Nutrition Education in U.S. Medical Schools: Latest Update of a

Nutrition Education

Nutrition Education in U.S. Medical Schools:

Latest Update of a National Survey

Kelly M. Adams, MPH, RD, Martin Kohlmeier, MD, and Steven H. Zeisel, MD, PhD

Abstract

Purpose

To quantify the number of required

hours of nutrition education at U.S.

medical schools and the types of courses

in which the instruction was offered, and

to compare these results with results

from previous surveys.

Method

The authors distributed to all 127

accredited U.S. medical schools (that

were matriculating students at the time

of this study) a two-page online survey

devised by the Nutrition in Medicine

Project at the University of North

Carolina at Chapel Hill. From August

2008 through July 2009, the authors

asked their contacts, most of whom

were nutrition educators, to report the

nutrition contact hours that were

required for their medical students and

whether those actual hours of nutrition

education occurred in a designated

nutrition course, within another course,

or during clinical rotations.

Results

Respondents from 109 (86%) of the

targeted medical schools completed

some part of the survey. Most schools

(103/109) required some form of

nutrition education. Of the 105 schools

answering questions about courses and

contact hours, only 26 (25%) required a

dedicated nutrition course; in 2004, 32

(30%) of 106 schools did. Overall,

medical students received 19.6 contact

hours of nutrition instruction during

their medical school careers (range:

0–70 hours); the average in 2004 was

22.3 hours. Only 28 (27%) of the 105

schools met the minimum 25 required

hours set by the National Academy of

Sciences; in 2004, 40 (38%) of 104

schools did so.

Conclusions

The amount of nutrition education that

medical students receive continues to be

inadequate.

Over the past three decades, numerous

professional groups, scientific

publications, and a congressional

mandate have highlighted the need to

improve the medical nutrition education

that future physicians receive.

1–4

Student

groups have attempted to define the goals

related to incorporating essential

nutrition-related teaching into the

curriculum,

and a major funding

initiative by the National Heart, Lung,

and Blood Institute created the Nutrition

Academic Award.

6,7

There is little dispute that a patient’s

dietary habits can influence chronic

disease risk and treatment outcomes.

Consumer surveys show that physicians

are considered credible sources of

nutrition information.

However, more

than half of graduating medical students

still rate their nutrition knowledge as

“inadequate,”

and physicians report that

they have not received adequate training

to counsel their patients on appropriate

nutrition.

10–13

Surveys of medical

students and physicians alike have found

suboptimal knowledge with respect to

nutrition facts.

13–15

It has been nearly a quarter-century since

the National Academy of Sciences

published its groundbreaking report

highlighting the insufficiency of nutrition

education in the medical school

curriculum.

Our study attempted to

answer two questions about that topic in

the intervening 25 years. First, have

medical schools responded to the

challenge by improving nutrition

knowledge and practice skills of future

physicians? And, second, do most schools

meet the minimum of 25 hours of

nutrition education recommended by

this landmark report on medical

nutrition education?

Since 1995, the Nutrition in Medicine

(NIM) Project at the University of North

Carolina at Chapel Hill has developed a

free, interactive, comprehensive nutrition

curriculum for medical students.

part of the NIM mission, the NIM team

surveys nutrition instructors at U.S.

medical schools every few years. This

effort aids the project in tracking trends

related to the provision of nutrition

instruction in medical school curricula

and gives the team feedback that will help

improve content and outreach. The

existence of the data from these surveys

provides the opportunity to compare

newly collected data with data from

previous surveys dating back to 2000.

The NIM team uses a survey

methodology that goes deeper than usual

by assessing more than the simple

existence of a nutrition course for

medical students. With the proliferation

of integrated curricula and problem-

based learning paradigms, much of the

nutrition instruction at medical schools

currently is occurring outside of

dedicated nutrition courses. The NIM

Project’s 2008 –2009 survey is designed to

capture and quantify the instruction that

occurs in different types of courses across

the four years of the undergraduate

medical curriculum. An important facet

of the methodology is that the NIM

database of medical school contacts

contains the names of the nutrition

educators themselves—those who are

actually providing the instruction—

Ms. Adams is research associate, Department of

Nutrition, University of North Carolina at Chapel Hill,

Chapel Hill, North Carolina.

Dr. Kohlmeier is professor, Department of

Nutrition, University of North Carolina at Chapel Hill,

Chapel Hill, North Carolina.

Dr. Zeisel is Kenan Distinguished University

Professor of Nutrition, Department of Nutrition, and

director, Nutrition Research Institute, University of

North Carolina at Chapel Hill, Chapel Hill, North

Carolina.

Correspondence should be addressed to Ms. Adams,

Department of Nutrition, CB #7461, University of

North Carolina at Chapel Hill, Chapel Hill, NC

27599-7461; telephone: (919) 408-3320, ext. 22;

fax: (919) 408-0674; e-mail: [email protected].

Acad Med. 2010;85:1537–1542.

doi: 10.1097/ACM.0b013e3181eab71b

Academic Medicine, Vol. 85, No. 9 / September 2010 1537

rather than the names of administrators,

who would be reporting secondhand

information.

Method

The NIM Project has administered

similar types of surveys several times

since 2000. In developing the 2008 –2009

survey, we retained the wording of key

questions from the 2000 –2001 and 2004

surveys to allow direct comparison of the

results through the years. Identical

questions had to do with the type and

total hours of nutrition education across

the medical school curriculum. New

questions pertained to the use of the

online curriculum of the NIM Project,

the ways in which it has influenced

nutrition education, and whether the

respondent is responsible for teaching

residents and other physicians.

In August and September 2008, we e-

mailed the online survey link to the NIM

database contacts at 127 of the 130 U.S.

medical schools accredited by the

Association of American Medical

Colleges (AAMC).

The three U.S.

medical schools not included in this

survey would not be matriculating

students until the fall of 2009, and thus

the survey could not include them. The

NIM database of medical school contacts

is unique in that, in most cases, NIM

Project staff members are in direct

contact with the instructor, the person

who is actually providing nutrition

education to medical students. The NIM

team continued to contact instructors via

phone, fax, and e-mail through July 2009

to encourage them to complete the

survey. Participation was voluntary.

The survey contained 13 items. As in

previous surveys, the first question asked

for the number of first-year medical

students at that school, and the second

question asked instructors to specify

whether nutrition instruction was

required, optional, or not offered at their

medical schools. The third question asked

them to estimate the total number of

required nutrition contact hours,

specifying in which years the instruction

was provided (first and second years or

third and fourth years). The fourth

question asked respondents to indicate

the type of course in which the nutrition

content was taught (e.g., nutrition,

physiology/pathophysiology,

biochemistry, or an integrated

curriculum). The fifth question asked

them to specify whether they felt that the

amount of instruction was sufficient.

Questions 6 through 9 had to do with the

use and impact of the NIM Project

curriculum at the respondent’s medical

school. The survey concluded with

questions 10 through 12, which inquired

whether the respondent’s responsibilities

included teaching preclinical students,

clinical students, or residents. The final

question, number 13, was an open field

for comments.

All but one recipient used the online

interface to fill out the survey. The

remaining survey was completed over the

telephone, and one of us (K.M.A.)

manually entered those responses into

the online form. The institutional review

board at the University of North Carolina

at Chapel Hill made the determination

that this project was exempt.

When the data collection was complete,

an NIM staff member produced a dataset

from all of the entries, and we used a

spreadsheet software program (Excel

2003; Microsoft Corp., Seattle,

Washington) to carry out all calculations.

We calculated means and standard errors

for the current survey and for all previous

survey years by using the same categories

and procedures.

In performing computations related to

the hours of required nutrition

instruction, we coded optional hours as

zero hours of required nutrition

education. If the respondent estimated a

range of hours (e.g., 15–20 hours), we

used the midpoint of the range (e.g., 17.5

hours) in calculations. We reanalyzed all

numbers from previous years’ surveys by

using the same criteria.

We determined the total number of

hours in the four years of medical school

by adding the required hours of nutrition

instruction in the first and second years

to the hours occurring in the third and

fourth years. In nine cases, a respondent

indicated the number of hours of

required instruction in the first and

second years but was unable to estimate

the number of hours of required

instruction in the third and fourth years.

In these cases, the analysis used zero

hours for the third and fourth years.

Results

Surveys were returned from 109 of 127

U.S. medical schools, for an 86%

response rate. Of these 109 schools, 103

(94%) reported that nutrition instruction

was required. Four schools (4%) offered

optional instruction only; one school

(1%) reported that it did not offer any

nutrition instruction, and the respondent

for one school (1%) did not know the

answer to the question.

A total of 105 schools completed the

portion of the survey regarding the

number of nutrition contact hours.

According to these responses, U.S.

medical schools provided an average of

19.6 hours of required nutrition teaching

(range: 0 –70 contact hours). Only 27%

(28/105) of U.S. medical schools

responding to this question indicated that

they provided the minimum of 25 hours

recommended by the National Academy

of Sciences in 1985.

Thirty medical

schools (29%) reported requiring 12 or

fewer hours of nutrition instruction

(Figure 1). Most of these contact hours

took place during the first two years of

medical training when students received

an average (standard error of the mean

[SEM]) of 15.4 (1.0) hours of required

nutrition instruction. The third and

fourth years provided an average (SEM)

of only 4.2 (0.6) additional hours.

Twenty-six schools specified that they

had a course dedicated to nutrition. In 10

Figure 1 Distribution of the total hours of

required nutrition instruction at U.S. medical

schools. Representatives from 109 U.S.

medical schools responded to the 2008–2009

Nutrition in Medicine survey (105 schools

provided data in response to this question; 4

schools did not). The graph compares the

number of schools meeting the recommended

minimum of 25 hours of required nutrition

education (white bars) with the number of

schools providing less than the minimum

number of required hours (black bars). The

number of schools at each level of required

nutrition instruction is indicated above each bar.

Nutrition Education

Academic Medicine, Vol. 85, No. 9 / September 20101538

of those institutions, this course

represented all of the available nutrition

instruction. These dedicated nutrition

courses provided an average of 16.4

nutrition contact hours (Table 1). Fifty-five

schools provided some nutrition

instruction within basic science courses

(physiology or biochemistry); on average,

each of these courses accounted for 6.2

hours or less.

At U.S. medical schools, 80% of the

nutrition instruction took place outside

of designated nutrition courses (Figure

2). During the third and fourth years, 35

(33%) of the 105 schools answering this

question offered five or more hours of

nutrition instruction.

More than three-quarters of the medical

school instructors (84/107, or 79%)

surveyed indicated that students at their

institution need more nutrition

instruction, whereas 16 (15%) of them

said that the students did not need more

nutrition instruction. Only 8 of these 16

instructors were at schools offering more

than the national average number of

hours of nutrition instruction. The

remaining 7% of instructors said that

they did not know whether their students

needed more nutrition education. (The

total percentage exceeds 100% because of

rounding of individual percentages.)

Table 2 more clearly illustrates the

current situation by presenting a

comparison of key data points from this

survey and of those from surveys of

previous years

18,19

; all three surveys used

the same methodology and (with one

exception in the 2000 –2001 survey)

asked the same core questions. Of the

three national surveys, the most recent

survey found the lowest number of

schools that require a nutrition course,

the lowest percentage of schools that

provide a total of at least 25 hours of

nutrition education, and the lowest

average number of required nutrition

contact hours. None of these differences

reached statistical significance, however.

Discussion

Our study shows that nutrition education

continues to be very limited in most

medical schools, a situation that casts

doubt on the readiness of future

physicians to effectively counsel their

patients about appropriate nutrition.

How did we determine that the current

amount of nutrition education is

“inadequate?” There are two major

recommendations in the literature about

this topic. One is the 1985 National

Academy of Sciences report that suggests

25 hours of nutrition instruction as a

minimum,

and the other is the 1989

American Society of Clinical Nutrition

recommendation that 37 to 44 hours be

dedicated to nutrition instruction during

medical school.

By either standard,

medical schools are falling far short of

providing adequate training.

There are many medical schools,

however, that manage to incorporate at

least 25 hours of nutrition education into

their curricula in any given year. We

examined the 86 medical schools from

which we had data for all three NIM

Project surveys over the past 10 years. In

each survey, a total of 28 of those schools

met or exceeded this minimum standard,

but they were not the same 28

institutions in every survey. Only nine

Figure 2 Distribution of the required nutrition contact hours (i.e., the actual number of hours of

nutrition education) among the various types of medical school courses. Representatives from 109

U.S. medical schools responded to the 2008–2009 Nutrition in Medicine survey (100 schools

provided data in response to this question; 9 schools did not). The chart shows the distribution of

required nutrition instruction throughout medical school curricula, whether in a designated

nutrition course (20%) or integrated into other courses or learning environments (80%).

Table 1

Course Distribution of Required Nutrition Contact Hours in U.S. Medical Schools

During 2008 –2009

Type of course

Schools providing part of their

required nutrition instruction

in this format, no.

No. of hours of nutrition

teaching provided in this

format, mean (SEM)

Nutrition 26 16.4 (1.7)

...................................................................................................................................................................................................................................................................................................................

Physiology, pathophysiology, or pathology 36 5.7 (0.6)

Biochemistry 48 6.2 (0.6)

Integrated curriculum 62 11.9 (1.1)

Clinical practice 49 6.4 (0.7)

Other

†

11 10.0 (3.1)

* One hundred nine U.S. medical schools responded to a survey conducted in 2008 –2009; 100 schools responded

to the question about the course distribution of their required nutrition education (three schools requiring

nutrition education did not indicate the number of hours). Note that schools could offer nutrition education in

more than one type of course. SEM indicates standard error of the mean.

†

Includes clerkships and clinical rotation lectures, clinical foundations, problem-based learning, nutrition selective,

and organ-based modules.

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Academic Medicine, Vol. 85, No. 9 / September 2010 1539

schools provided at least 25 hours of

nutrition instruction in all three surveys,

which attests to the persistently tenuous

state of nutrition education at most

medical schools. There seems to be a

great deal of flux from year to year in the

number of hours of nutrition instruction

offered, as indicated by the periodic NIM

Project surveys.

According to the 2008 –2009 survey, most

instructors still believe that the amount

of nutrition education in the curriculum

is inadequate. A small majority of

students share this view. AAMC last

included a nutrition question in its

graduation questionnaire in 2005. At that

time, 51.1% of all U.S. medical students

reported that the time devoted to

nutrition in the curriculum was

inadequate.

So it seems that, overall,

graduating medical students and

instructors alike continue to be

dissatisfied with the amount of nutrition

education in U.S. medical schools.

It is important to note that 80% of the

nutrition instruction in medical schools

is not specifically identified as such in the

curriculum. Nutrition instruction

provided outside of designated courses

could be considered diluted in

importance—presented as an aside,

instead of being given the emphasis it

deserves as a core component of modern

medical practice.

In addition, it still appears that most of

the nutrition instruction that does occur

in medical schools takes place during the

preclinical years—the first two years of

medical training. It may be more

beneficial, however, to emphasize

nutrition during the later clinical years,

when the student can see the direct

correlation between nutrition principles

and medical treatment.

Several reports suggest that recent

medical school graduates feel unprepared

to intervene in their patients’ care with

regard to nutrition.

9,11,21,22

Recent surveys

of residents and practicing physicians

support this view,

10,13

especially with

regard to the growing problem of

obesity.

22–25

This deficit in preparation is

rather alarming, considering the

importance of nutrition in obesity

prevention and the critical role of diet in

the energy balance equation.

There are many challenges to bringing

more nutrition education into medical

schools’ curricula. In the past, its absence

or scarcity seemed to be a consequence of

a lack of expert nutrition faculty who

could advocate for incorporating

nutrition into the undergraduate and

residency curricula and who could serve

as role models in demonstrating how

nutrition can be applied to modern

medical practice.

26,27

Another, more

recent barrier is the lack of time for new

courses or additional lectures.

The NIM

Project has developed an online

curriculum that addresses both of these

challenges.

Through this online

resource, fully developed content is

available to supplement the curriculum

when a faculty member trained in

nutrition is not available, and the

individual online modules contain units

that can be customized for the amount of

time available to any instructor. Even

though this resource can be used at no

cost by any medical school instructor

wishing to incorporate nutrition into

existing courses or clerkships, the

amount of nutrition instruction at

medical schools is still not where it

should be.

Strengths

Some strengths of the current survey

administration must be noted. One of

these strengths is that identical

questions have been used for three

consecutive survey administrations, a

practice that allows direct comparisons

across time. Before 2000, the NIM

Project administered several similar

surveys, so there were multiple chances

to improve and refine the wording of

the questions. We obtained response

rates of 86% in the 2008 –2009 survey,

84% in the 2004 survey, and 89% in the

2000 –2001 survey—rates much higher

than those in many surveys reported in

the literature. Another of these

strengths is that the method we used

targets the person at each medical

school who is likely to be the most

knowledgeable about the nutrition

curriculum. All but eight respondents

are actually involved in nutrition

teaching of first- and second-year

medical students at their schools (and

six of those eight teach more advanced

students, which leaves only two

respondents who claimed to be

knowledgeable about the curriculum

but were not actually teaching

nutrition). Thus, the responses to this

survey came from faculty who are

contributing directly to nutrition

Table 2

Comparisons Over Time of Selected Survey Data From U.S. Medical Schools With

Respect to Nutrition Education

Item 2000–2001 survey 2004 survey 2008–2009 survey

Average required nutrition contact hours, no.

*†

20.4 22.3 19.6

Schools with required nutrition course, %

(no./total)

35 (39/112) 30 (32/106) 25 (26/105)

Schools requiring ⱖ25 hours of nutrition

education, % (no./total)

32 (36/112) 38 (40/104)

‡

27 (28/105)

Instructors who think more nutrition

education is needed, %

—88 79

* All U.S. medical schools were surveyed at three distinct times: 2000 –2001, 2004, and 2008–2009 (the current

survey). The surveys used identically worded core questions (the only exception is that the question reflected in

the bottom row was not asked on the 2000–2001 survey). The response rates from the three surveys were

89%, 84%, and 86% from 2000–2001, 2004, and 2008–2009, respectively.

†

The averages represent data from all schools providing quantifiable responses. Schools reporting only optional

nutrition instruction were coded as having zero hours of required nutrition instruction.

‡

Two schools did not provide a response to this survey question.

Nutrition Education

Academic Medicine, Vol. 85, No. 9 / September 20101540

education, and we did not rely on

reports from administrators or other

faculty. Despite the difficulties in

quantifying an entity as diverse as

nutrition instruction across a four-year

curriculum, we present these results

with confidence.

Limitations

The survey methodology had some

limitations. Respondent self-selection

bias was possible, because the survey was

voluntary. If anything, however, we feel

that this bias might overestimate the

amount of nutrition education, because

nutrition educators, with whom we have

an established relationship, may feel

more compelled to answer the survey.

With a response rate of 86%, however,

this bias should not be so pronounced.

There is an inherent uncertainty about

how different instructors estimated the

hours of nutrition, given that nutrition is

a broad topic that is not always clearly

defined. It is possible that different

instructors at the same institution would

use different definitions and, thus, give

different answers.

The amount of nutrition education

required during the third and fourth

years of medical school is difficult to

estimate, given that much of this

instruction occurs during clerkships

under different instructors. Because

many more instructors in medical

schools are involved in clinical teaching

than are involved in basic sciences

curricula, it is plausible that an instructor

familiar with the basic sciences

curriculum may underestimate the

amount of instruction provided in the

second half of the medical curriculum.

To further examine this possibility, we

conducted a separate analysis comparing

responses of clinicians with those of basic

science instructors. The schools of

respondents who self-identified as

“clinical” instructors provide a similar

number of nutrition education hours as

do the schools of instructors with basic

science orientation.

Future surveys of this type, with

additional resources, could include

multiple instructors at the same

institution in an attempt to confirm and

complete the responses provided. In

addition, if attempts were made to

systematically survey clinical instructors,

the information gained would add to the

understanding of the depth and breadth

of nutrition instruction during the third

and fourth years of medical school.

Conclusions

The teaching of nutrition in U.S. medical

schools still appears to be in a precarious

position, lacking a firm, secure place in

the medical curriculum of most medical

schools. Concerns remain that many

future physicians will lack adequate

preparation in this essential component

of modern medical practice. Despite

these challenges, a minority of medical

schools still manage to provide

substantial nutrition training for their

students. Medical school faculty should

encourage administrators to retain the

nutrition education currently offered and

expand it to provide, at a minimum, the

25 nutrition education hours needed to

properly train physicians.

Acknowledgments: The authors gratefully

acknowledge all of the medical school faculty

members who completed surveys and express

appreciation to the Nutrition in Medicine Project

advisory board.

Funding/Support: The Nutrition in Medicine

Project was supported in part by grant no. R25

CA65474 from the National Cancer Institute and

the Office of Dietary Supplements, National

Institutes of Health, and by grant no. DK56350

from the University of North Carolina Clinical

Nutrition Research Unit.

Other disclosures: None.

Ethical approval: The institutional review board at

the University of North Carolina at Chapel Hill made

the determination that this project was exempt.

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