Nutrition Education for Medical Students: the University of Otago Experience

Nutrition education for medical students: the University of Otago experience

J Mann1*

1Department of Human Nutrition, University of Otago, Dunedin, New Zealand

Nutrition education for medical students in the University of Otago, New Zealand, has been adapted to comply with the newly introduced system-based teaching. Clinical cases provide the focus for class demonstrations, tutorials, self-directed learning and a limited number of lectures. In the preclinical curriculum nutrition is taught primarily in the Metabolism, Blood, Heart and Circulation, Endocrine and Cancer modules. The concept of nutrient requirements for growth and development and the maintenance of health; the various methods used for assessing dietary intakes and nutritional status as well as nutrition issues relevant to obesity are covered in the Metabolism module. The role of nutritional factors in the aetiology of disease is stressed in the other modules. Emphasis in the clinical curriculum is on the dietary management of some disease states. Students are also given insights into nutrition research and public health aspects of nutrition. This integration of nutrition teaching into the curriculum has been extremely well received by students but is labour intensive. Descriptors: nutrition; teaching; medical; undergraduates

Introduction and to provide students with some insights into nutrition research. These objectives have to date been achieved by Several approaches to the teaching of nutrition to medical lectures during the Endocrine attachment and tutorials as students have been suggested. This paper describes the part of the Public Health module. A revised clinical approach which has been developed in one of New Zeal- curriculum will necessitate revision of the method of and's two medical schools. delivery. We believe that our overall programme has Two hundred students start their medical training each been successful but it is extremely labour intensive. year at the University of Otago, the selection process is based on academic performance during a prescribed year of study in the Biological Sciences, Chemistry and Physics. Nutrition teaching in the metabolism module Before 1996 a fairly conventional medical training programme was followed, starting with Anatomy, Physiology The Metabolism Module is presented early in the second and Biochemistry; progressing through Pathology and year of study and principally includes teaching in Biochem- Pharmacology to the Clinical Sciences. A radical review istry and Human Nutrition. Several basic principles of resulted in a substantially revised delivery of the curricu- human nutrition are taught in this module. In particular it lum. The two preclinical years now involve system-based presents the concept of nutrient requirements for growth teaching, with clinical cases providing the focus of class and development and the maintenance of health; and the demonstrations, tutorials, self-directed learning and a lim- various methods used for assessing dietary intakes and ited number of lectures. The fourth and ®fth years involve nutritional status. The full list of human nutrition objectives clinical attachments in a range of specialties, the emphasis is given in Table 2. In addition, since the storage of fuels, being on bedside teaching, tutorials and self-directed learn- including fat and glycogen synthesis, is presented in the ing. During the ®nal year students act as trainee interns. Biochemistry component of the module, an additional set In the pre-1996 curriculum (Table 1) the teaching of of objectives relates to aspects of obesity which are relevant nutrition was con®ned to one half-day during the Biochem- to human nutrition (Table 3). A course book which includes istry course, when the analysis of a 4-day diet record was these objectives, details of the background reading, a 4-day discussed, and 12 `cameo' lectures scattered throughout the food record with instructions for completion and analysis, Abnormal Structure and Function (Pathology) course. In issues to be discussed during tutorial times, and methods of the new curriculum, nutrition forms an integral part of the assessment are provided at the beginning of the module. preclinical curriculum and is taught primarily in the Meta- A case presentation of a female vegetarian athlete and bolism, Blood, Heart and Circulation, Endocrine and her diet (Table 4), to the whole class, provides a useful Cancer modules. Teaching in the clinical years aims to introduction to this module since students are anxious to be review the nutritional aetiology of disease, to discuss in involved in practical clinical issues and sport has a high more detail dietary management of certain disease states, pro®le in New Zealand society. The students, encouraged by the lecturer, enjoy asking the athlete questions about her diet and the dietary analysis enables some discussion (albeit *Correspondence: Jim Mann, Department of Human Nutrition, University at a fairly super®cial level) about nutritional adequacy and of Otago, P O Box 56, Dunedin, New Zealand. bioavailability of nutrients in the light of the high intake of E-mail: [email protected] dietary ®bre. The low fat intake may also be a discussion Nutrition education for medical students J Mann S63 Table 1 Human nutrition teaching in the university of Otago medical school

Year

1. Biology, Chemistry, Biochemistry, Physicians for all students ( Æ 1000) enrolling in Health Science courses 200 selected for medical training Pre-1996 (Discipline based) Post 1996 (System-based) 2. Students complete, analyse and discuss 4-day diet records * Metabolism under supervision of Biochemistry Department * Blood 3. 12 stand-alone lectures scattered throughout Pathology * Heart and Circulation course (presented by Dept of Human Nutrition) * Endocrine 4. 3 lectures as part of Endocrine teaching (Dept of Human Nutrition) * Cancer 3 lectures as part of Endocrine teaching (Dept of Human Nutrition) 3 lectures as part of Endocrine teching (Dept of Human Nutrition) 5. 2 small group tutorials during Preventive Medicine attachment Teaching in Gastroenterology and Public Health under review (Dept of Human Nutrition) 6. Trainee intern year

*These modules include a signi®cant component of Human Nutrition teaching

Table 2 Objectives which indicate the knowledge required by a student Table 4 Diet of a female vegetarian athlete at the end of the Metabolism Module Breakfast 1. List the various methods in the assessment of dietary intake and 1 cup fruit salad nutritional status. 2 slices wholemeal bread with marmite and peanut butter 2. Explain the advantages, limitations and applications of each 1 cup black tea method. Mid morning 3. Discuss the concept of nutrient requirements of growth, 1 orange development and maintenance of health. 1 banana Explain the term dietary reference values. Distinguish between the lower reference nutrient intake (LRNI), Lunch estimated average requirement (EAR) and reference nutrient 1 wholemeal salad roll intake (RNI). 1 apple 4. Explain the need for dietary goals and guidelines and how they 40 g sultanas differ from dietary reference values (DRVs). 1 bran muf®n 5. Discuss the use of food groups in dietary guidelines and the Mid afternoon individual and public health approaches to encouraging 1 banana appropriate nutrient intakes. 1 slice wholemeal toast with peanut butter 6. Explain the limitations involved in evaluating an individual's Dinner nutrient intake by making comparisons with DRVs or RNIs. Falafel 7. Discuss your own diet and that of the class in relation to Pita Bread recommended nutrient intakes for iron and calcium. Salad 8. Describe the categories of vegetarianism and the potential French dressing health advantages and disadvantages of a vegetarian diet. Jelly with 2 Tablespoons of low calorie icecream During evening 1 cup black tea Analysis of vegetarian diet: Table 3 Human nutrition objectives relating to obesity Total energy 2111 kcals (8.8 MJ) Protein 11% 1 List ways in which obesity may be de®ned. Carbohydrate 72% 2. Be aware of the epidemiology and risk factors for obesity. Total fat 17% 3. Appreciate the interaction between genetic and nutritional factors Saturated fat 4% in the aetiology of obesity. Monounsaturated fat 9% 4. Have an understanding of the comorbidities associated with Polyunsaturated fat 4% obesity. Calcium 526 mg=d 5. Understand the issues underlying the individual and public Iron 20 mg=d health approaches to obesity. Dietary cholesterol 41 mg=d Dietary ®bre 59 mg=d Non-starch polysaccharide (NSP) 23.9 g=d point. Two lectures to the whole class summarise the methods for assessing dietary intake and nutritional status The cornerstone of the teaching in this module is based as well as the concept of dietary reference values and upon the analysis of 4-day estimated food records. Assess- associated terminology. Iron, calcium and iodine are used ment of individual and class results in relation to reference as examples of nutrients which may be de®cient in indivi- nutrient intakes and instruction regarding basic anthropo- duals or populations. Several chapters from the reference metry facilitates discussion on the pros and cons of the text, `Essentials of Human Nutrition' (Figure 1) (Chapters 8 different methods for assessing intake, the concepts of (Major Minerals: Calcium and Magnesium), 9 (Iron), 10 nutritional adequacy and the potentially confusing termi- (Trace Elements), 16 (Overweight and Obesity), 25 (Diet- nology relating to dietary reference values and methods for ary Assessment), 26 (Determining Nutritional Status), 33 assessing adiposity. This takes place during a single 3 h (Nutritional Recommendations for the General Popula- tutorial session. The nutrition component of this module is tion)) are recommended as background reading. assessed by a computerised multiple choice examination, Nutrition education for medical students J Mann S64 Table 5B

A 20 y old female patient presents with tiredness. She tells you that she doesn't like eating meat, and that she often doesn't get around to preparing meals for herself Ð her ¯atmates are keen meat-eaters. You order iron studies and a blood count. These are the results that come back from the lab: Value Reference range Serum ferritin 11 mg=L 20 ± 200 Serum iron 5 mmol=L10±30 Transferrin saturation 12% 16 ± 50 Haemoglobin 120 g=L 120 ± 155 What is your diagnosis? (a) Haemochromatosis (b) Normal iron status (c) Iron depletion (d) Iron-de®cient erythropoiesis (e) Iron de®ciency anaemia

However the past medical and family history (Table 6) as well as the results of the laboratory tests (Table 7) provided a lead into discussion which enabled the nutrition objectives (Table 8) to be ful®lled. The relevant teaching material was delivered in the three 50 min lectures and students were expected to refer to the recommended reading (Chapters 3, (Lipids) and 18 (Car- diovascular Diseases), Essentials of Human Nutrition). During the tutorials the students were presented with the patient's 24 h diet recall and the analysis of a quantitative Figure 1 Black and white copy of `Essentials of Human Nutrition'.

Table 6 Past and family history of the myocardial infarction case

the student being required to answer 70% of the questions Patient has had type 2 diabetes for 7 y, diet treated. correctly before being awarded a credit for completion of He has had intermittently raised blood pressures recorded by his GP. the module. Some sample questions are shown in Tables His father had his ®rst myocardial infarction in his early ®fties. 5A & B. A brother is known to be hypertensive, on drug therapy.

Nutrition and cardiovascular disease Table 7 Results of some biochemical tests on admission The nutrition teaching in individual modules is well illu- strated by that presented in the Heart and Circulation Units Reference range Result Module. Much of it is based on a clinical case involving Glucose mmol=l 4.2 ± 6.0 23.5 a 52 y old man who developed chest pain while working in Haemoglobin A1 % 4.0 ± 6.0 9.0 his garden. Obviously the early tutorials were devoted to Total cholesterol mmol=l 3.0 ± 5.5 7.8 the diagnosis and treatment of acute chest pain and of HDL cholesterol mmol=l 0.7 ± 1.9 1.0 Triglyceride mmol=l 0.4 ± 2.0 0.7 course relevant anatomy, physiology and pathology.

Table 5A

2. Match the method of assessing dietary intake with the most appropriate application from the second list. Method of assessment: 24 h recall Food frequency questionnaire 7-d diet record Most appropriate application: 1. Assess nutrient intakes for an individual 2. Estimate mean nutrient intakes for a large population group 3. Describe patterns of usual consumption of individual foods or food groups in epidemiology studies 3. Bread is a food that New Zealanders commonly eat as part of their lunch meal. You are trying to increase the amount of iron you absorb at this meal. For each of the following foods indicate whether the food is likely to inhibit, have no in¯uence on, or promote absorption of the iron FROM A SLICE OF WHOLEMEAL BREAD:

Inhibit iron absorption No in¯uence on iron absorption Promote iron absorption

Coffee Roast chicken Lettuce Orange juice Peanut butter Nutrition education for medical students J Mann S65 Table 8 Nutrition objectives for myocardial infarction case detail since diabetes is considered in greater detail in another module. Students are often particularly interested 1. Describe the epidemiology of coronary heart disease (CHD). 2. Explain the term `risk factor' and list the major risk factors for in discussing the role of antioxidant nutrients and folate as coronary heart disease, indicating which are lifestyle related. potentially protective factors in ischaemic heart disease 3. List the major dietary lipids, describe their structures and list the major since this has been extensively covered in the recent media. food sources of saturated, monounsaturated and polyunsaturated Tutors are therefore provided with additional review mate- fatty acids. rial to ensure that current literature may be presented to 4. Describe the nutritional determinants of lipoproteins. 5. Describe the nutritional determinants of hypertension and thrombosis. students. At the end of the module students are assessed by 6. Discuss your own diet and that of the class in relation to the an examination consisting of both multiple choice and short recommended nutrient intakes and dietary guidelines for fat. answer questions including a number relevant to the 7. Describe the `population' approach to cardiovascular risk reduction in nutrition objectives. countries with high rates of coronary heart disease.

Nutrition teaching in other preclinical modules and the clinical curriculum Table 9A Twenty-four hour dietary recall of patient who had suffered a myocardial infarction Further nutrition teaching is provided in several other preclinical modules: Blood (nutritional anaemias, subclini- Breakfast Muesli ± small bowl cal de®ciencies), Endocrine (diabetes) and Cancer (cancer Cream ± 1 tablespoon of the large bowel); though in these modules the contribu- Banana ± 1 small tion is limited to the inclusion of nutrition objectives, the Wholegrain toast ± 2 slices provision of reading material and a single lecture. It is Butter ± 2 teaspoons Jam, honey or marmalade ± 2 tablespoons intended to introduce a nutrition component in the Repro- Tea with milk duction, Development and Aging; Immunity and Gastro- Mid morning intestine modules. The eventual aim will be to develop Sweet biscuits with `cream' ®lling ± 2 teaching material which will be incorporated into the cases Coffee with milk which form the basis of the learning approaches in all Mid day meal modules. Wholegrain bread ± 2 slices In the clinical years nutrition is taught, by means of Butter ± 2 teaspoons lectures, as part of the Endocrine course with special Chicken ± 2 thick slices Tomato ± 1 small and Lettuce ± 2 leaves reference to obesity, diabetes, lipid disorders and other Hot chocolate with milk, whipped cream topping ± 1 cup cardiovascular risk factors. Two tutorial classes during the Mid afternoon Preventive Medicine attachment are based around a dis- Chocolate cake with butter icing cussion of published papers which the students are Tea with milk expected to have read beforehand. Examples of well Evening meal known prospective studies linking dietary characteristics Grilled steak with disease outcomes (for example the Health Profes- Potatoes mashed with butter and milk Carrots with melted butter ± 1=2 cup sionals Study in the United States) and nutritional inter- Green beans with melted butter ± 1 cup vention studies enable a discussion regarding nutritional Vanilla ice cream topped with grated chocolate and coconut ¯akes ± 1 epidemiological research as well as various issues relevant cup coffee with milk to public health nutrition. Revision of the clinical curricu- Late evening lum provides the opportunity to extend the problem-based Cashew nuts ± 1=2 cup learning approach, but in practice the full importance of Hot chocolate with milk ± 1 cup human nutrition in the aetiology, treatment and prevention of disease will only be appreciated when clinical teachers are themselves appropriately informed. It may well be that, Table 9B Analysis of a quantitative food frequency questionnaire of the for the present, nutritionists in medical schools should same patient (Reported as % total energy unless stated otherwise) devote their time principally to the preclinical curriculum Total energy 3200 kcals (13 MJ) and to informing their clinical colleagues by participation Protein 18% in grand rounds, research presentations and other postgrad- Carbohydrate 40% uate activities. Total fat 42% Saturated fat 21% Monounsaturated fat 12% Polyunsaturated fat 4% Student assessment of preclinical programme Dietary cholesterol 551 mg=d The overall student assessment of the programme has been Dietary ®bre 35 g=d Non-starch polysaccharide (NSP) 11.5 g=d very favourable (Table 10). Over 80% of the students considered nutrition to be extremely, or very, relevant to their training and a similar proportion reported that the food frequency questionnaire (Table 9). This facilitated course had stimulated their interest in the subject. In discussion on the interaction between genetic and lifestyle particular they felt that the subject was very relevant to factors which contribute to the development of ischaemic general practice. It was acknowledged that most would heart diseases and the role of diet in the management of the ultimately be involved in primary care. Three quarters rated dyslipidaemia. The presence of type 2 diabetes enables a the quality of the teaching as excellent or very good and felt brief discussion on the role of diet in the aetiology of this that the distribution of time between lectures, case pre- condition as well as the link between diabetes and ischae- sentations, tutorials and diet recording and analysis was mic heart disease. However this aspect is not discussed in about right. Sixty percent thought that the total amount of Nutrition education for medical students J Mann S66 Table 10 Student evaluation of preclinical programme the University of Otago where medical teaching was not traditionally regarded as a core activity in the Department Greatly Not at all 12 345 of Human Nutrition. However there is little doubt that there Extent to which course 25% 52% 20% 3% is a general shift away from the traditional discipline-based stimulated interest teaching towards interdisciplinary learning with an integra- Very tion of clinical and preclinical disciplines. There is no Extremely relevant Irrelevant doubt that the mix of case demonstrations, lectures and 12 345 Relevance of discipline 30% 52% 16% 2% tutorials based to a considerable extent on problem-based to clinical training learning is labour intensive. However integrating human Excellent Poor nutrition in a problem-based approach provides the student 12 345 with an appreciation of the integral role of nutrition in Quality of teaching 19% 57% 22% 2% Too little About right Too much clinical management of the patient before the student 12 345 embarks upon clinical rotations. Many medical schools Amount of time devoted 9% 24% 61% 3% will at present not have the staff or resources to develop to nutrition such a programme, so that the availability of appropriate case-based material and approved texts would facilitate the introduction of human nutrition issues in the early years of time devoted to nutrition was about right and the remainder medical education. An ultimate aim would be for clinicians would have liked to have had more time. Medically to include nutrition related issues into bedside teaching. quali®ed lecturers were particularly well received and However most clinical teachers at present have themselves over 95% appreciated the input from their tutors, most of had little training in nutrition and would therefore not have whom were PhD students in Human Nutrition. These the appropriate expertise. Once again those who were assessments are at least as good or better than for other willing could be aided by the availability of appropriate disciplines. teaching material. Ultimately a new generation of teachers should emerge once appropriately trained students mature into leadership roles. Response from academic staff and conclusions Academic staff were initially reluctant to embark upon a programme of integrated learning which clearly involved References an appreciably greater time commitment than that involved Mann JI & Truswell AS (1998): Essentials of Human Nutrition. Oxford: in a brief lecture course. This was particularly the case in Oxford University Press.