Historical Perspective

Hippocrates first recognized the science and philosophy of clinical nutrition in the 4th century B.C. when he espoused that health could only be assured by proper diet and hygiene. The word diet is derived from the Greek daita, which translates to healthful living according to proper selection of food. The science of nutrition, which is defined as the study of the nutrients in food and the body's handling of them, has advanced greatly during the last century and offers compelling evidence of the importance of diet in prevention and treatment of disease. Clinical nutrition, which is the application of nutrition in the clinical setting, has emerged only recently as an important discipline in modern medicine. Integration of clinical nutrition into the medical curriculum is essential to the production of future generations of medical practitioners who will recognize and effectively utilize proper diets for the prevention and treatment of disease.

In the early 1950s, the American Medical Association Council on Food and Nutrition recognized the lack of support for nutrition education in U.S. medical schools¹. A comprehensive report prepared by the National Academy of Science - National Research Council in 1985, Nutrition Education in U.S. Medical Schools, recommended that medical schools incorporate into their curricula a separate course in nutrition of at least 25 hours and reinforce this in the clinical clerkships². This recommendation was followed in 1989 by the National Research Council publication, Diet and Health: Implications for Reducing Chronic Disease Risk that required physicians to acquire counseling skills on diet, nutrition, and healthy lifestyles³. Perhaps the strongest support for medical nutrition education was found in the Healthy People 2000 Objectives that called for the provision and requirement of courses in human nutrition to all medical schools⁴. In 1990, the National Nutrition Monitoring and Research Act provided empowerment for all U.S. medical schools to include nutrition in the curriculum and provide for the training of medical students, residents, and fellows in clinical nutrition⁵. However, despite these recommendations, the status of nutrition education in U.S. medical schools has remained mostly unchanged over the past 30 years. In 1976, approximately one out of every five (19%) U.S. medical schools required a separate course in nutrition. By 1981, the number of schools that required a separate nutrition course increased to one out of every four (26%)⁶. Most U.S. medical schools now report that nutrition in integrated into other courses in the curriculum and two-thirds of all schools provide an elective course in nutrition.

Barriers

Historically, one of the barriers to medical nutrition education has been a lack of consensus about what to teach. In 1983, Young et al published results of the first national survey of practicing physicians that identified core competencies of nutrition knowledge and skills that primary care physicians should know⁷. In 1989, the American Society for Clinical Nutrition Committee on Medical/Dental School and Residency Nutrition Education published a list of 26 priority topics that should be incorporated into the medical curriculum. Topics that were given the highest priority include obesity, diet and hyperlipidemias and atherosclerosis, diet and diabetes, and pregnancy and lactation⁸. Weinsier, in a 1995 publication, referred to the list of priority topics as a key component of a successful medical nutrition education program⁶. More recently however, the Nutrition and Preventive Medicine Task Force of the American Medical Student Association (AMSA) formed the Nutrition Curriculum Project and developed a comprehensive list of 92 topics considered essential for developing physicians' competency in nutrition. The "Essentials of Medical Nutrition" were published in 1996 in Academic Medicine. This comprehensive list provides a guide for medical educators to assess nutrition content throughout the curriculum⁹.

Recent Accomplishments

The most recent initiative for medical nutrition education has been the development of the Nutrition Academic Award (NAA) by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The NAA was awarded to 10 medical schools in 1999 and to 11 medical schools in 2000 with a primary objective of providing for the development and enhancement of medical curricula that are focused on nutrition and prevention of cardiovascular disease, diabetes, obesity, and other chronic disease. The 21 NAA medical schools have participated in the development of the Nutrition Curriculum Guide for Physicians that will be published in early 2002.

References:

1. Council on Foods and Nutrition, American Medical Association. Nutrition Teaching in Medical Schools. JAMA 1963:183:955-6.

2. Committee on Nutrition in Medical Education, Food and Nutrition Board, Commission on Life Sciences, National Research Council. Nutrition Education in U.S. Medical Schools. Washington, D.C.:National Academy Press, 1985.

3. National Research Council. Diet and Health: Implications for Reducing Disease Risk. Washington, DC: National Academy Press, 1989.

4. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National health promotion and disease prevention objectives. Washington, D.C.: US GPO, DHHS, Pub. No. 93-1332, 1991.

5. National Nutrition Monitoring and Related Research Act of 1990. Public Law 101-455, 101st Congress. House Reports: No. 101-788 (Committee on Agriculture), Congressional Record, Vol. 136, 1990.

6. Weinsier RL. National Dairy Council Award for Excellence in Medical/Dental Education Lecture, 1995. Medical-nutrition education - factors important for developing a successful program. Am J Clin Nutr 1995; 62:837-40.

7. Young EA, Weser E, McBride HM, et al. Development of core competencies in clinical nutrition. Am J Clin Nutr 1983; 38:800-10.

8. Weinsier RL, Boker JR, Brooks CM, Kushner RF, Visek WJ, Mark DA, Anderson MS and Block K. Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators. Am J Clin Nutr 1989; 50:707-12.

9. American Medical Student Association, Nutrition Curriculum Project. Essentials of nutrition education in medical schools: a national consensus. Acad Med 1996; 71(9):969-971.