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4 Current Programs Medical educators, legislators, and science and health policymakers have expressed concern that nutrition educa- tion in medical schools is not adequate to prepare future physicians for their responsibilities (see Chapter 2~. In its study of this issue, the committee identified the fol- lowing questions that, when answered, should reflect the teaching of nutrition in U.S. medical schools: · How many hours of the required curriculum are clearly identified as nutrition education? · In the overall structure of the curriculum, where are the required nutrition education hours located? · Within the discipline of nutrition, what subject areas are taught? How adequate are current nutrition teaching materi · What methods are used to assess the nutrition knowl- edge of medical students? · How is the faculty responsibililty for nutrition education structured? · Regarding the faculty members who teach nutrition, what is their training, their current responsibilities within the medical school, and their sources of support? · What factors have contributed to successful integra- tion of nutrition into the curriculum of those schools that currently have a program? 57

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58 · What administrative and financial considerations are relevant to the successful incorporation of nutrition into the curriculum? · How do faculty and students perceive the adequacy of current nutrition teaching practices? To answer these questions, the committee (1) reviewed recent surveys of medical school teaching practices; (2) designed and conducted a separate, independent survey; (3) conducted detailed interviews with faculty members who have responsibility for designing and coordinating nutri- tion programs at selected U.S. medical schools that have established nutrition programs; (4) invited selected nutrition course coordinators to testify before the com- mittee; (5) requested comments from the American Medical Student Association and reviewed previous reports of medi cal student opinion; (6) evaluated and reviewed questions relating to nutrition on three recent National Board examinations; and (7) examined the current funding prac- tices for nutrition research and training by the National Institutes of Health (NIH) and other public and private organizations. SURVEYS OF MEDICAL SCHOOL CURRICULA Previous Surveys Surveys of nutrition education in medical schools have been conducted by persons and organizations, especially the American Medical Association (AMA), for more than 25 years. The historical aspects of these reports are pre- sented in Chapter 2. The earliest surveys, conducted in the late 1950s. indicated that approximately 20% of the responding schools offered required nutrition courses. By the late 1970s, the percentage of schools requiring nutri- tion education had increased to 27%. The percentage increased during the 1980s, but then dropped by 1984, ac- cording to results of the annual curriculum questionnaire sent to all U.S. medical schools by the joint Liaison Committee on Medical Education (LCME), which is composed of representatives of the AMA and the Association of American Medical Colleges (AAMC) (see Table 4-1~. - Each year all schools were asked if they offered a re- quired course in nutrition, if nutrition was incorporated

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59 into another course, and if there were elective opportuni- ties for courses, clerkships, or research in nutrition. In the most recent survey (1983-1984) of 127 medical schools, 34 schools (27%) reported a separate course in nutrition, and 84 schools (66%) indicated that nutrition was taught as a part of another course. Sixteen schools (13%) reported both a separate nutrition course and nutri- tion topics included in other courses; 21 schools (17%) reported neither a nutrition course nor nutrition topics in other courses (AAMC, 1984a). These results indicate that many U.S. medical schools do not teach nutrition. In many schools, however, these annual curriculum questionnaires may be completed by administrative assistants who either are not sufficiently familiar with their curriculum or may not be provided with accurate information to determine whether a subject such as nutrition is included. The committee determined that in many cases these persons do not check the data with faculty members who are responsible for nutrition courses at the surveyed school. For example, many of the respon- ses to the AAMC questionnaire were inconsistent with responses to the committees survey. Furthermore, TABLE 4-l Percentage of Positive Responses to Selected Ques- tions Regarding Nutrition in the Annual Survey Conducted by the Liaison Committee on Medical Education Between 1979 and 1984a Positive Response s ( % ) by Year (N = Number of Schools Responding) 1979-1980 1960-1981 1981-1982 1982-1983 1983-1984 Question (N = 125 ) (N ~125 ) (N ~125 ) (N = 127 ) (N = 127 ) Does your curriculum have a nutrition course, identif ie d as such, that is required? If you do not have a separate nutrition course, is nutri- t ion incorp orated into s ome o ther course? Do you have nutrition courses, identif fed as such, that can be taken as electives? 24 32 37 35 27 51 61 61 61 66 54 66 57 65 64 aData from AAMC, 1980, 1981b, 1982b, 1983c, 1984c.

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60 questions on previous surveys have been designed only to determine if a separate nutrition course is offered or if nutrition is included as part of another course. Although some general information was gathered, no information was obtained concerning the specific number of hours assigned to nutrition in the curriculum or allocated to specific subject areas. After reviewing the results from these questionnaires, it became apparent to the committee that the surveys alone could not provide an accurate measure of the status of nutrition education in medical schools. In recent years, several medical schools have examined the nutrition content of their curricula. Some reports of these examinations were reviewed by this committee, which found that particular nutrition-related topics were incor- porated into the teaching of other subjects and could not be identified as nutrition per se. In addition, the com- mittee learned that the teaching of some nutrition-related topics was duplicated, and in some cases, important topics were not taught at all. From these observations the com- mittee concluded that a reliable assessment of the nutri- tion content of a curriculum can be obtained only if informed faculty members review various sections of the curriculum and report the extent to which nutrition is included. The Committee's Survey Because previous surveys did not provide a reliable and detailed description of the current status of nutrition education in U.S. medical schools, the committee designed its own survey in an attempt to overcome these shortcom- ings. The committee first identified a faculty member with responsibility for teaching nutrition who could respond to the questions. It then requested a course outline to document the information provided by the faculty members. Because this approach required a substantial amount of time and effort, the committee decided to limit its survey to ho schools. Initially' every fourth school was select- ed from an alphabetical listing of the 127 accredited U.S. medical schools in the AAMC 1983-1984 Curriculum Directory (AAMC, 1983a). Several additional schools were then added to the sample to ensure that it represented a cross sec- tion of the schools (e.g., state and private, recently

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51 established and older). (See Appendix A for a list of the schools and general description of their characteristics.) The specific objectives of the committee's survey were to determine (1) the proportion of schools that offer or teach nutrition as an identifiable subject although not necessarily as a separate course, (2) whether specific faculty members have organizational responsibility for nutrition, (3) the approximate number of hours assigned to nutrition in the required curriculum, (4) the departments or courses in which nutrition is taught, and (5) the nutrition topics that are included in the curriculum. The committee sought only limited information on elective courses in nutrition because such courses do not necessar- ily benefit all students. In addition, it was not possi- ble to estimate the amount of time devoted to clinical nutrition teaching in hospitals and clinics because these experiences are usually not common to all students, are poorly documented, or vary with the clinical setting. The committee made the initial contact in the survey by writing a letter to the dean of each school that explained the committee's charge and the purpose of the survey. A preliminary questionnaire (Questionnaire Part I) (Appendix B) and letter were then sent to each school's associate dean for academic affairs or an equivalent administrator. The information requested concerned the general charac- teristice of the school, the inclusion of nutrition in the curriculum, and the identification of faculty personts) responsible for nutrition education. Another letter and Questionnaire Part III (Appendix C) were then sent to the identified faculty person or, if no such person was identified, to the chairman of the bio- chemistry department, asking that person to corroborate the information about nutrition obtained from the adminis- trator. This person was also asked to specify which nutrition topics were taught in various sections of the required curriculum and the number of hours assigned to each topic. Ultimately, responses in some form were obtained from 45 of the 46 schools contacted. Only one faculty member was unable to identify any portion of the curriculum devoted to nutrition; however, he indicated that a nutrition course was planned for the future. In all, 39 schools furnished sufficient information in the fore of course outlines or detailed descriptions of nutrition topics either on the questionnaire or derring

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~2 telephone interviews to corroborate the estimated total number of hours of nutrition. The responses from these 39 schools thus formed the basis of the analysis of tile survey results. Possible sources of error could have resulted in over- estim~tion or underestimation. The nutrition content of the curriculum might have been underestimated if the responding faculty members were not sure whether certain topics were covered in courses with which they were un- familiar. An overestimate might have resulted if the respondent identified parts of lectures as nutrition related when, in fact, they should have been classified as biochemistry, physiology, gastroenterology, or another discipline. The committee found discrepancies between responses to the preliminary questionnaire (usually completed by administrators) and those to the second questionnaire (completed by faculty). That is, on the preliminary questionnaire only 27 schools could identify a section of their curriculum with nutrition components, in contrast to 39 schools on the second questionnaire. In several cases, the committee subsequently obtained detailed outlines of required nutrition courses from schools that initially re- ported that the subject was not taught e This discrepancy reveals that reliable information about curricula may not be available from administrative offices in many medical schools. According to information obtained from course outlines, detailed responses to the questionnaires, or telephone in- terviews with faculty at the 39 schools that provided reliable information, the average total required number of identified nutrition hours is 21 (range, 3 to 56 hours) (see Figure 4-13. The committee determined that the distribution of nutrition teaching time among schools is not symmetrical: 20% of schools teach less than lO hours, 59% teach less than 20 hours, 30% teach 30 hours or more, and 10% teach 40 hours or more. No significant difference was found between the average number of hours of nutrition taught in public versus private schools. The distribution of hours taught in these two groups of schools was also similar. Most of the nutrition instruction was reported to be offered by 65% of the 39 schools surveyed during the first

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~3 10 ~8 o o I 7 C: On o 6 111 m em 5 4 1 o 10 15 20 40 TOTAL REQUIRED HOURS OF NUTRITION 45 50 55 60 Figure 4-1. Total required class hours of nutrition in cur riculum. year, by 24% of the schools during the second year, and by 11% of the schools during the third year. Nutrition is taught, at least in part , as a separate course in 33% of the schools that reported teaching nutrition in the re- quir~d curriculum. Only 18% of the schools reported that nutrition is taught entirely as a separate, free-standing course. In comparison, the AAMC 1983-1984 Curriculum Directory (AAMC, 1983a) lists 22 (17%) of All U.S. medical schools as offering nutrition as a separate course. How- ever, the committee found that the responses from one- tl~ird of the schools that completed both the AAMC and this committee's survey were discrepant. Elective courses in nutrition were reportedly offered in 64% of the 39 schools that provided reliable responses. Frequently, various sources in the same school gave dif- ferent responses to questions related to elective courses, but the committee made no special effort to corroborate the information. [The 1983-1984 LCME survey (AAMC, 1984c) indicates that 64% of all 127 U.S. medical schools offer electives in nutrition.] The survey responses also indi- cated that elective courses are distributed throughout the

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64 4-year curriculum and that their duration ranges from less than 4 weeks to more than 10 weeks. Less than 33% of medical students take nutrition electives in any of the 29 schools that provided this information. According to recent AAMC Medical Student Graduation Questionnaire Sur- veys, only 6% to 7% of all medical students take elective courses or clerkships in nutrition (AAMC 1982a, 1983b). These results imply that nutrition that is taught in elec- tive programs does not benefit most medical students. Nutrition topics included in the required curriculum of the 34 s chools that provided this inf ormation are summa- rized in Figure 4-2. Four of the topics are taught by fewer than 25% of the 34 schools. More than 75% of the schools teach 15 of the topics, including the basic as- pects of energy balance and specific topics, such as obesity, vitamin A, and other subjects listed in Question- naire Part III (Appendix C). More than 50% of the schools teach an additional 12 topics, including various aspects of nutrition in the life cycle and the role of nutrition in disease prevention and treatment. All schools reported teaching something about obesity, but only 15% of them provide their students with information about the nutri- tional aspects of preventing dental disease--one of the most dramatic disease prevention successes in recent years in the United States (DHHS, 1981a; Glass, 1982~. NUTRITION EDUCATION PROGRAMS AT SELECTED MEDICAL SCHOOLS In addition to information obtained from the general survey, the committee gathered more detailed information regarding program development and implementation by invit- ing speakers from selected institutions to discuss their nutrition programs and by extensive telephone interviews based on Questionnaire Part II (Appendix D). In all, one representative from the AMA, 12 from individual schools, and one from the flew York-New Jersey Regional Program for Nutrition Education were interviewed (Appendixes D and E). The sample was not representative of medical schools in general, because the institutions that were selected were those that had made a deliberate effort to organize nutri- tion education. The committee's overall impressions of nutrition educa- tion efforts at these institutions, as well as pertinent

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~5 ENERGY BALANCE OB ES i TY as. as. hi . -. ~.~, . . - . a. >.t ~ ~ >.U >. is. .. * a. *:::: : x: a:::::::::: :;:::: :.~::::::: E: <.*::::::::::;:: ..... Hi;: :::::::::: .: ::.::::.::::: ::::: : : >.; ; 2:::: ::: :$::: : : : : :::t ID ... ~. . s .. .: ~ ~ .: :: :: : :::::: :: ~ ..... , 1 1 1 1 1 1 0 10 20 30 40 50 60 70 80 90 1 00 PERCENTAGE OF SCHOOLS TEACHING TOPIC UNDERNUTRITION R E CO M M E N D E D D A I LY A L LOWA N C ES PROTEIN METABOLISM CARBOHYDRATE METABOLISM LIPID METABOLISM VITAMIN D CALCIUM I RON VlTAMiN B-12 VITAMIN A TRACE MINERALS NUTR I ENT-DRUG I NTERACTI ON PREGNANCY AND LACTATION INFANT NUTRITION ADOLESCENCE AGING NUTR ITI ONAL ASSESSM ENT PROTEIN ENERGY MALNUTRITION CARDIOVASCULAR DISEASE HYPERTENSION RENAL DISEASE GASTROINTESTINAL DISEASE LIVER DISEASE/ALCOHOLISM ALLERGY CANCER DIABETES SURGERY/STR ESS/BURNS DENTAL CARIES PARENTERAL AND ENTERAL NUTRITION IMMUNE RESPONSE CENTRAL NERVOUS SYSTEM CULTURAL VARIATIONS PRUDENT DIET VEGETARIANISM FOOD FADDISM MEGAVITAMINS Figure 4-2. Nutrition topics covered in the curriculum of 34 medical schools. findings from the literature, are summarized below accord- ing to faculty leadership, curricular organization, and problems of implementation. Faculty. Successful organization of nutrition teach- ing in medical schools depends on the leadership of faculty who are committed to nutrition education. Of the 12 schools interviewed, the committee found that this leadership is provided by an approximately equal number of M.D.s and Ph.D.s who represent various disciplines within the basic sciences and clinical departments. Only two of them have a graduate degree or other formal training in

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$~6 nutrition. Although these faculty members are strongly committed to teaching, they are also heavily engaged in research, which accounts for an average of 40% of their time. Most frequently, teaching responsibilities in nutrition are shared by faculty members who also repre- sent various basic science and clinical disciplines. Several consultants to the committee strongly empha- sized that effective integration of nutrition into the clinical training of medical students depends on the active participation of M.D. as well as Ph.D. faculty members. Physicians who are knowledgeable about nutrition are convincing role models because they are able to demon- strate the application of nutrition in clinical practice. Ill all the well-established nutrition programs evaluated in detail by the committee, physicians play an active role, even when faculty with Ph.D.s from basic science departments are responsible for organizing the curriculum. Furthermore, although dietitians and pharmacists are also involved in teaching nutrition principles, the committee's consultants stressed that their impact is limited unless there is a physician who is responsible for instruction and participates on the team that provides nutritional care. A few schools acknowledged a marked shortage of faculty members with adequate backgrounds for teaching nutrition. For example, schools in the New York-New Jersey metropoli- tan area noted this shortage and, as a result, established the New York-New Jersey Regional Center for Nutrition Edu- cation at the New York Academy of Medicine. This center serves as a resource planning and evaluation agency for faculty in 10 medical schools and other allied health- profession institutions (DHHS, 1983; Shils, 1984~. Because of the apparent success of this regional center for nutrition education, similar interinstitutional regional networks are being developed in other parts of the country. For example, the South Eastern Regional Medical Education in Nutrition (SEAMEN) Program, a four- state network based at the Medical College of Georgia, has recently been established (Weinsier _ al., 1985~. One of the early activities of the faculty participants in SERMEN was the identification of those aspects of nutrition with which medical students should be familiar. This informa- tion will assist the SERMON project in the development of future nutrition programs.

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67 Another effort to assist and encourage multiinstitu- tional sharing of nutrition resources is the development and testing of a National Nutrition Test-Item Bank (NNTIB) developed at the University of Alabama to serve as a national resource for scientifically accurate and techni- cally correct test questions (Weinsier et al., 1983~. Using the NNTIB as a test question resource, the SERMEN participants developed and administered an examination to senior level medical students at the 11 participating schools to assess their nutritional knowledge as ob jec- tively as possible. Preliminary results indicate that student Performance varies significantly ~ between schools and among topics within the same school (Weinsier et al., 1985~. This information promises to be of great value in helping schools improve their nutrition education pro grams. Because the schools interviewed already had a nutrition coordinator in place, they understandably did not cite a shortage of interested and trained faculty as the major limiting factor to incorporating nutrition in their curriculum. The committee believes, however, on the basis of its discussion with administrators and faculty at the 45 schools who responded to Questionnaire Parts I and III (Appendixes B and C), that inadequate faculty training or low interest in nutrition is a significant factor limiting nutrition education. Testimony from several experts at recent congressional hearings on the nutrition training of health professionals (U.S. Congress 1983) and recent federal reports that have evaluated the subject (Executive Office of the President, 1977, 198O, 1982 ~ support this belief. Curricular Organization. There are many variations in the way in which nutrition is incorporated into medical school curricula. Most commonly, it is taught as a block in the second half of the first year. Most of the con- sultants believe that nutrition should be a separate required course; a few believe that after an introductory block, nutrition should be integrated wherever relevant throughout the curriculum. Cohen and coworkers (1981) reported that students who take a separate course in nutrition acquire more knowledge than they do when nutri- tion is integrated into another course. Most schools that offer nutrition instruction first teach general biochemis- try, followed by nutrition as a separate course or in con- junction with endocrinology or gastroenterology. In only

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74 also supports clinical training in nutrition, albeit with extremely limited funds (Executive Office of the Presi- dent, 1982~. Several private organizations and philanthropic foun- dations have also provided support for nutrition research and training. For example, the AMA and the American Society for Clinical Nutrition offer some support for research projects for a limited number of undergraduate medical students. Organizations such as the Nutrition Foundation and the National Dairy Council provide research and training support at the postgraduate level. In addi- tion, one of the three awards presented by the Metro- politan Life Foundation between 1980 and 1982 was for development of nutrition education programs in medical schools (Young, 1983~. However, private organizations generally have not provided sufficient funding to support training of faculty for teaching nutrition. SUMMARY The committee used various resources to assess the adequacy of nutrition in U.S. medical schools: its own survey, and interviews with administrators, faculty members, and students from 49 medical schools. Further- more, it reviewed previous surveys, transcripts from congressional hearings, and other published reports to assess the adequacy of teaching practices in nutrition and to identify the factors that may be associated with successful introduction of nutrition into the medical curriculum. Much of the data available to the committee from previous surveys, from consultation with faculty and students, and from its own survey was qualitative. There- fore, a highly scientific analysis was not feasible. The committee believes, however, that although the data are difficult to quantify precisely with any degree of confi- dence, the questionnaire and interview responses were reliable enough to provide a general indication of current status of nutrition education in U.S. medical schools and to serve as a basis for identifying the problems therein and some solutions: · An average of 21 hours of nutrition are taught within the required curricula of U.S. medical schools, but the range is wide: from 3 to 56 hours. More than half the schools provide less than 20 hours.

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75 · In two-thirds of the schools that teach nutrition, the subject is most frequently taught in the first aca- demic year in combination with other subjects, and nutrition-related concepts are frequently not identified as such. Thus, it is possible for a student to complete a course without realizing that nutrition has been in- -- cluded. Currently, one-third of the schools teach nutri- tion in part as a separate course, and only 20% report that nutrition is taught entirely as a separate course. The committee could not accurately determine the amount of clinical teaching time devoted to nutrition. Nutrition electives are taught in two-thirds of the schools sampled; however, less than one-third of students participate in these courses. · The distribution of nutrition subjects that are taught is uneven. Whereas such topics as energy balance and essential nutrients are taught by more than three- fourths of the schools, the role of nutrition and disease prevention and treatment is taught by less than one-half of the schools. 0 The committee reviewed approximately 6,000 questions from National Board examinations administered in 1980, 1982, and 1984. Of these, 3% to 4% were, at least in part, related to nutrition; however, the distribution of questions among the basic sciences and clinical special- ties was uneven. Several topics, such as obesity and undernutrition, were strongly emphasized. Such topics as osteoporosis and the relationship between nutrition and cancer were overlooked. Nutrition knowledge, as measured by performance on the nutrition-related questions on the National Board examinations, was equal to student knowl- edge in other subjects. · There is no shortage of nutrition textbooks; how- ever, the faculty members who teach nutrition concur that most are inadequate to meet their needs and that they must therefore develop their own materials. O There is no clear pattern of faculty responsibility for nutrition at U.S. medical schools. In the committee's judgment, faculty responsibility for nutrition teaching is not clearly defined and depends on the individual school and the individual faculty person who teaches the course. Most faculty who have initiated the teaching of nutrition have a strong commitment to the subject. Among those

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75 TABLE 4-3 National Institutes of Health (NIH) Expenditures for Biomedical and Behavioral Nutrition Research and Training, Fiscal Years 1978-1983a Number of Expenditures and Dollar Cost (in thousands) FiscalYear 1978FiscalYear 1979Fiscal Year1980 Type of Cost, Cost, Cost, Expenditure NumberdollarsNumberdollarsNumber dollars Extramural: Research grants 80944,5861,10060,6831,213 68,472 Program projects 527,316659,96284 16,758 Contracts 13720,46720024,755200 17,168 Centers 649,2329112,03589 11,055 Genera 1 re search support 13 ,210 13,427 10 ,282 Reimbursement agreements 9881111,14216 1,636 Training 16gb2,419297b3,023333b 3,829 Re se a rch care er development awards 37b1,12930b1,06337b 1,150 New, young, and academic inves tigator awardsC llb34318h50744 b 989 Subtotal 1,28899,5831,812126,5972,018 131,339 Intramura 1: Pro jects 796 ,047496 ,24172 7 ,282 Training 31b66836b Subtotal 1106, 7158 5 NIH total nutrition re search and training _,398_ _. 877_ aData from DHHS, 1979, 1980, 1981b, 1982, 1983, and 1984. bNumber of persons. 1, 014 20b500 7,255 857,782 __110 139 12

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77 Fiscal Year 1981 Cost, Number dollars Fiscal Year 1982 Fiscal Year 1983 Cost, Cost, Number dollars Number dollars 1,30273,4511,318 77,3781,35587,370 7915,95983 16,4998319,243 17116,425148 8,18810812,957 9312,06766 12,2446612 ,477 26013,136262 14,86427415,551 161, 31915 1, 243159 55 304b3 ,708345b 2 ,83457b1,183 34982 58b 1, 361 73b 2,305 641,560601,960411b 3,447 2 ,323138, 6082 ,355136, 5712 ,442 155, 488 959,193857,36491 8,134 25b70024b44947 684 1209,8931097,813138 8,818 _.433148.5002.404144 3842,442 164.306__ ___ __ _____ tin fiscal year 1980 the New, Young, and Special Investigator Awards were combined under the new title, New Investigator Research Awards.

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78 faculty members who teach or coordinate a nutrition course, there are approximately equal numbers of Ph.D.s and M.D.s, but few of them have had formal training in nutrition. Faculty members who teach nutrition spend approximately 40% of their time on research, which pro- vides a major source of financial support. · Schools that successfully integrate nutrition into their curriculum can be characterized as having: --strong faculty leadership from those members who are willing to devote time to develop a nutrition educa- tion program; --a physician who demonstrates the application of nutrition principles to clinical practice; --an identifiable, discrete nutrition course or an identifiable block of nutrition hours within the curricu- lum; and --a strong research component that is effective, creative, and related to clinical nutrition, and that contributes to the visibility and credibility of nutrition as a science. ~ Medical school faculty currently believe that the restricted curricular time available is the most serious limitation to the incorporation of nutrition in U.S. medical schools. They also believe that students would be receptive to increased instruction in nutrition. · The majority of medical students believe that in- struction in nutrition is inadequate and that when nutri- tion is incorporated into other courses, as opposed to being a discrete course, its impact is lost. REFERENCES AAMC (Association of American Medical Colleges). 1980 The Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire. Association of American Medical Colleges, Washington, D.C. . AAMC (Association of American Medical Colleges). 1981a. Medical Student Graduation Questionnaire Survey. Sum- mary Report for All Schools. Association of American Medical Colleges, Washington, D.C.

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79 AAMC (Association of American Medical Colleges). 1981b. The Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire. Association of American Medical Colleges, Washington, D.C. AAMC (Association of American Medical Colleges). 1982a. Medical Student Graduation Questionnaire Survey. Sum- mary Report for All Schools. Association of American Medical Colleges, Washington, D.C. AAMC (Association of American Medical Colleges). 1982b. The Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire. Association of American Medical Colleges, Washington, D.C. AAMC (Association of American Medical Colleges). 1983a. AAMC 1983-1984 Curriculum Directory. Association of American Medical Colleges, Washington, D.C. AAMC (Association of American Medical Colleges). 1983b. Medical Student Graduation Questionnaire Survey. Summary Report for all Schools. Association of American Medical Colleges, Washington, D.C. AAMC (Association of American Medical Colleges). 1983c. The Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire. Association of American Medical Colleges, Washington, D.C. AAMC (Association of American Medical Colleges). 1984a. AAMC 1984-1985 Curriculum Directory. Association of American Medical Colleges, Washington, Doe. AAMC (Association of American Medical Colleges). 1984b. Medical Student Graduation Questionnaire Survey. Sum- mary Report for All Schools. Association of American Medical Colleges, Washington, D.C. AAMC (Association of American Medical Colleges). 1984c. The Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire. Association of American Medical Colleges, Washington, D.C. Cohen, J. D., J. Hunsley, A. Wattler, L. Karsten, and R. E. Olson. 1981. Evaluation of a nutrition education program for medical students. J. Med. Educ. 56:773-775.

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80 Cooper-Stephenson, C., and A. Theologides. 1981. Nutrition in cancer: Physician's knowledge, opinions, and educational needs. J. Am. Diet. Assoc. 78:472-476. DREW (U.S. Department of Health, Education, and Welfare) 1979. Program in Biomedical and Behavioral Nutrition Research and Training; Fiscal Year 1978. Annual Report of the National Institutes of Health. NIH Nutrition Coordinating Committee, Public Health Service, U.S. Department of Health, Education, and Welfare, Washington, D.C. DHHS (U.S. Department of Health and Human Services). 1980. Program in Biomedical and Behavioral Nutrition Research and Training; Fiscal Year 1979. Annual Report of the National Institutes of Health. NIH Nutrition Coordinating Committee, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. DHHS (U.S. Department of Health and Human Services). 1981a. The Prevalance of Dental Caries in United States Children 1978-1980: The National Caries Prevalance Survey. National Institutes of Health, National Institute of Dental Research, National Caries Program, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. DHHS (U.S. Department of Health and Human Services). 1981b. Program in Biomedical and Behavioral Nutrition Research and Training; Fiscal Year 1980. Annual Report of the National Institutes of Health. NIH Nutrition Coordinating Committee, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. . DHHS (U.S. Department of Health and Human Services). 1982. Program in Biomedical and Behavioral Nutrition Research and Training; Fiscal Year 1981. Annual Report of the National Institutes of Health. NIH Nutrition Coordinating Committee, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. DHHS (U.S. Department of Health and Human Services). 1983. Program in Biomedical and Behavioral Nutrition Research and Training; Fiscal Year 1982. Annual

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81 Report of the National Institutes of Health. NIH Nutrition Coordinating Committee, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. DHHS (U.S. Department of Health and Human Services). 1984. Program in Biomedical and Behavioral Nutrition Research and Training; Fiscal Year 1983. Annual Report of the National Institutes of Health. NIH Nutrition Coordinating Committee, Public Health Service, U.S. Department of Health and Human Services, Washington, D.C. Dunphy, M. K., and B. Bratton. 1980. Effective nutrition education program for medical students. J. Am. Diet. Assoc. 76:372-374. Executive Office of the President. 1977. New Directions in Federally-Supported Human Nutrition Research. Pre- pared by the Ad Hoc Nutrition Research Interagency Working Group and Office of Science and Technology Policy. Office of Science and Technology Policy, Executive Office of the President, Washington, D.C. Executive Office of the President. 1980. Federally- Supported Human Nutrition Research, Training, and Education: Update for the 1980's. II. Human Nutrition Research and Training. Joint Subcommittee on Human Nutrition Research of the Committee on Health and Medicine and the Committee on Food and Renewable Resources. Federal Coordinating Council on Science, Engineering, and Technology, Office of Science and Technology Policy, Executive Office of the President. Am. J. Clin. Nutr. 34(Suppl):978-1030. Human Executive Office of the President. 1982. Federally- Supported Human Nutrition Research, Training and Education: Update for the 1980s. III. Nutrition Education Research and Professional Personnel Needs for Nutrition Education of Professionals and the Public. Joint Subcommittee on Human Nutrition Research of the Committee on Health and Medicine and the Committee on Food, Agriculture, and Forestry Research. 1982. Federal Coordinating Council on Science, Engineering, and Technology, Office of Science and Technology Policy, Executive Office of the President, Washington, D.C.

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