Early Nutrition Research And Medical Education

During the early 1900s researchers discovered evidence for the importance of specific components of foods in maintaining health and in curing or preventing many recently identified deficiency diseases. These advances came at a time when medical education was under scrutiny. In 1902, W. G. Thompson, a professor of medicine at Cornell University Medical College, expressed concern about the absence of nutrition in medical education:

The subject of the dietetic treatment of disease has not received the attention in medical literature which it deserves, and it is to be regretted that in the curriculum of medical colleges it is usually either omitted or is disposed of in one or two brief lectures at the end of a course in therapeutics. One cannot fail to be impressed with the meager notice given to the necessity of feeding patients properly, and the subject is usually dismissed with brief and indefinite phrases such as: ''the value of nutritious diet requires more mention, .... a proper but restricted diet is recommended,'' or "the patient should be carefully fed" (Thompson, 1902).

Eight years later, Flexner (1910) characterized medical education in the United States as lacking structure, uniformity, and a strong scientific base.

The Golden Age of Nutrition

Following investigations during the first two decades of this century on metabolism and energy requirements by the distinguished nutritional physiologists Graham Lusk and Wilbur Atwater and the vitamin hypothesis proposed by Sir Frederick Gowland Hopkins, medical educators increasingly began to support the teaching of nutrition principles (Darby, 1977). The pioneering work on vitamins by such scientists as Casimir Funk and the discovery of essential nutrients and their relationship to the prevention of deficiency diseases then led to a burgeoning interest in experimental and clinical nutrition. These years would later come to be known as a golden age of nutrition (Darby, 1976). Other important research during the first two decades of this century included the now classic epidemiological studies of Goldberger; the determination of energy values for carbohydrates, fats, and proteins by Atwater; and Elmer McCollum's early work with vitamins and, later, trace minerals.

McCollum also encouraged the teaching of nutrition in medical schools. In his textbook Newer Knowledge in Nutrition (McCollum et al., 1918), which was widely used in medical schools, McCollum pointed out that many of the recent advances in nutrition knowledge had resulted from severe food shortages following World War I. This new knowledge, he claimed, should be taught in medical schools and made available to practicing physicians. Examination of several of the most commonly used biochemistry textbooks in medical schools during the 1920s and 1930s reveals that nutrition and foods were indeed emphasized (Bodansky, 1927; Lusk, 1917; Osler et al., 1938). Of the 16 chapters in Meyer Bodansky's Introduction to Physiological Chemistry (Bodansky, 1927), three chapters described the chemistry of carbohydrates, fats, and proteins; two described digestion and absorption; four described intermediary metabolism; and one each described animal calorimetry and animal nutrition.

In 1934 Bodansky enlarged his second edition by 200 pages and expanded the nutrition section to include a discussion of protein requirements, the indispensability of fat, and the role of vitamins (Bodansky, 1934). He also added new chapters on sources and composition of foodstuffs. These additions were due in part to advances in nutrition science since the first edition. For example, during the 1920s and 1930s ascorbic acid had been isolated and synthesized, linoleic acid was identified as an essential fatty acid, and other vitamins and trace elements were shown to be essential to the diet (Darby, 1976; Todhunter, 1976).

During the 1930s and 1940s many of the important micro-nutrients were isolated and synthesized, and medical educators were engaged in teaching students the biochemical and clinical aspects of nutrition (Darby, 1976; Todhunter, 1976). In addition, new organizations were formed to foster nutrition education in the medical school curriculum and to encourage the application of nutrition principles in medical practice. For example, the American Medical Association's (AMA) Council on Medical Education and Hospitals among other tasks studied the role of nutrition in medical education. The council reported that all but three medical schools in the United States taught a basic biochemistry course during the first year and those three schools taught it in the second year (Weiskotten et al., 1940). The Weiskotten report, as well as medical education textbooks that were commonly used in the 1930s (Bodansky, 1934; Harrow and Sherwin, 1935; Hawk and Bergeim, 1926; Osler et al., 1938), indicate that faculty in biochemistry, pediatrics, physiology, medicine, and, to a lesser extent, pathology participated in presenting basic and applied concepts of nutrition to first- and second-year medical students. It was uncommon, however, for nutrition to be offered as a separate course (Weiskotten et al., 1940).

Decline Of The Golden Age

In 1948 a vitamin found to protect against pernicious anemia was simultaneously isolated in the .United Kingdom (Smith and Parker, 1948) and in the United States (Rickes et al., 1948). In 1949, when it was identified and accepted as vitamin B12, the period of active identification and isolation of the major vitamins appeared to be ending (Mehlman, 1976). Concern for the classic deficiency diseases also diminished as they ceased to be a major public health problem in the United States. Furthermore, advances in food technology, especially the advent of food fortification and supplementation and the expanding food distribution and marketing systems, brought a more varied, nutritionally adequate diet within the reach of many Americans. Not yet knowing the role of nutrition in lowering the risk of coronary heart disease, stroke, hypertension, and cancer, most medical educators began to believe that the scientific basis for nutrition could be adequately taught in biochemistry and physiology courses. With a shift of interest in biochemistry and physiology toward cell biology and molecular biology, nutritional problems no longer offered the same intellectual challenge, and biochemists, once deeply concerned with nutritional problems, shifted their focus away from nutrition toward the molecular basis of gene structure and enzyme and endocrine function.

During the 1950s and 1960s nutrition was relegated to a low priority in the curriculum and no longer was taught as an independent course. Moreover, there was an increase in the number of subspecialities and specialized faculty, each with its own claim on the medical curriculum, and nutrition became fragmented and integrated into several basic science courses so that its principles were overlooked or became difficult to identify. Accordingly, their relevance to clinical practice was overlooked (Harlan et al., 1968; Mueller, 1967; Shank, 1966; Stare, 1959). For example, courses in biochemistry provided detailed descriptions of metabolism; however, little attention was given to the food sources that provide the substrates for these reactions. Similarly, although physiology dealt with digestion and absorption, the nutrient requirements of the human organism were generally not emphasized (Shank, 1966). The relevance of nutrition to clinical medicine was further diminished as medical practice shifted toward therapeutics and the use of new technology and away from prevention and comprehensive care. Results from a survey of medical schools in 1958 indicated that 12 of 60 schools (20%) offered a special course in nutrition (High, 1958). Thus, nutrition was no longer as important a part of the medical curriculum as it once had been.

Resurgence Of Interest In Nutrition In Medical Education

In the early 1960s there was a growing awareness in the medical community that nutrition education for physicians was inadequate and that physicians would find it increasingly difficult to advise their patients regarding questions of diet and health.

The AMA Council on Foods and Nutrition reported that nutrition in the U.S. medical schools received "inadequate recognition, support and attention" (White et al., 1961). In 1963, as a result of this evaluation, the AMA council and the Nutrition Foundation sponsored a nationwide conference in Chicopee Falls, Massachusetts, that enabled practicing physicians, teaching and research scientists, and administrators from medical schools and granting agencies to share ideas about improving nutrition in medical education. In their recommendations (AMA, 1963), the conferees urged that each medical school should designate a committee to develop a teaching program in nutrition; medical internship and residence programs should include a defined, supervised clinical nutrition experience; and industry and government should allocate funds to support research and training for health professionals in nutrition. The AMA Council on Foods and Nutrition formally concluded that there was inadequate recognition and support for nutrition in U.S. medical education at both the undergraduate and postgraduate levels and that expansion and improvement of present programs were essential.

There were other instances of institutions or groups recognizing the inadequacy of nutrition in medical education. In 1969 a Senate Select Subcommittee on Nutrition and Human Needs (U.S. Congress, 1969) heard testimony from more than 200 witnesses on nutritional deficiency in America. In the same year a White House Conference on Food, Nutrition, and Health led by Jean Mayer was convened (White House Conference, 1969). Attendees concluded that nutrition in medical education was inadequate and recommended that funds be made available for future program development. However, despite this growing interest in nutrition education for medical students, a 1971 survey (Phillips, 1971) of second-year medical students concluded that students' knowledge of the essential concepts of nutrition as defined by the White House conferees was generally inadequate.

Although some medical schools showed progress in improving nutrition education during the decade following the Chicopee Conference by developing specific courses or programs (Christakis, 1972; Frankle et al., 1972; Harlan, 1968), many of the recommendations, such as the development of specific departments and faculty positions, were not widely implemented (Mueller, 1967). Furthermore, of the 23 new medical schools that were established in the United States from 1960 to 1971, most were not planning nutrition programs (White et al., 1972). Therefore, the Williamsburg Conference (White et al., 1972) was organized in 1972 to reinforce the Chicopee Conference recommendations and to develop additional guidelines. Among other recommendations, the conferees urged that federal funds be allocated for research and training of physicians and other health professionals in nutrition. This effort, they felt, would enhance nutrition in medical education at the undergraduate, graduate, and postdoctoral levels.

Public And Professional Awareness

Public and professional awareness of the inadequacies in nutrition education for physicians and other healthcare professionals was further stimulated by Charles E. Butterworth's article, "The Skeleton in the Hospital Closet," which appeared in Nutrition Today (Butterworth, 1974). Although Butterworth had not specifically addressed the issue of nutrition education, proponents of nutrition education attributed his descriptions of malnutrition among hospitalized patients to physicians' ignorance of the principles of nutrition (Long, 1982).

In an effort to locate and describe these inadequacies and determine the status of nutrition in U.S. medical schools, the AMA Department of Foods and Nutrition during 1976 conducted a mail survey of the 114 accredited U.S. medical schools (Cyborski, 1977). Of the 102 schools responding, fewer than 20% offered a required nutrition course, whereas 95% taught nutrition topics within the framework of other courses. Many schools reported the availability of electives, clinical clerkships, research opportunities, and postgraduate training in nutrition.

The final section of the AMA survey requested comments on perceived trends in nutrition at each institution. Approximately one-third of the respondents reported an increased interest in nutrition at their institution by faculty and, in particular, by students. The most commonly cited limitations to increasing nutrition instruction in medical education were lack of funds, inadequate training of physicians in clinical nutrition, and the amount of time available in the curriculum.

The AMA survey was repeated 2 years later (Geiger, 1979). Questionnaires were sent to 124 accredited U.S. medical schools, and 118 schools responded. Although the survey findings appeared to show a slight increase in the amount of nutrition information presented in medical school curricula since 1976 (25% of schools required a course in nutrition), the results were incomplete. Deans were not able to identify the number of hours devoted to nutrition topics, particularly when the topics were integrated into other courses or incorporated into clinical clerkships.

A Public Policy Issue

During the late 1960s and 1970s the political climate prompted a heightened social awareness of existing malnutrition, hunger, and chronic disease in the United States and aroused medical as well as political concern. Congress responded by holding hearings on nutrition and human needs (U.S. Congress, 1977a,b,c) as well as on the training in nutrition that is provided to physicians and other health professionals (U.S. Congress, 1978, 1979). At the latter hearing (U.S. Congress, 1979), the U.S. General Accounting Office (GAO) reviewed the federal government's efforts to foster nutrition in medical education. The GAO testified that in spite of its importance to health, nutrition was not taught adequately in many medical schools, and it recommended an increase in federal funds to improve nutrition in medical education (GAO, 1980). In addition, consultants were requested by the Senate Subcommittee on Nutrition of the Committee on Agriculture, Nutrition, Forestry to evaluate the adequacy of nutrition-related questions on the 1978 National Board examinations. In the reviewers' judgment, the quantity of nutrition questions was low (3% to 4% of total examination questions were related to nutrition), and the quality and topical distribution of questions was poor (U.S. Congress, 1979). For example, they reported that were no questions on Recommended Dietary Allowances and nutritional assessment, and several questions addressed acute nutritional deficiency diseases that were primarily a health problem outside the United States.

At the same time as the Congressional hearings on the adequacy of medical education, the first Surgeon General's report on health promotion and disease prevention was released (DHEW, 1979a). The report, entitled Healthy People, cited accumulating research evidence that diet plays an important role in human health and that most Americans consult their private physicians or other medical care deliverers for nutritional guidance. The report advised that action be initiated to remedy the current deficiencies in medical education.

Three reports that further demonstrated federal concern about nutrition were issued jointly by Congress and the Office of Science and Technology Policy (OSTP) (Executive Office of the President, 1977, 1980, 1982). In these reports the federally supported nutrition programs were assessed for their effectiveness, and strategies for improvement were recommended. Furthermore, the 1980 and 1982 reports indicated the need to establish a more precise relationship between diet and chronic and degenerative disease as well as the need for further research.

The federal government began to increase its funding for nutrition research, research training, and education activities following the initial stimulation by the White House Conference in 1969 and subsequent congressional interest during the 1970s. The increased availability of resources helped to expand nutrition research and training programs and thereby contributed to research that provided early evidence associating diet and chronic disease. For example, the Nutrition Coordinating Committee was formed within the National Institutes of Health (NIH) to develop, monitor, and coordinate major research, training, and funding efforts in nutrition at NIH. Among other accomplishments, the committee helped establish the Clinical Nutrition Research Units (CNRUs)—a program designed to foster and stimulate scholarly research related to nutrition and health maintenance and disease treatment. A major function of the CNRUs was to provide a focus around which nutrition education in medical schools would operate. Seven units were funded under this program (DHEW, 1979b).

Thus, once again there was resurgent excitement in the area of diet and health. Although the emphasis had shifted dramatically from the treatment of deficiency diseases to the prevention of chronic disease, it was not yet understood how this change would involve physicians and their methods of patient care.

In 1979, the federal government demonstrated its support for improving and strengthening nutrition in medical education by sponsoring grants (U.S. Code, 1976) for curriculum development in applied nutrition. Although this support was truncated after 2 years, it helped to establish the National Workshop on Nutrition Education in' Health Professional Schools, sponsored by the Emory University School of Medicine (1981). The workshop speakers summarized epidemiological data and basic clinical research that showed a strong association between current dietary patterns and the so-called killer diseases. Based on their findings, the participants reported that prevention of these nutrition-related disorders was the best and most cost-effective strategy for conquering these diseases.

NIH also sponsored the Workshop on Physician Education in Cancer Nutrition, because it had noted a significant lack of courses addressing the relationship of nutrition and cancer in U.S. medical schools (NCI, 1980). The workshop participants explored the educational needs of physicians at various levels of training and recommended specific courses and teaching methods for improving the teaching of the relationship between nutrition and cancer in medical education.

Each year since its inception in 1977, NIH's Nutrition Coordinating Committee prepares the Annual Report of the NIH Program in Biomedical and Behavioral Nutrition Research and Training for the preceding year, which summarizes major research achievements and directions for future research. Reports from the last several years (DHEW, 1979b; DHHS, 1980, 1981, 1982, 1983, 1984) reflect important advances. For example, total parenteral nutrition and other forms of nutrition support have broadened the treatment possibilities for hospitalized and other patients; knowledge of premature infant care has grown, and the survival rate of these infants is increasing; understanding of the critical relationship between maternal nutritional status, fetal health, and pregnancy outcome has grown, and intervention strategies to lower the incidence of low birth-weight infants and infant mortality have been established; the relationship of obesity to such disease states as diabetes, coronary heart disease, cancer, stroke, and hypertension has been investigated; and research on the role of nutrition in disease prevention and health promotion has intensified.

Despite the increasing evidence that nutrition has an important effect on health promotion and disease prevention, the results of the 1981-1982 Liaison Committee on Medical Education (LCME) survey (AAMC, 1982b) indicated that only 46 of 125 schools polled (37%) had a required nutrition course. Results from the 1982-1983 LCME survey (AAMC, 1983c) were similar; few changes had occurred in the nutrition curriculum since the previous survey. And in fact, the 1983-1984 Association of American Medical Colleges Curriculum Directory (AAMC, 1983a) indicates that only 22% of medical schools have a clearly defined course in nutrition. Not surprisingly then, the majority of graduating medical students responding to recent annual AAMC Graduation Questionnaires (AAMC, 1981, 1982a, 1983b, 1984a) perceived that the nutrition instruction they received was insufficient (see Table 4-2 in Chapter 4, p. 71). According to these questionnaires, students also perceived that the time devoted to prevention was inadequate.

Although these data provide some insight into the status of nutrition in medical education, the statistics must be interpreted carefully for the following reasons. Many schools are not able to document the number of educational hours devoted to nutrition. The approaches to incorporating nutrition in medical education are varied, and the amount of attention devoted to nutrition instruction during the preclinical and clinical years (Howard and Bigaouette, 1983) depends on the structure of each curriculum as well as on the interest and skill of faculty members. Unfortunately, those factors make it Difficult to determine with certainty the extent to which nutrition is included in medical curricula.

Nutrition In Medical Education Abroad

Inadequate nutrition education in medical schools has also been recognized and examined in the United Kingdom (Gray, 1983) and Australia (Commonwealth Department of Health and National Health and Medical Research Council, 1983). Each of these countries issued strong policy statements and recommended strategies for ensuring that nutrition instruction in medical education keep pace with growing knowledge in science and technology and the increasing evidence that diet is integrally related to health. For example, the British task force (Gray, 1983) proposed, among other approaches, that the teaching of nutrition should begin at the preclinical stage, should be a component of the basic sciences as well as clinical medicine, and should be housed in a specific academic unit within the medical school in order that training may be clearly focused. Similar issues are gaining the attention of medical educators in the United States. For example, the latest report by the AAMC, although it does not specifically refer to nutrition, recommends that "medical students' general professional education should include an emphasis on the physician's responsibility to work with individual patients and communities to promote health and prevent disease" (AAMC, 1984b).

Summary

The emphasis on nutrition education in U.S. medical schools, once a major part of the curriculum during the early 1900s, began to diminish following the isolation and identification of the essential nutrients and the belief that no further advances in nutrition were likely. Major advances in nutrition science and technology did occur during the middle of this century, but these advances were not accompanied by an increased emphasis on nutrition in medical education. Today, nutrition is reemerging as a recognized and vitally important component of health, and once again, research is flourishing. A renewed commitment among human health professionals toward disease prevention and disease treatment is creating new challenges for research and patient care. These advances, together with the public's present concern about nutrition and expectations that physicians should provide sound dietary advice, have influenced medical schools to consider giving more emphasis to nutrition in their curricula.

Nutrition research can be viewed in three historic stages. The first stage began in the early 1900s and included the discovery of vitamins, the elucidation of many of the basic nutrient requirements, and the widespread teaching of nutrition principles in medical schools. During the second stage, the research emphasis shifted to the molecular basis of nutrition and subcellular function, and the perceived importance of nutrition education for physicians declined. The third stage, which we are now entering, focuses on the emerging epidemiological and clinical evidence that links nutrition to the etiology and prevention of disease and on the implications of this knowledge for planning public health programs and policy. Economic and social factors are now influencing the ways in which medical care is financed, delivered, and perceived. These forces should serve to redirect the emphasis of health care delivery from therapeutics to prevention. As a result, it will be necessary to revise medical education to prepare future physicians for the new demands of their profession.

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