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Historical Perspective
Early in the century, scientific principles of
nutrition were widely taught in the medical schools of
the United States. Later, as research in nutrition
declined, there was a parallel decline of interest in
nutrition education. Today, specific courses that teach
the science of nutrition are found in a minority of U.S.
medical schools.
EARLY NUTRITION RESEARCH AND MEDICAL EDUCATION
During the early 1900s researchers discovered evidence
for the importance of specific components of foods in
maintaining health and in curing or preventing many re-
cently identified deficiency diseases. These advances
came at a time when medical education was under scrutiny.
In 1902, W. G. Thompson, a professor of medicine at
Cornell University Medical College, expressed concern
about the absence of nutrition in medical education:
The subject of the dietetic treatment
of disease has not received the atten-
tion in medical literature which it
deserves, and it is to be regretted that
in the curriculum of medical colleges it
is usually either omitted or is disposed
of in one or two brief lectures at the
end of a course in therapeutics. One
cannot fail to be impressed with the
meager notice given to the necessity of
feeding patients properly, and the
subject is usually dismissed with brief
9
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10
and indefinite phrases such as: "the
value of nutritious diet requires more
mention," "a proper but restricted diet
is recommended," or "the patient should
be carefully fed" (Thompson, 1902~.
Eight years later, Flexner (1910) characterized medical
education in the United States as lacking structure, uni-
formity, and a strong scientific base.
THE GOLDEN AGE OF NUTRITION
Following investigations during the first two decades
of this century on metabolism and energy requirements by
the distinguished nutritional physiologists Graham Lusk
and Wilbur Atwater arid the vitamin hypothesis proposed by
Sir Frederick Gowland Hopkins, medical educators increas-
ingly began to support the teaching of nutrition princi-
ples (Derby, 1977~. The pioneering work on vitamins by
such scientists as Casimir Funk and the discovery of
essential nutrients and their relationship to the preven-
tion of deficiency diseases then led to a burgeoning
interest in experimental and clinical nutrition. These
years would later come to be known as a golden age of
nutrition (Derby, 1976~. Other important research during
the first two decades of this century included the now
classic epidemiological studies of Goldberger; the deter-
mination of energy values for carbohydrates, fats, and
proteins by Atwater; and Elmer McCollum's early work with
vitamins and, later, trace minerals.
McCollum also encouraged the teaching of nutrition in
medical schools. In his textbook Newer Knowledge in
Nutrition (McCollum_ al., 1918), which was widely used
in medical schools, McCollum pointed out that many of the
recent advances in nutrition knowledge had resulted from
severe food shortages following World War I. This new
knowledge, he claimed, should be taught in medical schools
and made available to practicing physicians. Examination
of several of the most commonly used biochemistry text-
books in medical schools during the 1920s and 1930s
reveals that nutrition and foods were indeed emphasized
(Bodallsky, 1927; Lusk, 1917; Osler et al., 1938~. Of the
16 chapters in Meyer Bodansky's Introduction to Physio-
lo~ical Chemistry (Bodansky, 1927), three chapters
described the chemistry of carbohydrates, fats, and
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11
proteins; two described digestion and absorption; four
described intermediary metabolism; and one each described
animal calorimetry and animal nutrition.
In 1934 Bodansky enlarged his second edition by 200
pages and expanded the nutrition section to include a
discussion of protein requirements, the indispensability
of fat, and the role of vitamins (Bodansky, 1934~. He
also added new chapters on sources and composition of
foodstuffs. These additions were due in part to advances
in nutrition science since the first edition. For
example, during the 1920s and 1930s ascorbic acid had been
isolated and synthesized, linoleic acid was identified as
an essential fatty acid, and other vitamins and trace
elements were shown to be essential to the diet (Derby,
1976; Todhunter, 1976~.
During the 1930s and 1940s many of the important micro-
nutrients were isolated and synthesized, and medics'
educators were engaged in teaching students the biochemi-
cal and clinical aspects of nutrition (Derby, 1976;
Todhunter, 1976~. In addition, new organizations were
formed to foster nutrition education in the medical
school curriculum and to encourage the application of
nutrition principles in medical practice. For example,
the American Medical Association's (AMA) Council on
Medical Education and Hospitals among other tasks studied
the role of nutrition in medical education. The council
reported that all but three medical schools in the United
States taught a basic biochemistry course during the first
year and those three schools taught it in the second year
(Weiskotten _ al., 1940~. The Weiskotten report, as well
as medical education textbooks that were commonly used in
the 1930s (Bodansky, 1934; Harrow and Sherwin, 1935; Hawk
and Bergeim, 1926; Osler et al., 1938), indicate that
faculty in biochemistry, pediatrics, physiology, medicine,
and, to a lesser extent, pathology participated in
presenting basic and applied concepts of nutrition to
first- and second-year medical students. It was uncommon,
however, for nutrition to be offered as a separate course
(Weiskotten _ al., 1940~.
DECLINE OF THE GOLDEN AGE
In 1948 a vitamin found to protect against pernicious
anemia was simultaneously isolated in the United Kingdom
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12
(Smith and Parker, 1948) and in the United States (Rickes
1948~. In 1949, when it was identified and
accepted as vitamin B12, the period of active identifi-
cation and isolation of the major vitamins appeared to be
ending (Mehlman, 1976~. Concern for the classic deficien-
cy diseases also diminished as they ceased to be a major
public health problem in the United States. Furthermore,
advances in food technology, especially the advent of
food fortification and supplementation and the expanding
food distribution and marketing systems, brought a more
varied, nutritionally adequate diet within the reach of
many Americans. Not yet knowing the role of nutrition in
lowering the risk of coronary heart disease, stroke,
hypertension, and cancer, most medical educators began to
believe that the scientific basis for nutrition could be
adequately taught in biochemistry and physiology courses.
With a shift of interest in biochemistry and physiology
toward cell biology and molecular biology, nutritional
problems no longer offered the same intellectual chal-
lenge, and biochemists, once deeply concerned with nutri-
tional problems, shifted their focus away from nutrition
toward the molecular basis of gene structure and enzyme
and endocrine function.
, . . .
During the 1950s and 1960s nutrition was relegated to a
low priority in the curriculum and no longer was taught as
an independent course. Moreover, there was an increase in
the number of subspecialties and specialized faculty, each
with its own claim on the medical curriculum, and nutri-
tion became fragmented and integrated into several basic
science courses so that its principles were overlooked or
became difficult to identify. Accordingly, their
relevance to clinical practice was overlooked (Harlan et
al., 1968; Mueller, 1967; Shank, 1966; Stare, 1959~. For
example, courses in biochemistry provided detailed de-
scriptions of metabolism; however, little attention was
given to the food sources that provide the substrates for
these reactions. Similarly, although physiology dealt
with digestion and absorption, the nutrient requirements
of the human organism were generally not emphasized
(Shank, 1966~. The relevance of nutrition to clinical
medicine was further diminished as medical practice
shifted toward therapeutics and the use of new technology
and away from prevention and comprehensive care. Results
from a survey of medical schools in 1958 indicated that 12
of 60 schools (20%) offered a special course in nutrition
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13
(High, 1958~. Thus, nutrition was no longer as important
a part of the medical curriculum as it once had been.
RESURGENCE OF INTEREST IN NUTRITION IN MEDICAL EDUCATION
In the early 1960s there was a growing awareness in
the medical community that nutrition education for physi-
cians was inadequate and that physicians would find it
increasingly difficult to advise their patients regarding
questions of diet and health.
The AMA Council on Foods and Nutrition reported that
nutrition in the U.S. medical schools received "inadequate
recognition, support and attention (White et al., 1961~-
In 1963, as a result of this evaluation, the AMA council
and the Nutrition Foundation sponsored a nationwide con-
ference in Chicopee Falls, Massachusetts, that enabled
practicing physicians, teaching and research scientists,
and administrators from medical schools and granting
agencies to share ideas about improving nutrition in
medical education. In their recommendations (AMA, 1963),
the conferees urged that each medical school should desig-
nate a committee to develop a teaching program in nutri-
tion; medical internship and residence programs should
include a defined, supervised clinical nutrition experi-
ence; and industry and government should allocate funds to
support research and training for health professionals in
nutrition. The AMA Council on Foods and Nutrition
formally concluded that there was inadequate recognition
and support for nutrition in U.S. medical education at
both the undergraduate and postgraduate levels and that
expansion and improvement of present programs were
essential.
There were other instances of institutions or groups
recognizing the inadequacy of nutrition in medical educa-
tion. In 1969 a Senate Select Subcommittee on Nutrition
and Human Needs (U.S. Congress, 1969) heard testimony from
more than 200 witnesses on nutritional deficiency in
America. In the same year a White House Conference on
Food, Nutrition, and Health led by Jean Mayer was convened
(White House Conference, 1969~. Attendees concluded that
nutrition in medical education was inadequate and recom-
mended that funds be made available for future program
development. However, despite this growing interest in
nutrition education for medical students, a 1971 survey
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14
(Phillips, 1971) of second-year medical students concluded
that students' knowledge of the essential concepts of
nutrition as defined by the White House conferees was
generally inadequate.
Although some medical schools showed progress in
improving nutrition education during the decade following
the Chicopee Conference by developing specific courses or
programs (Christakis, 1972; Frankle et al., 1972; Harlan,
1968), many of the recommendations, such as the develop-
ment of specific departments and faculty positions, were
not widely implemented (Mueller, 1967~. Furthermore, of
the 23 new medical schools that were established in the
United States from 1960 to 1971, most were not planning
nutrition programs (White et al., 1972~. Therefore, the
Williamsburg Conference (White et al., 1972) was
organized in 1972 to reinforce the Chicopee Conference
recommendations and to develop additional guidelines.
Among other recommendations, the conferees urged that
federal funds be allocated for research and training of
physicians and other health professionals in nutrition.
This effort, they felt, would enhance nutrition in medical
education at the undergraduate, graduate, and postdoctoral
levels.
PUBLIC AND PROFESSIONAL AWARENESS
Public and professional awareness of the inadequacies
in nutrition education for physicians and other health-
care professionals was further stimulated by Charles E.
Butterworth's article, "The Skeleton in the Hospital
Closet," which appeared in Nutrition Today (Butterworth
1974~. Although Butterworth had not specifically
addressed the issue of nutrition education, proponents of
nutrition education attributed his descriptions of
malnutrition among hospitalized patients to physicians'
ignorance of the principles of nutrition (Long, 1982~.
In an effort to locate and describe these inadequacies
and determine the status of nutrition in U.S. medical
schools, the AMA Department of Foods and Nutrition during
1976 conducted a mail survey of the 114 accredited U.S.
medical schools (Cyborski, 1977~. Of the 102 schools
responding, fewer than 20% offered a required nutrition
course, whereas 95% taught nutrition topics within the
framework of other courses. Many schools reported the
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15
availability of electives, clinical clerkships, research
opportunities, and postgraduate training in nutrition.
The final section of the AMA survey requested comments
on perceived trends in nutrition at each institution.
Approximately one-third of the respondents reported an
increased interest in nutrition at their institution by
faculty and, in particular, by students.
The most common
ly cited limitations to increasing nutrition instruction
in medical education were lack of funds, inadequate train-
ing of physicians in clinical nutrition, and the amount of
time available in the curriculum.
The AMA survey was repeated 2 years later (Geiger,
1979~. Questionnaires were sent to 124 accredited U.S.
medical schools, and 118 schools responded. Although the
survey findings appeared to show a slight increase in the
amount of nutrition information presented in medical
school curricula since 1976 (25% of schools required a
course in nutrition), the results were incomplete. Deans
were not able to identify the number of hours devoted to
nutrition topics, particularly when the topics were inte-
grated into other courses or incorporated into clinical
clerkships.
A PUBLIC POLICY ISSUE
-
During the late 1960s and 1970s the political climate
prompted a heightened social awareness of existing mal-
nutrition, hunger, and chronic disease in the United
States and aroused medical as well as political concern.
Congress responded by holding hearings on nutrition and
human needs (U.S. Congress, 1977a,b,c) as well as on the
training in nutrition that is provided to physicians and
other health professionals (U.S. Congress, 1978, 1979~.
At the latter hearing (U.S. Congress, 1979), the U.S.
General Accounting Office (GAO) reviewed the federal
government's efforts to foster nutrition in medical educa-
tion. The GAO testified that in spite of its importance
to health, nutrition was not taught adequately in many
medical schools, and it recommended an increase in federal
funds to improve nutrition in medical education (GAO,
1980~. In addition, consultants were requested by the
Senate Subcommittee on Nutrition of the Committee on
Agriculture, Nutrition, Forestry to evaluate the adequacy
of nutrit~on-related questions on the 1978 National Board
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16
examinations. In the reviewers' judgment' the quantity of
nutrition questions was low (3% to 4% of total examination
questions were related to nutrition), and the quality and
topical distribution of questions was poor (U.S. Congress'
1979~. For example' they reported that were no questions
on Recommended Dietary Allowances and nutritional assess-
ment, and several questions addressed acute nutritional
deficiency diseases that were primarily a health problem
outside the United States.
At the same time as the Congressional hearings on the
adequacy of medical education, the first Surgeon
General's report on health promotion and disease preven-
tion was released (DREW, 1979a). The report, entitled
Healthy People, cited accumulating research evidence that
diet plays an important role in human health and that
most Americans consult their private physicians or other
medical care deliverers for nutritional guidance. The
report advised that action be initiated to remedy the
current deficiencies in medical education.
Three reports that further demonstrated federal concern
about nutrition were issued jointly by Congress and the
Office of Science and Technology Policy (OSTP) (Executive
Office of the President, 1977, 1980, 1982~. In these
reports the federally supported nutrition programs were
assessed for their effectiveness, and strategies for im-
provement were recommended. Furthermore, the 1980 and
1982 reports indicated the need to establish a more pre-
cise relationship between diet and chronic and degenera-
tive disease as well as the need for further research.
The federal government began to increase its funding
for nutrition research, research training, and education
activities following the initial stimulation by the White
House Conference in 1969 and subsequent congressional
interest during the 1970s. The increased availability of
resources helped to expand nutrition research and training
programs and thereby contributed to research that provided
early evidence associating diet and chronic disease. For
example, the Nutrition Coordinating Committee was formed
within the National Institutes of Health (NIH) to develop,
monitor, and coordinate major research, training, and
funding efforts in nutrition at NIH. Among other accom-
plishments, the committee helped establish the Clinical
Nutrition Research Units (CNRUs)--a program designed to
foster and stimulate scholarly research related to
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17
nutrition and health maintenance and disease treatment. A
major function of the CNRUs was to provide a focus around
which nutrition education in medical schools would
operate. Seven units were funded under this program
(DHEW, 1979b).
Thus, once again there was resurgent excitement in the
area of diet and health. Although the emphasis had
shifted dramatically from the treatment of deficiency
diseases to the prevention of chronic disease, it was not
yet understood how this change would involve physicians
and their methods of patient care.
In 1979, the federal government demonstrated its sup-
port for improving and strengthening nutrition in medical
education by sponsoring grants (U.S. Code, 1976) for cur-
riculum development in applied nutrition. Although this
support was truncated after 2 years, it helped to estab-
lish the National Workshop on Nutrition Education in
TIealth Professional Schools, sponsored by the Emory
University School of Medicine (1981~. The workshop
speakers summarized epidemiological data and basic
clinical research that showed a strong association
between current dietary patterns and the so-called killer
diseases. Based on their findings, the participants
reported that prevention of these nutrition-related
disorders was the best and most cost-effective strategy
for conquering these diseases.
NIT also sponsored the Workshop on Physician Education
in Cancer Nutrition, because it had noted a significant
lack of courses addressing the relationship of nutrition
and cancer in U.Se medical schools (NCI, 1980~. The
workshop part icipants explored the educational needs of
physicians at various levels of training and recommended
specific courses and teaching methods for improving the
teaching of the relationship between nutrition and cancer
in medical education.
Each year since its inception in 1977, NIH's Nutrition
Coordinating Committee prepares the Annual Report of the
NIT Program in Biomedical and Behavioral Nutrition
Research and Training for the preceding year, which sum-
marizes major research achievements and directions for
future research. Reports from the last several years
(DREW, 1979b; 3HHS, 1980, 1981, 1982, 1983, 1984) reflect
important advances. For example, total parenteral
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18
nutrition and other forms of nutrition support have
broadened the treatment possibilities for hospitalized and
other patients; knowledge of premature infant care has
grown, and the survival rate of these infants is increas-
ing; understanding of the critical relationship between
maternal nutritional status, fetal health, and pregnancy
outcome has grown, and intervention strategies to lower
the incidence of low birth-weight infants and infant
mortality have been established; the relationship of
obesity to such disease states as diabetes, coronary heart
disease, cancer, stroke, and hypertension has been inves-
tigated; and research on the role of nutrition in disease
prevention and health promotion has intensified.
Despite the increasing evidence that nutrition has an
important effect on health promotion and disease pr~ven-
tion, the results of the 1981-1982 Liaison Committee on
Medical Education (LCME) survey (AAMC, 1982b) indicated
that only 46 of 125 schools polled (37%) had a required
nutrition course. Results from the 1982-1983 LCMI: survey
(AAMC, 1983c) were similar; few changes had occurred in
the nutrition curriculum since the previous survey. And
ifs fact, the 1983-1984 Association of American Medical
Colleges Curriculum Directory (AAMC, 1983~) indicates that
only 22% of medical schools have a clearly defined course
in nutrition. Not surprisingly then, the majority of
graduating medical students responding to recent annual
AAMC Graduation Questionnaires (AAMC, 1981, 1982a, 1983b,
1984a) perceived that the nutrition instruction they
received was insufficient (see Table 4-2 in Chapter 4,
?. 71~. According to these questionnaires, students also
perceived that the time devoted to prevention acts
inadequate.
Although these data provide some insight into the
status of nutrition in medical education, the statistics
oust be interpreted carefully for the following reasons.
Many schools are not able to document the number of educa-
tional hours devoted to nutrition. The approaches to in-
corporating nutrition in medical education are varied, and
the amount of attention devoted to nutrition instruction
during the preclinical and clinical years (Howard and
Biogaouette, 1983) depends on the structure of each cur-
riculum as well as on the i-merest and skill of faculty
members. Unfortunately, those factors make it difficult
to determine with certainty the extent to which rlutrition
is included in medical curricula.
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19
NUTRITION
-
MEDICAL EDUCATION ABROA_
Inadequate nutrition education in medical schools has
also been recognized and examined in the United 'kingdom
(gray, 1983) and Australia (Commonwealth Department of
Health and National Health and Medical Research Council,
1983~. Each of these countries issued strong policy
statements and recommended strategies for ensuring that
nutrition instruction in medical education keep pace with
growing knowledge in science and technology and the
increasing evidence that diet is integrally related to
health. For example, the British task force (&ray, 1983)
proposed. among other approaches. that the teaching of
_ ~ ~ IF ~ ~ ~
nutrition should begin at the preclinical stage, Should
be a component of the basic sciences as well as clinical
medicine, and should be housed in a specific academic
unit within the medical school in order that training may
be clearly focused. Similar issues are gaining the
attention of medical educators in the United States. For
example, the latest report by the AAMC, although it does
not specif ically refer to nutrition, recommends that
"medical students' general professional education should
include an emphasis on the physician's responsibility to
work with individual patients and communities to promote
health and prevent disease" (AAMC, 1984h).
SUMMARY
The emphasis on nutrition education in U.S. medical
schools, once a major part of the curriculum during the
early l900s, began to diminish following the isolation
and identification of the essential nutrients and the
belief that no further advances in nutrition were likely.
Major advances in nutrition science and technology did
occur during the middle of this century, but these ad-
vances were not accompanied by an increased emphasis on
nutrition in medical education. Today, nutrition is
reemerging as a recognized and vitally important component
of health, and once again, research is flourishing. A
renewed commitment among human health professionals toward
disease prevention and disease treatment is creating new
challenges for research and patient care. These advances,
together with the public's present concern about nutrition
and expectations that physicians should provide sound
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20
dietary advice, have influenced medical schools to
consider giving more emphasis to nutrition in their
curricula.
Nutrition research can be viewed in three historic
stages. The first stage began in the early 1900s and
included the discovery of vitamins, the elucidation of
many of the basic nutrient requirements, and the wide-
spread teaching of nutrition principles in medical
schools. Derring the second stage, the research emphasis
shifted to the molecular basis of nutrition and subcellu-
lar function, and the perceived importance of nutrition
education for physicians declined. The third stage, which
we are now entering, focuses on the emerging epidemiologi-
cal and clinical evidence that links nutrition to the
etiology and prevention of disease and on the implications
of this knowledge for planning public health programs and
policy. Economic and social factors are now influencing
the flays in which medical care is financed, delivered, and
perceived. These forces should serve to redirect the
emphasis of health care delivery from therapeutics to
prevention. As a result, it will be necessary to revise
medical education to prepare future physicians for the
new demands of their profession.
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Representative terms from entire chapter:
medical schools
