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INTRODUCTION
Despite several in-depth reviews on the subject (1–4), extensive analysis with recommendation by prestigious medical groups [eg, the National Academy of Sciences (NAS) (5), the American Society for Clinical Nutrition (6), and the Association of American Medical Colleges (7)], and a US congressional mandate (8), nutrition education for American medical students in all but a few medical schools has not improved appreciably in the past decade (9). In fact, in some medical settings, exposure to nutrition has actually decreased (1). Therefore, this symposium was organized to address this problem and to consider the ways that 3 medical school curricula have dealt with these concerns in a positive, innovative manner that has received rave reviews from medical students and educators alike. In this introductory overview, 3 points are made regarding this issue: 1) consideration of the problem, 2) approaches to the solution, and 3) future plans for medical school education. The latter point deals principally with the approaches discussed by the symposium speakers and the comments by Heimburger at the Dannon Educator Award lecture regarding the support for physician nutrition specialists envisioned by the Intersociety Professional Nutrition Education Consortium (IPNEC).
THE PROBLEM
In 1999 market forces in American medicine, with an emphasis on preventave care, provided an optimum opening that addressed the need for a practical nutrition curriculum in medical student education. Teaching nutrition education to medical students will enable future practicing physicians to provide appropriate medical advice to patients seeking a healthier lifestyle. Many diseases (eg, heart disease, cancer, diabetes, and hypertension) causing the highest morbidity and mortality among American adults have been linked directly to poor dietary habits. Despite good clinical and epidemiologic evidence that a poor diet over long periods of time represents a high risk factor for these diseases, medical students are not receiving adequate information to translate this knowledge into practical advice regarding healthier diets for their patients. American medicine, particularly academic medicine, has changed drastically in the last few years because of the perceived notion by the American public and the US government that health care costs are excessive and represent a disproportionate percentage of the gross national product expenditure. As a result, there is an increased concern that cost containment be an important component of medical care. What better way to contain medical costs than to prevent the expression of disease (10)? Because 4 of the top 10 diseases that commonly affect Americans are linked to poor diet, a natural approach to preventive medical care would be to appropriately advise patients as to what constitutes a healthy diet. Despite the obvious extension of this observation to medical care, very little has been done to improve practical nutrition teaching for students at the vast majority of US medical schools.
It is the consensus of the American Medical Association and the Association of American Medical Colleges that the vast majority of practicing physicians in primary and subspecialty care do not have an adequate font of knowledge to advise their patients on healthy diets. In most instances, physicians defer to nutritionists in large practice groups or to hospital dietitians. Surveys that document a lack of nutrition knowledge by practicing physicians (11, 12) place the blame for this deficiency on poor nutrition education in medical schools. In a 1993 survey of 15 medical schools in the southeast section of the United States (12), medical students were asked to identify areas of education deficit in their respective curricula. More than 60% of medical students identified practical nutrition knowledge as lacking. They all agreed that the molecular and cellular mechanisms of nutrients, (eg, vitamins, trace elements, etc.) were adequately covered by their professors, but that the role of the nutrients in clinical disease or their contribution to the morbidity in other illnesses was not presented. In addition, an NAS Nutrition Board report (7) recommended that "medical students should receive a minimum of twenty-five hours of clinical nutrition education as part of all medical school curricula." Despite this important review of nutrition education and specific recommendations, only 40% of US medical schools were noted to comply with the recommendation, and 50% of medical schools still had no identifiable nutrition course to offer as late as 1995. The primary reason for a lack of response to the NAS recommendations and the congressional mandate is that medical school curricula are sacrosanct. Course masters jealously guard lecture time and topics to prevent losing their influence within the medical community. Therefore, adding a large number of lectures to existing courses or adding a new course to the curriculum is very difficult. Nutrition educators must therefore use innovative ways to accomplish the goals of teaching clinical nutrition to medical students by minimizing a major change in the curriculum and by identifying aspects of established pre-clinical and clinical courses to emphasize the importance of nutrition. The participants in this supplement provide stimulating, innovative approaches to this challenge.
APPROACHES TO SOLUTIONS
Despite the seemingly insurmountable task of adding nutrition education to a fixed medical school curriculum, several medical schools have successfully accomplished this goal without a major reaction from the teaching faculty. Some of these approaches will be discussed briefly here.
To creatively integrate nutritional principles into the curriculum, the nutrition educator must be intimately familiar with the curriculum of his or her medical school. This familiarity will allow him or her to underscore the nutritional relevance of topics covered in established preclinical and clinical courses. This can be done by using a case study in cell biology to consider vitamin deficiency or the role of leptin in obesity. In the introduction to clinical medicine, students should be encouraged to include dietary information as part of a general history and should be aware of physical findings of malnutrition or complications of obesity. Supplemental bibliographies or conferences and seminars can be added to established courses to help underscore the nutritional contribution to disease. Finally, the nutrition educator needs to take advantage of the emphasis on disease prevention to underscore diet issues in the incidence of common American diseases. They should take advantage of the change in venue for teaching from the inpatient to outpatient settings to insert nutritional approaches to the diagnosis and treatment of disease (13).
An important consideration in innovative approaches to the curriculum is a longitudinal integration of nutrition into the curriculum. Instead of providing a single "nutrition and prevention of disease" course in the first or second year of medical school, medical students need to be aware of nutrition and its application to the prevention of chronic disease throughout the medical curriculum. As biochemistry and pathophysiology are taught, nutrition concepts can be emphasized. In the introduction to clinical care, the importance of asking dietary questions when recording a patient history need to be emphasized. When students begin their specialty rotations, nutritional concepts, dietary advice, and the role of good eating habits for health needs to be emphasized with each rotation. For those students with a strong interest in nutrition and medical care, electives in nutrition programs in teaching hospitals can be arranged. A list of priority nutrition topics for medical education, reported by nutrition and medical educators as absolutely essential to the curriculum of medical students, is provided in Table 1 (14).
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TABLE 1.. Nutrition topics essential in a medical school curriculum, by priority1
Nutrition educators must also be innovative because they are providing nutrition information to medical students who are already overloaded with information. They should take advantage of the increasing computer literacy of today's medical students as a means of providing access to nutrition materials and references (13). This includes providing Web access to nutrition databases at the National Institutes of Health (NIH), the US Department of Agriculture, and the Centers for Disease Control and Prevention, which routinely post updated resource materials on healthy diets, clinical nutrition studies, and recent suggestions for functional foods, weight reduction, and cancer prevention (15). Students should be made aware of clinical and research conferences on nutrition topics, and information provided by visiting professors giving grand rounds on nutrition and disease, case reports, and bibliographies on clinical nutrition topics can be posted on special Web sites for student access. Students with a strong interest in nutrition should have access to information concerning summer research fellowships and research studies being conducted within their respective medical communities. These innovative, adjunctive nutritional materials will help students answer medical questions related to nutrition, as well as broaden their nutrition knowledge without a need for new formal lectures within the curriculum.
The IPNEC representing nutrition societies (eg, the American Board of Nutrition, the American Society for Clinical Nutrition, the American Society for Parenteral and Enteral Nutrition, and the American Dietetic Association) have strongly recommended that physician nutrition specialists be supported in each medical school to encourage the teaching of nutrition in undergraduate and graduate medical education (16). These individuals would represent nutrition on medical curriculum committees, help organize and train teaching faculty, spearhead nutrition topics added to existing courses, and organize clinical and research electives in nutrition for interested students. IPNEC recommends that these individuals be funded by grants from the NIH (ie, the R-25 Cancer and Nutrition Grant), society resources, or medical teaching funds (16). In the event that a single medical school cannot support such an individual or individuals, a consortium of medical educators must establish nutrition programs, such as those represented by this supplement's participants, and prominent medical schools might be consulted to suggest additions to medical curriculum for central nutrition principles, vis-á-vis, grand rounds, case reports, or graduate symposium (17). These approaches to solutions for the dearth of nutrition education for medical students have been used with success by individual medical schools or geographically grouped medical schools that lack individual strength in nutrition on their faculty (14, 17).
THE FUTURE
In this symposium, we have brought together medical school educators who have established strong nutrition curricula. Such curricula may provide the basis for future approaches to solving the problem of adding nutrition education into an already tight medical school curriculum. Nutrition education should be established in a manner that allows medical school graduates a practical approach to preventing disease by establishing good nutrition habits in their patients. Zeisel reviewed his NIH-supported program to provide interactive CD-ROMs on important nutritional problems in medicine (eg, anemia, cancer, obesity, and hypertension). This program has been piloted in 10 medical schools and was well received by students and faculty alike. Students can use the CD-ROM at their convenience and can learn from any mistaken answers to provided questions. The program is now available to all medical schools within the United States. Armstrong reviewed her experience with educational training workshops in nutrition and their effect on the quality of nutrition teaching by that medical school. In addition, Lo provided a perspective for using nutrition in a 4-y theme, integrated into the established curriculum of the medical school. This included student access to a nutrition Web site that provides supplemental access to nutrition symposia, lectures, grand rounds, and recent references within the greater Harvard Medical School medical community. Finally, Hark described her experience with a Medical Nutrition and Disease Textbook, written exclusively for medical school teaching programs. We believe these discussions have helped to fill the void in nutrition education in American medical schools, in addition to providing cutting-edge future approaches to augment the recommendations previously suggested by medical educators, the NAS, and the American government.
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