A 4-Year Integrated Nutrition Curriculum for Medical Student Education

Abstract

While poor diet is the one of the primary contributors to death and disability in the USA, formal nutrition education in medical schools across the nation remains sparse. As it stands, few medical schools have formally incorporated nutrition education, and fewer still have integrated nutrition into the entire length of their 4-year curriculum. We describe how a new, formally integrated, 4-year nutrition curriculum was developed and is being implemented in a US medical school, and how this program will evolve as part of a twenty-first century medical school education.

Background

Poor food choices are some of the major predictive and significant factors for death and disability in the USA [1]. Almost 50% of all cardiovascular deaths may be linked to poor diet [2], and two thirds of all cancer deaths may be modulated by both diet and lifestyle changes [3]. Obesity-related illnesses account for over a fifth of annual US medical dollar spending [4]. Nutrition is linked not only to chronic disease, but also contributes acutely to improved medical and surgical outcomes. Malnutrition may affect between 30 and 50% of hospitalized adults at admission or during hospitalization, and is a serious contributor to morbidity and mortality, as well as to increasing patient length of stay and cost of care [5]. Adequate and timely medical nutrition therapy is linked with improved surgical, pediatric, obstetric, and geriatric outcomes [6–9]. Finally, food insecurity—which could be summarized as a situation of consistently limited quality, quantity, and/or variability of food in a way that impacts wellbeing [10]—is a growing public health concern, and is recognized as a significant determinant of health [11].

Although the National Research Council has previously recommended a minimum of 25–50 h of nutrition education in undergraduate medical training [12], there remains a significant dearth of formal nutrition education in US medical schools [13, 14]. A recent survey found that nearly three quarters of all US medical schools do not meet this minimum number of hours of formal nutrition education [13]. Since the United States Medical Licensing Examination (USMLE) contains nutrition-related content in at least seven out of 18 different topic areas [15], this lack of formal nutrition education may present a problem. Moreover, physicians feel their training is inadequate; less than 15% of doctors feel comfortable dispensing nutrition advice [16].

Challenges to incorporating more robust nutrition competencies into current medical school curricula include limited classroom hours and a lack of faculty trained in nutrition education [17]. However, a changing healthcare reimbursement landscape focused on preventative care and increasing student demand for nutrition education [18] are some of several factors re-shaping nutrition curricula at US medical schools.

Activity

The Geisel School of Medicine at Dartmouth has a mission to graduate the complete physician, and has undergone significant curriculum and administrative restructuring over the past several years. The Department of Medical Education was formed in 2016 to ensure a cohesive and continuous medical education by overseeing the full, 4-year undergraduate medical curriculum. In addition, a new core medical school curriculum is set to be adopted in 2019, with a cohesive and highly integrated focus.

At Geisel, the Medical Education Committee (MEC) is the body in charge of approving changes to the curriculum. Before major domains or topics are added, a Vertical Integration Group (VIG) is charged with reviewing current curricula, and making recommendations to the MEC. In the fall of 2016, a Nutrition VIG was charged with reviewing all existing nutrition content, planning a vertically integrated 4-year nutrition curriculum with clear objectives guided by the Geisel core curriculum competencies, and summarizing its findings and recommendations to the MEC for consideration. Once approved, the curriculum would be integrated and mapped into the school’s course and clerkship planner, and threaded throughout the 4 years of undergraduate medical education.

Results and Discussion

The chair of the commissioned Nutrition VIG was a faculty member and registered dietitian (RIA), with previous experience in graduate and medical education. The VIG consisted of both clinical and academic faculty members, each with a vested interest in nutrition education, as well as medical students. Student participation was crucial, so at least one student representative from each academic year was enlisted. The group met one to two times monthly, from January to April 2017, and identified existing nutrition-related content in the current medical curriculum by thoroughly reviewing course, clerkship, and session objectives. This laid the foundation for the VIG report, by identifying nutrition content already present in the curriculum, as well as opportunities for further, optional nutrition education within the surrounding community, such as work within school and community programs aimed at promoting nutrition education, cooking skills, and food security.

Within the framework of overarching Geisel competencies, and using guidelines put forth by the National Heart, Blood, and Lung Institute’s Nutrition Academic Award Program [19], the Nutrition VIG developed specific nutrition curriculum objectives. Nineteen curricular objectives, under seven specific domain competencies, were developed (Table 1). Each objective was tagged for potential courses or clerkships of relevance—to allow for standardized and consistent implementation and mapping. In April of 2017, the VIG chair presented the group’s findings at the Medical Education Committee monthly meeting. The report was discussed, and the nutrition objectives put forth were individually analyzed. The following month, the Medical Education Committee voted to approve the proposed nutrition curriculum in its entirety.

Table 1.

Nutrition in Medical Education Program Competencies and Objectives for the Geisel School of Medicine at Dartmouth

Geisel School of Medicine Competency	Nutrition in Medical Education Program Competency	Longitudinal Program Objectives	Examples of Areas in the Curriculum Where Objective is Addressed Year, Course/Clerkship, Session, Method
Medical Science	Nutrition in Medical Science	1. Describe core nutrition science concepts, such as nutritional biochemistry and metabolism, digestion, endocrinology, and adverse effects of malnutrition on human health.	• Y1, Biochemical and Genetic Basis of Medicine, Protein Metabolism; Lectures • Y1, Metabolism, Metabolism of Key Nutrients (Carbohydrate, Fat, Micronutrients), Lectures • Y1, Endocrine Physiology, Type 1 and 2 Diabetes Mellitus, Lecture • Y2, Gastrointestinal System, Integrated Response to a Meal, Large Group Discussion and Team-Based Learning • Y2, Gastrointestinal System, Maldigestion and Malabsorption, Large Group Discussion • Y2, Themes, Malnutrition in the Hospital Setting, Lecture
		2. Explain the links between nutrition science and other sciences, including those of the environment, exercise, toxicology, and pharmacology.	• Y1, Metabolism, Fuel Sources Sprint vs. Marathon, Lecture • Y1, Basic Science of Microbial Disease, Nutritional Considerations in Microbiology - Diet and the Microbiome, Lecture • Y2, Introduction to Medical Pharmacology, Food and Drug interactions, Herbal/Nutritional Supplements and drug interactions, Lectures
		3. Apply core nutrition science knowledge to understand and manage human health and disease through the lifespan.	• Y1, Metabolism, The Science of Healthy Eating, Lecture • Y2, Themes, Oral, Enteral, and Parenteral Nutrition Support, Lecture • Y3, Surgery Clerkship, Surgical Metabolism and Nutrition Case Studies, Case-Based Instruction/Learning
Clinical Care	Nutrition in Clinical Care	1. Perform a nutrition assessment and accurately measure anthropometrics.	• Y1, On Doctoring, Social History, Habits, and Review of Systems – nutrition history, Role Play/Dramatization • Y3, Pediatrics Clerkship, Ambulatory Practice Setting – Assessment of nutritional status, growth and diet, Clinical Experience
		2. Perform a complete nutritional exam to assess for presence of malnutrition.	• Y1, On Doctoring, Physical Exam Skills, Role Play/Dramatization • Y2, On Doctoring, Physical Exam Skills, Role Play/Dramatization • Y2, Themes, Malnutrition in the Hospital, Lecture
		3. Interpret, develop, and implement a nutrition plan for treatment, including nutritional additions or restrictions, culinary skill development, artificial nutrition support, and supplementation.	• Y2, Maldigestion and Malabsorption, Calculating and Prescribing Enteral Nutrition, Case-Based Instruction/Learning and Large Group Discussion • Y2, Bone and Connective Tissue, Nutrition Therapy for Orthopedic Cases, Case-Based Learning • Y3, OB/GYN Clerkship, Gestational Diabetes Nutrition Consultation, Role Play/Dramatization • Y3, Surgery Clerkship, Surgical Metabolism and Nutrition Case Studies, Case-Based Instruction/Learning
Population Health	Nutrition in Population Health	1. Explain the impact of nutrition on individual and population health and disease	• Y1, Metabolism, The Science of Healthy Eating, Lecture • Y1, Metabolism, Engaging in the Obesity Epidemic, Large Group Discussion • Y1, Metabolism, Nutritional Issues in Alcohol Abuse, Lecture • Y2, Themes, Malnutrition in the Hospital Setting, Lecture • Y2, Infectious Disease, Foodborne Illness, Large Group Discussion • Y2, Bone and Connective Tissue, Nutritional Modulators of Arthritis, Case-Based Learning and Small Group Discussion • Y2, Bone and Connective Tissue, Nutritional Modulators of Bone Health and Fracture Healing; Lecture
		2. Assess the impact of social, environmental, behavioral, economic, cultural, and personal factors on the nutritional health of individuals, and the incidence and burden of disease in populations.	• Y1, Patients and Populations, Social Determinants of Health, Lecture and Small Group Discussion
		3. Explain and exemplify the physician’s role for promoting nutrition in public health.	• Y1, Metabolism, Engaging in the Obesity Epidemic, Large Group Discussion • Y2, Patients and Populations, Obesity Stigma, Case-Based Instruction/Learning and Large Group Discussion
Communication Skills	Communication Skills in Nutrition Practice	1. Demonstrate empathy for individuals’ concerns, and be respectful of others’ perspectives and personal, cultural, and religious dietary restrictions and beliefs, and communicate nutrition advice respectfully and without judgment.	• Y1, On Doctoring, Culture Essay, Reflection • Y2, Patients and Populations, Obesity Stigma, Case-Based Instruction/Learning and Large Group Discussion
		2. Promote positive behavioral change through nutrition-specific motivational interviewing and cognitive behavioral therapy.	• Y1, On-Doctoring, Motivational Interviewing Parts 1 and 2, Role Play/Dramatization • Y2, On-Doctoring, Motivational Interviewing, Role Play/Dramatization
		3. Translate nutrition science concepts into useful information to educate patients, families, peers, and others.	• Y1 Metabolism, The Science of Healthy Eating, Lecture • Y3, Pediatrics Clerkship, Ambulatory Practice Setting – Advising Parents on appropriate feeding practices, Clinical Experience
Personal, Professional, and Leadership Development	Personal, Professional and Leadership Development in Nutrition Practice	1. Engage in lifelong learning to improve one’s performance in the application of nutrition science.	• Across the curriculum
		2. Apply nutrition science and culinary competency to enhance resiliency and physician self-care.	• Y1, On Doctoring, Wellness Begins At Home: Taking Care of Yourself, Large Group Discussion • Culinary competency: In Development
		3. Advocate for environments that promote healthy nutritional lifestyles in the community, while removing any existing barriers.	• In Development
Evaluation and Improvement in Medicine	Evaluation and Improvement in Nutrition Practice	1. Identify and utilize healthcare and community resources to provide nutrition care and improve patient outcomes and patient satisfaction.	• In Development
		2. Identify credible, evidence-based sources of nutrition information and apply knowledge gained from the literature to clinical care, teaching, research, and population health.	• Y3, Family Medicine Clerkship, Comprehensive Resource List for Patient Nutrition Education, Reference
Collaboration and Teamwork	Collaboration and Teamwork in Nutrition Practice	1. Recognize and capitalize on different roles and strengths of team members, including the clinical dietitian, to develop and address shared goals, and foster a working relationship with all team members built on mutual respect and trust.	• Y4, Health, Society, and the Physician, Learning from Each Other and Taking Care of Each Other, Large Group Discussion
		2. Demonstrate the ability to share and allocate responsibilities among team members.	• Y3 Clerkships and Electives, Multidisciplinary Clinical Experience • Y4 Clerkships and Electives, Multidisciplinary Clinical Experience

Y Year, OB/GYN Obstetrics and Gynecology

Based on the recommendations of the Nutrition VIG, the school instituted a formal nutrition program, the Nutrition in Medical Education (NIME) Program, in the summer of 2017—with a goal of developing, disseminating, and evaluating nutrition content vertically into the entire 4 years of the medical school curriculum. To date, the NIME Program at Geisel has formalized, captured, and appropriately mapped existing nutrition content for many courses and clerkships. Column 4 in Table 1 provides examples of where these objectives are met in the curriculum. Mapping allows for identification of where objectives are covered, and where gaps exist. For example, objective no. 1 under the Nutrition in Medical Science Competency is represented in at least six different areas, while objective no. 1 under Evaluation and Improvement in Nutrition Practice is not covered at all and must be developed further (Table 1).

The NIME program has also developed and disseminated new content for a number of courses spanning across the years, including metabolism, microbiology, gastroenterology, family medicine, obstetrics and gynecology, rheumatology, and orthopedics. Content is presented in a variety of forms, ranging from traditional lectures, to practical experience in motivational interviewing and nutrition counseling, as well as case study discussions. Curricular changes are continually evaluated as they are implemented, and as the curriculum evolves.

A series of local factors, unique to Geisel, contributed to the formation of the NIME Program. First, a local need was identified since the college lacks an academic nutrition department at both the undergraduate and graduate levels. This was addressed by hiring an expert faculty member in nutrition education—who currently directs the NIME program. Geisel’s participation in the regional Northeast Nutrition Education Summit in 2016 [20] provided a framework, and paved the way for, the formation of the permanent nutrition program. In addition, informal surveys showed student demand for nutrition education at Geisel.

A vertical integration model was used because the curriculum could not house an independent nutrition course. However, students often fail to identify content, nutrition, or other, when it is woven through several courses rather than presented in a unified manner. The NIME Program circumvented this barrier by assigning one faculty member to direct and advise nutrition content dissemination. This continuous student-faculty interaction allows better identification and retention of content. In the Geisel curriculum inventory, nutrition content is tagged and mapped overall in the curriculum, and this further helps with content recognition and retention.

With nutrition playing such an integral role in the health of our society, a comprehensive nutrition in medical education component is necessary to graduate the complete physician. Geisel was able to develop and integrate a 4-year nutrition curriculum in a traditional medical school setting in the relatively short time frame of about 18 months. Nutrition education will empower our students, and position them to work collaboratively with registered dietitians and other members of the healthcare team to support patients. Future directions include integrating a hands-on culinary medicine component, with the aim of training future physicians to better guide patients in translating current nutrition evidence into practical life skills for disease prevention and management, including strategies for sustained lifestyle change and their own personal wellness. As Geisel moves to a new core curriculum in 2019, the NIME program will continue to be expanded, integrated, and evaluated as an integral part of a comprehensive and modern medical education.

Compliance with Ethical Standards

Conflict of Interest

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