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Clinical nutrition education in medical schools: Results of an ESPEN survey
Clinical Nutrition xxx (2017) 1e2
Contents lists available at ScienceDirect
Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu
Editorial
Clinical nutrition education in medical schools: Results of an ESPEN survey
Clinical Nutrition is the discipline that deals with the prevention, diagnosis, and management of nutritional and metabolic changes related to acute and chronic diseases and conditions caused by a lack or excess of energy and nutrients [1]. Nutritionrelated disorders at the two extremes, undernutrition/malnutrition and overweight/obesity, are highly prevalent in many countries and, therefore, should be a priority for policymakers and healthcare professionals. In addition, the most prevalent causes of morbidity and mortality in developed and developing countries are associated with diet. Moreover, disease-related malnutrition has a major impact on global clinical outcomes as well as on the quality of life of patients. Questions on nutrition are probably the most frequent queries a physician receives from patients. Most physicians are unable to correctly identify and intervene in patients who are at risk of malnutrition or malnourished. Regardless of their discipline, all physicians must deal, at some point, with malnourished patients. This highlights the importance of providing adequate clinical nutrition training to all healthcare professionals in order to perform appropriate screening, assessment, and treatment of nutritional problems in all clinical settings. This issue has been approached in many countries in the last few decades, where attempts have been made to improve clinical nutrition education in medical schools [2e6]. However, practising physicians continually rate their nutrition knowledge and skills as inadequate and more than half of graduating medical students report that the time dedicated to clinical nutrition instruction is insufficient [7,8]. The main barriers to delivery of high quality instruction on clinical nutrition include high variability among academic centres, the broad range of areas of medical science in which nutrition education is included, and lack of time in the medical curriculum. This is exacerbated by a widespread movement toward more integrated curricula and problem-based learning that reduce the number of hours that the students spend in traditional lectures and also reduce the enthusiasm and interest of the instructors. Based on these arguments, the European Society for Clinical Nutrition and Metabolism (ESPEN) decided to launch a survey among representatives from all 57 countries on its Council to circulate to different university centres within their countries. A closed questionnaire was created and sent at the end of November 2016. Data were collected from the 1st of December, 2016, to the 28th of February 2017. We received 56 questionnaires from academic centres that were located in 29 countries (50.8% of the target): 22 from Europe, 4 from Asia, 2 from South America, and 1 from Australia (Table 1).
The results of the survey showed that specific instruction on clinical nutrition exists in the majority of university centres (73.3%), being obligatory in 55.4% and elective in 17.9%, with high variability within each country. The number of hours dedicated to clinical nutrition was more than 8 h in 72.5% of centres, between 4 and 8 h in 15%, and less than 4 h in 12.5%. The centres usually offer instruction on clinical nutrition in the final years of the medical curriculum (17.1% in the 5th year, 14.3% in the 4th year), and in 45.7% of the centres, the instruction was imparted over multiple years (vertically integrated). The list of contents covered by clinical nutrition instruction is highly variable among the centres, as is shown in Table 2. Most centres (66.1%) reported that the number of hours dedicated to clinical nutrition education in their institution was inadequate, and 83.4% considered it appropriate to devote more than 8 h to this topic in the curriculum. Table 1 Countries participating in the survey. Country
No. of university centres
Austria Belgium Bulgaria Croatia Denmark England France Finland Germany Greece Ireland Latvia Lithuania Norway Poland Portugal Republic of Macedonia (FYROM) Spain Sweden Switzerland The Netherlands Turkey Indonesia Japan Singapore Sri Lanka Brazil Colombia Australia
1 2 1 1 3 1 2 5 2 1 1 1 1 4 1 1 1 6 4 1 1 1 1 6 1 1 1 3 1
http://dx.doi.org/10.1016/j.clnu.2017.05.001 0261-5614/© 2017 Published by Elsevier Ltd.
Please cite this article in press as: Cuerda C, et al.Clinical nutrition education in medical schools: Results of an ESPEN survey, Clinical Nutrition (2017), http://dx.doi.org/10.1016/j.clnu.2017.05.001
2
Editorial / Clinical Nutrition xxx (2017) 1e2 Table 2 List of contents covered by clinical nutrition curricula. List of contents covered
% centres
Malnutrition/screening Nutritional assessment Nutrient requirements Energy expenditure Enteral nutrition Parenteral nutrition Micronutrients Specific nutrients Disease-related malnutrition/requirements Monitoring Refeeding syndrome Microbiota/probiotics Other (food allergy/intolerance, obesity, eating disorders, dietetic treatment: diabetes, obesity, kidney failure)
84.2 89.5 81.6 76.3 86.8 78.9 63.2 52.6 71.1 47.4 55.3 43.2 24.3
In most universities, clinical nutrition lectures were part of the instruction on different disciplines (paediatrics 60.4%, gastroenterology 54.7%, surgery 53.8%, endocrinology 49.1%, intensive care 43.4%, geriatrics 38.5%, cardiology 24.5%, internal medicine 24.5%, oncology 23.1%, nephrology 20.8%, and others 17%). Our results are comparable to a recent European survey that included 32 medical schools from 10 countries in which nutrition education, in some form, was required in 68.8% of schools, covering, on average, less than 24 h of the curriculum [9]. In another survey in the US that included 109 medical schools, most programs required some form of nutrition education but only 25% of them had a dedicated nutrition course. Overall, medical students received 19.6 contact hours of nutrition instruction during their medical school careers and only 27% of the centres met the minimum 25 required hours set by the National Academy of Sciences [10]. These surveys highlight the fact that clinical nutrition education in medical schools continues to be an important issue with high variability between and within countries. Nutrition instruction must be broad in nature and be vertically integrated across the preclinical and clinical years and continued through postgraduate training. Nutrition teachers must be involved in or, preferably, in charge of these courses. Active adult learning, “hands-on”, and problem-based learning should be practiced whenever possible, moving from traditional teaching to more innovative techniques, including web-based resources [11]. However, we must consider that the results of these surveys are probably biased by the interest in clinical nutrition of the university centres that completed the questionnaire. To our knowledge, there are no specific recommendations for teaching clinical nutrition in the medical curriculum, at least in Europe. In order to improve the knowledge and skills of medical students in the area of clinical nutrition, ESPEN has developed a structured course (pre- Graduate LLL program, http://lllnutrition.com/ course/view.php?id¼806) that consists of 11 essential topics for use by teachers in medical schools. This is in line with the ESPEN mission of promoting knowledge of clinical nutrition worldwide. We hope this effort to improve instruction in clinical nutrition in the medical curriculum will be shared by all national PEN societies.
In conclusion, this survey confirms that education in clinical nutrition in undergraduate medical schools is heterogeneous among university teaching centres and most frequently underpowered.
Acknowledgments We would like to thank all the ESPEN council members and university centres that have contributed to this survey.
References [1] Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017;36:49e64. [2] Donini LM, Leonardi F, Rondanelli M, Banderali G, Battino M, Bertoli E, et al. The domains of human nutrition: the importance of nutrition education in academia and medical schools. Front Nutr 2017;4:2. art L, Kupka R, Tchibindat F, et al. Glob [3] Sodjinou R, Bosu WK, Fanou N, De Health Action 2014;7:24827. [4] Orimo N, Ueno T, Yoshida H, Sone H, Tanaka A, Itakura H. Nutrition education in Japanese medical schools: a follow-up survey. Asia Pac J Clin Nutr 2013;22: 144e9. M, Balanz J. The [5] S anchez L, García-Lorda P, Bullo a R, Megias I, Salas-Salvado teaching of nutrition at medical schools: current situation. Nutr Hosp 2003;18:153e8. [6] Zivkovic R. Nutrition and dietetics- neglected subjects in medical education. Acta Med Croat 2000;54:129e34. [7] Frantz DJ, McClave SA, Hurt RT, Miller K, Martindale RG. Cross-sectional study of U.S. interns' perceptions of clinical nutrition education. J Parenter Enter Nutr 2016;40:529e35. [8] Gramlich LM, Olstad DL, Nasser R, Goonewardene L, Raman M, Innis S, et al. Medical students' perceptions of nutrition education in Canadian universities. Appl Physiol Nutr Metab 2010;35:336e43. [9] Chung M, van Buul VJ, Wilms E, Nellessen N, Brouns FJ. Nutrition education in European medical schools: results of an international survey. Eur J Clin Nutr 2014;68:844e6. [10] Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in US medical schools: latest update of a national survey. Acad Med 2010;85:1537e42. [11] Underbakke G, McBride PE, Spencer E. Web-based resources for medical nutrition education. Am J Clin Nutr 2006;83:951Se5S.
Cristina Cuerda, MD, PhD, ESPEN Council member* ~o n, Nutrition Unit, Hospital General Universitario Gregorio Maran Madrid, Spain phane M. Schneider, MD, PhD, Chairman of the ESPEN Ste Educational and Clinical Practice Committee Department of Gastroenterology and Clinical Nutrition, Archet Hospital, University of Nice Sophia Antipolis, Nice, France Van Gossum, MD, PhD, Chairman of the ESPEN Executive Andre Committee Department of Gastroenterology, Clinic of Intestinal Diseases and Nutritional Support, Hopital Erasme, Free University of Brussels, Brussels, Belgium * Corresponding author. Nutrition Unit, Hospital General ~o n, Doctor Esquerdo 46, 28007 Universitario Gregorio Maran Madrid, Spain. E-mail address: [email protected] (C. Cuerda).
2 May 2017
Please cite this article in press as: Cuerda C, et al.Clinical nutrition education in medical schools: Results of an ESPEN survey, Clinical Nutrition (2017), http://dx.doi.org/10.1016/j.clnu.2017.05.001
Contents lists available at ScienceDirect
Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu
Editorial
Clinical nutrition education in medical schools: Results of an ESPEN survey
Clinical Nutrition is the discipline that deals with the prevention, diagnosis, and management of nutritional and metabolic changes related to acute and chronic diseases and conditions caused by a lack or excess of energy and nutrients [1]. Nutritionrelated disorders at the two extremes, undernutrition/malnutrition and overweight/obesity, are highly prevalent in many countries and, therefore, should be a priority for policymakers and healthcare professionals. In addition, the most prevalent causes of morbidity and mortality in developed and developing countries are associated with diet. Moreover, disease-related malnutrition has a major impact on global clinical outcomes as well as on the quality of life of patients. Questions on nutrition are probably the most frequent queries a physician receives from patients. Most physicians are unable to correctly identify and intervene in patients who are at risk of malnutrition or malnourished. Regardless of their discipline, all physicians must deal, at some point, with malnourished patients. This highlights the importance of providing adequate clinical nutrition training to all healthcare professionals in order to perform appropriate screening, assessment, and treatment of nutritional problems in all clinical settings. This issue has been approached in many countries in the last few decades, where attempts have been made to improve clinical nutrition education in medical schools [2e6]. However, practising physicians continually rate their nutrition knowledge and skills as inadequate and more than half of graduating medical students report that the time dedicated to clinical nutrition instruction is insufficient [7,8]. The main barriers to delivery of high quality instruction on clinical nutrition include high variability among academic centres, the broad range of areas of medical science in which nutrition education is included, and lack of time in the medical curriculum. This is exacerbated by a widespread movement toward more integrated curricula and problem-based learning that reduce the number of hours that the students spend in traditional lectures and also reduce the enthusiasm and interest of the instructors. Based on these arguments, the European Society for Clinical Nutrition and Metabolism (ESPEN) decided to launch a survey among representatives from all 57 countries on its Council to circulate to different university centres within their countries. A closed questionnaire was created and sent at the end of November 2016. Data were collected from the 1st of December, 2016, to the 28th of February 2017. We received 56 questionnaires from academic centres that were located in 29 countries (50.8% of the target): 22 from Europe, 4 from Asia, 2 from South America, and 1 from Australia (Table 1).
The results of the survey showed that specific instruction on clinical nutrition exists in the majority of university centres (73.3%), being obligatory in 55.4% and elective in 17.9%, with high variability within each country. The number of hours dedicated to clinical nutrition was more than 8 h in 72.5% of centres, between 4 and 8 h in 15%, and less than 4 h in 12.5%. The centres usually offer instruction on clinical nutrition in the final years of the medical curriculum (17.1% in the 5th year, 14.3% in the 4th year), and in 45.7% of the centres, the instruction was imparted over multiple years (vertically integrated). The list of contents covered by clinical nutrition instruction is highly variable among the centres, as is shown in Table 2. Most centres (66.1%) reported that the number of hours dedicated to clinical nutrition education in their institution was inadequate, and 83.4% considered it appropriate to devote more than 8 h to this topic in the curriculum. Table 1 Countries participating in the survey. Country
No. of university centres
Austria Belgium Bulgaria Croatia Denmark England France Finland Germany Greece Ireland Latvia Lithuania Norway Poland Portugal Republic of Macedonia (FYROM) Spain Sweden Switzerland The Netherlands Turkey Indonesia Japan Singapore Sri Lanka Brazil Colombia Australia
1 2 1 1 3 1 2 5 2 1 1 1 1 4 1 1 1 6 4 1 1 1 1 6 1 1 1 3 1
http://dx.doi.org/10.1016/j.clnu.2017.05.001 0261-5614/© 2017 Published by Elsevier Ltd.
Please cite this article in press as: Cuerda C, et al.Clinical nutrition education in medical schools: Results of an ESPEN survey, Clinical Nutrition (2017), http://dx.doi.org/10.1016/j.clnu.2017.05.001
2
Editorial / Clinical Nutrition xxx (2017) 1e2 Table 2 List of contents covered by clinical nutrition curricula. List of contents covered
% centres
Malnutrition/screening Nutritional assessment Nutrient requirements Energy expenditure Enteral nutrition Parenteral nutrition Micronutrients Specific nutrients Disease-related malnutrition/requirements Monitoring Refeeding syndrome Microbiota/probiotics Other (food allergy/intolerance, obesity, eating disorders, dietetic treatment: diabetes, obesity, kidney failure)
84.2 89.5 81.6 76.3 86.8 78.9 63.2 52.6 71.1 47.4 55.3 43.2 24.3
In most universities, clinical nutrition lectures were part of the instruction on different disciplines (paediatrics 60.4%, gastroenterology 54.7%, surgery 53.8%, endocrinology 49.1%, intensive care 43.4%, geriatrics 38.5%, cardiology 24.5%, internal medicine 24.5%, oncology 23.1%, nephrology 20.8%, and others 17%). Our results are comparable to a recent European survey that included 32 medical schools from 10 countries in which nutrition education, in some form, was required in 68.8% of schools, covering, on average, less than 24 h of the curriculum [9]. In another survey in the US that included 109 medical schools, most programs required some form of nutrition education but only 25% of them had a dedicated nutrition course. Overall, medical students received 19.6 contact hours of nutrition instruction during their medical school careers and only 27% of the centres met the minimum 25 required hours set by the National Academy of Sciences [10]. These surveys highlight the fact that clinical nutrition education in medical schools continues to be an important issue with high variability between and within countries. Nutrition instruction must be broad in nature and be vertically integrated across the preclinical and clinical years and continued through postgraduate training. Nutrition teachers must be involved in or, preferably, in charge of these courses. Active adult learning, “hands-on”, and problem-based learning should be practiced whenever possible, moving from traditional teaching to more innovative techniques, including web-based resources [11]. However, we must consider that the results of these surveys are probably biased by the interest in clinical nutrition of the university centres that completed the questionnaire. To our knowledge, there are no specific recommendations for teaching clinical nutrition in the medical curriculum, at least in Europe. In order to improve the knowledge and skills of medical students in the area of clinical nutrition, ESPEN has developed a structured course (pre- Graduate LLL program, http://lllnutrition.com/ course/view.php?id¼806) that consists of 11 essential topics for use by teachers in medical schools. This is in line with the ESPEN mission of promoting knowledge of clinical nutrition worldwide. We hope this effort to improve instruction in clinical nutrition in the medical curriculum will be shared by all national PEN societies.
In conclusion, this survey confirms that education in clinical nutrition in undergraduate medical schools is heterogeneous among university teaching centres and most frequently underpowered.
Acknowledgments We would like to thank all the ESPEN council members and university centres that have contributed to this survey.
References [1] Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017;36:49e64. [2] Donini LM, Leonardi F, Rondanelli M, Banderali G, Battino M, Bertoli E, et al. The domains of human nutrition: the importance of nutrition education in academia and medical schools. Front Nutr 2017;4:2. art L, Kupka R, Tchibindat F, et al. Glob [3] Sodjinou R, Bosu WK, Fanou N, De Health Action 2014;7:24827. [4] Orimo N, Ueno T, Yoshida H, Sone H, Tanaka A, Itakura H. Nutrition education in Japanese medical schools: a follow-up survey. Asia Pac J Clin Nutr 2013;22: 144e9. M, Balanz J. The [5] S anchez L, García-Lorda P, Bullo a R, Megias I, Salas-Salvado teaching of nutrition at medical schools: current situation. Nutr Hosp 2003;18:153e8. [6] Zivkovic R. Nutrition and dietetics- neglected subjects in medical education. Acta Med Croat 2000;54:129e34. [7] Frantz DJ, McClave SA, Hurt RT, Miller K, Martindale RG. Cross-sectional study of U.S. interns' perceptions of clinical nutrition education. J Parenter Enter Nutr 2016;40:529e35. [8] Gramlich LM, Olstad DL, Nasser R, Goonewardene L, Raman M, Innis S, et al. Medical students' perceptions of nutrition education in Canadian universities. Appl Physiol Nutr Metab 2010;35:336e43. [9] Chung M, van Buul VJ, Wilms E, Nellessen N, Brouns FJ. Nutrition education in European medical schools: results of an international survey. Eur J Clin Nutr 2014;68:844e6. [10] Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in US medical schools: latest update of a national survey. Acad Med 2010;85:1537e42. [11] Underbakke G, McBride PE, Spencer E. Web-based resources for medical nutrition education. Am J Clin Nutr 2006;83:951Se5S.
Cristina Cuerda, MD, PhD, ESPEN Council member* ~o n, Nutrition Unit, Hospital General Universitario Gregorio Maran Madrid, Spain phane M. Schneider, MD, PhD, Chairman of the ESPEN Ste Educational and Clinical Practice Committee Department of Gastroenterology and Clinical Nutrition, Archet Hospital, University of Nice Sophia Antipolis, Nice, France Van Gossum, MD, PhD, Chairman of the ESPEN Executive Andre Committee Department of Gastroenterology, Clinic of Intestinal Diseases and Nutritional Support, Hopital Erasme, Free University of Brussels, Brussels, Belgium * Corresponding author. Nutrition Unit, Hospital General ~o n, Doctor Esquerdo 46, 28007 Universitario Gregorio Maran Madrid, Spain. E-mail address: [email protected] (C. Cuerda).
2 May 2017
Please cite this article in press as: Cuerda C, et al.Clinical nutrition education in medical schools: Results of an ESPEN survey, Clinical Nutrition (2017), http://dx.doi.org/10.1016/j.clnu.2017.05.001