The Renaissance of Nutrition Education by William J. Darby, M.D., Ph.D.
N
ineteen seventy-six marked the Bicentennial year of the United States and of the modern science of nutrition.' As we now enter the third century, there is evidence of a Nutrition Renaissance, a rebirth of vigorous intellectual activity in the science of nutrition and its application in medicine and the health sciences. This Renaissance is based upon centuries2of discovery and knowledge and has the characteristics of an evolutionary maturation, not of an eruptive revolution. It promises to result in the widest utilization of the wisdom of the past to benefit mankind - t o preserve health, prolong years, enhance the quality of life and cure the ill - and, parenthetically, to accelerate the advancement of knowledge through research in the basic sciences. The subject area of nutrition was succinctly defined in 1928 by the distinguished American physiologist, Graham Lusk, in his remarkable book, "The Science of Nutrition," (reprinted3 as the first Nutrition Foundations' Reprint) as: . . . the sum of the processes concerned in the growth, maintenance and repair of the living body as a whole or of its constituent organs.
Reflection on this definition reveals that knowledge and understanding of nutrition are basic to all fields of biology, comparative and human, and of medicine, preventive and curative. This universal role of nutrition in medicine was early stated by Hippocrates4 (c. 460 B.C.): For the art of medicine would not have been invented at first, nor would it have been made Or. Darby is President of The Nutrition Foundation, 489 Fifth Avenue, New York, New York 10017. Reprints of this article may be obtained from The Nutrition Foundation, 888 Seventeenth Street, N.W., Washington, D.C. 20006. THERE ARE NO REPRINTS OF UNSIGNED REVIEWS.
a subject of investigation . . . if when men were indisposed, the same food and other articles of regimen which they eat and drink when in good health were proper for them, and if no others were preferable to these. But now necessity itself made medicine to be sought out and discovered by men, since the same things when administered to the sick, neither did nor do agree with them. . .
Hippocrates4underscored his view in no less then 37 of his aphorisms that pertain to food, diet or nutrition.
Nutrition Teaching Observed Prior to development of the sulfonamides and antibiotics in medicine, the majority of specific therapeutic agents were nutritional. The successful conquest of classical deficiency diseases (beriberi, pellagra, scurvy, rickets, xerophthalmia) in industrialized countries was closely followed by dramatic advances in treatment and control of infectious disease, exciting advances in surgery, immunology, genetic disorders, reproductive physiology and psychopharmacology. Nutrition as a subject was "crowded out of" the curriculum of most medical schools and became a neglected area of medical and postgraduate education. Recognition of this neglect stimulated the Council on Foods and Nutrition of the American Medical Association and The Nutrition Foundation jointly to sponsor a nationwide conference5 on nutrition teaching in medical schools in 1962. The 47 participants meeting at the Chicopee Conference included practicing physicians, and teaching and research scientists and administrators from medical schools and granting agencies. They reidentified the principles of nutrition that are an integral aspect of the practice of medicine, applicable in diagnosis and treatment, rehabilitation from chronic NUTRITION REVIEWS / VOL. 35, NO. 2 /FEBRUARY 1977
33
illness, and in disease prevention and health promotion. They asserted5 that, “It is the responsibility of the faculty of each medical school to assure the student an opportunity to learn the modern concepts of nutrition and to obtain some supervised experience in the application of nutrition to clinical (and public health) problems.” The recommendations of this conference dealt with delegation of responsibility for program development, nutrition standards for approved hospital internships and residencies, continuing education, financial support, reinforcement of education through research, and education of dental students. A Decade Reviewed A decade later (1972) the same two institutions, in cooperation with 13 others, organized the Williamsburg Conference6 on nutrition education programs. The 87 participantsat this conference identified the essential nutritional principles that every physician should understand and utilize. These are of two broad categories: (1) the Science of Nutrition, and (2) the Sociology of Nutrition. This basic knowledge is best obtained during medical school training, perfected during postdoctorate clinical education and updated in continuing educational programs for the physician. At the 1972 conference there were represented but six significant programs in nutrition education in the medical schools. Subsequent changes within those six leading institutions and their nutrition programs from 1972-1976 reflect overall curricular alterations, losses of personnel in leadership roles and other reorganizational alterations, plus the failure to provide federal support for educational programs in nutrition in medical schools. Nevertheless, it is significant that in all of these six schools there continues teaching and research interest and activity in nutrition. Clearly, this reflects an on-going concern of faculty and students for this subject area. Parenthetically, it is with some pride to note that five of these six programs have been significantly supported or initiated by grants from The Nutrition Foundation (Vanderbilt University, Tulane University, Mount Sinai Medical School, 34
NUTRITION REVIEWS I VOL. 35, NO. 2 I FEBRUARY 1977
Columbia University and University of Missouri). The Nutrition Renaissance Of greatest significance, however, is the current virtual ground swell of educational activity directed toward meeting the call of the earlier conferees5 for establishing “meaningful opportunities through required and/or elective courses in nutrition for medical and other health personnel to learn the modern concepts of nutrition and to obtain supervised experience in the application of nutrition to clinical (and public health) problems.” A recent tabulation by The Nutrition Foundation of available information on some 80 medical schools in the United States reveals that 28 of these are identified as having significant required instruction in nutrition. Seventy-three of the 80 schools have indicated that they have elective courses in nutrition for medical students. Some of these 73 also have required instruction in nutrition. Departmental and curricular placement of these courses vary greatly depending upon the organization of the particular medical school’s educational program. During the last half of this century medical schools have discarded the “traditional” educational plan that became the standard of the post-Flexner era. Following World War I I , reorganization of teaching in medical schools has introduced a flexibility that results in schools differing in the time allotted to conventional subjects, the year(s) in which the student addresses an area of knowledge and the viewpoints from which subject matter is approached. The student has much choice in the use of his time and his choice of new elective courses. Accordingly, the effective way of incorporating nutrition into the teaching program varies. It, therefore, is important to design any development with an understanding of the institutional organization and schedule into which it must fit. The department in which faculty leadership for these programs resides differs from school to school. Any department or a wide range of subspecialties may serve as the locus for the leadership: medicine (hematology, gastroenterology, endocrinology and metabolism);
pediatrics (inborn errors, gastroenterology, growth and development); surgery (especially departments with strong interest in total parenteral nutrition, intestinal bypass); preventive medicine; community medicine; family practice; obstetrics and gynecology; biochemistry; pathology; physiology or dietetics. The diversity of faculty leadership concerned with nutrition and the current responsiveness of students to nutrition education reflects: An increasing interest by medical students and young physicians in societal problems and needs, coupled with the general postWorld War II awareness of the gravity of malnutrition and hunger in the developing world. Realization by physicians and surgeons that many new therapeutic advances in medicine have a potential that obviously is limited by a failure to apply nutritional principles. The increasing availability of sensitive laboratory diagnostic tests for assessing levels of nutriture (state of nutrition). Increasing recognition of the beneficial influence of a few outstanding academic centers with recognized programs in clinical nutrition. The renewed appreciation within all specialties of medicine of the need to treat the patient rather than the disease.
The more effective teaching programs have the active involvement and support of senior clinicians and a competently staffed nutritional biochemical laboratory that makes available a variety of laboratory measures useful for assessing nutriture. Nutrition consultation and laboratory assessments are as integral a part of patient care as are similar services in endocrinology, hematology, roentgenology and others. Formal or informal faculty interest groups or committees maintain communication relative to the educational program in nutrition and interdepartmental participation is maintained through common teaching and research interests, seminars and rounds. Prominent in such activities are those with interest in total parenteral nutrition, renal dialysis, growth and development, cardiovascular disease, diabetes, rehabilitation, gastroenterology, pedia-
tric feeding, community health, geriatrics and international nutrition. Obligatory or required nutrition content may be in the curriculum as a required course designated as “nutrition,” or as coordinated nutrition subject matter in lectures, laboratory or clinical experience within several offerings throughout the curriculum. The former is regarded by many as the more effective. Electives vary from an organized consideration of basic nutrition concepts to opportunities for supervised clinical, field or research experiencies or participation in seminars. The important unifying feature is that responsible faculty leaders and curriculum planners recognize that an opportunity to learn nutrition concepts and their application must be properly incorporated in the learning experience of the student and that there is coordinated planning for presenting these in an interesting and useful manner.
Nutrition Foundation Programs An early and continued interest of The Nutrition Foundation7 has been the improvement of nutrition teaching and its use in medicine. Since 1972, the Foundation program has given high priority to encouraging the growing awareness of the importance of nutrition in medical education. The Nutrition Foundation has awarded a number of critically selected educational grants to assist in establishing teaching programs in medical centers. It has also acted to stimulate funding from other sources. The long experience of The Nutrition Foundation staff has led to the realization that catalyzing communications among medical schools is an effective way to enhance the quality of nutrition teaching programs. The Foundation, therefore, has encouraged regional, national and international workshops, seminars and publications* with participation of faculty, curriculum planners and administrators from medical and health professional schools. Such conferences, complemented by frequent informal meetings, can provide forums within which nutrition education leaders in the same area or state can develop cooperative teaching programs, plan joint utilization of resources and personnel, and exchange experiences relative to valuable or ineffective efforts. NUTRITION REVIEWS I VOL. 35, NO. 2 IFEBRUARY 1977
35
The Foundation staff has been invited to assist in planning, counseling and implementing important developments within medical institutions. It has responded by participating in university-based seminars, national symposia, advisory committees, clinics and courses in a large proportion of the nation’s medical schools. Several Nutrition Foundation Future Leaders Awards have supported career development of promising young scientists who are now on medical school faculties and maintain a primary interest in nutrition. In addition, beginning in 1974, the Foundation has provided the American College of Physicians with a grant for support of Scholars in Medical Nutrition. Two young physicians annually are selected by the American College of Physicians upon nomination by professors of medicine throughout the United Statesg Simultaneously, a program of support of Canadian fellows in nutrition was announced9 by the Sick Children’s Hospital Foundation of Toronto. Literature reviewslO and conference recomm e n d a t i o n ~often ~ point to the need to define nutrition concepts that should be taught to physicians. The Nutrition Foundation has recently published an example of a model curriculum, “Nutrition Education in the Medical School: A Curriculum Design,” developed by Dr. Reva T. Frankle.11>12This provides teaching-learning units with specific instructional objectives, activities, organization and evaluation methodology for integrating nutrition concepts into the curriculum at three levels. The theme for the first level is the science of nutrition with problem-oriented clinical correlation; for the second level the sociology of nutrition, community problems and family medicine; and for the third level the application of the science and sociology of nutrition in the clinical clerkship. The annotated bibliography on “Education in Nutrition for Physicians and Dentists” is available from The Nutrition Foundationlo and summarizes 60 published journal articles, reports of seven conferences, several published reports of Congressional hearings, and unpublished lectures over the last six years, and it lists selected earlier publications. The Foundation has, with advice from some 30 medical centers, compiled for distribution a 36
NUTRlTlON REVlEWS / VOL. 35, NO. 2 /FEBRUARY 7977
list of Selected Reference Texts in Nutrition that are basic for medical school and departmental libraries.13 Nutrition Reviews and the new fourth edition of “Nutrition Reviews’ Present Knowledge in Nutrition”14 provide critically informative syntheses of current research basic to medical nutrition. For example, among the 53 chapters of Present Knowledge are ones on diabetes, dietary fiber, renal disease, parenteral nutrition, protein-calorie malnutrition, xerophthalmia, immunity, alcohol, milk intolerances, nutritional toxicology, oral biology and dental caries, and a unique introduction to enriching the student’s appreciation of the evolution of the science of nutrition and the men and women who have given us that science. Enrichment of educational resources through the international Nutrition Foundations’ Reprint series3 meets a further need.
National Nutrition Policy Guidelines Interest in nutrition teaching in medical schools makes it timely to review recommendations by the National Nutrition Consortium in its 1974 “Guidelines for a National Nutrition P ~ l i c y . ” ~Section s IV of this document defines programs needed to meet previously stated objectives. Two programs recommended are directly revelant: Medical schools should be encouraged to establish faculty and resources for teaching nutrition in clinical as well as preclinicaldepartments and nutrition training and services should be promoted in hospitals and clinics . . . Research should be supported in colleges and universities, in nutrition centers of excellence, in health care facilities, in special institutes, in industry and in the Federal agencies. Support for training of nutrition scientists to conduct such research should have high priority.
The broad response on the first of these is evidenced by other activities during 1976. In April, the American Society for Clinical Nutrition and the American Institute of Nutrition jointly sponsored a conference, Teaching Nutrition in Medical Schools.16 In July, the Society for Nutrition Education held a special session
on Nutrition Education in Medical and Dental Curricula17 at its annual meeting. The Department of Foods and Nutrition of the American Medical Association released in late summer of 1976 a Summary of Nutrition Curricula in Medical Education Survey18 which provided information regarding the availability of required and elective courses, clerkships, research experience and postgraduate or continuing education in nutrition. A review by Dutra de Oliveiralg underscores the international concern for this need. Concurrent with these efforts, the Bureau of Health Manpower of DHEW-HRA sponsored a Survey of Nutrition Teaching in Nine Medical Schools20 which were identified as having significant programs in this area.
Federal Support Needed Requests from medical schools to The Nutrition Foundation for support to help establish programs of nutrition education indicate an annual need of at least six million dollars. This far exceeds the modest resources of The Nutrition Foundation. Federalfunding for this purpose has not been available. In the latter part of 1976, the Bureau of Health Manpower, Health Resources Administration, announced awards of special project grants to six institutions: University of Miami, New York Medical College, Baylor College of Medicine, University of Oklahoma, University of Hawaii and the College of Osteopathic Medicine and Surgery, Des Moines. These awards totaled $434,548 -far short of the conservative estimate of needs of six million dollars. The Federal Register of November 24, 1976, announced that applications for grants in the year 1977 for Health Professional Special Projects are being accepted to . . . Establish and operate programs at schools of medicine and osteopathy (and when applicable, at other health professional schools) . . . Providing increased emphasis on, and training and research in, the science of human nutrition and the application of such science to health . . .” It is hoped that this represents a beginning of an awakened consciousness of this enormous need previously unheeded at the Federal level. “
Nutrition Research Is Essential The Guidelines for a National Nutrition Policy15 state: Nutrition research should be supported at all levels. Basic and applied research in nutrition are both essential for solving current and future problems.
Universities, granting agencies and other institutions sometimes classify vaguely relevant research as “nutrition” in an effort to conceal neglect of or inattention to the subject. Research in nutrition is needed to answer such fundamental questions as nutrient requirements, function and distribution in foods of trace elements, quality and safety of food, the role of diet in degenerative diseases, and as defined by Lusk, “processes concerned in the growth, maintenance and repair of the living body as a whole or of its constituent organs.” The classification of studies peripheral to the core of this science as “nutrition research” reflects a misunderstanding of the continuing need for basic nutrition knowledge. Scholars, students, administrators, donors and the public should not be misled by such misnomers. Excellent examples of the scope of research - undirected, basic and applied - that can be properly termed nutrition are well illustrated by the some 550 papers reporting research supported by The Nutrition Foundation, 19421976, and listed in the recently published History of The Nutrition Foundation.7 Research supported by The Nutrition Foundation is selected after critical review by the gcientific advisors to the Foundation who are distinguished nutrition and food scientists of the highest professional standing. The proposals are derived from universities and academic centers throughout the United States and abroad. Hence, the subject areas represent interests deemed especially relevant to the science of nutrition. Promotion of a wider base of support for such studies is an essential ingredient of national policy for the third century which now we have entered . . . the provision of adequate funding is essential.
Challenge of the Third Century At the beginning of 1977 the outlook is promising for sustaining the Renaissance in NUTRITION REVIEWS I VOL. 35, NO. 2 I FEBRUARY 1977
37
Nutrition and to warrant the optimism that I expressed in 1975.' The knowledge and planning ability exists to establish a system for the future which will minimize crises and it should increase improvement of health and relief from suffering through nutritional betterment. . . may society insure its own future with that support essential for us more fully to transmit our rich heritage so that man may rise in proportion as he receives it and so that the third centennial of America and of the science of nutrition may fulfill the promise of our heritage. 0
1. W.J. Darby: Nutrition Science: An Overview of American Genius. 1975 W.O. Atwater Lecture. Nutrition Reviews 34: 1-14, 1976 2. E. Neige Todhunter: Chronology of Some Events in the Development and Application of the Science of Nutrition. Nutrition Reviews 34: 353-365, 1976 3. G. Lusk: The Elements of the Science of Nutrition. Fourth edition. A Nutrition Foundations' Reprint. Johnson Reprint Corporation, New York, 1976 4. F. Adams: The Genuine Works of Hippocrates. Trans. from the Greek. The New Sydenham Society, London, 1849 5. Council on Foods and Nutrition: Nutrition Teaching in Medical Schools. J. Am. Med. Assn. 183: 955-957, 1963 6. Conference on Guidelines for Nutrition Education Programs, held in Wi IIiamsburg, Virginia, June 25-27, 1972. P.L. White, L.K. Mahan and M.E. Moore, Editors. The Nutrition Foundation, New York, 1972 7. C.G. King: A Good Idea: The History of the Nutrition Foundation. The Nutrition Foundation, New York and Washington, D.C., 1976 8. The Application of Nutrition in the Health Sciences. Proceedings of a symposium of the
30
NUTRITION REVIEWS I VOL. 35. NO. 2 I FEBRUARY 1977
Texas Medical Center. The Nutrition Foundation, Washington, D.C., 1975 9. New Fellowships in Nutrition Available for Physicians. Nutrition Reviews 33: 158-159, 1975 10. Education in Nutrition for Physicians and Dentists: An Annotated Bibliography. The Nutrition Foundation, Washington, D.C., 1976 11. R.T. Frankle: Nutrition Education in the Medical School: A Curriculum Design. The Nutrition Foundation, Washington, D.C., 1976 12. R.T. Frankle: Nutrition Education in the Medical School Curriculum: A Proposal for Action: A Curriculum Design. Am. J. Clin. Nutrition 29: 105-109, 1976 13. Selected Nutrition Reference Texts for Physicians and Medical Students. The Nutrition Foundation, Washington, D.C., 1976 14. Nutrition Reviews' Present Knowledge in Nutrition. Fourth edition. The Nutrition Foundation, New York and Washington, D.C., 1976 15. Guidelines for a National Nutrition Policy. Proposed by the National Nutrition Consortium, Inc. Nutrition Reviews 32: 153-157, 1974 16. Teaching Nutrition in Medical Schools, held in Anaheim, California, April 12, 1976. Sponsored by the American Institute of Nutrition and the American Society for Clinical Nutrition 17. Revitalization, Re-evaluation, Redirection. Ninth Annual Meeting of the Society for Nutrition Education, held in Kansas City, Missouri, July 11-14, 1976 18. Summary of Nutrition Curricula in Medical Education Survey. C. Cyborski, compiler. Department of Foods and Nutrition, American Medical Association, Chicago, 1976 19. J.E. Dutra de Oliveira: Teaching Nutrition in Medical Schools: Past, Present and Future. World Review Nutrition Diet. 25: 142-165, 1976 20. R.E. Easton: A Study-of the Nutrition Curricula in the Nine Schools of Medicine. Prepared for DHEW-HRA, Bureau of Health Manpower, Rockville, Maryland, 1976
N
ineteen seventy-six marked the Bicentennial year of the United States and of the modern science of nutrition.' As we now enter the third century, there is evidence of a Nutrition Renaissance, a rebirth of vigorous intellectual activity in the science of nutrition and its application in medicine and the health sciences. This Renaissance is based upon centuries2of discovery and knowledge and has the characteristics of an evolutionary maturation, not of an eruptive revolution. It promises to result in the widest utilization of the wisdom of the past to benefit mankind - t o preserve health, prolong years, enhance the quality of life and cure the ill - and, parenthetically, to accelerate the advancement of knowledge through research in the basic sciences. The subject area of nutrition was succinctly defined in 1928 by the distinguished American physiologist, Graham Lusk, in his remarkable book, "The Science of Nutrition," (reprinted3 as the first Nutrition Foundations' Reprint) as: . . . the sum of the processes concerned in the growth, maintenance and repair of the living body as a whole or of its constituent organs.
Reflection on this definition reveals that knowledge and understanding of nutrition are basic to all fields of biology, comparative and human, and of medicine, preventive and curative. This universal role of nutrition in medicine was early stated by Hippocrates4 (c. 460 B.C.): For the art of medicine would not have been invented at first, nor would it have been made Or. Darby is President of The Nutrition Foundation, 489 Fifth Avenue, New York, New York 10017. Reprints of this article may be obtained from The Nutrition Foundation, 888 Seventeenth Street, N.W., Washington, D.C. 20006. THERE ARE NO REPRINTS OF UNSIGNED REVIEWS.
a subject of investigation . . . if when men were indisposed, the same food and other articles of regimen which they eat and drink when in good health were proper for them, and if no others were preferable to these. But now necessity itself made medicine to be sought out and discovered by men, since the same things when administered to the sick, neither did nor do agree with them. . .
Hippocrates4underscored his view in no less then 37 of his aphorisms that pertain to food, diet or nutrition.
Nutrition Teaching Observed Prior to development of the sulfonamides and antibiotics in medicine, the majority of specific therapeutic agents were nutritional. The successful conquest of classical deficiency diseases (beriberi, pellagra, scurvy, rickets, xerophthalmia) in industrialized countries was closely followed by dramatic advances in treatment and control of infectious disease, exciting advances in surgery, immunology, genetic disorders, reproductive physiology and psychopharmacology. Nutrition as a subject was "crowded out of" the curriculum of most medical schools and became a neglected area of medical and postgraduate education. Recognition of this neglect stimulated the Council on Foods and Nutrition of the American Medical Association and The Nutrition Foundation jointly to sponsor a nationwide conference5 on nutrition teaching in medical schools in 1962. The 47 participants meeting at the Chicopee Conference included practicing physicians, and teaching and research scientists and administrators from medical schools and granting agencies. They reidentified the principles of nutrition that are an integral aspect of the practice of medicine, applicable in diagnosis and treatment, rehabilitation from chronic NUTRITION REVIEWS / VOL. 35, NO. 2 /FEBRUARY 1977
33
illness, and in disease prevention and health promotion. They asserted5 that, “It is the responsibility of the faculty of each medical school to assure the student an opportunity to learn the modern concepts of nutrition and to obtain some supervised experience in the application of nutrition to clinical (and public health) problems.” The recommendations of this conference dealt with delegation of responsibility for program development, nutrition standards for approved hospital internships and residencies, continuing education, financial support, reinforcement of education through research, and education of dental students. A Decade Reviewed A decade later (1972) the same two institutions, in cooperation with 13 others, organized the Williamsburg Conference6 on nutrition education programs. The 87 participantsat this conference identified the essential nutritional principles that every physician should understand and utilize. These are of two broad categories: (1) the Science of Nutrition, and (2) the Sociology of Nutrition. This basic knowledge is best obtained during medical school training, perfected during postdoctorate clinical education and updated in continuing educational programs for the physician. At the 1972 conference there were represented but six significant programs in nutrition education in the medical schools. Subsequent changes within those six leading institutions and their nutrition programs from 1972-1976 reflect overall curricular alterations, losses of personnel in leadership roles and other reorganizational alterations, plus the failure to provide federal support for educational programs in nutrition in medical schools. Nevertheless, it is significant that in all of these six schools there continues teaching and research interest and activity in nutrition. Clearly, this reflects an on-going concern of faculty and students for this subject area. Parenthetically, it is with some pride to note that five of these six programs have been significantly supported or initiated by grants from The Nutrition Foundation (Vanderbilt University, Tulane University, Mount Sinai Medical School, 34
NUTRITION REVIEWS I VOL. 35, NO. 2 I FEBRUARY 1977
Columbia University and University of Missouri). The Nutrition Renaissance Of greatest significance, however, is the current virtual ground swell of educational activity directed toward meeting the call of the earlier conferees5 for establishing “meaningful opportunities through required and/or elective courses in nutrition for medical and other health personnel to learn the modern concepts of nutrition and to obtain supervised experience in the application of nutrition to clinical (and public health) problems.” A recent tabulation by The Nutrition Foundation of available information on some 80 medical schools in the United States reveals that 28 of these are identified as having significant required instruction in nutrition. Seventy-three of the 80 schools have indicated that they have elective courses in nutrition for medical students. Some of these 73 also have required instruction in nutrition. Departmental and curricular placement of these courses vary greatly depending upon the organization of the particular medical school’s educational program. During the last half of this century medical schools have discarded the “traditional” educational plan that became the standard of the post-Flexner era. Following World War I I , reorganization of teaching in medical schools has introduced a flexibility that results in schools differing in the time allotted to conventional subjects, the year(s) in which the student addresses an area of knowledge and the viewpoints from which subject matter is approached. The student has much choice in the use of his time and his choice of new elective courses. Accordingly, the effective way of incorporating nutrition into the teaching program varies. It, therefore, is important to design any development with an understanding of the institutional organization and schedule into which it must fit. The department in which faculty leadership for these programs resides differs from school to school. Any department or a wide range of subspecialties may serve as the locus for the leadership: medicine (hematology, gastroenterology, endocrinology and metabolism);
pediatrics (inborn errors, gastroenterology, growth and development); surgery (especially departments with strong interest in total parenteral nutrition, intestinal bypass); preventive medicine; community medicine; family practice; obstetrics and gynecology; biochemistry; pathology; physiology or dietetics. The diversity of faculty leadership concerned with nutrition and the current responsiveness of students to nutrition education reflects: An increasing interest by medical students and young physicians in societal problems and needs, coupled with the general postWorld War II awareness of the gravity of malnutrition and hunger in the developing world. Realization by physicians and surgeons that many new therapeutic advances in medicine have a potential that obviously is limited by a failure to apply nutritional principles. The increasing availability of sensitive laboratory diagnostic tests for assessing levels of nutriture (state of nutrition). Increasing recognition of the beneficial influence of a few outstanding academic centers with recognized programs in clinical nutrition. The renewed appreciation within all specialties of medicine of the need to treat the patient rather than the disease.
The more effective teaching programs have the active involvement and support of senior clinicians and a competently staffed nutritional biochemical laboratory that makes available a variety of laboratory measures useful for assessing nutriture. Nutrition consultation and laboratory assessments are as integral a part of patient care as are similar services in endocrinology, hematology, roentgenology and others. Formal or informal faculty interest groups or committees maintain communication relative to the educational program in nutrition and interdepartmental participation is maintained through common teaching and research interests, seminars and rounds. Prominent in such activities are those with interest in total parenteral nutrition, renal dialysis, growth and development, cardiovascular disease, diabetes, rehabilitation, gastroenterology, pedia-
tric feeding, community health, geriatrics and international nutrition. Obligatory or required nutrition content may be in the curriculum as a required course designated as “nutrition,” or as coordinated nutrition subject matter in lectures, laboratory or clinical experience within several offerings throughout the curriculum. The former is regarded by many as the more effective. Electives vary from an organized consideration of basic nutrition concepts to opportunities for supervised clinical, field or research experiencies or participation in seminars. The important unifying feature is that responsible faculty leaders and curriculum planners recognize that an opportunity to learn nutrition concepts and their application must be properly incorporated in the learning experience of the student and that there is coordinated planning for presenting these in an interesting and useful manner.
Nutrition Foundation Programs An early and continued interest of The Nutrition Foundation7 has been the improvement of nutrition teaching and its use in medicine. Since 1972, the Foundation program has given high priority to encouraging the growing awareness of the importance of nutrition in medical education. The Nutrition Foundation has awarded a number of critically selected educational grants to assist in establishing teaching programs in medical centers. It has also acted to stimulate funding from other sources. The long experience of The Nutrition Foundation staff has led to the realization that catalyzing communications among medical schools is an effective way to enhance the quality of nutrition teaching programs. The Foundation, therefore, has encouraged regional, national and international workshops, seminars and publications* with participation of faculty, curriculum planners and administrators from medical and health professional schools. Such conferences, complemented by frequent informal meetings, can provide forums within which nutrition education leaders in the same area or state can develop cooperative teaching programs, plan joint utilization of resources and personnel, and exchange experiences relative to valuable or ineffective efforts. NUTRITION REVIEWS I VOL. 35, NO. 2 IFEBRUARY 1977
35
The Foundation staff has been invited to assist in planning, counseling and implementing important developments within medical institutions. It has responded by participating in university-based seminars, national symposia, advisory committees, clinics and courses in a large proportion of the nation’s medical schools. Several Nutrition Foundation Future Leaders Awards have supported career development of promising young scientists who are now on medical school faculties and maintain a primary interest in nutrition. In addition, beginning in 1974, the Foundation has provided the American College of Physicians with a grant for support of Scholars in Medical Nutrition. Two young physicians annually are selected by the American College of Physicians upon nomination by professors of medicine throughout the United Statesg Simultaneously, a program of support of Canadian fellows in nutrition was announced9 by the Sick Children’s Hospital Foundation of Toronto. Literature reviewslO and conference recomm e n d a t i o n ~often ~ point to the need to define nutrition concepts that should be taught to physicians. The Nutrition Foundation has recently published an example of a model curriculum, “Nutrition Education in the Medical School: A Curriculum Design,” developed by Dr. Reva T. Frankle.11>12This provides teaching-learning units with specific instructional objectives, activities, organization and evaluation methodology for integrating nutrition concepts into the curriculum at three levels. The theme for the first level is the science of nutrition with problem-oriented clinical correlation; for the second level the sociology of nutrition, community problems and family medicine; and for the third level the application of the science and sociology of nutrition in the clinical clerkship. The annotated bibliography on “Education in Nutrition for Physicians and Dentists” is available from The Nutrition Foundationlo and summarizes 60 published journal articles, reports of seven conferences, several published reports of Congressional hearings, and unpublished lectures over the last six years, and it lists selected earlier publications. The Foundation has, with advice from some 30 medical centers, compiled for distribution a 36
NUTRlTlON REVlEWS / VOL. 35, NO. 2 /FEBRUARY 7977
list of Selected Reference Texts in Nutrition that are basic for medical school and departmental libraries.13 Nutrition Reviews and the new fourth edition of “Nutrition Reviews’ Present Knowledge in Nutrition”14 provide critically informative syntheses of current research basic to medical nutrition. For example, among the 53 chapters of Present Knowledge are ones on diabetes, dietary fiber, renal disease, parenteral nutrition, protein-calorie malnutrition, xerophthalmia, immunity, alcohol, milk intolerances, nutritional toxicology, oral biology and dental caries, and a unique introduction to enriching the student’s appreciation of the evolution of the science of nutrition and the men and women who have given us that science. Enrichment of educational resources through the international Nutrition Foundations’ Reprint series3 meets a further need.
National Nutrition Policy Guidelines Interest in nutrition teaching in medical schools makes it timely to review recommendations by the National Nutrition Consortium in its 1974 “Guidelines for a National Nutrition P ~ l i c y . ” ~Section s IV of this document defines programs needed to meet previously stated objectives. Two programs recommended are directly revelant: Medical schools should be encouraged to establish faculty and resources for teaching nutrition in clinical as well as preclinicaldepartments and nutrition training and services should be promoted in hospitals and clinics . . . Research should be supported in colleges and universities, in nutrition centers of excellence, in health care facilities, in special institutes, in industry and in the Federal agencies. Support for training of nutrition scientists to conduct such research should have high priority.
The broad response on the first of these is evidenced by other activities during 1976. In April, the American Society for Clinical Nutrition and the American Institute of Nutrition jointly sponsored a conference, Teaching Nutrition in Medical Schools.16 In July, the Society for Nutrition Education held a special session
on Nutrition Education in Medical and Dental Curricula17 at its annual meeting. The Department of Foods and Nutrition of the American Medical Association released in late summer of 1976 a Summary of Nutrition Curricula in Medical Education Survey18 which provided information regarding the availability of required and elective courses, clerkships, research experience and postgraduate or continuing education in nutrition. A review by Dutra de Oliveiralg underscores the international concern for this need. Concurrent with these efforts, the Bureau of Health Manpower of DHEW-HRA sponsored a Survey of Nutrition Teaching in Nine Medical Schools20 which were identified as having significant programs in this area.
Federal Support Needed Requests from medical schools to The Nutrition Foundation for support to help establish programs of nutrition education indicate an annual need of at least six million dollars. This far exceeds the modest resources of The Nutrition Foundation. Federalfunding for this purpose has not been available. In the latter part of 1976, the Bureau of Health Manpower, Health Resources Administration, announced awards of special project grants to six institutions: University of Miami, New York Medical College, Baylor College of Medicine, University of Oklahoma, University of Hawaii and the College of Osteopathic Medicine and Surgery, Des Moines. These awards totaled $434,548 -far short of the conservative estimate of needs of six million dollars. The Federal Register of November 24, 1976, announced that applications for grants in the year 1977 for Health Professional Special Projects are being accepted to . . . Establish and operate programs at schools of medicine and osteopathy (and when applicable, at other health professional schools) . . . Providing increased emphasis on, and training and research in, the science of human nutrition and the application of such science to health . . .” It is hoped that this represents a beginning of an awakened consciousness of this enormous need previously unheeded at the Federal level. “
Nutrition Research Is Essential The Guidelines for a National Nutrition Policy15 state: Nutrition research should be supported at all levels. Basic and applied research in nutrition are both essential for solving current and future problems.
Universities, granting agencies and other institutions sometimes classify vaguely relevant research as “nutrition” in an effort to conceal neglect of or inattention to the subject. Research in nutrition is needed to answer such fundamental questions as nutrient requirements, function and distribution in foods of trace elements, quality and safety of food, the role of diet in degenerative diseases, and as defined by Lusk, “processes concerned in the growth, maintenance and repair of the living body as a whole or of its constituent organs.” The classification of studies peripheral to the core of this science as “nutrition research” reflects a misunderstanding of the continuing need for basic nutrition knowledge. Scholars, students, administrators, donors and the public should not be misled by such misnomers. Excellent examples of the scope of research - undirected, basic and applied - that can be properly termed nutrition are well illustrated by the some 550 papers reporting research supported by The Nutrition Foundation, 19421976, and listed in the recently published History of The Nutrition Foundation.7 Research supported by The Nutrition Foundation is selected after critical review by the gcientific advisors to the Foundation who are distinguished nutrition and food scientists of the highest professional standing. The proposals are derived from universities and academic centers throughout the United States and abroad. Hence, the subject areas represent interests deemed especially relevant to the science of nutrition. Promotion of a wider base of support for such studies is an essential ingredient of national policy for the third century which now we have entered . . . the provision of adequate funding is essential.
Challenge of the Third Century At the beginning of 1977 the outlook is promising for sustaining the Renaissance in NUTRITION REVIEWS I VOL. 35, NO. 2 I FEBRUARY 1977
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Nutrition and to warrant the optimism that I expressed in 1975.' The knowledge and planning ability exists to establish a system for the future which will minimize crises and it should increase improvement of health and relief from suffering through nutritional betterment. . . may society insure its own future with that support essential for us more fully to transmit our rich heritage so that man may rise in proportion as he receives it and so that the third centennial of America and of the science of nutrition may fulfill the promise of our heritage. 0
1. W.J. Darby: Nutrition Science: An Overview of American Genius. 1975 W.O. Atwater Lecture. Nutrition Reviews 34: 1-14, 1976 2. E. Neige Todhunter: Chronology of Some Events in the Development and Application of the Science of Nutrition. Nutrition Reviews 34: 353-365, 1976 3. G. Lusk: The Elements of the Science of Nutrition. Fourth edition. A Nutrition Foundations' Reprint. Johnson Reprint Corporation, New York, 1976 4. F. Adams: The Genuine Works of Hippocrates. Trans. from the Greek. The New Sydenham Society, London, 1849 5. Council on Foods and Nutrition: Nutrition Teaching in Medical Schools. J. Am. Med. Assn. 183: 955-957, 1963 6. Conference on Guidelines for Nutrition Education Programs, held in Wi IIiamsburg, Virginia, June 25-27, 1972. P.L. White, L.K. Mahan and M.E. Moore, Editors. The Nutrition Foundation, New York, 1972 7. C.G. King: A Good Idea: The History of the Nutrition Foundation. The Nutrition Foundation, New York and Washington, D.C., 1976 8. The Application of Nutrition in the Health Sciences. Proceedings of a symposium of the
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Texas Medical Center. The Nutrition Foundation, Washington, D.C., 1975 9. New Fellowships in Nutrition Available for Physicians. Nutrition Reviews 33: 158-159, 1975 10. Education in Nutrition for Physicians and Dentists: An Annotated Bibliography. The Nutrition Foundation, Washington, D.C., 1976 11. R.T. Frankle: Nutrition Education in the Medical School: A Curriculum Design. The Nutrition Foundation, Washington, D.C., 1976 12. R.T. Frankle: Nutrition Education in the Medical School Curriculum: A Proposal for Action: A Curriculum Design. Am. J. Clin. Nutrition 29: 105-109, 1976 13. Selected Nutrition Reference Texts for Physicians and Medical Students. The Nutrition Foundation, Washington, D.C., 1976 14. Nutrition Reviews' Present Knowledge in Nutrition. Fourth edition. The Nutrition Foundation, New York and Washington, D.C., 1976 15. Guidelines for a National Nutrition Policy. Proposed by the National Nutrition Consortium, Inc. Nutrition Reviews 32: 153-157, 1974 16. Teaching Nutrition in Medical Schools, held in Anaheim, California, April 12, 1976. Sponsored by the American Institute of Nutrition and the American Society for Clinical Nutrition 17. Revitalization, Re-evaluation, Redirection. Ninth Annual Meeting of the Society for Nutrition Education, held in Kansas City, Missouri, July 11-14, 1976 18. Summary of Nutrition Curricula in Medical Education Survey. C. Cyborski, compiler. Department of Foods and Nutrition, American Medical Association, Chicago, 1976 19. J.E. Dutra de Oliveira: Teaching Nutrition in Medical Schools: Past, Present and Future. World Review Nutrition Diet. 25: 142-165, 1976 20. R.E. Easton: A Study-of the Nutrition Curricula in the Nine Schools of Medicine. Prepared for DHEW-HRA, Bureau of Health Manpower, Rockville, Maryland, 1976
