Advancing Nutrition Training, and Research for Medical Students, Residents, Fellows, Attending Physicians and other Clinicians

Workshop Objectives

1. To discuss, identify, and prioritize core nutrition competencies for use in updating the objectives of the NIH-funded Nutrition Academic Award (NAA) Curriculum Guide to include new knowledge in nutrition science and its clinical application, incorporate changes in response to contemporary models of learning and knowledge acquisition, and take advantage of technological advances that have profoundly influenced preclinical and clinical training.
2. To identify and prioritize nutrition research needed to identify, validate and further investigate new research questions and directions generated by the revised NAA objectives.
3. To challenge key workshop attendees/volunteers to update, revise, and reformulate the current NAA objectives based on identified competencies and workshop discussions, with the goal of incorporating relevant information and addressing specific approaches for including the concepts in the National Board Examinations.

Discussions

After brief introductions and charge, the workshop focused on four main discussion topics:

1. What is the landscape of nutrition in medicine?
2. What approaches are needed to develop a medical nutrition curriculum in medical schools and residency programs?
3. What processes are needed in the development of competency-based nutrition curricula?
4. What approaches should be emphasized in a patient-centered approach to nutrition, physical activity, and lifestyle behavior change across the continuum of care?

Various panelists provided their perspectives and recommendations on nutrition in the medical school curricula, inter-professional nutrition instruction (e.g., for nurses and dental students), as well as approaches to integrating nutrition into specialty programs for residents and fellows. Representatives from NBME®, LCME, and ACGME discussed their perspectives on incorporating nutrition in the United States Medical Licensing Examination ® (USMLE®) and clinical programs for residents and fellows, respectively. Breakout sessions focused on sustainability of nutrition programs in medical schools, resident and fellowship programs, and on research needed to enhance the training of medical students, residents, and fellows, using team-based clinical care delivery model.

Participants made recommendations for research, medical school curricula development and implementation, and sustainability of education programs. More details from this workshop and comprehensive recommendations for the future will be available in a publication that will follow.

Recommendations:

Potential Research Topics

• Studies that examine student assessment methods used by schools for the nutrition curriculum, and the granularity and effectiveness of nutrition curriculum content and methods of curriculum delivery.
• Studies that examine Graduate Medical Education (GME) program satisfaction on Post Graduate Year 1 (PGY-1) resident knowledge, skills, and attitudes regarding nutrition education (measure of Undergraduate Medical Education (UME) nutrition curriculum effectiveness and/or usefulness).
• A longitudinal study of physicians who are trained in nutrition versus those with limited nutrition training. Measure physicians’ personal health (i.e., nutrition, exercise, avoiding burnout) and, if possible, the quantity and quality of their medical practice through patient outcomes.
• Studies that include comparative effectiveness research testing the effectiveness of medical nutrition education by, for example, instruction by a physician alone versus by both a physician and registered dietitian nutritionist.

Clinical Applications and Practice

• Studies that examine the effect of nutrition education of physicians and training of physicians in nutrition counseling focusing on the impact of comprehensive diet and lifestyle assessment and intervention on patient health outcomes (e.g. clinical warehouse data, audits).
• Dissemination and implementation research to compare the effectiveness or personal health (as an intermediate indicator of efficacy) of physicians trained with and without nutrition in their curriculum
• Randomized controlled trials that compare different approaches and assess both quantitative and qualitative outcomes to inform best practices for training. 
• Studies that determine the most effective ways to present health apps data to providers and identify how providers use this information.  For example, assess what tools and resources are needed for patient assessment and counseling.
• Studies that examine how to address uncomfortable topics with patients, how to use non-judgmental terminology, and how to effectively enable patients to change lifestyle behaviors.
• Studies that integrate nutritional risk assessment into predictive models to determine levels of intensity of nutritional care post-discharge. For example: High-risk: intervention delivered by a dietitian; Medium-risk: intervention delivered by nurses or by non-certified nutrition graduates; or Low-risk: intervention delivered by a social worker or lay-health worker to address issues related to social determinants of health indicators and to link patients to community food and other resources.
• Studies that identify and review programs instituted by hospitals to address nutrition needs post-discharge. Common elements: Program costs, cost savings, sustainability, and patient outcomes.
• Research that develop ways to enhance the longitudinal/continuity of relationship between patient/provider and assess changes in patient self-efficacy.
• Research-based tools for training and practice, such as interactive videos and web-based applications.

Medical School Curricula and Implementation

• Consider integrating established learning objectives into the UME curriculum, either as a discreet course or as an integrated thread.
• Consider integrating basic nutrition sciences and nutrition as a biological science discipline, as well as clinical medicine and practice in the continuum of medical education training, with more focus on sciences in the medical school and on practice in residency/fellowship.
• Consider identifying nutrition champions and role models in medical schools and train interested faculty in teaching nutrition using train-the-trainer models (e.g., Physician Nutrition Scientist/Specialist). Partnerships with various organizations may be needed to provide funding support and sustain such scientists and specialists within medical schools.
• Encourage training of medical students with immersion in the broader system of health care, and in population health management, inter-professional collaboration, health system improvement, and contextual factors (i.e., social determinants of health) in patient care.

• In collaboration with other entities, develop a nutrition subspecialty (nutrition, metabolism, and lifestyles), particularly as a career path for pediatricians. Diet and nutrition issues are extremely common in the U.S. pediatric population and a gap exists in nutrition expertise in medicine.

Sustainability of Education in Graduate Programs

Participants made recommendations regarding strategies to use to strengthen and sustain nutrition programs including:

• Increasing the appeal of the curricula at the undergraduate level so that the interest in nutrition can be sustained in the graduate programs
• Enhancing innovative approaches to make education programs more interactive
• Developing and reinforcing nutrition knowledge and counseling skills of trainees, holding them accountable by “board level” testing
• Involving students in all years of medical school in both basic (biomedical) and applied nutrition education, along with graduate teaching to increase students’ confidence and comfort with nutrition counseling skills.

Meeting Participants

• Rachel Ballard, MD, MPH, Senior Scientific Officer, Office of Disease Prevention

• Bettina M. Beech, Dr PH, MPH, Dean, John D. Bower School of Population Health, Professor of Population Health Science, University of Mississippi Medical Center

• Michael A. Barone, MD, MPH, Vice President, Licensure Programs, National Board of Medical Examiners

• Patricia Carney, Ph.D, Professor of Family Medicine and of Public Health, OHSU Family Medicine

• Janet De Jesus, MPH, RD, Center for Translational Research and Implementation Science

• Rose Ann DiMaria-Ghalili, PhD, RN, CNSC, FASPEN, FAAN, Drexel University, College of Nursing and Health Professions

• William H. Dietz, MD, PhD, Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health

• Stephanie A. Dunbar, MPH, RD, American Society for Nutrition

• Lawrence Fine, MD, DrPH, Branch Chief, DCVS/CAPB, National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Prevention and Population Sciences Program

• Paul George, MD, Assistant Dean for Medical Education, Associate professor of family medicine, Warren Alpert Medical School, Brown University

• David Goff, MD, PhD, Director, NHLBI/DCVS, National Heart, Lung and Blood Institute, Office of the Director

• Timothy S. Harlan, MD, FACP, Tulane University School of Medicine, Associate Dean for Clinical Services, Associate Professor of Medicine, Executive Director of the Goldring Center for Culinary Medicine

• Robert Hash, MD, LCME Assistant Secretary, American Medical Association

• Emily Johnston, PhD Student, Penn State University

• Martin Kohlmeier, MD, Research Professor, Department of Nutrition, University of North Carolina

• Kathryn M Kolasa PhD, RD, LDN, Professor Emeritus and Affiliate Professor, Master Educator, Vidant Health Nutrition Consultant, Department of Family Medicine; of Pediatrics, Brody School of Medicine at East Carolina University

• Nancy F. Krebs, MD, MS, Professor of Pediatrics, Head, Section of Nutrition, Vice Chair, Academic Affairs, Dept of Pediatrics, University of Colorado School of Medicine

• Robert Kushner, MD, Professor of Medicine, Northwestern University Feinberg School of Medicine

• Carine Lenders, MD, MS, ScD, Co-Chair, Associate Professor of Pediatrics, Boston University School of Medicine, Chief, Division of Pediatric Nutrition, Boston Medical Center

• Zhaoping Li, MD, PhD, Professor of Medicine, Lynda and Stewart Resnick Endowed Chair in Human Nutrition, Director, Center for Human Nutrition, Chief, Division of Clinical Nutrition, David Geffen School of Medicine at UCLA

• Mary Lieh-Lai, MD, FAAP, FCCP, ACGME Senior Vice President, Medical Accreditation, Accreditation Council for Graduate Medical Education

• Janet E. Lindsley, PhD, Associate Professor of Biochemistry, Assistant Dean of Curriculum, Foundational Sciences, University of Utah School of Medicine, Department of Biochemistry

• Christopher Lynch, PhD, National Institute of Diabetes and Digestive Kidney Diseases, Office of Nutrition Research

• William C. McGaghie, PhD, Professor of Medical Education, Professor of Preventive Medicine, Northwestern University Feinberg School of Medicine, Department of Medical Education and Feinberg Academy of Medical Educators

• Kathryn McMurry, MS, National Heart Lung and Blood Institute

• Susan L. Meacham, Ph.D., R.D., Professor, Preventive Medicine, Edward Via Virginia College of Osteopathic Medicine

• Holly Nicastro, PhD, MPH, National Institutes of Health, National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Prevention and Population Sciences Program

• Emma Norland, PhD, CEO and Senior Science Advisor, Cedarlock Research LLC

• Professor Caryl Nowson, PhD,  Chair of Nutrition and Ageing, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University

• Voula Osganian, MD, ScD, MPH, Paediatric Clinical Obesity Program Director, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

• Carol Palmer, EdD, RD, Head of the Division of Nutrition & Oral Health Promotion, Tufts University School of Dental Medicine & Friedman school

• Miguel Paniagua, MD, FACP, Medical Advisor, Test Materials Development, National Board of Medical Examiners

• Magda Pasarica MD, PhD, Associate Professor of Medicine, Family Medicine Chair for Education, Family Medicine Interest Group Faculty Advisor, KNIGHTS Clinic Faculty Advisor, University of Central Florida College of Medicine

• Edward M. Phillips, MD, Director, Institute of Lifestyle Medicine, Assistant Professor of Physical Medicine and Rehabilitation, Harvard Medical School, Chief, Physical Medicine and Rehabilitation Services, VA Boston Healthcare System

• Charlotte A. Pratt, PhD, RD, FAHA, Program Director, National Institutes of Health, National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Prevention and Population Sciences Program

• Sumantra Ray, MD, NNEdPro Founding Chair and Wolfson Governing Body Fellow at the University of Cambridge, MRC Senior Clinician Scientist in Nutrition & Vascular Studies and Lead Clinician for the National Diet & Nutrition Survey, Honorary Professorships – Imperial College London (Visiting), Ulster University (Visiting) and University of Waterloo (Adjunct)

• Nicole Redmond MD, PhD, MPH, Medical Officer, DCVS/NHLBI

• Suzanne Rose, M.D., MSEd., Senior Vice Dean for Medical Education, Perelman School of Medicine, University of Pennsylvania

• Marcel Salive, MD, National Institute on Aging, Division of Geriatrics & Clinical Gerontology

• Marsha Schofield, MS, RD, LD, FAND, Senior Director, Governance and Nutrition Services Coverage, Academy of Nutrition and Dietetics

• Kathryn Thompson, PhD, RD, Department of Biomedical Sciences, College of Osteopathic Medicine

• Jennifer L. Trilk, PhD, Clinical Assistant Professor, Dept. of Biomedical Sciences, University of South Carolina School of Medicine Greenville

• Gwen Twillman, Vice President, Education & Development, American Society for Nutrition

• Ashley Vargas, PhD, Health Scientist Administrator, NIH Office of Disease Prevention

• Linda Van Horn, PhD, RD, Co-Chair, Professor of Preventive Medicine, Associate Dean for Faculty Development, Department of Preventive Medicine, Northwestern University

• Gina S. Wei, MD, MPH, Associate Director, DCVS/NHLBI, Director, PPSP, Prevention and Population Sciences Program, Division of Cardiovascular Sciences, NHLBI, NIH

• Jeffrey D. White, MD, Director, Office of Cancer Complementary and Alternative Medicine, Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH

Chairs

• Carine Lenders. MD, MS, ScD, Boston University School of Medicine

• Linda Van Horn, PhD, RD, Northwestern University
   

NIH Staff

NHLBI

• Janet de Jesus, MS, RD, Center for Translational Research and I

• Kathryn McMurry, MS, Office of Science Policy, Engagement, Education, and Communications

• Holly Nicastro, PhD, MPH, Division of Cardiovascular Sciences

• Charlotte A. Pratt, PhD, RD, FAHA, Division of Cardiovascular Sciences

• Nicole Redmond MD, PhD, MPH, Division of Cardiovascular Sciences

NIA

• Marcel Salive, MD, Division of Geriatrics & Clinical Gerontology

• Giovanna Zappala, PhD, MPH, Division of Geriatrics and Clinical Gerontology

NCI

• Jeffrey D. White, MD, Office of Cancer Complementary and Alternative Medicine

NIDDK

• Christopher Lynch, PhD, Office of Nutrition Research

• Voula Osganian, MD, ScD, MPH, Division of Digestive Diseases and Nutrition

NIH OD

• Rachel Ballard, MD, MPH, Office of Disease Prevention

• Ashley Vargas, PhD, MPH, RD, Office of Disease Prevention

• Abby Ershow, Sc.D., R.D., Office of Dietary Supplements

• Johanna T. Dwyer, D.Sc., R.D, Office of Dietary Supplements
   

Next Steps

Workshop participants, in collaboration with the American Society for Nutrition and other partners (e.g., LCME, ACGME and NBME), will develop a plan to update the comprehensive list of curricula objectives to include the survey results from the American Society for Nutrition. The co-chairs will lead the development of a peer-reviewed manuscript that describes the workshop discussions and curriculum development framework.

Selected References

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