary guidance.
Recent surveys of nurses by the institute revealed some of the pitfalls of nutritional training and interprofessional education. West said that one particularly delicate problem is the division of labor between nurses and dietitians; if a nurse is not working with a dietitian, nutrition may take a back seat, but if the dietitian becomes too involved in the patient's care, the nurse may feel sidelined.
The surveys also identified the best strategies for educating health care workers. Short interactive online courses are popular, with built-in breaks at ten- to twenty-minute intervals. Tying nutrition to other hot topics, such as patient safety or strategies to reduce the length of hospital stays, also draws participants.
To assess learning, the institute tests participants before and after each module. Some courses includes game-like competitions in which students to compete against each other while learning the material.
The session ended with a panel discussion and question session moderated by Darwin Deen. Panelists argued that health care workers need to work more effectively in multi-disciplinary teams to provide consistent nutrition counseling and management. Territorial disputes between different disciplines are counterproductive but common. Panelists suggested that encouraging medical, nursing, and other health care students to work together during their training could help improve collaboration once they enter practice.
Speakers also emphasized the importance of physical activity, which seldom receives more than a brief mention in current nutrition curricula. This could be achieved by integrating information on nutrition with information on the benefits of regular exercise, particularly through programs that require students to track their own habits.
Recipes for success: new directions in nutrition education
The conference concluded with a series of short presentations about specific curriculum-reform efforts, facilitated by Judith Wylie-Rosett from Albert Einstein College of Medicine. Friedman described an interest group he set up for medical students who want to learn more about nutrition. The program has grown rapidly, and Friedman is now designing a stand-alone class in the subject, as well as additional modules for Mount Sinai Medical School's biochemistry and physiology courses. At the Albert Einstein College of Medicine, Yasmin Mossavar-Rahmani has developed a successful elective course in nutrition for first-year medical students and Wylie-Rosett runs an independent study elective for fourth-year students.
Nancie H. Herbold explained her efforts to foster collaborative training between students in nutrition, nursing, and social work at Simmons College. "The biggest challenge is [assessing whether] these interdisciplinary teams make a difference in patient care and patient outcomes," she said.
Christina M. Stark and her colleagues have cast a broader net with the Cornell Nutrition Works website, which reaches over 15 000 students in 178 countries with online courses in nutrition and obesity prevention. At Rutgers School of Dental Medicine, Riva Touger-Decker has built online courses with an eye toward incorporating more nutrition training into the dental curriculum.
Although these and other initiatives continue to struggle for funding, the meeting gave reason to be optimistic about the future of nutrition training. As pilot programs grow into integral components of clinical curricula, future health care workers will develop a stronger grasp of this critical topic—and not a moment too soon.