The White Paper Section 3

American Society for Clinical Nutrition (ASCN)

ASCN Standing Committees
The Committee on Professional Nutrition Education monitors national events affecting nutrition education, reports on these events, and makes recommendations to further the society’s goals in promoting undergraduate and graduate nutrition education. The committee interacts with the American Board of Nutrition (ABN) and other relevant groups to develop criteria for nutrition training programs and to set standards for evaluating such programs. A list of clinical nutrition training programs is compiled with criteria for evaluating them. The committee includes liaisons from the American Dental Association, the American Medical Association, and the American Medical Student Association.

Nutrition Topics Essential in a Medical School Curriculum in Priority Order
(Adapted from: Weinsier RL et al. Am J Clin nutr 1989;50:707-12)

Ranking	Topic
1	Obesity Diet, hyperlipidemia, and atherosclerosis Lipids (including cholesterol) Diet and Diabetes Pregnancy, lactation Water, electrolytes, and acid-base balance Major minerals
2	Carbohydrates, fiber Vitamins Proteins and amino acids Cell growth, infancy, adolescence Nutrition and immunity
3	Nutritional assessment and support; hospital malnutrition Nutrition in surgery, trauma, and infection Diet and hypertension Body weight, body composition and energy balance Geriatrics Nutrition and cancer The gastrointestinal tract: an overview of function Criteria of an adequate diet Nutrition in diseases of the oral cavity and gastrointestinal tract Hormonal control of nutrient metabolism
4	Nutritional anemias Drug-nutrient interactions Trace minerals Nutrition and alcohol, other substance abuse

American Board of Nutrition

Purpose
The American Board of Nutrition (ABN) is an independent credentialing organization which was established in 1948. It certifies Specialists in Clinical Nutrition and Human Nutrition. The purpose of the American Board of Nutrition is to establish standards for the qualification of persons as Specialists in the fields of Clinical Nutrition and Human Nutrition, and to certify as such those persons who comply with the standards.

ABN Certification Exam Topic Priorities
The ABN has established the following general outline to guide the ABN Examination Committee in the preparation of the ABN certification examinations. …the prioritization of topics is outlined below to assist you in your preparation for this section of the examination. That is, the highest priority topics generally have the largest number of test items.

Priority Level 1 Body Weight, Body Composition, Energy Metabolism Proteins and Amino Acids Carbohydrates and Fiber Vitamins Major Minerals Nutritional Assessment and SupportPriority Level 2 Gastrointestinal Tract Function Lipids Trace Minerals Pregnancy and Lactation Growth and Development Stress, Immunity, AIDS Hyperlipidemia, Coronary Artery Disease Diabetes Mellitus ObesityPriority Level 3 Geriatrics Gastrointestinal Disease Priority Level 4 Water, Electrolytes, Acid-Base Balance Dietary Goals, RDA’s Cancer Alcohol, Other Substance Abuse Nutritional Anemias

Priority Level 5 Hormonal Control of Nutrient Metab. HypertensionPriority Level 6 Food Fads, Health Food Trends, Vegetarianism Diet & Allergy Eating Disorders Priority Level 7 World Food Supply, Hunger Food Contamination Effects of Food Processing on Nutritional Values of Foods Chemical Additives in Foods Exercise and Environmental Stress Renal Disease Inborn Errors of Metabolism Skeletal & Connective Tissue Disorders Neurological Disorders Handicapped Conditions & Rehabilitation Drug-Nutrient InteractionsPriority Level 8 General Aspects of Nutrition Hunger & Satiety Other Endocrine Disorders

American College of Nutrition

Objectives
To enhance knowledge of nutrition and metabolism and the application of such knowledge to the maintenance of health and the treatment of disease.

To provide an organization which encompasses the needs of professionals from all disciplines with a common interest in nutrition.

To provide a forum where an interchange of views, professional and educational experiences, and research results in the general field of nutrition which may be conducted in an atmosphere of professional congeniality.

To encourage the incorporation of a strong, clearly defined nutrition teaching module in the curriculum of all medical schools and to encourage the inclusion of nutritional education in medical post graduate training.

To promote educational programs at all levels and provide advocacy support for non MD nutrition professionals.

Certification Board for Nutrition Specialists (CBNS)

The CBNS is the only organization providing voluntary certification to all professional nutritionists with advanced training in nutrition science. In addition to nutritionists at the doctoral level, the CBNS offers certification to registered dietitians, pharmacists, nurses and other health professionals with graduate degrees in nutrition with significant experience as professional nutritionists.

American Society for Parenteral and Enteral Nutrition

ASPEN established the National Board of Nutrition Support Certification, Incorporated (NBNSC) in 1984 as an independent credentialing board to administer certification programs in specialized nutrition support. The NBNSC certification program is designed to: establish the body of knowledge necessary for certification, test through written examination the common body of knowledge necessary to deliver parenteral or enteral nutrition support, recognize specialty knowledge by granting certification to successful candidates, and promote continual professional development of individuals delivering nutrition services. The NBNSC currently has available certification programs for nurses, physicians, and dietitians.

The NBNSC, Incorporated Website

Mission Statement (from website document)
To promote the enhanced delivery of safe and effective nutritional care through the certification of qualified clinicians practicing nutrition support.

Objectives
Recognizing formally those individuals who meet eligibility requirements of the National Board of Nutrition Support Certification and pass the Certification Examination for Nutrition Support Physicians.

Encouraging continued professional growth in the practice of nutrition support.

Establishing and measuring the level of knowledge required for certification of physicians practicing nutrition support.

Providing a standard of specialty knowledge deemed appropriate for physicians practicing nutrition support; thereby assisting the employer, public, and members of the health professions in the assessment of physicians practicing nutrition support.

Content Outline of the Examination for Nutrition Support Physicians is:

• Nutrition assessment and reassessment – 20%
• Therapeutic plan – 35%
• Implementation -15%
• Patient monitoring and evaluation – 25%

American Dietetics Association

Position of The American Dietetic Association:
Nutrition education for health care professionals.
(Adapted from Website: http://www.eatright.org/)

POSITION STATEMENT (annotated from website document)
It is the position of The American Dietetic Association that nutrition education is an essential component of the curricula for the majority of health care professionals. Curricula should include nutrition principles and identification of nutrition risk factors for appropriate and timely referral to a qualified dietetics professional for comprehensive nutrition services.

Nutrition education in the curricula of various programs of health professions should be commensurate with the nutrition competencies essential for such professionals to carry out their roles in the health management of clients (1-9). …the Society of Teachers of Family Medicine strongly supports the inclusion of nutrition in the curriculum for family physicians (10). …current professional literature provides suggestions on nutrition education for a variety of health professions, such as nursing (including midwives), dentistry, physical therapy, medicine (including physician assistants), and home health aides (1-9).

RECOMMENDATIONS FOR NUTRITON CURRICULA
The Table provides a suggested listing of screening, assessment, education, counseling, and referral responsibilities for health care professionals Practitioners’ responsibilities drive the educational curriculum. The content of the curriculum to achieve the skills listed in the Table varies by category. Curricula for primary care providers need to be more extensive because these providers diagnose nutrition disorders, prescribe diets, and provide preliminary counseling on specific nutrition needs. The focus of such curricula should be to provide skill development to enable primary care providers to improve the nutritional health of the public through early recognition of the need for medical nutrition therapy, suitable direct education or basic counseling, and appropriate referral to qualified dietetics professionals. Since the early 1950s, numerous reports on the status and importance of nutrition in medical education have been published. However, competition for curriculum time has limited the implementation of nutrition courses in medical education. Recently, several foundations and government agencies have funded model programs to promote the integration of comprehensive nutrition education into the medical curriculum (6,11,12). Rock (13), for example, has proposed content for a residency program

SUMMARY
The curriculum needs for teaching nutrition in health care professional education programs are determined on the basis of the nutrition services that future practitioners will provide within the scope of their practice. The shift in health care to earlier intervention and increased ambulatory care services makes it necessary that health practitioners be able to identify nutrition risk and recognize when it is necessary to refer a patient to a registered dietitian for medical nutrition therapy and intervention. The majority of health care providers need initial and continual lifelong learning about comprehensive nutrition services to enhance the nutritional health of the public. The nutrition-related skills required by various health care providers need to be identified and a curriculum specific to the type of care provided needs to be developed. The competencies expected of health care professionals will continue to evolve, but a foundation for quality entry-level and continuing nutrition education should be developed for all health practitioners.

Table Aspects of nutrition care that health care practitioner education programs should include, by amount of patient education responsibility. (Adapted from Website: http://www.eatright.org/)
	Nutrition education responsibilities
Aspect of nutrition care	Minimala	Limitedb	Broadc	Extensived
Screen for nutrition risk	X	X	X	X
Assess nutritional health
Reinforce message of the importance of nutrition to health	X	X	X	X
Reinforce that nutrient needs differ by person and at different points throughout the lifespan			X	X
Educate about public health Nutrition guidelines and the use of nutrition as a complementary therapy			X	X
Prescribe diets, including enteral and parenteral nutrition				X
Counsel on specific nutrition needs				X
Educate on nutrition principles that relate closely to a specific discipline			X	X
Refer to a registered dietitian for in-depth nutrition evaluation or counseling			X	X

^a Includes practitioners with beyond-high-school certificates such as home health aides and patient care assistants.

^b Includes practitioners with a limited role in patient education such as diagnostic imaging professionals and vascular technologists.

^c Includes practitioners with a large role in patient education such as physical and occupational therapists, nurses, and respiratory therapists.

^d Includes primary care providers such as family practitioners, internal medicine physicians, obstetricians and pediatricians, midwives, nurse practitioners, and physician assistants and medical specialists such as cardiologists, oncologists, nephrologists, and surgeons.

References

1. Fitz P. Nutrition education of health care professionals and paraprofessionals. Top Clin Nutr. 1997;12:1-3.
2. Weigley E. Nutrition in baccalaureate nursing education and beginning clinical nursing practice. Top Clin Nutr. 1997;12:8-14.
3. Morse W. Incorporating nutrition in a baccalaureate nursing curriculum: one school’s experience. Top Clin Nutr. 1997;12:15-22.
4. Touger-Decker R, Gilbride J. Nutrition education of dental students and professionals. Top Clin Nutr. 1997;12:23-32.
5. Nelson L, Smith B, Hunter A. Nutrition knowledge of acute care physical therapists. Top Clin Nutr. 1997;12:33-41.
6. Hark L. One program’s experience in nutrition education of medical students. Top Clin Nutr. 1997;12:42-48.
7. O’Sullivan-Maillet J, Fixelle R, Thornton J. What physician assistants should know about nutrition. Top Clin Nutr. 1997;12:49-57.
8. Kolasa K, Zinn B, Moss, N. Nutrition education of nurse-midwives: one example. Top Clin Nutr. 1997;12:58-62.
9. Patenaude J. Home health aide training: an opportunity for dietitians. Top Clin Nutr. 1997;12:69-75.
10. Greenspan J, Path FR. Current and future prospects for oral health science and technology. J Dental Educ. 1995;59:149-167.
11. Rock C. Nutrition education in the clinical setting: educating the physician and resident. Top Clin Nutr. 1995;10:49-57.
12. Center for the Health Professions at the University of California. Core Curricula Workshop Proceedings. San Francisco, Calif: Bureau of Health Professions Conference Proceedings; January 7-8, 1995.
13. Position of The American Dietetic Association: oral health and nutrition. J Am Diet Assoc. 1996;96:184-189.
14. Center for the Health Professions at the University of California. Core Curricula Workshop Proceedings. San Francisco, Calif: Bureau of Health Professions Conference Proceedings; January 7-8, 1995.

ADA Position adopted by the House of Delegates on October 26, 1997. This position is in effect until December 31, 2003. The American Dietetic Association authorizes republication of the position statement/support paper, in its entirety, provided full and proper credit is given. Requests to use portions of the position must be directed to ADA Headquarters at 800/877-1600, ext 4896 or holler@eatright.org (Adapted by ACN with ADA permission: Position of the American Dietetic Association: Nutrition-essential component of medical education. J Amer Diet Assoc 1994;94:555-7..)

The Medical Physiology Curriculum Objectives Project

This is a joint project of The American Physiological Society and the Association of Chairs of Departments of Physiology. The project is being headed by Dr. Robert G. Carroll, Professor, Department of Physiology, East Carolina University School of Medicine, Dr. L. Gabriel Navar, Professor and Chair, Department of Physiology, Tulane University School of Medicine, and Dr. Mordecai P. Blaustein, Professor and Chair, Department of Physiology, University of Maryland School of Medicine.

Overview (adapted form website http://www.the-aps.org/education/MedPhysObj/medcor.htm)

As medical and other professional schools in the health sciences continue to modify their curricula, a variety of approaches are being utilized to teach the students. These widely diversified approaches range from the traditional and systematic course in physiology and neuroscience to those in which there is not an identifiable course in physiology. While a systematic presentation of physiological concepts under the direction of physiology faculty continues to be the most efficient way to ensure appropriate depth and breadth, physiologically related topics are often spread out over several courses. It is, nevertheless, essential that all medical and health professional students receive sufficient exposure to the physiological concepts that provide the foundations needed for further studies in pharmacology, pathology, physiology, and medicine. The mechanisms of deranged function can not be appreciated without an in-depth understanding of basic biophysical and physiological mechanisms. The purpose of developing these core competency criteria is to provide guidelines for the breadth and depth of knowledge in the physiological principles and concepts that are considered minimal and essential for further progress in understanding mechanisms of disease and body defenses. Regardless of the specific didactic or educational approach used by any given institution, that institution must develop mechanisms to assure that the students are being inculcated with these basic principles and concepts at an appropriate depth of understanding. The development of these core learning objectives will allow all programs to determine if their students are achieving at least this basic level of understanding.