Abstract
Abstract
The need to educate and train future physicians about nutrition and wellness has become increasingly apparent in the past decade. A rising incidence of chronic health conditions with a nutrition background (e.g., obesity, cardiovascular disease, type 2 diabetes) has led to an even greater need for nutrition educational content in medical school curricula so that physicians may counsel patients regarding their lifestyle factors. This review provides an overview of the successful development and integration of a nutrition thread in a 5-year medical school curriculum. Based on a survey conducted in our medical school program, students beginning medical school are lacking formal nutrition education, as only 8% arrived with some form of exposure. Despite this, nearly 85% of these medical students recognized that nutrition education is necessary in their training, and 70% state that the nutrition education they have received has influenced the way they care for patients.
- Key teaching points
Physicians are faced with rising incidence of chronic health conditions that have a nutritional risk factor
Physician self-care including optimal nutrition to support resilience is gaining importance.
Nutrition education in medical schools is inadequate to address these rising needs.
Implementing a comprehensive nutrition curricula that addresses personal wellness strategies, basic science concepts related to nutrition, and diagnosis and management of diseases that can be modified by or are related to nutrition as a topic thread that is woven throughout all years of the curriculum highlights the importance of nutrition in health and disease.
Introduction
Chronic disease has a significant impact on the health of the United States population. In 2016, 7 of the top 10 causes of death in the United States were due to chronic disease, with heart disease and cancer accounting for 46% of all deaths (1). This rise in chronic disease translates into rising health care costs, as indicated in a 2014 report published by the Agency for Healthcare Research and Quality that 86% of the nation’s annual health care expenditures were for people with chronic and mental health conditions (2). Lifestyle choices have a significant impact on chronic disease, as documented by Eisenberg and Burgess (3). The Nurses’ Health Study suggests that “individuals who do not smoke, are not overweight, exercise modestly, have a good but not necessarily exemplary diet, and drink a glass or less of wine or spirits daily reduce their risk of coronary heart disease by 82%” (4). Recent evidence suggests that interventions that target multiple risk factors, including diet and lifestyle, may be effective in reducing the incidence of multiple chronic conditions (5). These are lifestyle choices that can be controlled by patients, and that if improved could have a significant impact on controlling chronic disease. Therefore, the ability of physicians to counsel patients regarding lifestyle factors, including diet, that prevent and/or treat chronic disease is imperative. Furthermore, they need to be able to explain their recommendations to patients, and effectively find ways to help patients implement these recommendations into their daily lifestyle.
Research indicates that personal health habits of physicians are important predictors of their patient counseling practices (6–8). Both physician personal lifestyle habits and attitude toward health promotional counseling also influence how frequently and how aggressively they counsel their patients (7). Patients also perceive physicians who practice healthy lifestyle habits as more credible and motivating compared to those who do not exhibit healthy habits (6,9,10). A survey of physicians (102 trainees and 81 attending physicians) evaluated the effect of their lifestyle behaviors on their ability to change patient behavior and found that they were more effective at changing patient behavior and counseling if they themselves exercised, maintained a normal body weight, and were adequately trained in counseling patients (10).
In addition to patient benefits, improving physician personal health habits can also reduce the prevalence of physician burnout, which is on rise. Physician burnout can adversely affect quality of care, job satisfaction, career longevity, and risk of suicide (11). There are multiple drivers of physician burnout, including unmanaged stress and sleep deprivation (12). While insufficient sleep is associated with decreased attention and alertness, inadequate sleep (<7 hours per day) is also linked with cardiometabolic diseases including cardiovascular disease, hypertension, diabetes, and obesity (13). There is an increased awareness regarding the importance of improving physician wellness, which includes addressing work–life balance, social and family support, and getting adequate rest and regular physical activity (12).
Patients count on their physicians to be good and credible sources of health information, and they expect dietary advice and guidance that will help them avoid risk factors and prevent disease (14,15). The United States Preventive Services Task Force (USPSTF) recommends healthy diet and physical activity counseling to prevent cardiovascular disease for those with cardiovascular risk factors, and that clinicians should offer or refer adults with a boyd mass index (BMI) greater than 30 to intensive, multicomponent behavioral interventions (16).
In order to facilitate these guidelines, it has been recommended that undergraduate medical education include at least 25 hours of nutrition education in the curriculum (17). A 2015 study reported that most medical schools (71%) provided less than the recommended hours, and most of this education takes place in the pre-clerkship curriculum (18). Hence, most medical students do not have an opportunity to learn fundamental principles of nutrition, nor do they have an opportunity to apply these principles in clinical settings with patients.
Incorporating additional content into the undergraduate medical school curriculum is challenging since there has been a tendency to reduce curriculum hours and to integrate more basic science within clinical training. Often some existing content is eliminated to make room for the new content, but this is frequently unpopular. Another approach used by medical school curriculum committees is to integrate new and updated concepts into the existing curriculum when possible, adding content to case studies, problem-based learning, and clinical activities. This article focuses on outlining a method for integrating nutritional content successfully into an undergraduate medical education curriculum. The aim of this review is to describe the process taken at our facility with the goal of being able to provide future physicians with all aspects in the science of nutrition and medical nutrition therapy as a means to prevent and/or treat chronic disease.
The Cleveland Clinic Lerner College of Medicine of CWRU (CCLCM) curriculum
The Cleveland Clinical Lerner College of Medicine was founded in 2002 as an innovative medical school program focused on training physician investigators (19). It is a 5-year program with several research opportunities built into the curriculum: a 9-week basic science research experience the first summer, a 9-week clinical research experience the second summer, and a full year of research the fourth year. The students choose to pursue a basic, translational, or clinical research project for the full year of research. The CCLCM curriculum is based on professional characteristics that graduates are expected to develop. These characteristics were used to create curricular and assessment principles that guided the development of an integrated basic science, clinical science, and research curriculum. The CCLCM uses a unique approach to student assessment that is designed to promote student-directed learning. The program uses a competency-based assessment system that is fully integrated with the curriculum to foster an educational environment focused on learning (19). The competencies include research and scholarship, knowledge for practice, interpersonal and communication skills, professionalism, patient care, teamwork and interprofessional collaboration, systems-based practice, personal and professional development, and reflective practice.
The basic science curriculum during the first 2 years applies adult learning principles that link clinical problems with basic science learning through problem-based learning (PBL) and seminars. An organ-system approach is used to instruct students in the basic science threads (i.e., anatomy, physiology, cell biology/biochemistry, etc.) in the context of a clinical problem presented in a problem-based learning format. The basic science thread content is also taught in seminars by content experts to supplement or extend knowledge learned through PBL. Basic science content learned during Year 1 focuses more on “normal,” whereas content learned during Year 2 focuses mainly on pathology. The basic science threads are not limited to the first 2 years of the curriculum; rather, they are interwoven throughout the 5-year curriculum, in the clinical years 3–5 where relevant (Figure 1).
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06 February 2019![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/uacn20/2019/uacn20.v038.i05/07315724.2018.1551158/20190624/images/medium/uacn_a_1551158_f0001_b.jpg"})
Figure 1. Overview, Cleveland Clinic Lerner College of Medicine 5-year curriculum.
Identifying the gaps in nutrition curricular content
Appreciating nutrition as a modifiable risk factor in chronic disease, a Faculty/Student Nutrition Task Force was convened for the Cleveland Clinic Lerner College of Medicine (CCLCM) in December 2014. The charge of the Task Force was to address what nutrition topics were currently included and should be included, how the nutrition domain should be incorporated into the CCLCM curriculum, and what available resources could be used to facilitate the expansion of nutrition in the curriculum. The Task Force was to consider nutrition content throughout the 5-year curriculum in the context of disease and wellness in both basic and clinical science components. The Task Force was to consider learning goals related to the role that nutrition has in the (1) function of normal metabolism and ways that nutrition abnormalities can lead to abnormal function and anatomy; (2) personal health and wellness of medical students; and (3) treatment of acute and chronic disease.
The Nutrition Task Force (NTF), chaired by a faculty member, a clinical dietitian with a doctoral degree in biochemistry and molecular biology, was comprised of multiple faculty members throughout the Cleveland Clinic Enterprise in areas of health and wellness including gastroenterology, lifestyle medicine, functional medicine, and molecular cardiology, as well as medical students in training (years 3–5). CCLCM education faculty members interested in wellness and nutrition were also included.
The NTF was charged to provide a report to the CCLCM Curriculum Steering Council. The following items were to be included:
Field expert recommendations on knowledge and skills CCLCM students should gain prior to graduating, including personal wellness strategies, basic science concepts related to nutrition, and diagnosis and management of diseases that can be modified by or are related to nutrition. Recommendations were to address what should be included in the basic science and clinical science curricula in each year of the 5-year curriculum.
A review of the current CCLCM curriculum and identification of nutrition-related topics included in the formal and informal curriculum was performed to gauge what and where nutrition content needed to be included.
In order to maximize expertise within Cleveland Clinic Enterprise, identification of available resources within the health system that would be of assistance to CCLCM students in achieving the learning objectives was undertaken.
To facilitate integration of new nutrition learning objectives into the curriculum, a collaborative strategy with curriculum leaders in the basic science and clinical science educational programs was undertaken.
NTF proposal development
The NTF critically evaluated the current curriculum for nutritional content, which is electronically housed on a system portal. Current offerings were then benchmarked against what nutritional content was reportedly recommended for undergraduate medical education (20–24), as well as content recommended from experts in the field and those on the NTF, including recommendations from the current medical students.
The NTF compiled a list of 8 nutrition concepts that should be provided to undergraduate medical students: nutrition principles, nutrition assessment, behavior principles, community and population health, nutrition support, research, contemporary trends, and physical activity. Content areas were then outlined for each concept (Table 1). The NTF then determined in which course and in which year each concept should be presented. Each concept was color coded regarding its current presence in the curriculum: red (not present), orange (present, but needed improvement), or green (present and no improvement needed) (Figures 2a and 2b).
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06 February 2019![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/uacn20/2019/uacn20.v038.i05/07315724.2018.1551158/20190624/images/medium/uacn_a_1551158_f0002_c.jpg"})
Figure 2. Example of nutrition concepts and content areas.
Table 1. Nutrition thread concepts and content areas for 5-year CCLCM curriculum.
Approval by CCLCM Curriculum Steering Council
The NTF adhered to an aggressive schedule of biweekly meetings to review, evaluate and make recommendations for targeted nutrition curricula content. In July 2015 the NTF chair presented the NTF recommendations to the CCLCM Curriculum Steering Council. The recommendations were viewed highly and approved. The plan was to begin to integrate the nutrition content into the curriculum immediately.
Introduction of a nutrition thread
Shortly after gaining approval by the CCLCM Curriculum Steering Council, the Executive Dean of CCLCM announced that a new “nutrition thread” was being created. Thus, rather than having a stand-alone course in nutrition, nutrition was to be woven into courses throughout the 5-year curriculum where deemed appropriate. This innovative strategy acknowledges and highlights the importance of the impact nutrition has on each organ system throughout the lifecycle and allows for education around how nutrition has impact in health and disease.
The NTF chair was appointed the Nutrition Thread Director. The role of the thread director is to understand the “big picture” of the curriculum particularly in regard to how the thread fits into the entire curriculum, communicating this to faculty and students, and assuring the thread is an integral part of the curriculum. Responsibilities in this role are included in Table 2. In order to keep current with the dynamic science of nutrition, the nutrition thread is evaluated weekly and at the end of each course, and the thread director reviews feedback and utilizes it to make modifications in the curriculum as deemed appropriate.
Table 2. Nutrition thread director responsibilities.
Nutrition content integration
Adding new content to an already full curriculum is challenging. Realizing the unlikelihood of all recommendations being implemented immediately, content has been integrated in a stepwise manner. This has occurred either for new and revised content in 2-hour seminar format, updated or newly developed problem-based learning sessions, journal clubs, advanced research in medicine sessions, or CAPSTONE sessions for year 5 students, as well as in the content of weekly self-assessment (i.e., multiple-choice) questions and essay questions in years 1 and 2. We recognized the importance of including assessments of student understanding of nutrition concepts to reinforce content and provide formative feedback to students about their understanding of key nutrition concepts throughout the curriculum. The seminars and presentations are all highly interactive, allowing students to get feedback immediately about their understanding and application of knowledge and skills. Consistent with the integration of nutrition across the curriculum, nutrition relation self-assessment questions were included at least once in the weekly assessments in 8 of the 15 organ-system courses in years 1 and 2, and the essay questions were included in the weekly essay questions in 3 of these courses. In the third year of the nutrition thread, nutrition content was formally introduced into the core clinical clerkships. Here the content is provided in didactic sessions that are case based. Sessions are provided during each 6-week rotation for the surgical, internal medicine, and pediatric cores. In the fourth year of the nutrition thread, a 2-week clinical nutrition elective was implemented. In this rotation medical students rotate within the various areas of both adult and pediatric clinical nutrition, working with the clinical dietitians and nutrition-physicians. These rotations include inpatient internal medicine, cardiology, oncology, solid organ transplant, gut rehabilitation and transplant services, intensive care units, inpatient parenteral nutrition service, and ambulatory care services. During these rotations the students participate in assessment of patient malnutrition employing nutrition-focused physical examination, assessment of macro- and micronutrient requirements, evaluation for enteral and parenteral feeding, and patient education for chronic disease management, including obesity, diabetes, and cardiovascular disease.
Coinciding with the introduction of the nutrition thread, CCLCM also began a “self-care” curriculum for the first-year medical students. This program is offered weekly during the first semester. It includes sessions on resilience, exercise, sleep, mindfulness, and nutrition. The nutrition component of self-care is woven into the content in the nutrition thread. For example, during self-care sessions students are provided with information on keeping a food diary to monitor eating and hydration behaviors. They are then asked to bring their food diaries to seminars on “introduction to nutrition,” where they are asked to compare their daily intakes with the recommended nutrient guidelines. Food diaries are also utilized in the “overview of metabolism” seminar, where students evaluate their dietary intakes to predict which metabolic pathways their bodies may be utilizing based on their current metabolic state.
Nutrition thread evaluation
Each week in years 1 and 2 students provide formative feedback on course content presented that week. This information is provided to course and thread directors and revisions to curriculum content are made as deemed appropriate. Additionally, each thread director provides a biennial evaluation report regarding curriculum interventions, student performance, as well as feedback to the curriculum committee. Another measure of success of the thread is seen in the USMLE Step 1 subscore in Nutrition for CCLCM students in 2017, which is half a standard deviation above the national Step 1 mean score. Figure 3 is a flow chart summarizing the process taken to develop and integrate a nutrition thread into the CCLCM medical curriculum.
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06 February 2019Figure 3. Flowchart outlining the process taken for the development of nutrition thread.
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/uacn20/2019/uacn20.v038.i05/07315724.2018.1551158/20190624/images/medium/uacn_a_1551158_f0003_b.jpg"})
Figure 3. Flowchart outlining the process taken for the development of nutrition thread.
Since this was a new thread, we sought to gain more formal detailed feedback from students regarding the nutrition thread, as well as gain insight into their background in nutrition training prior to entering medical school. We took the opportunity to survey students from all 5 years in the program, where years 1–3 had exposure to the nutrition thread and years 4–5 did not.
Survey methods
A 12-question anonymous survey was delivered to 164 current Cleveland Clinic Lerner College of Medicine Students (Classes of 2018–2022) in November 2017. Using Likert and dichotomous scales, the survey queried nutrition education interest and experiences among medical students prior to entering and during medical school. The survey was distributed electronically using an encrypted database, Research Electronic Data Capture (REDCap), a Web-based data capture tool hosted by Cleveland Clinic to the student e-mail accounts. All participants had 2 weeks to complete the survey. Survey data were securely stored and managed using REDCap. Privacy was protected in compliance with the U.S. Health Insurance Portability and Accountability Act (HIPAA). The study protocol was approved by the institutional review board. The data represent counts and percentages for categorical data, and means ± standard deviation for group analysis. Student’s t-test was used for parametric analysis of 2 groups (e.g., “yes” versus “no”). Statistical significance was defined as p < .05. The analysis was performed using the Prism software Version 5.02 (GraphPad Software, San Diego, CA).
Survey results
An overall 41% survey response rate (66/160 students) was achieved and is represented as Class 2018: 7, Class 2019: 15, Class 2020: 14, Class 2021: 11, and Class 2022: 19. Of those surveyed, approximately 8% reported having had formal nutrition education during their undergraduate pre-medical school education (p < .05; Figure 4a), and 27% rated their nutrition education prior to medical school as above average (p < .05; Figure 4b). The majority of survey participants responded that nutrition education is necessary compared to somewhat necessary during medical school training (85%; p < .05; Figure 4c). Survey participants not exposed to the targeted nutrition thread curriculum content (Classes 2018 and 2019) were less likely (77%) to rate the need for nutrition education in medical school education as necessary, compared to 89% of those exposed to the integrated nutrition curriculum (Classes 2020–2022) (Figure 4c). Approximately 70% of all survey participants responded that the nutrition education they have received has influenced the way they care for patients (p < .05; Figure 4d). While only 42% of the class of 2022 survey participants responded that nutrition education they have received has influenced the way they care for patients, this is expected. The survey was distributed in the first semester of medical school; therefore, the class of 2022 had only been exposed to minimal (5 hours) nutrition curricular content, and they had not yet participated in extensive patient care. When asked whether they felt prepared to identify nutritional deficiencies in patients, more than half of all participants agreed (53%) (Figure 4e). However, as expected, participants from the classes of 2018–2021 felt more prepared (68%) than those from the class of 2022 (16%) (Figure 4e).
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06 February 2019Figure 4. Results of survey of CCLCM Students Regarding Nutrition Education: (A) undergraduate nutrition education provided; (B) quality of undergraduate nutrition education; (C) necessity for nutrition education; (D) nutrition education and impact on patient care; (E) competency in assessing nutrition deficiencies. Data are presented as percentages of responses per year group and mean ± standard deviation; *p < .05.
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/uacn20/2019/uacn20.v038.i05/07315724.2018.1551158/20190624/images/medium/uacn_a_1551158_f0004_b.jpg"})
Figure 4. Results of survey of CCLCM Students Regarding Nutrition Education: (A) undergraduate nutrition education provided; (B) quality of undergraduate nutrition education; (C) necessity for nutrition education; (D) nutrition education and impact on patient care; (E) competency in assessing nutrition deficiencies. Data are presented as percentages of responses per year group and mean ± standard deviation; *p < .05.
Conclusion
In summary, here we describe our approach for initial integration of nutrition content into a 5-year undergraduate medical school curriculum. This is an ongoing process, and we plan to continue with content integration and modification as changes occur within the dynamic field of nutrition and wellness. We have embraced the fact that with the rising incidence in chronic diseases, future physicians need to be equipped and confident in offering lifestyle modification recommendations to their patients. Realizing that those who incorporate healthy lifestyle habits in their own personal lifestyles will be more apt to offer these recommendations to others, we have initiated formal education in self-care to undergraduate medical students. Harnessing the concept that nutrition is a modifiable risk factor in chronic diseases, we have embarked upon a means to assertively educate undergraduate medical students in nutritional science, at the level of both basic and clinical science. Capitalizing on the facet of our program in training physician-scientists, we hope to add to the number of not only nutrition-focused physicians, but also future nutrition scientists, which will lead to advancements in nutrition-related evidence-based approaches to chronic disease preventions and/or treatments.
| Concepts | Content areas |
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| □ Developing and recruiting faculty to serve on a Thread Planning Committee. |
| □ Determining where content areas should be included in the curriculum and serve as a resource to course/clerkship directors to include the topics. |
| □ Facilitating integration of the objectives across courses/clerkships and other curriculum activities. |
| □ Attending appropriate seminars to assure thread objectives are addressed in suitable depth. |
| □ Assuring that appropriate nutrition knowledge and skills assessments of students are included in the curriculum. |
| □ Evaluating thread objectives and content annually and make adjustments as necessary. |
Acknowledgments
We thank all the members of the NTF for their time and commitment in launching the nutrition thread: Gail A.M. Cresci, Julie Foucher, Mladen Golubic, Patrick Hanaway, Laurie Hofmann, Alan Hull, J. Harry Isaacson, Donald Kirby, John Kirwan, Julie Tebo, Danny Urcuyo-Llanes, David Van Wagoner, and Stuart Zeltzer.
References
- Heron M. National vital statistics reports deaths: leading causes for 2016. US Department of Health and Human Services. 2018;67. [Google Scholar]
- Leroy L, Bayliss E, Domino M. The agency for healthcare research and quality multiple chronic conditions research network. Medical Care. 2014;52:15–22. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Eisenberg DM, Burgess JD. Nutrition education in an era of global obesity and diabetes: thinking outside the box. Acad Med. 2015;90(7):854–860. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Colditz GA, Philpott SE, Hankinson SE. The Impact of the nurses' health study on population health: prevention, translation, and control. Am J Public Health. 2016;106(9):1540–1545. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Adams ML, Katz DL, Shenson D. A healthy lifestyle composite measure: significance and potential uses. Prev Med. 2016;84:41–47. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med. 2000;9:8–11. [Crossref], [Google Scholar]
- Wells KB, Lewis CE, Leake B, Ware JE. Do physicians preach what they practice? a study of physicians' health habits and counseling practices. JAMA. 1984;252(20):2846–2848. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Yeager KK, Donehoo RS, Macera CA, Croft JB, Heath GW, Lane MJ. Health promotion practices among physicians. Am J Prev Med. 1996;12(4):238–241. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Frank E, Wright EH, Serdula MK, Elon LK, Baldwin G. Personal and professional nutrition-related practices of US female physicians. Am J Clin Nutr. 2002;75(2):326–332. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Howe M, Leidel A, Krishnan SM, Weber A, Rubenfire M, Jackson EA. Patient-related diet and exercise counseling: do providers ’ own lifestyle habits matter? Prev Cardiology. 2010;13(4):180–185. doi:10.1111/j.1751-7141.2010.00079.x. [Crossref], [PubMed], [Google Scholar]
- Shanafelt TD, Oreskovich MR, Dyrbye LN, Satele DV, Hanks JB, Sloan JA, Balch CM. Avoiding burnout: the personal health habits and wellness practices of us surgeons. Ann Surg. 2012;255(4):625–633. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- McClafferty H, Brown OW. Clinical Report: Physician Health and Wellness. Am Ac Pediatrics. 2014;134(4):830–838. [PubMed], [Google Scholar]
- Cappuccio FP, Taggart FM, Kandala NB, Currie A, Peile E, Stranges S, Miller MA. Meta-analysis of short sleep duration and obesity in children and adults. Sleep. 2008;31(5):619–626. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Glanz K. Review of nutritional attitudes and counseling practices of primary care physicians. Am J Clin Nutr. 1997;65(6 Suppl):2016S–2019S. [Crossref], [PubMed], [Google Scholar]
- Price JH, Desmond SM, Losh DP. Patients' expectations of the family physician in health promotion. Am J Prev Med. 1991;7(1):33–39. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- U.S. Preventive Services Task Force A and B Recommendations. Available from: https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations-by-date/. Accessed October 12, 2018. [Google Scholar]
- Nutrition Education in U.S. Medical Schools. Washington, DC: National Academy of Press; 1985. [Google Scholar]
- Adams KM, Butsch WS, Kohlmeier M. The state of nutrition education at US Medical Schools. J Biomed Educ. 2015;2015:1. doi:10.1155/2015/357627. [Crossref], [Google Scholar]
- Dannefer EF, Henson LC. The portfolio approach to competency-based assessment at the cleveland clinic lerner college of medicine. Acad Med. 2007;82(5):493–502. doi:10.1097/ACM.0b013e31803ead30. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Lenders C, Gorman K, Milch H, Decker A, Harvey N, Stanfield L, Lim-Miller A, Salge-Blake J, Judd L, Levine S. A novel nutrition medicine education model: the boston university experience. Adv Nutr. 2013;4(1):1–7. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Kushner RF, Van Horn L, Rock CL, Edwards MS, Bales CW, Kohlmeier M, Akabas SR. Nutrition education in medical school : a time of opportunity. Am J Clin Nutr. 2014;99:1167–1173. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- Aspry KE, Van Horn L, Carson J, Wylie-Rosett J, Kushner RF, Lichtenstein AH, Devries S, Freeman AM, Crawford A, Kris-Etherton P. Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: a science advisory from the american heart association. Circulation. 2018;137(23):e821–e841. doi:10.1161/CIR.0000000000000563. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
- American Academy of Family Physicians: Recommended Curriculum Guidelines for Family Medicine Residents. Available from: www.aafp.org/cg. Accessed August 15, 2018. [Google Scholar]
- Nutrition Education for Health Professionals. National Heart Lung and Blood Institute; 2015. https://www.nhlbi.nih.gov/events/2012/nutrition-education-health-professionals. Accessed February 15, 2015. [Google Scholar]