Integrating Nutrition Education Across the Medical Student Curriculum

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Integrating Nutrition Education Across the
Medical Student Curriculum

• ATPM Teaching Prevention Institute
• March 25, 2004
• Arlo Kahn, MD
• Professor, Department of Family and Preventive
  Medicine
• University of Arkansas for Medical Sciences

http//preventivenutrition.uams.edu/
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Workshop objective

• Participants will develop a preliminary plan for
  improving a nutrition curriculum

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• What issues do you hope this workshop will
  address?

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Workshop Agenda

• Assessing the curriculum
• Building a case
• Resources
• Implementing and Integrating
• Maintaining the curriculum

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Assessing the Curriculum

• Describe your curriculum
• How will you determine what needs to be taught?
• Current or potential faculty
• Existing courses and/or opportunities
• Barriers
• Greatest need

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Help in Assessing Curriculum

• AAMC Curriculum Management Information Tool
  (CurrMIT)
• http//www.aamc.org/meded/curric/start.htm
• School Curriculum Committee or Dean
• Survey

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What should medical students know about nutrition?

• How to counsel any patient about healthy
  lifestyle, including eating a healthy diet and
  engaging in appropriate physical activity
• How to positively influence the health of
  communities through better nutrition and
  increased physical activity

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Nutrition Academic Award (NAA)

• 5-year grants awarded by the National Heart,
  Lung, and Blood Institute (NHLBI) to 21 U.S.
  Medical Schools (1998-2005)
• To develop or enhance medical school curricula
• Increase opportunities for students, house staff,
  faculty, and practicing physicians to learn
  nutrition principles and clinical practice skills
• Emphasis on preventing cardiovascular diseases,
  obesity, diabetes, and other chronic diseases

http//www.nhlbi.nih.gov/funding/training/naa/
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NAA Schools
University of Arkansas
University of Alabama University of Colorado

University of Iowa University of Maryland
University of
Nevada University of Texas, Houston
University of Texas,
Southwestern University of Vermont
University of
Washington University of Wisconsin Albert
Einstein College of Medicine
Brown University Columbia University
Harvard University Mercer
University School of Medicine
Northwestern University Stanford University
School of Medicine
Tufts University University of Rochester School
of Medicine University of
Pennsylvania

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Table of Contents Preface/Users
Guide Dedication A. Practice Behavior Skills
Across the Curriculum A.1 Practice Behavior
Skills Across the Curriculum A.2 Attitudes Across
the Curriculum B. Overview and Nutrition
Basics B.1 Nutrition Principles B.2 Community and
Population Health B.3 Behavioral Science
Principles B.4 Nutrition Assessment B.5 Physical
Activity C. Lifespan C.1 Pediatrics C.2 Young
Adulthood/Middle Age C.3 Geriatrics C.4 Womens
Health D. Cardiovascular System (See also
Physical Activity, Obesity, and Diabetes
Mellitus) D.1 Hyperlipidemia and
Atherosclerosis D.2 Hypertension D.3 Heart
Failure and Cardiomyopathy
http//www.nhlbi.nih.gov/funding/training/naa/curr
_gde/table_contents.htm
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Table of Contents Continued E.
Metabolic/Endocrine Systems E.1 Obesity E.2
Diabetes Mellitus F. Other Organ Systems F.1
Gastrointestinal F.2 Hematology/Oncology F.3
Immunology F.4 Rheumatology F.5 Pulmonary F.6
Renal F.7 Bone G. Other Areas G.1 Nutrition
Support G.2 Contemporary Trends H.
Appendices H.1 Nutrition Academic Award Program
Principal Investigators H.2 Nutrition Curriculum
Guide for Training Physicians Contributors H.3
Description of How the Guide Was Developed
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Workshop Agenda

• Assessing the curriculum
• Building a case
• Resources
• Implementing and Integrating
• Maintaining the curriculum

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Building the Case

• AAMC Graduate Survey
• USMLE sub scores
• Obesity epidemic
• NRC and other recommendations
• Consultation from another school

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Obesity Trends Among U.S. AdultsBRFSS, 1994
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Obesity Trends Among U.S. AdultsBRFSS, 2002
Source Mokdad A H, et al. JAMA 20032891
Source Mokdad A H, et al. JAMA
19992821620032891
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Recommendations for Nutrition Curricula in
Medical Schools

• National Research Council (1985, 1989) minimum
  of 25 hours
• Healthy People 2000 US DHHS (1991)
• NHLBI (1994)
• USPSTF (1996)
• NAA Collaborative Group (2001)

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Workshop Agenda

• Assessing the curriculum
• Building a case
• Resources
• Implementing and Integrating
• Maintaining the curriculum

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Nutrition Academic Award

• Spend a day with the NAA web sites

• http//www.nhlbi.nih.gov/funding/training/naa/prod
  ucts.htm

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University of Arkansas
http//preventivenutrition.uams.edu/
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Brown University
http//bms.brown.edu/nutrition/index.htm
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Columbia University
http//www.columbia.edu/itc/hs/medical/nutrition/
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http//www.aecom.yu.edu/nutrition/default.htm
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Mercer University
http//med2.mercer.edu/ncvd/naa/default2.htm
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http//www.feinberg.northwestern.edu/nutrition/
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Stanford University
http//summit.stanford.edu/ourwork/PROJECTS/NUTRIT
ION/stanford_naa_main.html
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University of Pennsylvania
http//www.med.upenn.edu/nutrimed/index.html
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University of Texas Medical School at Houston
http//www.uth.tmc.edu/courses/nutrition-module/
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University of Wisconsin
http//www.medicine.wisc.edu/mainweb/DOMPages.php?
sectionnaapagenaamain
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Nutrition in Medicine

• CD-ROM Series produced at the University of North
  Carolina at Chapel Hill will be accessible over
  the web beginning fall 2004.
• Principal Investigator Steven H. Zeisel, MD,
  PhD
• Designed to teach nutritional science in a
  case-oriented format
• Distributed free to all 126 US medical schools,
  most US osteopathic schools, and 99 international
  medical schools
• To Contact NIM www.med.unc.edu/nutr/nim

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Nutrition in Medicine Titles

• The Disease SeriesDiet, Obesity, and
  Cardiovascular Disease
• Nutrition and Cancer
• Diabetes and Weight Management
• Nutritional Anemias
• Nutrition and Metabolic Stress
• The Lifecycle SeriesMaternal and Infant
  Nutrition
• Nutrition and Growth
• Nutrition for the Second Half of Life
• Special Topics in Nutrition Series
• Dietary Supplements and Fortified Foods
• Sports Nutrition

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Use and Efficacy

• Used in some way by 91 US medical schools an
  additional 33 are planning or evaluating use
• Used by 26 international medical schools
• Efficacy evaluations have shown good learning
  effects in first- and second-year medical
  students
• Can be used in small or large groups or for
  independent learning

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Teaching the science

• Explain nutrient metabolism
• Demonstrate nutrient action
• Link nutrients to disease
• Discuss nutritional risk factors
• Show assessment methods

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Clinical exercises

• Emphasize clinical relevance
• Practice nutritional assessment
• Build dietary interview skills
• Show clinical problem-solving
• Demonstrate nutrition therapy

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• What resources have I missed?

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Workshop Agenda

• Assessing the curriculum
• Building a case
• Resources
• Implementing and Integrating
• Maintaining the curriculum

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• How would you begin the process of adding
  nutrition content to your curriculum?

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Key Strategies for Integrating Nutrition Into the
Medical Curriculum

• Know your own curriculum
• Identify faculty with an interest and expertise
  in nutrition
• Develop a proposal integrating nutrition into the
  medical curriculum
• Watch for a window of opportunity
• Make nutrition cross-sectional and longitudinal
• Kushner, et al. Am J Clin Nutr 199052401-3.

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Other Keys

• Find co-champion (s)
• Start early in the curriculum and warn the
  students that they are pioneers
• Look for student contact in each year
• Clinical reinforcement from residents and faculty
• Emphasize office systems for clinical nutrition
  assessment and counseling

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Opportunities in the curriculum

• ICM courses
• Basic science courses clinical correlations
• Clerkships
• Electives
• Stand alone required courses

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Evaluation strategies

• Attitude Survey Development of a measure of
  attitude toward nutrition in patient care
• Knowledge Tests Nutrition Knowledge Pretest
• OSCE

McGaghie WC, et al. Am J Prev Med
20012015-20. Knopp R, et al. 1999,
rhknopp_at_u.washington.edu
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Longitudinal integration building on previous
experiences
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UAMS Curriculum
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Supermarket Tour

• Two hour tour covering
• how foods prevent or promote disease
• how people make food choices
• how food is marketed and regulated
• how foods are labeled
• nutrients in specific food products
• Live
• Virtual PowerPoint with Audience Response System
• Interactive CD-ROM
• Web-based

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• 6. Of the following which is the healthiest oil?
  
• a. Corn oil
• b. Olive oil
• c. Peanut oil
• d. Soybean oil
• e. Sunflower oil

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• 14. Who regulates milk and eggs?
• a. Food and Drug
• Administration
• b. Department of Agriculture
• c. Federal Trade Commission
• d. Bureau of Alcohol, Tobacco
• and Firearms

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ICM 1 Paired Nutrition Assessment

• Complete the Diet and Habit Assessment form
  with a classmate
• Using the Diet and Habit Assessment form and
  the 2-day diet diary, complete the Nutrition
  Assessment form (calculate BMI from height and
  weight)
• Complete the CHD Risk Factor Assessment form
  (include BP and lipids if known)

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Diet and Habit Assessment
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Nutrition Assessment
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Coronary Heart Disease Risk Assessment
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ICM 1 Standardized Patient Group Assignment

• Student 1 complete the Diet Habit Assessment
  with the patient and figure the patients BMI.
• Student 2 review the patients 2-day diet diary
  with the patient. The patient or the dietetic
  intern will answer questions about the diet
  diary.

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ICM 2 Nutrition Counseling

• Learn How to Counsel a Patient to Improve Diet
  and Reduce the Risk of Dying from Heart Disease

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The 4-A Technique

• ASK
• ADVISE
• ASSIST
• ARRANGE

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Assist

• How you assist depends on the patients readiness
  to change behavior
• Pre-contemplation (not interested)
• Contemplation (within 6 months)
• Preparation (within a month)
• Action (working on it)
• Maintenance

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Counseling Practice Session

• Objectives
• Determine the patients stage of readiness to
  change
• Provide brief, personalized advice explaining the
  behavior that should be changed and why
• Assist the patient in a manner that is
  appropriate for the stage of readiness to change

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FP Clerkship CHD Risk Factor and Nutrition
Assessment

• Objectives
• assess risk factors for diabetes, obesity and CVD
  with actual patients
• discuss the prevalence of cardiovascular risks in
  a family practice setting
• recommend dietary changes to reduce disease risks
  in a specific patient

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CHD Risk Factor Assessment

• Assessment of cardiovascular risk factors seen
  in 10 patients at clerkship sites

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• Complete a nutrition assessment and determine
  readiness to change for 1 patient, with known
  cardiovascular risk factors
• Recommend dietary and other lifestyle changes

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Workshop Agenda

• Assessing the curriculum
• Building a case
• Resources
• Implementing and Integrating
• Maintaining the curriculum

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Strategies for Building and Maintaining Support

• Faculty Development
• Involve as many volunteers as possible
• Use other disciplines (dieticians)
• Create a demand
• Community
• Students
• Patients

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• UAMS Preventive Nutrition Seminars
• Statewide Presentations
• Arkansas Preventive Nutrition and Physical
  Activity Summit
• Act 1220, 2003

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Arkansas BMI Initiative challenges and
opportunities

• Weigh and measure 450,000 children
• Educate parents and kids
• Continuing Medical Education for providers
• Establish data base on child weight in Arkansas

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Workshop Agenda

• Assessing the curriculum
• Building a case
• Resources
• Implementing and Integrating
• Maintaining the curriculum