Publication: What nutrition-related knowledge, skills and attitudes should medical students develop?

Fri, 8 Dec 2017 17:15:32 GMT

Abstract

Nutrition is a significant determinant in the leading causes of the death in the USA, and yet recent studies have shown that most American medical schools provide insufficient nutrition education. To address this deficiency, a concise and updated set of nutrition learning objectives was created from the 2002 Nutrition Curricular Guide for Training Physicians. A panel of 66 experts provided feedback to revise the initial objectives. The resulting objectives are presented here, as well as one recommended overarching goal to help match the needs of patients with the skills of future physicians.

Keywords: Nutrition, Medical education, learning objectives, Nutrition education, curriculum, clinical competence, medical students

Abbreviations:

NAA: Nutrition Academic Award; IAMSE: International Association of Medical Science Educators; IRB: Institutional Review Board; BMI: Body Mass Index; DRI: Dietary Reference Intake; RDA: Recommended Dietary Allowance; AI: Adequate Intake; UL: Upper Limit; CDC: US Centers for Disease Control and Prevention; DASH: Dietary Approaches to Stop Hypertension; RD: Registered Dietitian; RDN: Registered Dietitian Nutritionist; WIC: Women, Infants and Children; SNAP: Supplemental Nutritional Assistance Program; EFNEP: Expanded Food and Nutrition Education Program

Acknowledgements: The authors would like to thank Martin Kohlmeier, MD, PhD, for sharing the survey link with his network of nutrition educators.

Background

The insufficiency of nutrition education in medical schools has been lamented for over five decades.1,2 There is ample evidence that suffering and expense caused by nutrition-related chronic diseases has significantly increased during this half century, while physician competency in nutrition has not.3,4 There are many complex reasons for this discrepancy, including funding models that have rewarded interventions and treatments over prevention, but the reality is that there is currently a “disturbing mismatch between the skills of physicians and the needs of patients”1 in relation to nutrition.

To help address this problem the National Heart, Lung and Blood Institute initiated the Nutrition Academic Award (NAA) Program two decades ago. One of the outcomes of this funding was the creation of the Nutrition Curricular Guide for Training Physicians by a committee of 43 faculty plus staff members.5,6 This 65-page guide is a list of 473 nutrition learning objectives for medical students, residents and specialists that was made available in 2002.7 These consensus objectives provided a comprehensive, if lengthy, reference for medical school faculty and administrators passionate about improving nutrition education. Since the publication of this guide, most medical schools have undergone significant curricular modifications, with increased emphasis on helping students to achieve integrated clinical competencies. As a response, in 2014 Kushner, Van Horn and colleagues identified 11 nutritional competency domains for medical students, to be integrated vertically across the 4-year curriculum, and importantly identified the need to update the Nutrition Curricular Guide as the next step to improving nutrition education for healthcare professionals.8

Activity

In 2015 two of the authors (Lindsley and Thompson) facilitated a focus session at the annual International Association of Medical Science Educators (IAMSE) conference entitled “Becoming an advocate for a longitudinal, competency-based nutrition curriculum for health professions education.” The participants of this session formed an informal working group (the IAMSE Nutrition Advocates) to identify and/or create useful curricular resources. We began by organizing the 473 nutrition learning objectives from the NAA Nutrition Curricular Guide7 around a slightly modified version of the 11 competency domains8. The working group assessed the objectives for relevance to medical student education, updated and simplified several and removed redundancies, resulting in 92 preliminary objectives. These objectives were formatted into a survey designed to gather expert opinion on their relevance (“Do you think that all medical students should meet thefollowing learning objectives/outcomes by the end of their undergraduate medical education related to [competency domain]?”) together with open text response fields for recommended improvements. An electronic link to the anonymous survey was emailed to 748 nutrition educators and made available to IAMSE members. The University of Utah Institutional Review Board (IRB) determined this study to be Exempt research (IRB00092292).

Results & discussion

Sixty-six individuals responded to the survey, approximately one third each identifying as physician (31%), dietitian/nutritionist (27%), and basic scientist (47%), with 16% identifying as “other”. After applying a cut-off of at least 75% support from this expert panel and removing identified redundancies 83 learning objectives remained. A few objectives were reworded based on survey feedback. The final learning objectives, organized into 11 competency domains, are presented in Table 1.

This new set of nutrition learning objectives provides a more concise recommendation for what knowledge, skills and attitudes medical students should achieve prior to graduation. However, in the context of chronically overcrowded medical school curricula, adding and assessing even 83 new learning objectives may be an improbable, if not impossible task. Therefore, we have reanalyzed the objectives and the evaluated the medical education literature looking for the most essential elements of both. Based on this analysis we propose one overarching goal for medical nutrition education: All graduating medical students will assess nutritional status and manage the clinical encounter to facilitate a personalized nutritional approach for optimal health.

The IAMSE Nutrition Advocates are currently creating curricular learning activities that directly support this primary goal. The learning objectives shown in Table 1 will help to guide the development of these learning activities. Appropriate learning activities will be informed by recommendations from a recent evaluation of effective educational interventions to improve nutritional care.9 These recommendations include an emphasis on skills development, utilization of technology, providing appropriate clinical tools and improving the personal health habits of physicians-in-training.

Ultimately, we want students who graduate with an MD/DO to feel confident in their abilities to assess a patient’s current nutritional situation, and utilize the patient’s personal preferences and characteristics (activity level, genetic data, etc.) to thoughtfully advise and collaborate with them to manage their health, adjusting the plan as necessary over a long therapeutic relationship.10

Table 1: Medical student learning objectives organized by competency domain

1. Micronutrients and macronutrients

Describe the role of each of the required vitamins and minerals in molecular and systemic physiology.

Explain how a daily vitamin or mineral intake that is greater than or less than the DRI including Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Upper Limit (UL) can cause common

clinical symptoms or pathology.

Recognize the major dietary sources of the macronutrients and micronutrients and list foods, medications

and pathological states that can affect their absorption.

Define glycemic index, complex and simple carbohydrates.

Describe the physiologic role and requirements of dietary carbohydrates, lipids and proteins.

Define nitrogen balance and explain how it is affected by dietary intake, energy intake, protein quality,

growth and illness.

Describe the mechanisms of lipid, carbohydrate and protein digestion, absorption and distribution.

Describe the defining structural feature of each of the following lipids: cholesterol and fatty acids (including saturated, mono-, polyunsaturated, omega-6 and omega-3; short-, medium, long-chain; oddand

uneven chain, essential fatty acids).

Distinguish between soluble and insoluble fiber, and explain the potential contributions of fiber to health

maintenance.

Explain how varying levels of physical activity influence an individual’s nutritional requirements.

2. Energy metabolism– calculating basal energy expenditure body composition

Outline the key regulatory steps of the metabolic pathways involved in the generation of energy from fuel

oxidation and explain how each pathway is regulated in response to cellular energy demand.

Distinguish among the three major classes of fuels (plus alcohol) in the human diet (carbohydrate, fat and

protein) according to their structural features and caloric content.

Describe the role of the major hormones that regulate fuel homeostasis such as insulin, glucagon,

epinephrine and cortisol, in response to variations of dietary, physiologic and pathologic states.

Using a metabolic map, outline the metabolic pathways involved in fuel interconversion, fuel storage and fuel mobilization. Specify the tissues involved in synthesis and storage of fuels, and outline the pathway of

transport among the tissues.

Describe how calorie intake, basal metabolic rate, respiratory quotient, and daily energy expenditure are

measured or calculated and how each value is related to weight changes with physical activity or pathological conditions.

Describe the most common methods for the clinical evaluation of body composition.

Describe the environmental and biological causes of malnutrition (including caloric excess and protein

malnutrition) and its clinical presentations.

3. Nutrition assessment– BMI weight gain/loss, nutrient deficiencies

Identify the behavioral, genetic, environmental, pharmacological or socio-cultural risk factors for dietary vitamin and mineral deficiencies or imbalances in a patient of any age.

Assess pediatric and adult and geriatric patient history, diet, physical exam and laboratory test

information; recognize healthy behaviors and make appropriate recommendations for physical activity and nutritional modifications to maintain good health and prevent chronic disease.

Identify laboratory data and physical exam findings that indicate malnutrition and vitamin/mineral deficiencies or toxicities in a patient of any age.

Utilize the Dietary Guidelines for Americans to evaluate a patient's diet and offer guidance about portion

size, caloric and nutrient intake and distribution.

Incorporate appropriate anthropometric measurements to assess nutritional status when conducting a

physical examination in a patient of any age.

Given height and weight, calculate the BMI of an adult patient, and interpret the BMI according to

published NIH guidelines.

Evaluate the length/height, weight, head circumference, and Body Mass Index (BMI) of an infant, child, or adolescent over time against the appropriate growth charts published by the US Centers for Disease

Control and Prevention (CDC).

Given a detailed medical, dietary, and social history of a patient of any age and weight, evaluate the patient’s nutritional risk factors for developing chronic disease.

Recognize the value of nutritional assessment in the comprehensive care of ambulatory and hospitalized

patients and patients in long term care facilities.

Describe the measures used to assess patients' levels of physical activity or physical fitness.

4. Nutrient requirements throughout the lifecycle

Describe how nutrition needs change during pregnancy and apply current nutritional recommendations for women during preconception, pregnancy, and lactation.

Identify when pregnant women should be referred to aRegistered Dietitian Nutritionist (RD or RDN)for more intensive nutrition counseling (e.g.weight gain, gestational diabetes, hypertension).

Discuss appropriate weight gain goals during pregnancy for normal-weight, underweight and overweight

women.

Actively support women who choose to breast-feed and be aware of breast feeding education and support

resources.

Identify the nutritional, metabolic, immunologic, social, economic, and long-term health benefits of

breast-feeding for both baby and mother.

Compare and contrast the energy, protein, vitamin, and mineral needs of premature, low-birth weight,

and normal-birth weight infants.

Explain to a patient the progression from breast feeding/formula to solid foods and identify recommended

food intake during the first year of life.

Summarize the short-term and long-term impacts of malnutrition on the physical and cognitive

development of infants, children, and adolescents.

Identify when children and adolescents should be referred to aRegistered Dietitian Nutritionist (RD or RDN)for more intensive nutrition counseling (e.g.weight gain, diabetes, metabolic disorders, allergies,

celiac disease, eating disorders, hypertension).

Identify high-risk eating patterns (e.g.low calcium intake, high soda intake, losing weight for sports) that

may negatively impact the growth and development of adolescents.

Describe how nutrition needs are affected by the physiological and biochemical changes that occur during

aging.

Identify social, economic, and medical factors that may affect the nutrient intake in the elderly population.

5. Taking a diet/physical activity history, prescription for physical activity

Take an appropriate and culturally sensitive patient medical history, that includes nutritional/dietary, physical activity, recent weight change, use of prescription medicines, over-the-counter medicines, dietary

and herbal supplements, and consumption of alcohol and other recreational drugs for patients of all ages.

Conduct an appropriate physical activity history and assess the adequacy of the patient's activity patterns.

Demonstrate a commitment to promote sound nutritional decision-making and appropriate levels of

physical activity for all patients regardless of health status.

6. Patient counseling and motivational interviewing

Effectively counsel patients, individually or through collaboration with a multidisciplinary team, to make informed nutritional decisions consistent with adopting and maintaining a healthy lifestyle and

establishing appropriate dietary, exercise and behavioral goals.

Employ effective counseling techniques matched to the patient’s level of motivation and readiness for

change, encouraging the use of goal setting, identification of barriers, problem solving, self-monitoring, self-reinforcement, and stimulus control.

Demonstrate sensitivity to the social, emotional, and psychological factors that may affect an individual’s

behavior and body image.

Demonstrate a commitment to interact with patients in a culturally competent manner that appropriately

acknowledges the unique characteristics and nutritional needs of each individual.

Effectively counsel families with children to develop and maintain healthy eating habits and appropriate

lifelong physical activity.

Demonstrate a commitment to interact with overweight and/or obese patients in a non-judgmental

manner.

Effectively educate patients about the goals they can realistically expect to achieve, as well as the potential

complications of common therapies for overweight or obese individuals.

Demonstrate an awareness of the impact of co-morbid conditions of patients with various diseases that

may influence adherence with diet and lifestyle goals.

7. Nutrition in health promotion and disease prevention

Recognize that nutrition, physical activity, and health lifestyle behaviors can have direct, substantial, and

long-term effects on growth and development, quality of life, health maintenance, and disease prevention and treatment.

Evaluate a patient's diet and lifestyle to determine whether it is consistent with the promotion of health

and wellbeing.

Using current dietary guidelines from relevant medical societies and governmental agencies (e.g. MyPlate, the Mediterranean diet, and the DASH diet), describe the general characteristics of a healthy diet, including the recommended contribution of various food groups, good common sources ofindividual

nutrients, foods to be consumed in limited amounts, and the carbohydrate: fat: protein distribution.

Describe food-borne illnesses, and outline the process of reporting and investigating outbreaks of these

illnesses.

Outline contemporary public health strategies aimed at reducing the burden of disease in the United

States through nutrition education.

Demonstrate a personal commitment to the importance of prevention and personal wellbeing in health

care.

Describe at least one nutritional intervention effective for preventing each of the following diseases:

dental caries, obesity, type 2 diabetes, hypertension, cardiovascular disease and osteoporosis.

Utilize the recommendations and guidelines for healthy nutrition of infants, children, and adolescents by

age, gender, and activity level as proposed by relevant medical societies and governmental agencies.

Utilize national nutrition recommendations and guidelines proposed by relevant medical societies and

government agencies for prevention, diagnosis and treatment of chronic diseases.

8. Critical care– enteral and parenteral nutrition

Summarize the adverse impacts of malnutrition on disease and the associated benefits of providing

appropriate nutritional support.

Describe the importance of addressing malnutrition and related issues in patients before surgery.

Carefully attend to the ethical issues involved in the provision of nutritional support in palliative care and

in settings where patients cannot provide consent.

Describe the primary considerations involved in determining when a patient’s diet should be advanced

from NPO to solid foods after major GI surgery.

Differentiate between the indications for enteral and parenteral nutrition support as well as the

indications for potential delivery sites for each type of support.

Explain the refeeding syndrome, identify the type of patient at risk for this syndrome, and outline the most

appropriate feeding strategy to minimize metabolic complications.

Explain how neuro-endocrine and immunologic factors mediate the hypermetabolic injury response, define catabolic stress and explain how it affects organ and whole-body nutrient utilization.

9. Referral to an RD for nutrition consult

Seek multidisciplinary consultation to assess own knowledge and limitations regarding nutrition.

Consult with or refer to a Registered Dietitian Nutritionist (RD or RDN) as appropriate for patient disease

state or condition, age, lifestyle, and nutrition needs.

Demonstrate a commitment to utilize a multi-disciplinary team approach in medical care, seeking consultation with and referring patients to Registered Dietitian Nutritionists and other credentialed

healthcare professionals as appropriate.

Identify community programs that provide nutrition education and assistance to low income populations

and refer patients to programs (e.g. WIC, school breakfast/lunch, meals on wheels, senior congregate meals, SNAP, Food$sense, EFNEP)

10. Evaluating nutritional evidence

Evaluate the quality of nutritional information provided in lay and medical literature.

Access the most accurate current general and disease-specific nutritional information and

recommendations, including information about nutritional dietary supplements.

Effectively communicate with patients to provide accurate nutritional information and dispel

misinformation, including information about dietary supplements and fad diets.

11. Outpatient and inpatient nutrition management – medical nutrition therapy for acute and chronic

disease

Identify individuals who require medical nutrition therapy and lifestyle modification.

Integrate nutritional assessment information into an individualized nutritional management and physical

activity plan for optimal health, risk factor reduction and common medical problem for every patient.

Compare and contrast the utility of a food-first approach to maintaining health and treating disease vs. the

use of nutritional supplements and vitamin/mineral formulas.

Compare and contrast food allergies vs food intolerance, and describe pathophysiological manifestations

of each.

Effectively communicate to patients that their body weight and responsiveness to dietary interventions are influenced in a complex manner by metabolic, genetic, epigenetic, social, dietary factors, weight

history and behavioral elements such as physical activity and eating habits.

Recognize the value of early nutrition intervention during cancer treatment to reduce or delay the

development of malnutrition and to mitigate certain symptoms (nausea, pain - both of which can be significantly impacted by food choices).

Given a specific inborn error of metabolism, explain how the diet should be adjusted to accommodate the

resultant changes of metabolite concentrations.

Recognize the central importance of nutrition in the treatment and management of patients with chronic disease and demonstrate a commitment to providing appropriate nutritional intervention (including

dietary modification and enteral or parenteral nutrition therapy).

Given a specific chronic disease, explain how the diet should be adjusted to manage symptoms and prevent secondary complications.

Evaluate all medications and supplements (prescribed and OTC) to identify potential drug nutrient

interactions.

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

anet E. Lindsley1* Emine Ercikan Abali3, Benjamin T. Bikman4, Susan D. Cline5, Tracy Fulton6, Blanca Lopez7, Oren D. Rosenthal8, Virginia E. Uhley9, Roberta J. Weintraut10, D. Pauline Williams11, Jonathan J. Wisco12 and Kathryn Thompson2*

1 University of Utah School of Medicine, Department of Biochemistry, 15 N. Medical Dr. East, Salt Lake City, UT 84112-5650

801-581-2797

Janet.Lindsley@hsc.utah.edu

ORCID: 0000-0002-5318-8268

2 University of New England College of Osteopathic Medicine, Department of Biomedical Sciences, 11 Hills Beach Road, Biddeford, ME 04005

207-602-2216

kthompson@une.edu

3 Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane, Piscataway, NJ 07670

4Brigham Young University, Department of Physiology and Developmental Biology, 4005 LSB, Provo, UT 84602

5 Mercer University School of Medicine, Department of Biomedical Sciences, 1501 Mercer University Dr., Macon, GA 31207

6University of California, San Francisco, Department of Biochemistry and Biophysics, 450 Parnassus Ave., San Francsico, CA 94143-0450

7 Mercer University School of Medicine, Department of Community Medicine, 1501 Mercer University Drive, Macon, GA 31207

8 LECOM Bradenton College of Osteopathic Medicine 5000 Lakewood Ranch Blvd., Bradenton, Fl 34211

9 Oakland University William Beaumont School of Medicine

10Mercer University School of Medicine/Navicent Health, Department of Family Medicine, 1550 College St. Macon, GA 31207

11 Brigham Young University, Department of Nutrition, Dietetics, and Food Science, S- 221 ESC, Provo, UT 84602

12 Department of Physiology and Developmental Biology, Neuroscience Center, Brigham Young University, Provo, UT 84602

References

1. Morris NP. The neglect of nutrition in medical education: a firsthand look.

JAMA internal medicine. 2014;174(6):841-842.

2. Nestle M, Baron RB. Nutrition in medical education: from counting hours to measuring competence. JAMA internal medicine. 2014;174(6):843-844.

3. Kimokoti RW, Millen BE. Nutrition for the Prevention of Chronic Diseases.

The Medical clinics of North America. 2016;100(6):1185-1198.

4. Kahan S, Kushner RF. Nutrition in Clinical Medicine: A Core Competency for Healthcare Providers. The Medical clinics of North America. 2016;100(6):xvii- xx.

5. Pearson TA, Stone EJ, Grundy SM, McBride PE, Van Horn L, Tobin BW. Translation of nutritional sciences into medical education: the Nutrition Academic Award Program. The American journal of clinical nutrition. 2001;74(2):164-170.

6. Van Horn L. The Nutrition Academic Award: brief history, overview, and legacy. The American journal of clinical nutrition.2006;83(4):936s-940s.

7. Curriculum Committee of the Nutrition Academic Award Program. Nutrition curriculum guide for training physicians. Available from:

https://www.nhlbi.nih.gov/research/training/naa/products/curr_gde/index.htm.

8. Kushner RF, Van Horn L, Rock CL, et al. Nutrition education in medical school: a time of opportunity. The American journal of clinical nutrition. 2014;99(5Suppl):1167s-1173s.

9. Mogre V, Scherpbier AJ, Stevens F, Aryee P, Cherry MG, Dornan T. Realist synthesis of educational interventions to improve nutrition care competencies and delivery by doctors and other healthcare professionals. BMJ open. 2016;6(10):e010084.

10. Eisenberg DM. Nutrition Education in 2040-An Imagined Retrospective.

Journal of graduate medical education. 2015;7(3):489-491.

Department of Neurobiology and Anatomy, University of Utah Medical School, Salt Lake City, UT 84132

*Co-corresponding authors