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Position of the American dietetic association: Nutrition — an essential component of medical education
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Position of The American Dietetic Association: Nubrition - an essential component of medical education ublic interest in nutrition and demand for nutrition information and services continue to increase. Congressional concern regarding the escalation of health care expenditures is coupled with increased consumer demand for reliable nutrition information and interventions that will improve health and lower medical costs. These and other factors are prompting a renewed interest in nutrition education for physicians. Yet physicians, who are generally regarded as primary nutrition information and education resources, are often ill-prepared to recognize, let alone treat, nutrition problems in their patients (1-3). POSITION STATEMENT The position of The American Dietetic Association is to support the inclusion of education in nutritionas an essential component at all levels of medical education. RATIONALE Compelling evidence documents the central role of nutrition in disease prevention and health promotion (4,5). Eight of the ten most common causes of morbidity and mortality in the United States are linked directly or indirectly to diet. Thus, clinical nutrition is strategically positioned in the health care arena. Interventions that enhance diet quality and improve nutrient intakes may lessen or, in some cases, prevent the pain, sickness, disease, or trauma associated with acute or chronic disease. Nutrition interventions are cost-effective, significantly reducing the economic burden to individual patients and to the health care system as a whole (6-8). The care-effectiveness and cost-effectiveness of nutrition screening, assessment, and intervention are more than adequate justification to educate and train physicians in nutrition theory and practice (9). Physicians must be prepared so that they will be better able to respond to the public outcry for reliable nutrition information. The lay press has noted that the public is increasingly presented with a negative image of the nutrition interest and expertise of physicians (10). This is unfortunate and, in many cases, inaccurate. It is an attitude that encourages the public to seek nutrition information from sources that may be unreliable (11-13). A landmark study of the National Academy of Sciences (1), which was commissioned to evaluate the status of nutrition training and education of our nation's physicians, concluded that nutrition education in US medical schools is inadequate. Although required courses in nutrition were recommended for every medical school in the country, recent surveys document a downward trend in the number of required courses offered (2). Participation
Approved by the House of Delegates on October 26, 1986, and reaffirmed on September 10, 1993, with updates to be in effect until October 1998. The American Dietetic Association authorizes republication of this Position Paper, in its entirety, provided full and proper credit is given.
by medical students in elective nutrition courses nationwide is sporadic at best. Faculty in medical schools that have chosen to educate by integrating nutrition information into other courses, into clerkships, or via case presentations face challenges such as time constraints and development of course content that are unique and often insurmountable. Residency and fellowship training are additional points in the medical education continuum where nutrition education may be inserted. Postgraduate medical education settings present a separate set of challenges for nutrition educators (14). Continuing education in nutrition offered for practicing physicians must disseminate new information to augment that acquired during prior training, remediate deficits in the existing knowledge base, and enhance services delivery skills (15). Barriers to the incorporation of nutrition education into training programs for physicians are numerous, but are generally categorized under the headings of inadequate administrative support, competition for curricular time, lack of qualified and active faculty, inadequate physician or practice-based role models, lack of consensus regarding appropriate curricular elements, and inadequate funding (2,14). The lack of professional reimbursement or incentives for delivery of nutrition services is also problematic. These barriers can be overcome, to a certain extent, when nutrition education programs for physicians are tailored to fit the faculty, resources, and specific needs of sponsoring institutions. Curricular content must also be structured to use available resources and address site-specific needs. KEY POINTS The content of nutrition education programs for physicians should focus on issues relevant to the physician's area of practice (15,16). Realistic expectations regarding the physician's role in the recognition and management of patients' nutrition needs must be maintained. A definition of terms and expectations regarding the knowledge base and skills level of physicians receiving nutrition education must be developed. For example, when physicians state that they "counsel patients regarding nutrition," the services delivered are considerably different from those provided by dietetics professionals providing nutrition consultation. Yet all too often we fail to differentiate or to appreciate the distinct role that each should play in the provision of nutrition care. The knowledge base, skills level, and outcome expectations for the primary care physician who assesses and treats nutrition problems in the context of a busy office practice are, and should be, considerably different from those for the physician nutritionist or dietetics professional whose primary area of expertise is provision of nutrition care. The value of consultative relationships in the provision of nutrition services must be taught in this as in other areas of medical practice. Nutrition professionals are integral to the successful implementation of complex intervention strategies. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 555
.ADA
E WPORTS PORTS ORT................................................. ............... ADA
Opportunitiesforincorporationof nutritioneducation, including types of learning experiences and potential educators, at various levels of medical education Premedical Nutrition Education The premedical years are a time to emphasize the basic principles of normal nutrition during all stages of the life cycle, primary preventive nutrition strategies, and food sources of nutrients. A supervised self-assessment of dietary habits and food preferences and a redirection of identified problem behaviors can serve as positive, attitude-forming learning experiences at this preliminary stage of professional development (16,17). Courses in basic nutrition, when available, should be aggressively marketed to the faculties of premedical and related disciplines, to curriculum counselors and student advisers, and to students themselves. Nutrition education should also be provided in association with food-related campus activities, such as cafeteria or restaurant foodservice and selected social functions where food is served. Nutrition education opportunities are available to dietetics students and faculty in the role of peer health/nutrition counselors and as providers of nutrition education and information in dormitories, at campus health fairs, and at student health and recreation centers. Campus publications and broadcasting facilities offer opportunities to provide nutrition education to the student and faculty population at large. They can also be used to provide targeted messages to selected audiences. Medical School Nutrition Education During medical school, nutrition education should be incorporated into both the basic sciences and clinical curriculums, and sequenced over the 4-year medical curriculum to parallel other phases of medical education. Courses specifically focused on nutrition are strongly recommended (1,2,16,18-20). Alternatives include required modules or problem sets within primary care, physical diagnosis, or other required courses. Mandating discrete courses or course constituents supports a systematic and integrated approach to nutrition education and emphasizes nutrition as an integral aspect of medical education. The National Cancer Institute has supported the development and testing of teaching methodologies in nutrition for students through its R25 Program (14). A review of the outcomes of this program may be helpful. During the majority of clinical rotations, medical students should have opportunity to apply preventive and therapeutic 556 / MAY 1994 VOLUME 94 NUMBER 5
principles learned in didactic settings to a wide variety of specific clinical situations. Case-based simulations are a useful and wellaccepted adjunct to didactic course offerings. Physicians cognizant of the significance of nutrition and effective physiciandietitian team models are needed to accomplish this task. Many potential formal and informal educational opportunities in the medical school setting are unrecognized or underused by dietetics professionals employed in these settings. Registered dietitians are encouraged to assume a more active role in the provision of seminars, grand rounds, teaching rounds, clinical case presentations and conferences, preceptorships, and patient care interactions that offer the opportunity for educational outreach in the context of the delivery of patient care (16). Graduate (Residency/Fellowship) Nutrition Education Physicians should receive targeted nutrition education during graduate training (residency/fellowship). Nutrition education should center on the recognition and management of nutritional risk factors in diseases and conditions common to the physician's area of specialization. Nutrition education should also encompass the design, implementation, evaluation, and modification of preventive and therapeutic measures appropriate to the chosen discipline of the physician (21,22). The initiation, development, or, at a minimum, participation in clinical nutrition research projects or projects that include a nutrition component is the ideal (9). Opportunities to attain national certification in nutrition for physicians should be promoted and expanded. Medical residency/fellowship programs are encouraged to use registered dietitians/clinical nutritionists with advanced degrees to provide physician education in the context of direct patient care. Residents and fellows in programs that provide training in nutrition can serve as role models. The clinical application of nutrition principles and the appropriate use of dietetics professionals in the delivery of patient care are skills that can be effectively demonstrated and taught through peer interaction. The discipline of family practice has provided leadership in mandating nutrition education for practitioners and in the effective use of physician-dietitian teams to accomplish nutrition education and patient care goals (15).
Nutrition in Continuing Medical Education A lifelong commitment to the enhancement of basic nutrition knowledge and skills by all physicians is the ideal. Nutrition education can be provided to practicing physicians on a continuing basis via critical review and distribution of relevant nutrition literature and provision of structured courses, self-study modules, videocassettes and audiocassettes, computer-assisted learning devices, and other traditional and nontraditional continuing education resources (1,2,16-20). Dietetics practioners can also provide continuing education in nutrition to physicians on a more informal level through the daily interactions that surround the delivery of patient care (22-25). Examples of such interactions include, but are not limited to, daily rounds in institutional settings, participation on the patient care team, quality assurance activities, and outpatient education and counseling opportunities in clinics, private offices, and managed-care settings. The nutrition education potential is limitless!
ROLE/RESPONSIBILITY OF THE DIETETICS PROFESSIONAL Physicians view their registered dietitian colleagues as credible sources of nutrition information (15,23,24). Collegial relationships and referral networks currently exist (17-22, 25-27) and serve as models for formal and informal educational outreach and optimal delivery of nutrition services. Opportunities to reach an even greater segment of the physician community abound in this milieu (Figure). The preprofessional and continuing educational preparation of dietetics professionals must include didactic and experiential components that prepare them to become effective physician educators. Members of The American Dietetic Association must then capitalize on the abundance of educational outreach options available to them at all levels of medical education.
SUMMARY The public is increasingly nutrition conscious and actively seeks reliable sources of nutrition education. Physicians with appropriate training in nutrition can and should be a powerful force in providing accurate nutrition information and quality health care. As physician educators, dietetics professionals can facilitate this outcome. Appropriate use of nutrition resources and professionals will efficiently and effectively maintain or improve the nutritional statusof the public and, ultimately, the health of our nation.
References 1. Committee on Nutrition in Medical Education, Food and Nutrition Board, National Research Council. NutritionEducation in US Medi-
cal Schools. Washington, DC: National Academy Press; 1985. 2. Young EA. National Dairy Council Award for Excellence in Medical/ Dental Nutrition Education Lecture, 1992: perspectives on nutrition in medical education. Am J Clin Nutr. 1992; 56: 45-51. 3. Association of American Medical Colleges. Physicians for the twentyfirst century. The CPEP Report: report of the panel on the general professional education of the physician and college preparation for medicine. JMed Educ. 1984; 59(suppl). 4. TheSurgeon General'sReportonNutritionandHealth.Washington, DC: US Dept of Health and Human Services, Public Health Service; 1988. DHHS (PHS) publication No. 8-50210. 5. Committee on Diet and Health. Diet and Health: Implicationsfor Reducing ChronicDisease Risk. Washington, DC: National Academy Press; 1991. 6. Reilly JJ Jr, Hull SF, Albert N, Waller A, Bringardener S. Economic impact of malnutrition: a model system for hospitalized patients. JPEN. 1988;12:371-376. 7. Coats KG, Morgan SL, Bartolucci AA, Weinsier RL. Hospital-associated malnutrition: a reevaluation 12 years later. JAmDietAssoc. 1993; 93:27-33. 8. Health care reform legislative platform: economic benefits of nutrition services. JAm DietAssoc. 1993; 93:686-690.
9. HearingtoReview theNutritionResearchandEducationActivities Before the Subcommittee on Department OperationsandNutrition of the House of Representatives Committee on Agriculture, 103rd Cong, 1st Sess (1993) (testimony of E.A. Young, PhD, RD, LD). 10. Schollar A. Why med students miss their minimum daily requirement of nutrition education. New Physician. 1989; 38:16-21. 11. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs and use of. NEngl JMed. 1993; 328:246-252 12. Campion EW. Why unconventional medicine? N Engl J Med. 1993;328: 282-283. 13. Green S. A critique of the rationale for cancer treatment with coffee enemas and diet. JAMA. 1992; 268:3224-3227. 14. Bruer RA, Schmidt RE, Chapel T. NutritionEducationforPhysicians. Alternative FederalRolesfor Creatingan Improved System. Washington, DC: Richard Schmidt Associates, Ltd, and Macro International, Inc; 1993. 15. American Academy of Family Physicians Foundation and Society of Teachers of Family Medicine. Report on the National Conference on NutritionEducationin Family Medicine. Kansas City, Mo: American Academy of Family Physicians; 1990. 16. Position of The American Dietetic Association: Nutrition-essential component of medical education. JAmDietAssoc. 1987;87:642-647. 17. Levine BA, Wigren MM, Chapman DS, Kerner JF, Bergman RL, Rivlin RS. A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of clinical nutritionin medical practice.AmJ ClinNutr. 1993; 57:115-119. 18. Kushner RF, Thorp FK, Edwards J, Weinsier RL, Brooks CM. Implementing nutrition into the medical curriculum: a user's guide.Am J Clin Nutr. 1990; 52:401-403. 19. American Society of Clinical Nutrition Committee on Medical/ Dental School and Residency Nutrition Education. Priorities for nutrition content within a medical school curriculum: a national consensus of medical educators. Acad Med. 1990; 65:538-540. 20. Feldman EB. Educating physicians in nutrition -a view of the past, the present, and the future. Am J Clin Nutr. 1991; 54:618-622. 21. Society of Teachers of Family Medicine. Recommended core educational guidelines on nutrition for family practice residents. AAFP Reporter August 1989. Reprint no. 274. 22. Lasswell AB. Incorporating nutrition into pediatric practice: physicians and dietitians working together to improve children's health. PediatrAnn. 1992; 21:676-687 23. Gaare J, Maillet JO, King D, Gilbride J. Perceptions of clinical decision making by physicians and dietitians. JAm Diet Assoc. 1990; 90:54-58. 24. Rosen O, Downes NJ, Sucher KP, Shifflett B. Physician's perceptions of the role of clinical dietitians are changing. J Am Diet Assoc. 1991; 91:1074-1077. 25. White JV, Dwyer JT, Wellman NS, Blackburn GL, Barrocas A, Chernoff R, Cohen D, Lysen L, Moore S, Moyer B, Pla G, Roe D. Beyond nutrition screening: a systems approach to nutrition intervention. Challenges and opportunity for dietetics professionals. J Am Diet Assoc. 1993; 93:405-407. 26. SkipperA, Young M, Rotman N, Nagl H. Physicians' implementation of dietitians' recommendations: a study of the effectiveness of dietitians. JAm Diet Assoc. 1994; 94:45-49. 27. Murphy PS. Nutrition activities of physicians in their family practice setting: changes following a continuing education nutrition program. J Can Diet Assoc. 1993; 54(4):208-211.
* ADA Position adopted by the House of Delegates on October 26, 1986, and reaffirmed on September 10, 1993. The update will be in effect until October 1998. * Recognition is given to the following for their contributions: Authors: Jane V. White, PhD, RD; Eleanor Young, PhD, RD; and Anita Lasswell, MS, RD Reviewers: Ronni Chernoff, PhD, RD; Gerald Keller, MD; Sylvia Moore, PhD, RD; Sara Morgan, MD, RD; Nutrition Educators of Health Professionals dietetic practice group. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 557
Position of The American Dietetic Association: Nubrition - an essential component of medical education ublic interest in nutrition and demand for nutrition information and services continue to increase. Congressional concern regarding the escalation of health care expenditures is coupled with increased consumer demand for reliable nutrition information and interventions that will improve health and lower medical costs. These and other factors are prompting a renewed interest in nutrition education for physicians. Yet physicians, who are generally regarded as primary nutrition information and education resources, are often ill-prepared to recognize, let alone treat, nutrition problems in their patients (1-3). POSITION STATEMENT The position of The American Dietetic Association is to support the inclusion of education in nutritionas an essential component at all levels of medical education. RATIONALE Compelling evidence documents the central role of nutrition in disease prevention and health promotion (4,5). Eight of the ten most common causes of morbidity and mortality in the United States are linked directly or indirectly to diet. Thus, clinical nutrition is strategically positioned in the health care arena. Interventions that enhance diet quality and improve nutrient intakes may lessen or, in some cases, prevent the pain, sickness, disease, or trauma associated with acute or chronic disease. Nutrition interventions are cost-effective, significantly reducing the economic burden to individual patients and to the health care system as a whole (6-8). The care-effectiveness and cost-effectiveness of nutrition screening, assessment, and intervention are more than adequate justification to educate and train physicians in nutrition theory and practice (9). Physicians must be prepared so that they will be better able to respond to the public outcry for reliable nutrition information. The lay press has noted that the public is increasingly presented with a negative image of the nutrition interest and expertise of physicians (10). This is unfortunate and, in many cases, inaccurate. It is an attitude that encourages the public to seek nutrition information from sources that may be unreliable (11-13). A landmark study of the National Academy of Sciences (1), which was commissioned to evaluate the status of nutrition training and education of our nation's physicians, concluded that nutrition education in US medical schools is inadequate. Although required courses in nutrition were recommended for every medical school in the country, recent surveys document a downward trend in the number of required courses offered (2). Participation
Approved by the House of Delegates on October 26, 1986, and reaffirmed on September 10, 1993, with updates to be in effect until October 1998. The American Dietetic Association authorizes republication of this Position Paper, in its entirety, provided full and proper credit is given.
by medical students in elective nutrition courses nationwide is sporadic at best. Faculty in medical schools that have chosen to educate by integrating nutrition information into other courses, into clerkships, or via case presentations face challenges such as time constraints and development of course content that are unique and often insurmountable. Residency and fellowship training are additional points in the medical education continuum where nutrition education may be inserted. Postgraduate medical education settings present a separate set of challenges for nutrition educators (14). Continuing education in nutrition offered for practicing physicians must disseminate new information to augment that acquired during prior training, remediate deficits in the existing knowledge base, and enhance services delivery skills (15). Barriers to the incorporation of nutrition education into training programs for physicians are numerous, but are generally categorized under the headings of inadequate administrative support, competition for curricular time, lack of qualified and active faculty, inadequate physician or practice-based role models, lack of consensus regarding appropriate curricular elements, and inadequate funding (2,14). The lack of professional reimbursement or incentives for delivery of nutrition services is also problematic. These barriers can be overcome, to a certain extent, when nutrition education programs for physicians are tailored to fit the faculty, resources, and specific needs of sponsoring institutions. Curricular content must also be structured to use available resources and address site-specific needs. KEY POINTS The content of nutrition education programs for physicians should focus on issues relevant to the physician's area of practice (15,16). Realistic expectations regarding the physician's role in the recognition and management of patients' nutrition needs must be maintained. A definition of terms and expectations regarding the knowledge base and skills level of physicians receiving nutrition education must be developed. For example, when physicians state that they "counsel patients regarding nutrition," the services delivered are considerably different from those provided by dietetics professionals providing nutrition consultation. Yet all too often we fail to differentiate or to appreciate the distinct role that each should play in the provision of nutrition care. The knowledge base, skills level, and outcome expectations for the primary care physician who assesses and treats nutrition problems in the context of a busy office practice are, and should be, considerably different from those for the physician nutritionist or dietetics professional whose primary area of expertise is provision of nutrition care. The value of consultative relationships in the provision of nutrition services must be taught in this as in other areas of medical practice. Nutrition professionals are integral to the successful implementation of complex intervention strategies. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 555
.ADA
E WPORTS PORTS ORT................................................. ............... ADA
Opportunitiesforincorporationof nutritioneducation, including types of learning experiences and potential educators, at various levels of medical education Premedical Nutrition Education The premedical years are a time to emphasize the basic principles of normal nutrition during all stages of the life cycle, primary preventive nutrition strategies, and food sources of nutrients. A supervised self-assessment of dietary habits and food preferences and a redirection of identified problem behaviors can serve as positive, attitude-forming learning experiences at this preliminary stage of professional development (16,17). Courses in basic nutrition, when available, should be aggressively marketed to the faculties of premedical and related disciplines, to curriculum counselors and student advisers, and to students themselves. Nutrition education should also be provided in association with food-related campus activities, such as cafeteria or restaurant foodservice and selected social functions where food is served. Nutrition education opportunities are available to dietetics students and faculty in the role of peer health/nutrition counselors and as providers of nutrition education and information in dormitories, at campus health fairs, and at student health and recreation centers. Campus publications and broadcasting facilities offer opportunities to provide nutrition education to the student and faculty population at large. They can also be used to provide targeted messages to selected audiences. Medical School Nutrition Education During medical school, nutrition education should be incorporated into both the basic sciences and clinical curriculums, and sequenced over the 4-year medical curriculum to parallel other phases of medical education. Courses specifically focused on nutrition are strongly recommended (1,2,16,18-20). Alternatives include required modules or problem sets within primary care, physical diagnosis, or other required courses. Mandating discrete courses or course constituents supports a systematic and integrated approach to nutrition education and emphasizes nutrition as an integral aspect of medical education. The National Cancer Institute has supported the development and testing of teaching methodologies in nutrition for students through its R25 Program (14). A review of the outcomes of this program may be helpful. During the majority of clinical rotations, medical students should have opportunity to apply preventive and therapeutic 556 / MAY 1994 VOLUME 94 NUMBER 5
principles learned in didactic settings to a wide variety of specific clinical situations. Case-based simulations are a useful and wellaccepted adjunct to didactic course offerings. Physicians cognizant of the significance of nutrition and effective physiciandietitian team models are needed to accomplish this task. Many potential formal and informal educational opportunities in the medical school setting are unrecognized or underused by dietetics professionals employed in these settings. Registered dietitians are encouraged to assume a more active role in the provision of seminars, grand rounds, teaching rounds, clinical case presentations and conferences, preceptorships, and patient care interactions that offer the opportunity for educational outreach in the context of the delivery of patient care (16). Graduate (Residency/Fellowship) Nutrition Education Physicians should receive targeted nutrition education during graduate training (residency/fellowship). Nutrition education should center on the recognition and management of nutritional risk factors in diseases and conditions common to the physician's area of specialization. Nutrition education should also encompass the design, implementation, evaluation, and modification of preventive and therapeutic measures appropriate to the chosen discipline of the physician (21,22). The initiation, development, or, at a minimum, participation in clinical nutrition research projects or projects that include a nutrition component is the ideal (9). Opportunities to attain national certification in nutrition for physicians should be promoted and expanded. Medical residency/fellowship programs are encouraged to use registered dietitians/clinical nutritionists with advanced degrees to provide physician education in the context of direct patient care. Residents and fellows in programs that provide training in nutrition can serve as role models. The clinical application of nutrition principles and the appropriate use of dietetics professionals in the delivery of patient care are skills that can be effectively demonstrated and taught through peer interaction. The discipline of family practice has provided leadership in mandating nutrition education for practitioners and in the effective use of physician-dietitian teams to accomplish nutrition education and patient care goals (15).
Nutrition in Continuing Medical Education A lifelong commitment to the enhancement of basic nutrition knowledge and skills by all physicians is the ideal. Nutrition education can be provided to practicing physicians on a continuing basis via critical review and distribution of relevant nutrition literature and provision of structured courses, self-study modules, videocassettes and audiocassettes, computer-assisted learning devices, and other traditional and nontraditional continuing education resources (1,2,16-20). Dietetics practioners can also provide continuing education in nutrition to physicians on a more informal level through the daily interactions that surround the delivery of patient care (22-25). Examples of such interactions include, but are not limited to, daily rounds in institutional settings, participation on the patient care team, quality assurance activities, and outpatient education and counseling opportunities in clinics, private offices, and managed-care settings. The nutrition education potential is limitless!
ROLE/RESPONSIBILITY OF THE DIETETICS PROFESSIONAL Physicians view their registered dietitian colleagues as credible sources of nutrition information (15,23,24). Collegial relationships and referral networks currently exist (17-22, 25-27) and serve as models for formal and informal educational outreach and optimal delivery of nutrition services. Opportunities to reach an even greater segment of the physician community abound in this milieu (Figure). The preprofessional and continuing educational preparation of dietetics professionals must include didactic and experiential components that prepare them to become effective physician educators. Members of The American Dietetic Association must then capitalize on the abundance of educational outreach options available to them at all levels of medical education.
SUMMARY The public is increasingly nutrition conscious and actively seeks reliable sources of nutrition education. Physicians with appropriate training in nutrition can and should be a powerful force in providing accurate nutrition information and quality health care. As physician educators, dietetics professionals can facilitate this outcome. Appropriate use of nutrition resources and professionals will efficiently and effectively maintain or improve the nutritional statusof the public and, ultimately, the health of our nation.
References 1. Committee on Nutrition in Medical Education, Food and Nutrition Board, National Research Council. NutritionEducation in US Medi-
cal Schools. Washington, DC: National Academy Press; 1985. 2. Young EA. National Dairy Council Award for Excellence in Medical/ Dental Nutrition Education Lecture, 1992: perspectives on nutrition in medical education. Am J Clin Nutr. 1992; 56: 45-51. 3. Association of American Medical Colleges. Physicians for the twentyfirst century. The CPEP Report: report of the panel on the general professional education of the physician and college preparation for medicine. JMed Educ. 1984; 59(suppl). 4. TheSurgeon General'sReportonNutritionandHealth.Washington, DC: US Dept of Health and Human Services, Public Health Service; 1988. DHHS (PHS) publication No. 8-50210. 5. Committee on Diet and Health. Diet and Health: Implicationsfor Reducing ChronicDisease Risk. Washington, DC: National Academy Press; 1991. 6. Reilly JJ Jr, Hull SF, Albert N, Waller A, Bringardener S. Economic impact of malnutrition: a model system for hospitalized patients. JPEN. 1988;12:371-376. 7. Coats KG, Morgan SL, Bartolucci AA, Weinsier RL. Hospital-associated malnutrition: a reevaluation 12 years later. JAmDietAssoc. 1993; 93:27-33. 8. Health care reform legislative platform: economic benefits of nutrition services. JAm DietAssoc. 1993; 93:686-690.
9. HearingtoReview theNutritionResearchandEducationActivities Before the Subcommittee on Department OperationsandNutrition of the House of Representatives Committee on Agriculture, 103rd Cong, 1st Sess (1993) (testimony of E.A. Young, PhD, RD, LD). 10. Schollar A. Why med students miss their minimum daily requirement of nutrition education. New Physician. 1989; 38:16-21. 11. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs and use of. NEngl JMed. 1993; 328:246-252 12. Campion EW. Why unconventional medicine? N Engl J Med. 1993;328: 282-283. 13. Green S. A critique of the rationale for cancer treatment with coffee enemas and diet. JAMA. 1992; 268:3224-3227. 14. Bruer RA, Schmidt RE, Chapel T. NutritionEducationforPhysicians. Alternative FederalRolesfor Creatingan Improved System. Washington, DC: Richard Schmidt Associates, Ltd, and Macro International, Inc; 1993. 15. American Academy of Family Physicians Foundation and Society of Teachers of Family Medicine. Report on the National Conference on NutritionEducationin Family Medicine. Kansas City, Mo: American Academy of Family Physicians; 1990. 16. Position of The American Dietetic Association: Nutrition-essential component of medical education. JAmDietAssoc. 1987;87:642-647. 17. Levine BA, Wigren MM, Chapman DS, Kerner JF, Bergman RL, Rivlin RS. A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of clinical nutritionin medical practice.AmJ ClinNutr. 1993; 57:115-119. 18. Kushner RF, Thorp FK, Edwards J, Weinsier RL, Brooks CM. Implementing nutrition into the medical curriculum: a user's guide.Am J Clin Nutr. 1990; 52:401-403. 19. American Society of Clinical Nutrition Committee on Medical/ Dental School and Residency Nutrition Education. Priorities for nutrition content within a medical school curriculum: a national consensus of medical educators. Acad Med. 1990; 65:538-540. 20. Feldman EB. Educating physicians in nutrition -a view of the past, the present, and the future. Am J Clin Nutr. 1991; 54:618-622. 21. Society of Teachers of Family Medicine. Recommended core educational guidelines on nutrition for family practice residents. AAFP Reporter August 1989. Reprint no. 274. 22. Lasswell AB. Incorporating nutrition into pediatric practice: physicians and dietitians working together to improve children's health. PediatrAnn. 1992; 21:676-687 23. Gaare J, Maillet JO, King D, Gilbride J. Perceptions of clinical decision making by physicians and dietitians. JAm Diet Assoc. 1990; 90:54-58. 24. Rosen O, Downes NJ, Sucher KP, Shifflett B. Physician's perceptions of the role of clinical dietitians are changing. J Am Diet Assoc. 1991; 91:1074-1077. 25. White JV, Dwyer JT, Wellman NS, Blackburn GL, Barrocas A, Chernoff R, Cohen D, Lysen L, Moore S, Moyer B, Pla G, Roe D. Beyond nutrition screening: a systems approach to nutrition intervention. Challenges and opportunity for dietetics professionals. J Am Diet Assoc. 1993; 93:405-407. 26. SkipperA, Young M, Rotman N, Nagl H. Physicians' implementation of dietitians' recommendations: a study of the effectiveness of dietitians. JAm Diet Assoc. 1994; 94:45-49. 27. Murphy PS. Nutrition activities of physicians in their family practice setting: changes following a continuing education nutrition program. J Can Diet Assoc. 1993; 54(4):208-211.
* ADA Position adopted by the House of Delegates on October 26, 1986, and reaffirmed on September 10, 1993. The update will be in effect until October 1998. * Recognition is given to the following for their contributions: Authors: Jane V. White, PhD, RD; Eleanor Young, PhD, RD; and Anita Lasswell, MS, RD Reviewers: Ronni Chernoff, PhD, RD; Gerald Keller, MD; Sylvia Moore, PhD, RD; Sara Morgan, MD, RD; Nutrition Educators of Health Professionals dietetic practice group. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 557