Nutrition in Med School Curriculum?
Abe Young
It brought up an issue I've been thinking of and kind of frustrated about this year: It seems--in life and shadowing my PCP--that so many of the problems that patients come in with are based so much on their diet & nutrition (or lack therof). Why has our curriculum (nearing end of MS1; and I hear MS2 is also lacking) included so little on this most basic, essential, and practical of topics for a future physician. Aren't the major health epidemics facing this country nowadays based on diet & nutrition?
Thoughts, anyone?
-Abe
http://www.amsa.org/tnp/articles/article.cfx?id=496
Is nutrition getting its just desserts in medical school?
The New Physician, April 2009
| by Linda Childers | Volume 58, Issue 3 |
“An
apple a day keeps the doctor away” might be a good mantra for medical
students and residents. Experts say physicians-in-training need an
increased understanding of nutrition to effectively meet the current
and future demands of the medical profession.
“Nutrition is a high priority among medical professionals across the nation, and a huge primary health indicator when it comes to conditions including osteoporosis, cancer, heart disease and diabetes,” says Dr. Patrick McBride, associate dean of students at the University of Wisconsin School of Medicine and Public Health (UW) and a family physician specializing in preventive cardiology. McBride recently served as chairman of the Association of American Medical Colleges committee that drafted curriculum guidelines for teaching students about overweight and obesity.
In the past, nutrition education hasn’t always been a part of the core curriculum at many medical schools. If the subject is taught, it’s often incorporated into other courses, like biochemistry or pathology, or offered as an elective. Responding to concerns about the prevalence of nutrition education in medical schools, in 1994 the National Academy of Sciences called for improved nutrition education at all U.S. medical schools. In addition, the Healthy People 2010 report, published by the U.S. Department of Health and Human Services, also identified the need for physician counseling and education relating to diet and disease.
While nutrition education in medical school has increased over the past two decades, experts say there is room for improvement. A study published in the April 2006 issue of the American Journal of Clinical Nutrition found that 60 percent of medical schools in this country are not meeting minimum recommendations for their students’ nutrition education.
Historically, one of the barriers to medical nutrition education has been a lack of consensus on what concepts should be taught.
Without a clear home for nutrition, some came to view the subject as alternative medicine. “We don’t see nutrition as complementary and alternative medicine. We see it as an emerging mainstream medical specialty,” says Dr. Lisa Neff, who sits on an ad hoc subcommittee within the American Society for Nutrition’s Graduate and Professional Education Committee. “Much of complementary and alternative medicine has not been science-based or evidence-based, although that is changing somewhat…. But nutrition has always been a science-driven field.”
Neff, a clinical scholar at Rockefeller University, believes that views are changing. “There are probably some schools where nutrition is still not as represented as we’d like it to be, by clinical nutrition experts.”
This changed nine years ago when the National Heart, Lung and Blood Institute selected 21 medical schools to receive a five-year, $1 million Nutrition Aca¬demic Award. UW was one of the schools to receive the grant.
In addition to the Nutrition Academic Award, Step 1 now has a nutrition sub-score. Though individual students can’t find out their own sub-score, schools do find out how their students as a whole score on nutrition. Asking the school about its students’ performance on the nutrition sub-score could lend some traction to curricular change.
Learning How to Prevent Disease
According to the Centers for Disease Control and Prevention (CDC), obesity in America has increased dramatically in the past 20 years. As a result, doctors are seeing more patients with metabolic syndrome, a cluster of cardiovascular disease and diabetes risk factors.
McBride co-directs a comprehensive clinical preventive cardiology program with more than 20 professional staff members. The program includes inpatient and outpatient cardiac rehabilitation, one of the United States’ first preventive cardiology and cholesterol clinics, and a diabetes prevention program.
“There’s a bevy of medical literature that says diet and exercise can be just as effective as medication in treating and preventing illnesses,” McBride says.
While most doctors agree on the importance of nutrition education for patients, some disagreement remains about who should provide patients with this kind of counseling. With the New England Journal of Medicine reporting that the average medical office visit lasts 18 minutes, many physicians may feel they don’t have the time, or expertise, to make nutrition recommendations.
Partnering With Dietitians
Lisa Hark, a nutrition expert and director of the Nutrition Education Program at the University of Pennsylvania School of Medicine, advises medical students to shadow a dietitian and for residents and doctors to partner with nutritionists who can help guide their patients in making smart lifestyle choices.
Hark, a registered dietician who holds a doctorate in education, has partnered with Dr. Darwin Deen, a family physician and professor of family medicine at the Albert Einstein College of Medicine, to write several books, including The Complete Guide to Nutrition in Primary Care, that help clinicians counsel patients on diet and lifestyle. The book offers practical guidance on nutrition counseling in the office setting and nutritional recommendations throughout life.
Doctors can use such resources to build a team approach to nutrition education in their practices.
“There are so many resources out there to help doctors,” McBride says. “In many cases dietitians are underutilized.”
“If you are a primary care physician, for example, you are going to get all kinds of questions about nutrition, many of which you may not be able to answer if you haven’t had appropriate training in nutrition,” Neff says.
In this case, physicians need to be able to turn to a registered dietician.
“As busy professionals, [physicians] may not—or probably will not—have the time to keep up on all the literature, and so a dietician, who will keep up on the nutrition literature for you and counsel your patients, that is a really important relationship to have.”
The issue of reimbursement has also been an obstacle in promoting nutrition education among physicians. While in¬surance companies don’t readily reimburse physicians for preventive nutrition counseling, McBride says he has had suc¬cess in working with insurers directly.
“I’ve found many insurers who are very interested in the concept of preventive education and are willing to provide reimbursement for programs that benefit health outcomes,” he says.
Nutrition Begins in the Medical School Cafeteria
Over the years, medical schools have discovered that students become more interested in nutrition when they see how it applies to their own lives. In addition to their classroom nutrition studies, medical students at UW are served a hot buffet-style lunch that meets nutrition guidelines and demonstrates a healthy eating plan.
McBride says these meals show students that healthy food can also taste good, and that moderation is key. Students also learn by logging the food they have eaten over a two-day period in a computer program that tells them how closely their selections match the national food pyramid. Some studies have shown that doctors who make improvements in their own eating habits are more likely to give good nutrition ad¬vice to their patients.
“We also teach our students to ex¬amine their eating habits through the eyes of a person who may have diabetes or high cholesterol to see where they might make dietary changes,” McBride says.
At Gundersen Lutheran Health System in La Crosse, Wisconsin, nutrition is simplified through a healthy eating program called the 500 Club, coordinated by registered dietitians and recommended by physicians. In the hospital cafeteria and throughout the region, grocery stores, vending machines and restaurants carry selections with the 500 Club logo. Those selections contain 500 calories and 15 grams of fat or less.
Doctors and medical residents at Gundersen use the 500 Club brochures when talking to patients about dietary changes. The medical center’s Winning Weighs program complements the 500 Club selections with 12-week programs offering practical dietary advice.
The Future of Nutrition In Medicine
With research showing that lifestyle interventions can be very powerful, often reducing the need for medications, more patients are turning to their doctors for nutrition advice.
“It’s important for physicians to start the nutrition conversation with patients, even if they ultimately refer them to a dietitian,” says Jo Ann Carson, a professor of clinical nutrition at University of Texas Southwestern Medical School, who holds a doctorate in nutritional science. “Most patients view their doctor as a trusted source of information, and they do pay attention to their [doctor’s] recommendations.” Even patients who are on prescription medications can benefit from sound nutrition advice.
“Sometimes prescribing a pill can seem easier than finding out the sources of saturated fat in a patient’s diet,” Carson says. “But learning your patient drinks five sodas a day and suggesting they switch to water can have a significant impact on their overall health.”
With the CDC reporting that 1.7 million Americans die and 25 million are disabled each year by chronic diseases caused or made worse by unhealthy lifestyles, the need for medical students to learn lifestyle medicine has never been greater.
“It’s so important to help patients understand how their daily habits and practices can impact their health and quality of life,” Carson says. “Showing them how to make good nutrition choices and lifestyle changes is often the best medicine.”
Abe Young
Yeah I heard from somebody else today too the same thing, that in the Nutrition elective that you all took, you discussed the possibilities & difficulties of implementing this topic into the general MS1/2 curriculum. I'm glad to hear this issue is at least on the table.
Last year when I interviewed at another school (Tufts I think?), the class I happened to sit in on was their Nutrition lecture (the auditorium was pretty filled, so I'm guessing it was a required class and not elective)--I just remember some didactic about grocery food packings' messenging/marketing and different cultural diets, and the professor mentioned the ongoing assignment for students to record/itemize their personal daily meals intake, while learning to apply the nutritional labels, etc. Don't recall that the students were snoring or anything, haha. I remember thinking Wow that was so practical, so many friends/relatives of mine could use good nutritional counseling from a doctor--and I was excited at the thought of learning in med school, since I personally feel pretty ignorant about those things.
I wonder if Dr. Golden and other faculty at Downstate have considered looking at and discussing with other schools that are implenting/have implented Nutrition curriculum--what works, what didn't, what obstacles and their solutions, etc.
Oh, and I'm cc'ing some friends at other med schools (including one who's at Tufts), if they have any thoughts to chime in?
-Abe
Hey Abe,
I actually took the Nutrition seminar course with Dr. Golden this past semester and this was one of the issues that was introduced. It is extremely important, but as we were going through the course, it became apparent that the issue of nutrition is a lot more complex than we once thought. Dr. Golden was using this course as a pilot for a larger scale course, but given the amount of material and the complexity of the issues within nutrition, those of us who took the seminar believed that a lot would be lost if the class was scaled up to an ECM sized lecture/small group.
On the other hand, there is a definite need for this in our curriculum, but with the rapidly changing research going on in this field, it may be hard to teach during our first 2 years. Additionally, the research done in this field is not always entirely sound because a lot depends on subjects and their ability to commit to a diet and subject recall. These are some of the issues that we saw in this seminar, but I still feel like it is an important issue that should be addressed in our education. It may be harder to implement than we think, just a class on nutrition in ECM will not be enough.
Best,
Jon
Jessica Bloome
I agree with what you all have been saying about nutrition, and I feel
like it is reflective of a related flaw in our curriculum, which is
lack of training in preventive medicine generally. Especially for
those of us interested in primary care, I feel like we skip over that
aspect, and nutrition is a prime example because it's such an
important issue in patient care these days. I wonder if we could cut
out some of the more random ECM classes in first semester in favor of
more in-depth curriculum on nutrition, smoking cessation, and that
type of stuff. Anyone else feel this way?
-Jess
Abe Young
Hi Abe,
We have a nutrition course in the first year at Tufts. Given that Tufts is one of the leading institutions on nutrition research, it would make sense that it is part of our med school curriculum! I think one of the practical elements of the course was a 3-day personal dietary assessment that every student had to complete. We had to make a record of our food intake over 3 days and analyze it using MyPyramid. It was pretty interesting to see how our usual diet, which we might consider "healthy", in fact, lacks a lot of essential nutrients and has an excess of fat and calories. This website is a great tool to refer patients to, and you can even have them fill it out and go over it with them at their next appointment. After this assignment, we also had to complete a 3-day DASH diet which is the cornerstone of nutrition intervention for many diseases including hypertension, CV disease, obesity/weight maintenance and Type 2 Diabetes. We got to see how successful we were in implementing a healthy diet. Finally, we also had an assignment which was to complete a nutrition intervention on someone, applying the knowledge and skills we had gained.
I think what made the nutrition class applicable were these assignments. While the knowledge they teach in class about particular aspects of a healthy diet are important, it is just as essential to learn how to do a nutritional assessment and intervention, and understand why a patient may or may not be able to implement these diet changes.
Also, there has been substantial research done in this area. I know we learned about several important studies such as the Framingham Heart study and Nurses' Health Study so I think there is plenty of data out there to support dietary interventions. Anyways, just some of my thoughts!
~Eva
(Tufts, M'11)
On Mon, Apr 27, 2009 at 11:13 PM, Abe Young <abey...@gmail.com> wrote:
pete...@gmail.com
How are things going? Sounds interesting about nutrition integrating into the curriculum. We had a sporadic few days of nutrition when we did biochen (at brown med) during our first year, but nothing as structured as what tufts has. Our nutrition stuff really comes in our third year in medicine and surgery, but more so surgery when you do some time with the tpn team (tpn= total parental nutrition), so you get to round with a group of hospital nutritionists and residents/attendings who put in tpn lines, and of course in medicine listening in on nutrition consults you call for your patients etc, but I think its definitely a good idea (have you ever tried to do a low sodium cardiac diet?? Bland and nearly impossible!) To have some of this in the first year, but at the same time I liked the practical experience I got on the wards.
Peter (brown md '10)
Ps: agree with eva on tons of studies done on nutrition and health. There's a new article in last weeks's jama about indian women and stature (as a measure of healthy diet) and its relation to chronic disease and birth outcomes (mortality) in their children
Sent via BlackBerry by AT&T
From: Abe Young
Date: Tue, 28 Apr 2009 00:07:31 -0400
To: Eva Tseng<ev.t...@gmail.com>
Subject: Re: [Primary Healthcare] Nutrition in Med School Curriculum?