APPENDIX A

FUNDING FOR TRAINING OF PUBLIC HEALTH AND COMMUNITY NUTRITIONISTS

AND DIETITIANS

Funds, facilities and staffing for education of dietitians and public health and community nutritionists at various levels of competence are urgently needed and should be immediately provided with planned progression.

At the present time there are about $1,000 prepared to effect nutritional care to people: 30,000 dietitians and 1,000 nutritionists. While data for estimating the number actually needed to provide even moderately adequate services to the American people are not presently at hand, there is common agreement that these numbers should be no less than doubled within five years. There is urgent need for their services in emerging anti-poverty programs, in school health programs, and in providing consultation to patients of private physicians, in addition to the need to fill the increasing number of more traditional posts in health departments, other community agencies, clinics, hospitals and other medical care facilities. Specifically, there is need for:

1. Funding for traineeships and institutional support for post-bachelor's dietetic interships to relieve hospital budgets and encourage development of more internships which can prepare more people. (The American Dietetic Association has expanded the number of internships as well as the number of people in some internships. In September 1968 there were 770 interns in 65 approved internships, whereas in September 1969 there were 815 in 68 internships. There are four newly approved internships for 1970 and more in the organization stage.) Hospitals and universities in which these internships are based are currently carrying the financial cost of internship training. Increasingly, hospitals are finding this a burden and many are already stating that they will be unable to continue internship training without financial assistance.

Estimated minimum amount needed annually to maintain 72 hospital and university based internships (for use of facilities and personnel, including one fulltime educational director per internship at a salary of $14,000), $1,440,000.

Traineeships for dietetic interns: 500 at $2400 annually, presently funded by hospitals and universities, $1,200,000.

This amount will need to be doubled within five years to provide 1,000 traineeships.

2. Increased funding for master's degree training in public health nutrition. Traineeships and institutional funds for public health nutrition have been se verely curtained at a time when the number of institutions, offering such training needs to be increased at once from 16 to 32 or more, and the number of students trained anually at the master's degree level increased from approximately 100 to 300. Within five years these numbers should be tripled.

(a) Funding for institutional grants within a year, to provide staff and facilities for setting up public health nutrition training programs. Five at $50,000 each, $250,000.

Within five years this should be increased to $750,000.

(b) Student traineeships per year, within a year-100 at $3,500, $350,000. Within five years this should be increased to $1,050,000.

(c) Reimbursement of field agencies for expenses incurred in providing field experience to students, $10,000.

3. Funding for the experimental development of under graduate professional training in dietetics and public health or community nutrition. While positions of major responsibility in these fields will continue to require graduate training, the urgent need for more nutritionists and dietitians at the staff level and the higher level of competence of undergraduate students today make such experimentation not only necessary but also feasible. Guidelines for such training for public health nutritionists have been developed1 and at least one bachelor's

1 See "Public Health Nutritionists-Their Responsibilities and Qualifications," by the Steering Committee on Roles, Qualifications and Training of Nutrition Workers in Health Agencies, July 1969, p. 20.

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level training program for dietitians already exists. Funding for institutional grants to provide necessary specialized staff and facilities to institutions setting up training programs annually within one year, five at $40,000 each, $200,000. Within five years this should be increased to $800,000.

4. Funding for doctoral level training in dietetics and public health nutrition. Such training is to provide first of all teachers for the training of nutritionists and dietitians in schools of public health, nutritional sciences, home economics and others; also for the teaching of nutrition in medical, dental and nursing schools, teacher training institutions and other colleges. Existing positions in colleges and universities already are not being filled. With the proposed increase n number of training centers and increased emphasis on nutrition in the curricula of health-related professions and teachers, need for teachers with doctoral level training will become more acute. Such advanced training is needed also to provide leaders with depth understanding of problems and programs in nutrition and dietetics and the ability to do research toward advancement of these fields.

(a) Funding for institutional grants to provide needed specialized staff and facilities-annually within 1 year, three at $70,000-$210,000.

(b) Traineeships for doctoral candidates-annually within 1 year, 12 at $6,000, $72,000. Annually for third year, 24 continuing plus 12 additional: $144,000. Annually for third year, 24 continuing plus 12 additional: $216,000. Within 5 years funding for institutional grants and traineeships should be doubled.

5. Money for research on the feasibility of training and using food aides to expedite the work of the public health or community nutritionist. While aides are already being employed by some agencies, there is indication that much remains to be learned before widespread use of them can be recommended. Three projects within 1 year, $120,000. Within 5 years this should be increased to eight, for a total of $320,000.

Part B

The public needs to know about opportunities for careers in dietetics, public health, and community nutrition. Many have not heard of these professions as they have of doctors and nurses. There is need for funding to publicize these careers to the general public and particularly to high school students, their parents and counselors. There seems little doubt that these "people-centered" professions could appeal to presentday youth.

Specifically, there is immediate need for a small number of personnel to give impetus to such publicity with adequate funds to operate effectively. Estimate of amount needed: $150,000 for each of 3 years (three salaries of $20,000 each plus materials, travel, use of mass media, etc.).

(N.B. Obviously funding for training is to no avail unless budgeting for positions is assured. Other panels will speak to this point.)

APPENDIX B

NUTRITION TEACHING IN MEDICAL SCHOOLS

ADEQUACY OF NUTRITION TEACHING IN MEDICAL SCHOOLS

Only a few formal studies have been made of the adequacy of nutrition teaching in schools of medicine. Such studies have disclosed that:

1. A need for improvement in nutrition teaching is readily acknowledged by many medical schools.

2. Only a few schools have a separate division or department of nutrition.

3. Special courses in nutrition are rare and nutritional material is commonly incorporated in courses in bio-chemistry and physiology and in the teaching of clinical specialties such as medicine, surgery, pediatrics, and obstetrics.

(a) At the preclinical level, nutritional subject matter is often displayed by more "basic" topics such as enzyme kinetics, and membrane theory. In addition, instructors in biochemistry and physiology not infrequently emphasize their own research interests out of proportion to their relevance to the overall subject and to clinical problems. Often, little attempt is made to provide the student with the basic information about nutrition upon which "clinical nutrition" is necessarily based.

(b) In the clinical department and subspecialities of medicine there has been little or no correlation of nutrition teaching; thus, the student has been offered only a fragmentary selection of aspects of nutrition having particular relevance to various clinical subjects. Such fragmentation inevitably has led to appreciable gaps in nutrition education.

4. A few medical schools offer elective courses on therapeutic diets (medical dietetics), experience in a "nutrition clinic," and in nutritional investigation. 5. Many medical students only learn about florid malnutrition in man when they take electives involving participation in overseas programs based in countries where protein-calorie malnutrition and vitamin deficiencies are common.

6. In medical schools with a good program in nutrition there is usually either a strong division or department interested in nutrition, or professors with a speical interest in clinical nutrition or nutritional research.

7. A thorough and definitive survey of nutrition teaching in American medical schools remains to be done.

(a) No objective assessment of the nutritional knowledge acquired by medical students has been made.

(b) Sufficient nutritional questions do not appear on National or State Board examinations to provide a fair test of nutritional knowledge.

(c) Current knowledge of the extent and effectiveness of nutritional teaching necessarily is based in large part on the results of questionnaires distributed to various medical schools and on the impression, observations, and opinions of a relatively few faculty members. These sources give a useful preliminary indication of the state of nutritional teaching in American medical schools; however, the information they contain does not provide a sufficiently strong foundation upon which a national policy with respect to nutritional teaching at the medical school level can be based.

(d) (See addendum No. 1.)

I. Opportunities for Nutrition Teaching to Medical Students

No plan designed to improve nutrition teaching to medical students can overlook the striking changes introduced into the curriculums of most medical schools during the past 5 years. These include:

1. Reduction of time spent in laboratory exercises in anatomy, biochemistry, physiology, pharmacology, and other preclinical sciences.

2. Strong efforts made to coordinate teaching of basic science material so that biochemical, physiologic, pharmocologic, and clinical information about the various organ systems of the body is presented to the student in an integrated fashion.

3. Increased emphasis on interdisciplinary teaching with some beginning dissolution of departmental boundaries.

4. Introduction of the student to clinical problems earlier than previously; often in the first year, or early in the second year.

5. More emphasis on elective opportunities for students after they have completed a "core curriculum," usually during the last 18 months of medical school. These elective opportunities include:

(a) Assignments to medical facilities in technically underdeveloped countries and to poverty areas in the United States.

(b) "Clerkships" in community medicine where problems in the delivery of medical care by the hospital center are given special attention.

II. Nutrition Teaching During the Preclinical Years

In considering how nutrition teaching can be fitted into and articulated with the medical school curriculum, it must be kept in mind that the time available for basic science courses is being increasingly compressed. Thus, it would seem difficult to add a required course on basic aspects of nutrition during the so

called preclinical years, even though establishment of such a course has been recommended on a number of occasions. However, since there is an increasing emphasis on integration of basic science material, it is possible that the presentation of what is ordinarily considered to be nutritional subject matter can be used to organize biochemical or physiological information. For example, a discussion of the factors affecting nitrogen balance could be used to pull together a great deal of material on protein biochemistry that otherwise might not be related readily to human health problems. A discussion of calorie requirements in man might serve to give relevance to the subject of energy transformations at the cellular level.

It has been pointed out that some medical schools offer courses in clinical correlation or pathophysiology, in which an attempt is made to bridge the gap between basic science and clinical training. In such a course nutritional information can help the student understand the relationship between the clinical picture and the underlying physiologic or biochemical disorder. For example, the symptoms that accompany growth-onset diabetes mellitus can be best understood in terms of the conditioned malnutrition that results from inability to utilize carbohydrate properly.

III. Nutrition Teaching in the Clínical Specialties

The importance of nutritional considerations in medicine, surgery, pediatrics and obstetrics is acknowledged. Unfortunately (as mentioned previously), the nutrition teaching provided by the various medical specialties is necessarily fragmented, and sometimes superficial. For example, the student may be taught a rule-of-thumb approach to nutritional therapy without being given an understanding of the principles upon which such treatment is based.

It has been suggested that a properly qualified member of the faculty with a strong interest in nutrition could help to coordinate and strengthen the teaching of nutrition in the clinical specialties and, by means of lectures, conferences, clinics, or teaching rounds, fill in any important gaps that remain.

IV. Nutrition Teaching in Electives

1. Electives that involve participation in programs designed to deliver medical care in poverty areas in the United States or abroad often bring the medical student into direct contact with patients who exhibit florid deficiency states, including protein-calorie malnutrition. Such experiences are far more effective than slides or textbook pictures in convincing the student that malnutrition remains a major world health problem and that clinical nutrition is a subject providing many challenges for the young physician.

2. Clerkships in community medicine are increasingly offered by the various divisions and departments of community medicine that are developing in medical schools and teaching hospitals throughout the country. In such programs, the medical student can work in a nutrition clinic, participate in nutrition surveys, study the role of nutrition in disease prevention or retardation and learn to work effectively with other members of the "health care team," including the public health nutritionist. This type of training can lead logically into a career in public health nutrition or to a program of graduate training in comprehensive medicine designed to train a new type of specialist for whom the designation "primary physician" has been suggested.

3. An elective in a division where nutritional and metabolic research are conducted can serve as an introduction to a career in academic clinical nutrition. Medical students who participate in such electives may be motivated to obtain 2 to 4 years of postdoctoral training in nutrition and metabolism after completing 1 or 2 years of residency work in a medical specialty.

V. Recruitment

Recruitment of young physicians into clinical nutrition has been extremely difficult and there is a critical shortage of trainees and of teachers and investigators in this field.

Some of the reasons for this situation have been identified. These include the following:

1. A lack of identity for clinical nutrition.

2. Lack of a subspecialty status for clinical nutrition.

3. Dearth of superior training programs in nutrition designed to meet the needs and interests of young physicians.

4. Lack of recognition by medical schools and teaching hospitals of a need for clinical nutrition programs.