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Nov 3 2010

What physicians don’t know about nutrition (but have every reason to learn)

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Image for What physicians don’t know about nutrition (but have every reason to learn) A quick look at the leading causes of illness and death makes it clear that knowledge of nutrition is critical to the modern practice of medicine. Cardiovascular disease, type 2 diabetes, hypertension, innumerable cancers —all are linked at least in part to poor diet. What’s more, the success of many of the treatments and interventions used to address these illnesses hinges on improving diet and nutrition.

Yet a recent study by the Nutrition in Medicine (NIM) program at UNC Chapel Hill’s School of Public Health found nutrition education at U.S. Medical Schools to be woefully inadequate. Just one in four U.S. medical schools offer students the minimum recommended number of hours in nutrition education, according to the study, which was published in September in the journal Academic Medicine (See STUDY article). That suggests conspicuous nutrition-knowledge gaps exist among practicing physicians, according to the study authors. And, by extension, it means that many patients are likely receiving less than optimal care.

NIM combats this problem on two fronts. First, it has developed core nutrition curricula for use by U.S. medical schools for nearly 15 years. Currently, a majority of medical schools in this country use the NIM curriculum. However, even schools using the curriculum don’t cover nutrition at the level needed to give physicians the practical knowledge they need to practice.

That’s where NIM’s latest endeavor comes in. The Nutrition Education for Practicing Physicians (NEPP), fully funded by a grant from the National Cancer Institute, offers brief, targeted modules that teach physicians specific topics in nutrition, such as encouraging behavior change in overweight patients. Modules are designed with busy practicing physicians in mind. Most are between just five and 15 minutes in length and lessons are designed to allow the physician to immediately use what he or she has learned in practice. For those seeking deeper knowledge of nutrition, the program also offers several longer foundational modules. The entire NEPP curriculum is posted online and is available to registered users free of charge. Visit for more information.

Forum Editor Jean Fisher Brinkley recently spoke with NIM program director Martin Kohlmeier, MD, about Nutrition Education for Practicing Physicians.


How did the NEPP get started?
We have had our NIM for medical students curriculum for about 15 years. It had evolved into a full and robust curriculum that now is used by a majority of U.S. medical schools with, I believe, very good outcomes. But it is still not enough. We still do not reach the level of instruction that is necessary to really prepare a physician for practice. So that’s how it got started. It was the logical next step. I must say, we are fortunate to be fully funded by the National Cancer Institute. Without them, this whole program would not exist.

Why is it important for a practicing physician to have an understanding of nutrition?
The simple truth is that we estimate that somewhere between 50 to 70 percent of disease burden and mortality is related in some way or another to nutrition. And, probably more important in a practical way, a lot of the therapies and the interventions that physicians do really don’t work as well if they don’t work on a foundation of nutrition intervention. Very often it’s very simple things, but you have to know them.

Who comes up with the curriculum?
We have a very good team here [in the NIM program] and we do it. When we put together the grant application, we proposed a set of topics. We also solicit input from our national advisory board, which is made up of 20 or so nationally renowned nutrition educators. They provide us with input. We also ask users, what else would you like to see? So it’s continuously evolving.

What types of physicians do you envision using these modules?
Our primary target right now is physicians in training, or residents. Because they are just not done with their training. We know that. They’re also usually part of structured programs so we can approach residency directors,
fellowship directors, etc., so it’s an efficient way for us to get this out to people.

So you think you can have the most impact with residents?
I’m not sure I would say that. We have to start somewhere and it’s an obvious place to start. We definitely see the importance also for all physicians. A lot of this science didn’t even exist when many physicians completed their training. All physicians are welcome to use the curriculum.

How do you envision physicians who complete some of these modules using what they have learned in practice?
We want to provide skill-building education that empowers physicians to use that information directly. I like to say when they get up from the computer they go right to their patients and use it. Our vision is that physicians will continue using this information. And as they encounter particular issues, problems or interesting cases, they can return and use it as a resource. And that’s part of the reason why we have it so focused.

It’s 5-10 minutes. You can always fit that in. We provide pocket notes, which are basically printable summaries of the key information learned in the module. They can print these out when they’re done and literally put them in their pocket. The pocket notes are designed to help them remember. We are also working on tools that would allow these pocket notes to work on portable devices so you can keep the information on your iPad, your smart phone, etc. This is where we’re going—to have resources that are used while they are studying and that they continue to use as they practice. As we go along, feedback will shape how these things are delivered. We see it as an iterative, interactive process with physicians.

As you know, practicing physicians are extremely busy. They don’t have a lot of time and there are quite a lot of modules to choose from. Could you recommend a top five, or maybe suggest just one module that, if you’re only going to do one, you wouldn’t want to miss?
One of them, which would be fairly close to the top, is how to take a supplement history. Because more than 60 percent of adults are taking dietary supplements and their physicians don’t know about it. And we know quite well about the impact. Very often, physicians are unsure how to do this [take a supplement history]. So that is one that I would recommend because it really applies to everybody. Another one would be assessment, particularly for undernourished patients. But there are so many. It really depends on what your practice is.

One that seemed quite important to me is the module on encouraging behavior change in overweight patients.
Oh, yes. I think that’s an excellent one, if I may say so. I don’t want to crimp anyone’s style. I think it will be quite different for everybody. We’ve always been quite surprised which topics are of most interest.

Are continuing medical education hours available for those who complete NEPP modules?
Not at this time, but we are preparing to do this. I would expect that within a year or so, maybe less, we will do that. The project is so new. We are still filling in the content and running as fast as we can.

Is there any formal program in place to measure the response to the curriculum?
It’s planned at two levels. The first level is a simple survey at the end that asks about use and practice. The second level is, as physicians continue to use this, we will ask returning users if they have implemented these particular skills [learned in a previous module] in practice. We are very interested in how effective this is.

Is there anything I haven’t asked you about that you would like practicing physicians to know about this project?
It’s most important that they understand that this is a work in progress and that we are developing and releasing new modules almost monthly. There’s a whole slew in the pipeline. If they don’t see it today, they should definitely come back. It might well be there a little bit later.

 Comments on this article:

As an undergraduate in the 1970s, I took a nutrition course and was questioned as to why. I stated then—and now: nutrition is the bastard child of medicine. Diet is an important aspect of good health and yet, historically, the least regarded.

In view of NC’s failing marks for childhood obesity, rampant diabetes and otherwise preventable diseases, I am certainly heartened ? this is on the front burner as we venture into 21st century medicine!

By C M Morris on Nov 05, 2010 at 4:32pm

Thank you for including this article and the link in the online newsletter. A large portion of my day is spent discussion nutrition with my patients, encouraging them and giving them lifestyle tips for healthier eating. I was fortunate that during my medical school nutrition was emphasized and then after residency I learned a lot on my own. My own lifestyle has been vegetarian, becoming vegan 18 months ago. Never felt better! Keep up the good work.

By Verena Boylan MD FACOG on Nov 06, 2010 at 11:54am
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