Curriculum Developments in Nutrition

At the University of Texas Medical School at Houston, nutrition has not been formally organized as a separate course primarily due to time constraints within the curriculum and lack of faculty who have nutrition training and expertise. Instead, nutrition has been integrated into some of the basic science courses however; the students have not recognized this integrative approach as nutrition. In 1996, basic science course directors were asked to complete a survey to identify specific nutrition topics that were taught in their courses. This survey revealed a scattering of nutrition topics mostly in Biochemistry, Physiology, and Pathology. The results of this survey are given in the following table.

Nutrition topics included in the curriculum in 1996:

Course	Topic
Biochemistry	Vitamins, functions and deficiency Carbohydrates Proteins and amino acids Lipids Major minerals and trace minerals Iron deficiency anemia
Physiology	Water, electrolytes, and acid-base balance The GI tract: overview of function Pregnancy and lactation Diabetes (not diet management) Growth and development Body composition (discontinued in 1999) Obesity (not diet management)
Pathology	Atherosclerosis and lipoproteins
Neuroscience	Appetite control and food intake regulation
Fundamentals of Clinical Medicine	Hypertension (not diet management)

In addition to the first and second year basic science courses, the Problem Based Learning (PBL) curriculum was reviewed for nutrition content. PBL, which is organized into four eight-week blocks throughout the second year and includes 42 clinical case studies, provides numerous opportunities for students to learn nutrition as it relates to patient care. Specific learning objectives for nutrition have been added to appropriate PBL cases. Nutrition learning issues for the current PBL cases now include risk factors for chronic disease, prevention, and treatment of a variety of nutrition- and lifestyle-related diseases. A Clinical Nutrition Elective for first and second year students was begun in 1996 and has become an annual lecture series that includes some of the priority nutrition topics that, for the most part, are not covered in the existing medical curriculum. The topics covered in the Clinical Nutrition Elective are given in the following table:

Nutrition Topics in the Clinical Nutrition Elective:

Criteria of an Adequate Diet: Guidelines for Prevention of Chronic Disease
Nutritional Assessment in Medical Practice
Nutritional Requirements during Pregnancy and Lactation
Nutritional Management of the Diabetic Patient
Obesity and Weight Management
Diet and Cardiovascular Disease
Nutrition and Cancer Prevention
Use of Herbal Supplements
Physical Activity and Health Promotion
Nutritional Support of Surgery and Trauma Patients
Nutrition and Aging

Since the inception of the Nutrition Academic Award, a 5-year grant from the National Heart, Lung, and Blood Institute in the year 2000, meetings with course directors have resulted in the inclusion of additional nutrition topics throughout the curriculum. The goal is to develop a longitudinal approach to teaching nutrition in courses where it is most clinically relevant for the students, and furthermore, in an organized sequence that allows students to build on their knowledge of basic nutrition principles. The following table lists nutrition topics and course assignments that are required beginning in the 2001-2002 academic year.

Nutrition Content in the Curriculum - 2001-2002 Academic Year

Course or Activity	Course Content	Instructional Tool or Assessment	Year in Medical Training
Orientation		Nutrition in Patient Care Attitudes Survey	Entering class
1^stday of class		Nutrition Knowledge Pretest	MSI
Biochemistry	Macronutrients: Lipids - essential fatty acids, saturated vs. unsaturated fatty acids, cholesterol, omega-3 fatty acids, recommended intakes Protein - RDA, nitrogen balance Carbohydrates - glycemic index Diseases of malnutrition - kwashiorkor, marasmus Micronutrients: Water-soluble vitamins: structures, functions, and food sources Fat-soluble vitamins: food sources, function and metabolism vitamin A: visual cycle vitamin D: activation vitamin E: antioxidant properties vitamin K: clotting factors, intestinal biosynthesis, Iron metabolism Essential trace elements: RDA, biochemical function, deficiency vitamin E: antioxidant properties Energy: Regulation of energy metabolism, regulation of energy storage and mobilization, metabolic fuels, starvation, ketone body metabolism Basal Metabolic Rate (BMR), Resting Energy Expenditure (REE), energy balance, Harris-Benedict equations for men and women, composition of body fuel stores, Optimum Body Weight (OBW), Body Mass Index (BMI) Metabolic Disorders: Obesity - appetite control, the metabolic syndrome Diabetes - Type I and Type II, insulin action, ketoacidosis		MSI
Physiology	Gastrointestinal tract - overview of function Digestion and absorption Gastrointestinal motility Diabetes Pregnancy, lactation Calcium metabolism, hormonal regulation of calcium and vitamin D Growth		MSI
Neuroscience	Appetite regulation Neural mechanisms of hunger and satiety Eating disorders: anorexia nervosa, bulimia		MSI
Microbiology	Food borne illness		MSI
Introduction to Clinical Medicine	Introduction to Nutrition Assessment Taking a Diet History	3-day records of food intake	MSI
Physical Diagnosis	Nutritional Assessment: Clinical Signs of Malnutrition		MSII
Fundamentals of Clinical Medicine	Nutrition in the context of these diseases is integrated into FCM: Acquired immunodeficiency syndrome Anemias Cancer Cardiovascular disease Congestive heart failure Cystic fibrosis Diabetes Growth, failure to thrive Hepatitis Hypertension Immune function Liver disease Osteoporosis Parkinson's disease Peptic ulcer disease Pregnancy Renal failure Rheumatoid disease Thromboembolic diseases		MSII
Pharmacology	Drug-nutrient interactions Dyslipidemia		MSII
Pathology	Atherosclerosis Coronary artery and cerebrovascular disease Cancer Diabetes		MSII
Behavioral Sciences	Depression Schizophrenia		MSII
		Nutrition in Patient Care Attitudes Survey	MSIV

In summary, efforts will continue to be made to organize the nutrition content in the curriculum in such a way that students will be aware of the longitudinal nature of their nutrition instruction and training. The following steps need to be taken:

Include the Nutrition in Medicine CD-ROM series into selected courses and clerkships
Provide credible and current resources for students, including textbooks, publications, web-based materials, and syllabus
Develop a nutrition component for the standardized patients
Establish a means for evaluation of students' nutrition knowledge throughout the curriculum
Conduct nutrition knowledge testing at beginning of clinical year and do post-test at end of 4^th year