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~ - ~ IN U.S ~ _ MEDICAL SCHOOLS Committee on Nutrition in MecTical Education Food and Nutrition Boarc! Commission on Life Sciences National Research Council National Academy Press Washington, D.C. 1985

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National Academy Press ~ 2101 Constitution Avenue, NW ~ Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and of advising the federal government. The Research Council operates in accordance with general policies determined by the Academy under the authority of its congressional charter of 1863, which establishes the Academy as a private, nonprofit, self-governing membership corporation. The Research Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in the conduct of their services to the government, the public, and the scientific and engineering communities. It is administered jointly by both Academies and the Institute of Medicine. The National Academy of Engineering and the Institute of Medicine were established in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. The work on which this publication is based was supported by the Ruth Mott Fund, the William H. Donner Foundation, and the National Research Council (NRC) Fund, a pool of private, discretionary, nonfederal funds that is used to support a program of Academy- initiated studies of national issues in which science and technology figure significantly. The NRC Fund consists of contributions from a consortium of private foundations including the Carnegie Corporation of New York, the Charles E. Culpeper Foundation, the William and Flora Hewlett Foundation, the John D. and Catherine T. MacArthur Foundation, the Andrew W. Mellon Foundation, the Rockefeller Foundation, and the Alfred P. Sloan Foundation; the Academy Industry Program, which seeks annual contributions from companies that are concerned with the health of U.S. science and technology and with public policy issues with technological content; and the National Academy of Sciences and the National Academy of Engineering endowments. Library of Congress Catalog Card Number 85-61572 International Standard Book Number 0-309-03587-2 Printed in the United States of America

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Committee on Nutrition in Medical Education MYRON WINICK (Chairman), Institute of Human Nutrition, College of Physicians and Surgeons, Columbia University, New York, New York STANLEY M. ARONSON, Division of Biology and Medicine, Brown University, Providence, Rhode Island RICHARD BEHRMAN, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio LUCILLE S. HURLEY, Department of Nutrition, University of California, Davis, California DOUGLAS S. KERR, Department of Pediatrics and Biochemistry, Case Western Reserve University, and Division of Pediatric Endocrinology and Metabolism, Rainbow Babies & Children's Hospital, Cleveland, Ohio ALEXANDER LEAF, Department of Preventive Medicine and Clinical Epidemiology, Harvard Medical School, and the Cardiovascular Health Center, Massachusetts General Hospital, Boston, Massachusetts l. MICHAEL McGTNNIS, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Washington, D.C. JACQUELINE ANN REYNOLDS, Physiology Department, Duke University Medical Center, Durham, North Carolina Advisors ATTALLAH KAPPAS, The Rockefeller University, New York, New York ROBERT LEVY, Department of Health Sciences, Columbia University College of Physicians and Surgeons, New York, New York Staff SUSAN E. BERKOW, Staff Officer FRANCES M. PETER, Editor MARIANNE LA VElLLE, Research Associate BARBARA C. MILLER, Secretary SUSHMA PALMER, Executive Director, Food and Nutrition Board .

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Food and Nuirition Board KURT l. ISSELBACHER (Chairman), Harvard Medical School and Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts RICHARD L. HALL (Vice ChairmanJ, Science and Technology, McCormick and Company, Inc., Hunt Valley, Maryland HAMISH N. MUNRO (Vice ChairmanJ, U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts WILLIAM E. CONNOR, Department of Medicine, Oregon Health Sciences University, Portland, Oregon PETER GREENWALD, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland JOAN D. GUSSOW, Department of Nutrition Education, Teachers College, Columbia University, New York, New York RICHARD l. HAVEL, Cardiovascular Research Institute, University of California School of Medicine, San Francisco, California VICTOR HERBERT, Hematology and Nutrition Laboratory, Veterans Administration Medical Center, Bronx, New York NAMES R. KIRK, Research and Development, Campbell Soup Company, Camden, New Jersey REYNALDO MARTORELL, Food Research Institute, Stanford University, Stanford, California I. MICHAEL McGTNNIS, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Washington, D.C. MALDEN C. NESHElM, Division of Nutritional Sciences, Cornell University, Ithaca, New York ROBERT H. WASSERMAN, Department/Section of Physiology, New York State College of Veterinary Medicine, Cornell University, Ithaca, New York MYRON WINICK, Institute of Human Nutrition, College of Physicians and Surgeons, Columbia University, New York, New York Staff SUSHMA PALMER, Executive Director, Food and Nutrition Board 1V

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Preface As the American public becomes increasingly aware of the impor- tance of nutrition in health maintenance and disease prevention and treatment, physicians are frequently expected to provide their patients with accurate, up-to-date information and guidance con- cerning diet, food, and health. This increased public demand for nutrition information, along with growing recognition of the inte- gral role of nutrition in health, has contributed to a heightened awareness within the medical community of the need to provide physicians with adequate training in this area. The Food and Nutrition Board (FNB) of the National Research Council viewed the question of adequate and appropriate nutrition education in medical schools to be of sufficient national concern to warrant assessment. Thus, at the request of the Ruth Mott Fund and the William H. Donner Foundation, the Committee on Nutrition in Medical Education was established within the FNB and charged with examining three major issues: (1) How and to what extent is nutrition incorporated into medical school curricula? (2) What per- centage of medical schools teaches nutrition? (3) How successfully is nutrition taught in different categories of medical schools, and what are the reasons for the success or failure of the programs? The committee was also asked to make recommendations, based on its analysis of these questions, concerning the role that nutrition should play in medical education and the feasibility of and strat- egies for implementing them. In doing so, it drew upon the wide range of expertise of its eight members, who have experience in academic, clinical, and administrative aspects of medical education. Collectively, the committee represented such disciplines as bio- chemistry, physiology, nutritional sciences, pediatrics, medicine, family practice, university administration, and science and health policy. v

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The report prepared by the committee begins with an Executive Summary, Chapter 1, which highlights the major findings and recommendations resulting from the study. The scientific, social, and economic forces that have shaped the role of nutrition in the medical curriculum during this century are discussed in Chapter 2. Chapter 3 directs the reader's attention to the ever-growing body of knowledge implicating nutrition as one of the etiological factors contributing to many forms of chronic and degenerative disease. The application of nutrition principles to patient care within the many medical specialties is illustrated. Chapter 4 contains sum- maries of previous conferences, congressional hearings, and sur- veys that have examined this subject as well as reviews of other relevant reports. This chapter also contains the results of an inde- pendent survey conducted by the committee to determine how and to what extent nutrition is incorporated into the curricula. The committee's review of nutrition-related questions on the National Board examinations and the view of the American Medical Student Association regarding nutrition education are also presented. To assist medical schools in incorporating nutrition into their curricula, the committee developed an outline of core concepts to identify the basic body of nutrition knowledge that all graduating medical students should acquire during their medical training. These concepts, along with examples to illustrate specific kinds of information, are presented in Chapter 5. Chapter 6 is a summary of the committee's findings based on all the data that it analyzed. It also presents the strategies for effectively incorporating nutrition into the medical school curriculum. The committee is grateful to all who contributed to the study. It wishes especially to acknowledge the contribution of the following consultants, who provided valuable information and expertise: El- eanor Young, University of Texas, San Antonio; Roland Weinsier, University of Alabama School of Medicine at Birmingham; Willard Visek, University of TIlinois; Harold Lubin, American Medical Asso- ciation; Maurice Shils and Barbara Howell, New York-New Jersey Regional Medical Center; and William Kassler, President of the American Medical Student Association. Special thanks are also due to Edithe Levit, President of the National Board of Medical Examiners, and Robert lewett, Deputy Vice President for Evaluation Programs, who were unfailingly help- fu! and supportive in providing the committee with information from the National Board examinations. The following persons also provided valuable information and V1

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insight that helped make this evaluation possible: lames Schofield, Association of American Medical Colleges; Merrill S. Read, National Institutes of Health; and more than 45 deans, associate deans, and nutrition course coordinators who responded to our survey and provided support and encouragement. The committee commends Susan Berkow, the FNB staff officer for the study, for her superior performance in supporting all aspects of the committee's work and in taking the initiative, wherever needed, to propose and apply innovative approaches to accom- plishing the task. It also wishes to thank Frances Peter and Judy Grumpstrup-Scott, who provided patient and careful editorial assistance: Marianne La Veille for providing bibliographical mate- rial and other research support; and Barbara Miller for dedicated secretarial services. The committee is particularly indebted to the officials of the Commission on Life Sciences and the Food and Nutrition Board: Frederick C. Robbins, Chairman of the Commission, for his invalu- able support and assistance to the study, and Sushma Palmer, Executive Director of FNB, for her untiring dedication and commit- ment to excellence. MA 4, - ~ ^c: / MYRON WINICK Chairman Committee on Nutrition in Medical Education e V11

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Contents 1 2 EXECUTIVE SUMMARY HISTORICAL PERSPECTIVE 3 RATIONALE FOR INCLUDING NUTRITION INSTRUCTION IN MEDICAL EDUCATION 9 29 4 CURRENT PROGRL\MS 57 5 CURRICULUM GUIDELINE FOR INCORPORATING NUTRITION IN MEDICAL EDUCATION 85 6 CONCLUSIONS AND RECOMMENDATIONS 95 APPENDIXES A U.S. Medica:! Schools Surveyed by the Committee and Their Characteristics B Survey of Medical School Deans and Associate Deans ................... C Survey of Medical School Nutrition Course Coordinators ............... D Personal Interview Survey of Nutrition Course Coordinators .............. E Speakers at Nlarious Committee Meetings 101 103 107 111 119 F Testimony of the American Medical Student Association: Nutrition Education in the Undergraduate Medical Curriculum 121 G Nutrition Science Content of National Board Examinations INDEX 1X 127 137

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