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5 Curriculum Guideline for Incorporating Nutrition in Medical Education To assist medical schools in incorporating nutrition into their curricula, the committee has developed an out- line of core concepts, which is presented in this chapter. This outline identifies the basic nutrition knowledge that all graduating medical students should have acquired dur- ing their medical education. The major concepts are identified and illustrated by examples of specific information that may be included. This outline is neither a comprehensive list of topics on clinical nutrition nor a detailed course outline. Rather, the suggestions are a guide both to the development of specific courses that can become part of the basic science curriculum and to the integration of nutrition into clini- cal clerkships, such as pediatrics, medicine, surgery, and obstetrics and gynecology, in which nutrition has an inte- gral role in patient care. Where and how the components of the proposed curriculum should be incorporated into medical school programs are discussed in Chapter 6, Con- clusions and Recommendations. In developing this curriculum guideline, the committee gathered information in several ways. Approximately one- third of the medical schools in the United States were asked to respond to a survey regarding their nutrition curricula (see Chapter 4, Current Programs). To identify clearly those nutrition concepts most frequently taught, the committee requested a course outline or syllabus from each school. In addition, it received testimony from and conducted telephone interviews with several persons directly responsible for the curricular design of nutri- tion programs at selected medical schools. It also reviewed previously published curriculum guides (Frankle, 85

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86 n.d., and 1976) and current nutrition course outlines from 18 schools (see Chapter 4, Current Programs). The information obtained from these sources and the collective experience and expertise of its members formed the basis of the nutrition concepts developed by the com- mittee. They are intended to help medical schools develop a program to inform medical students not only about nutri- ent requirements and metabolism but also about the role of nutrition in the prevention, etiology, and treatment of disease. Especially emphasized are aspects of nutrition that apply to clinical medicine. Because of the diversity of instructional approaches and curricular organization in U.S. medical schools, the essential nutrition information for a core curriculum can be organized in several, perhaps equally effective, ways. Nonetheless, the approach described in this chapter should provide a useful and practical guide for the development of a nutrition program at most medical schools. The committee identified eight main topics on which a curriculum can be based: energy balance, role of specific nutrients, nutrition in the life cycle, nutritional assessment, protein energy malnutrition, the role of nutrition in disease prevention and treatment, possible risks from poor dietary practices, and social and cultural factors that influence dietary practices. Graduating phy- sicians who receive instruction in these subjects should acquire a background knowledge of nutrition that should equip them to deliver effective patient care and to keep abreast of new developments in the field. . ENERGY BALANCE A discussion of energy balance should include informa- tion on control of food intake, the effect of inadequate or excessive energy intake, and metabolic determinants of energy expenditure. Suggested Topics · measurements of energy consumption the components of energy needs, exercise of energy balance and utilization, , and the economy

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87 · physiological and behavioral aspects of hunger and satiety as they relate to modulation of food intake o the prevalence of obesity, obesity as an etiological factor in other diseases, and prevention and therapy of obesity · negative energy balance and undernutrition, includ- ing appropriate measurement and assessment techniques clinical significance of undernutrition as illustra- ted by such conditions as anorexia nervosa, bulimia, ill- ness or malabsorption disorders, the metabolic and physiological adaptations associated with these condi- tions, and appropriate methods of prevention, therapy, and rehabilitation ROLE OF SPECIFIC NUTRIENTS Medical students should be instructed in nutrient re- quirements, food sources providing essential nutrients, the effects of nutrient deficiency and excess, and nutri- ent interactions with other factors, such as other nutri- ents and drugs. Instruction should emphasize the clinical applications of these topics. Students should learn to recognize specific conditions that may predispose patients to particular nutrient defi- ciencies, such as increased physiological requirements due to pregnancy, older age, disease states, malabsorption, or alcoholism. Also important is an understanding that the interaction of one nutrient with another or with drugs may affect the bioevailability of a nutrient and that pro- longed intake of excessive or pharmacological doses of some vitamins and minerals may pose potential hazards. Suggested Topics biochemical function of specific nutrients · general principles of the Recommended Dietary Allow- ances (RDAs), including the definition of the RDAs, how they differ from requirements, the methods of expression, criteria for an adequate diet, and the uses of the RDAs, especially their applicability to patient care

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88 ~ ~acronutrients (i.e., lipids, carbohydrates, and protein), their significance to clinical medicine, normal requirements for growth and maintenance, and appropriate dietary sources --lipids: lipid transport, cholesterol metabolism, and role of essential fatty acids --carbohydrates: forms and sources in the diet, simple sugars, complex carbohydrates, and role of fiber in the diet --protein: basis of protein requirements, sources in the diet, potential toxicity, protein quality, altera- tions in disease states (e.g., liver or renal complica- tions), or protein-depleting enteropathies micronutrients, including requirements, biological function, and clinical usefulness, in the prevention of deficiency states and in the treatment of other diseases --vitamin A: renal function, role in preventing - xerophthalmia, relationship to liver disease and partic ular forms of cancer --calcium, phosphorus, and vitamin D: role in metabolic bone disease and osteoporosis --folate metabolism: intestinal function and folate absorption, interaction with alcohol, antibiotic therapy, and oral contraceptives --vitamin B12: hematopoietic disorders --iron: criteria for assessing iron nutrition, the bioavailability of iron, and iron requirements for various populations --functions of such trace minerals as zinc, iodine, copper, selenium, and fluoride NUTRITION IN THE LIFE CYCLE Instruction regarding the influence of nutrition and nutritional factors on people at various ages should include discussion of the overall relationship between nutrition and reproduction, the physiology of pregnancy and lactation and the nutritional needs of women during this period, the nutritional merits of various formulas, cows' milk or human milk for infant feeding, and the nutritional problems and nutritional requirements during adolescence, adulthood, and aging.

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89 Suggested Topics pregnancy and lactation: nutrient requirements, maternal gain, and nutritional status · early infant feeding: nutrient requirements for the full-term and premature infant; nutritional considerations in the use of human milk, cows' milk, or infant formulas; introduction of solid foods and whole milk; and infant vitamin-mineral supplements · adolescence: changes in body composition, growth patterns of boys and girls, changes in eating behavior patterns, and pregnancy · aging: problems associated with drug-nutrient interaction; alterations in utilization and absorption of nutrients; calcium and osteoporosis; and states of depen- dency, isolation, depression, or physical disability, which may affect the acquisition of an adequate diet NUTRITIONAL ASSESSMENT Nutritional assessment is a valuable tool that may assist the clinician in diagnosis. Students should be informed of the various techniques for assessing patients' nutritional status, such as dietary history and physical examination, including anthropometric measurements and laboratory tests. PROTEIN ENERGY MALNUTRITION Protein energy malnutrition (PEM) is second only to infection as a major cause of death and morbidity for most of the world's children. Although acute protein depletion in infants is uncommon in developed countries, it has occurred under some circumstances. Through complex inter- actions, the depletion of energy and specific nutrients exerts profound effects on growth, development, and resis- tance to infection. These effects also provide striking examples of the relevance of nutrition to patients with chronic illness.

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Do Suggested Topics · identif ication, etiology, and treatment of PEM and its long-term effects on growth, development, and behavior · relationship of surgery, trauma, and sepsis to PEM and appropriate intervention techniques THE ROLE OF NUTRITION IN DISEASE PREVENTION AND TREATMENT Inadequate or excessive nutrient intake, increased nutrient requirements, and decreased bioavailability of nutrients due to decreased absorption or to a high rate of either breakdown or excretion may be associated with many disease states. The relationship of nutrition and nutri- tional factors to the etiology, prevention, and treatment of various diseases and organ systems should be discussed with emphasis on the application of nutrition to patient care. Suggested Topics · atherosclerosis and cardiovascular disease: rela- tionship of dietary cholesterol and saturated fat to cardiovascular disease; the influence of dietary modifica- tions on plasma cholesterol and lipid concentrations; distinction between the various types of hyperlipidemias, their etiology, relationship to disease, and principles of dietary modification; relationship of obesity to cardio- vascular disease and the principles and components of the prudent diet o hypertension: risk factor in cardiovascular disease; potential influence of sodium, calcium, magne- sium, and phosphorus and the dietary sources of these elements; relationship of hypertension to obesity · diabetes: dietary factors and etiologies of type I and type II diabetes; modalities of treatment, including the principles and objectives of dietary management, insu- lin administration, and exercise therapy; education of diabetic patients about the objectives and methods of diet therapy and conditions with dietary implications that complicate diabetes, such as pregnancy, renal failure, congestive heart failure, and gastrointestinal complica- tions

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91 · cancer: dietary factors that may play a role in the etiology of cancer, especially nutritional myths and mis- conceptions; metabolic aspects of the cachexia that is frequently associated with cancer; strategies for dietary intervention renal disease: role of protein, sodium, calcium, phosphorus, and vitamin D; physiological basis of nutri- tion therapy; strategies to improve nutritional status in order to alleviate symptoms by the use of such techniques as parenteral nutrition therapy and defined formulas that are composed of amino acids or their ketoanalogues · gastrointestinal disease and malabsorption: role of various segments of the gastrointestinal tract in nutrient assimilation; nutritional consequences of malabsorption and the clinical and laboratory measurements that identify them; principles of nutritional therapy for specific gastrointestinal or malabsorption disorders, such as spree, celiac disease, ileitis, ulcerative colitis, disaccharidase deficiency, short bowel syndrome, and infantile diarrhea; the role of dietary factors in the etiology of various gastrointestinal disorders · liver, biliary tract, pancreatic disease, and alcoholism: effects of alcohol use on health and nutri- tional status; synergism of alcohol and malnutrition; hypovitaminosis of the B vitamins, such as thiamin and folate; nutritional management · immune response: role of nutrients in the develop- ment and function of the immune response and the mechanism by which infection affects nutritional status 0 surgery, trauma, thermal injury, and sepsis: char- acteristic metabolic responses, including potential changes in metabolic rate and cardiac output; requirements for energy, protein, ascorbic acid, zinc, and other vita- mins and trace elements; methods of nutritional support (see next section). . parenteral and enteral nutrition: indications for use, suitability of a particular route of administration, the principles of formulation, potential hazards and com- plications that may be associated with these techniques, and the importance of monitoring electrolyte balance and nutritional status

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92 · inborn errors of metabolism: such disorders as disaccharidase deficiency, lactose intolerance, phenyl- ketonuria, principles of dietary modification and manage- ment, including prevention of toxic accumulation of substrate and its metabolites, replacement of a deficient product or its derivative, and supplementation of the deficient enzyme or coenzyme to amplify catalytic activity · dental caries and oral disease: conditions that interfere with the chewing or swallowing of food and practical means for providing adequate nutrients finder those circumstances, etiology and prevention of oral disease, role of sucrose in plaque formation, the role of bacteria, and the role of fluoride in the prevention of dental caries POSSIBLE RISKS FROM POOR DIETARY PRACTICES Many persons are selecting reducing diets or diets to improve athletic performance or are taking vitamin or mineral supplements in an attempt to improve their nutri- tional well-being. Discussions should emphasize the health risks and benefits of these self-selected diets. Suggested Topics · food fads and popular diets, megavitamins and mega- minerals, and weight-reduction diets . alcoholism and other substance abuse · toxic substances in food (e.g., mercury, lead, naturally occurring toxicants) and nutritional consequen- ces of self-medication (e.g., antacids) . diet and athletic performance SOCIAL AND CULTURAL FACTORS THAT INFLUENCE DIETARY - PRACTICES Nutrition education should present some of the anthro- pological, sociological, and psychological factors that influence food choices and various dietary patterns and practices.

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93 a_ ted Topics · the clinical consequences of various dietary prac- tices, both cultural and ethnic . vegetarianism · public health programs and policy recommendations relating to dietary practices · the implications of all these topics for the prac- ticing physician REFERENCES Frankle, R. T. n.d. Nutrition Education in the Medical School: A Curriculum Design. The Nutrition Foundation, Washington, D.C. Frankle, R. T. 1976. Nutrition education in the medical school curriculum: A proposal for action: Curriculum design. Am. J. Clin. Nutr. 29:105-109.

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