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Seminar on nutrition in health and agricultural planning for national development
Nutrition education and training in schools of medicine, pharmacy, and dentistry

Seminar on nutrition in health and agricultural planning for national development

A seminar on Nutrition in Health and Agricultural Planning for National Development, jointly sponsored by the University of Hawaii School of Public Health, the United Nations University, and the Nutrition Center of the Philippines, was held at the Nutrition Center of the Philippines, 26 - 28 February 1979. Forty-three participants, policy-makers and leaders in the fields of agriculture, nutrition, population, and health, from six countries-Bangladesh, Indonesia, Thailand, Malaysia, Sri Lanka, and the Philippines-took part. The general objective of the seminar was to assist various agencies concerned with the nutritional health of a country to understand the conceptual and operational problems of nutrition-planning as it relates to national economic development, a concept that is relatively new in Asia. The goal was to improve national nutrition policies and their impact on agriculture, population, and family health by initiating discussions among the policy-makers from the participating countries. Specific objectives were:
1. to evolve recommendations for implementing nutrition components in the national policy of participating countries;
2. to compare and contrast current policies related to nutrition in the participants' respective countries;
3. to discuss mutual experiences in promoting regional co-ordination in the field of nutrition; and 4. to analyze communication linkages in nutrition, agriculture, health, and policy-making bodies in their respective countries in order to evolve a co-ordinated nutrition programme.

The first session stressed that planning depends upon co-ordination among the involved segments of society. Some participants expressed concern at the over-emphasis on economic development, when the greatest need appears to be for human development, which strongly implies the need for education.

The issue of sophistication versus simplification in the planning process was discussed. While sophisticated nutrition-planning might have a place in national development and multi-sectoral planning, a simplified planning process should be devised for local-level planning. Involvement of the community in the planning process was considered crucial by many delegates. Two major constraints on community involvement in planning are high rates of illiteracy and inadequate communication between government planners and the communities they are meant to serve. Furthermore, the constraints on effective planning were pointed out; for example, priority-setting, especially when it involves inadequately informed "Western experts"; the inadequate time dimension allowed in programme-planning; lack of incentives for the multi-disciplinary personnel needed in multi-sectoral planning; and inappropriate control of the planning process.

The second session dealt mainly with the issue of nutrition as an important factor in national development, and specifically with the relationship between nutrition and development indicators in the areas of economics, health, and education. It was also noted that the nutrition factor in the Philippine experience cuts across many development sectors. The nutrition system is composed of three subsystems: food supply, distribution, and the consumer subsystem, which, in turn, points up the need for a multi-sectoral approach, not to mention the need for integrated planning to maximize use of limited money, manpower, and facilities.

It was pointed out that agricultural planners should consider the malnutrition problem in terms of total human development and help seek long-term solutions. Studies should be undertaken to determine the effect of agricultural policies, programmes, and methods on human development. It was further recommended that for substantial nutrition improvement, policy-makers and planners should strengthen and broaden the inputs of the sectors of health, agriculture, and family-planning.

It was noted that the solution to malnutrition could come only with improved family economic status, which is known to be closely associated with the opportunity for productive work, improvements in environmental sanitation, family-planning, and the delivery of health and other basic services.

The major development objectives appropriate to developing countries were identified as:
(a) achieving national economic growth;
(b) expanding employment opportunities;
(c) increasing family income; and
(d) arresting rapid population growth. These objectives can be achieved through integration of economic and health development in the planning process.

It was also realized that the management of primary health care is a common effort of all countries, with the basic implementing principle of getting to the people. The success of the primary-health workers depends to a great extent on the government health system and its support to motivate them.

The participants were then divided into discussion groups in each area: nutrition, health, agriculture, and policymaking. The nutrition group emphasized the importance of nutrition education for children; for the nation's leaders through a national-level task force; and at the grass-roots level. The need for the "bottom-up planning" approach was discussed. This approach is being tested in the Philippines, in which the planning process is from the barangay (village) to the national level. This approach necessitates training in nutrition-planning at all levels. It was also pointed out that there is a need for strengthening nutrition-planning expertise in the national planning body and in the health and agriculture sectors.

The agriculture group pointed out that agriculture has the current capacity for increasing food production in order to supply sufficient nutritious foods. To prevent malnutrition, nutritious food supplements should be provided through an effective distribution system involving local health workers.

Some approaches linking agriculture with nutrition-planning were suggested. Planning should begin with studies of current levels of food consumption and the nutritional status of the population. Feasibility targets should also be developed. Intervention actions should likewise be stimulated with reference to production, processing, and distribution of foods through the use of fertilizers, loaning systems, and co-operatives.

It was also pointed out that agricultural planners should convince national policy-makers and planners to stabilize prices; this is needed particularly when cash crops are converted to nutritious food crops for local consumption.

The national development planning group suggested that nutrition improvement be one of the national objectives in a development plan. The organization of a National Nutrition Council for multi-sectoral planning was recommended. This body could be established either in the national planning body or as a separate entity, depending on the political system within which it operates and on its authority, technical knowledge, and political linkages.

The discussion in the health group opened with the contention that national development plans should accomodate sectoral needs in terms of meeting national problems concerning health, nutrition, and population. To strengthen multi-sectoral planning, there is a need for new approaches, for simplifying processes, and for clearly defining sectoral responsibilities in planning and implementation. Nutrition should be one of the major concerns of the health sector because a nutrition programme has an important role in identifying the extent of malnutrition problems, in providing curative and rehabilitative care, in disease prevention, and in health promotion. A major thrust of the health sector's nutrition programme should be nutrition education to promote long-lasting behavioural modification. It was further recommended that nutrition education be integrated in the curricula of all schools, particularly in fields related to health science.

It was pointed out that the goals of nutrition programme and family-planning programme are different. Whereas family-planning programmes aim at reducing birth rate, nutrition programmes aim at reducing mortality and morbidity rates. There should therefore be a balance of goals, targets, and overall programming in an integrated family-planning and nutrition programme. For this programme-to be successful, long-term health and nutrition interventions should be planned. Target groups should also be identified.

The importance of integrating nutrition and agriculture for the improvement of health and socio-economic well-being of families was stressed. The session ended with emphasis on nutrition education as an important component, especially for policy-makers and planners.

Following the close of the third session, a twenty-minute report was presented by each country chairman, following which a consensus emerged regarding the need for a continuing dialogue among national development, agriculture, and health- and nutrition-planners to strengthen strategies and methodologies for integrating nutrition-planning in area development programmes. This would involve the strengthening of planning units within the national planning body and the agriculture and the health and nutrition sectors, and would require collaboration among these sectors for effective multi-sectoral planning and implementation of programmes directed toward improvements in the indicators of family health, nutritional status, and family income.

The final recommendations were to pursue mechanisms for regional collaboration and information exchange directed toward improved nutrition-, health-, and agriculture-planning in formulating multi-sectoral, total development policies and plans.

Nutrition education and training in schools of medicine, pharmacy, and dentistry

An abridged report of IUNS Committee 1/V.

The importance of nutrition education in the health sciences has been stressed in the recommendations of international and national agencies. Relevant is the recent position assumed by officials of WHO in dealing with the health needs of the future. According to them, the new approach to health is one that "... would make good use of today's scientific knowledge while avoiding the constraining tentacles and the professional biases of the consumer medical industry." More than therapeutic medical care is needed; essential is a health management where disease prevention is the main task and where the users are involved.

To quote Krehl: "As in the traditional practice of crisis-oriented medicine, in preventive medicine, establishing a diagnosis provides the basis for a preventive management to be initiated. In some cases the therapeutic program may involve suitable chemotherapy. More frequently, however, the practice of preventive medicine involves efforts to induce change in the behavior or life style of the individual. Insofar as the treatment involves patient behavior and its changes, the physician may be thought of as an educator to attempt to induce a greater personal responsibility for health; the physician may be required to develop and utilize a broad spectrum of the health education team to assist the individual in his compliance in a preventive health maintenance program.

"As an educator, the doctor's role may not be that of providing the patient with all the information he needs, but with alerting the patient in some effective way to his need for information, to pointing out methods whereby the information may be obtained by the patient and sources of information, as well, of course, as providing the patient with feedback concerning how well the patient has achieved the knowledge he needs and has acted appropriately on the basis of the knowledge obtained. Because the role of educator is unfamiliar to most physicians in the traditional frame of reference in medicine (but in the original conception of 'doctor') and because the behavioral changes involved may require much greater skill, more time and understanding than the biochemical changes associated with administration of medications, many or most physicians fail to recognize the importance of this role at all. As a result, a huge communication gap exists between the doctor and the patient."

Nutrition has a key role in this approach, and ail the operators in the field of health, who, of course, have to integrate their work in a team, should have appropriate training in nutrition as well as in social and educational sciences in order to further the nutrition education of the user, who has to share the management of health. Another general problem is one of terminology in the use of education and training.

According to Aylward in a report prepared for UNESCO: "The term education system in English has a range of meanings but in common use it covers forma/ education at different levels from schools to universities and includes vocational schools and professional courses in universities, university colleges and in sub-university institutions. The word training (as distinct from education) is often used in a narrower vocational concept, and tends to be used outside the university system."¹

According to the Food and Nutrition Terminology of WHO and FAO, with the collaboration of the IUNS, "nutrition education" is defined as "education of the public aimed at a general improvement of the nutritional status mainly through promotion of adequate food habits, elimination of unsatisfactory dietary practices, introduction of better food hygiene, and more efficient use of food resources." In distinction, "nutrition training" is " the academic and practical instruction in nutrition, dietetics, and food science, usually including the scientific, economic, and social aspects of the subject."

At the Conference on Education organized by Teachers College of Columbia University, "nutrition education" was defined as "... the development of an understanding capable of producing intelligent decisions and actions. Education is not merely the acquisition of a fund of technical knowledge. Education in nutrition is the meaningful interpretation of that knowledge."²

For Darby the objective of nutrition education is to motivate the individual to practice healthful food habits.³

What follows is an area-by-area survey.

Africa

According to a survey of 43 medical schools carried out in 1977 by A. Omololu, of the 18 replying, nutrition as such is taught in only two, and in the others it is integrated mainly with biochemistry, physiology, medicine, pediatrics, and preventive medicine. About half give an examination, and in only one are there nutrition questions in the final examination at the end of the fifth year.

The topics considered deal mostly with basic nutrition and local problems of malnutrition. In general, the students are interested in nutritional problems of the country, and after graduation they make use of nutrition knowledge in their practice, in some cases as educators of the population. In a few countries (Mozambique and Tanzania) new approaches are under way that are very promising. For instance, in Tanzania nutrition is taught in the context of malnutrition and its association with poor production and distribution of foods and/or wealth, disease, and the resulting lack of vitality.

In two of the six dental schools surveyed, there is no nutrition examination, and the subject is integrated with preventive dentistry or physiology. Present training methods are considered insufficient to motivate interest in the students. In the only school of pharmacy responding among the ten questioned, nutrition is taught mostly in the context of physiology, dealing particularly with the nutritional value of local food. There is an examination.

In 1977 the Regional Office for the Eastern Mediterranean of WHO did a follow-up of the excellent Workshop on Nutrition Teaching in Medical Schools held in Isfahan in December 1973.

Asia

A. Valyasevi surveyed schools of medicine and pharmacy in India t2);Japan (37); Korea (7); Malaysia (1); Pakistan (1 ); Philippines (2); Sri Lanka (1); and Thailand (4). No information is available for schools of dentistry.

TABLE 1. Category of Health Professionals Responsible for Prevention and Treatment of Nutritional Diseases in 37 Schools of Medicine and Pharmacy in Japan, and in 18 Such Schools in Seven Other Asian Countries

____________________________________________

Ministry of Health 42%
Physician 37%
Nurse 26%
Nutritionist 26%
Health personnel 31%
Food and Nutrition Research Institute 5%
Ministry of Agriculture 5%
Dentist 5%
Scientist 5%
____________________________________________

According to the available data from these eight Asian countries, the common nutritional problems are similar (except in Japan), and include protein-energy malnutrition, nutritional anemia, vitamin-A deficiency, and riboflavin deficiency Health personnel are responsible for the prevention and treatment of these nutritional deficiency diseases.

In reference to the curricula and teaching methods, it is found that basic nutrition is being taught in basic medical science departments, such as biochemistry and physiology. During their clinical years, students do not receive enough nutrition education. Emphasis is on the basic knowledge of nutrition sciences, such as function and metabolism of nutrients, taught largely by lectures and laboratory practice. Therefore, it is always difficult for students to relate nutrition to patient care, which is what they are most interested in. They may be aware of the relationship between food and nutrition and health, but it is very important for us to show them how to apply nutrition to solve health problems. One must realize that, in health sciences, we learn by doing.

Efforts are needed to educate and tram medical staffs in clinical departments, especially pediatrics, internal medicine, and surgery. Exchange of ideas and information among individuals and institutes with useful experience in nutrition education in professional schools should be arranged.

Latin America (J.E. Dutra de Oliveira)

Besides the improvements recently achieved in training medical students in clinical nutrition at the Medical School of Ribeirao Preto, University of Sao Paulo, Brazil,⁴ the only other available information is on the National Project for Improving the Teaching of Nutrition at the professional level in the field of health sciences in Venezuela.

In addition to the recommendations arising out of the regional subcommittees, a general recommendation is for training the person responsible for the nutrition education programme at the faculty level. Because this person should be highly qualified in nutrition, this poses the problem of having few well-recognized centres in the world for training the best qualified and most highly motivated nutrition leaders or scientists. The UN University in collaboration with FAD/WHO should undertake this responsibility, particularly for developing countries.

North America (W. Krehl)

The only information available is for the US, where there is now evidence of a nutrition education renaissance.³ In a recent US survey,⁵ the following data were obtained from 102 medical schools among the 114 questioned: 19 per cent have a required nutrition course; 70 per cent have an elective nutrition course; 95 per cent incorporate nutrition into another course (some schools offer nutrition to the students in two or more of these ways); 28 per cent offer clerkships in nutrition; 80 per cent provide students with opportunities for doing nutrition research; 31 per cent offer post-graduate or continuing education studies in nutrition. While it is clear that the presence of nutrition teaching does not give any indication of its effectiveness in improving patient care, these results do show that more is being done in this area than previously believed.

There is great variety in the departmental and curricular placement of these courses. An example of a model curriculum was published by the Nutrition Foundation in Nutrition Education in the Medical School: A Curriculum Design, developed by R.T. Frankle.⁶ Of special importance is the Heinz Nutrition Education Program in Pennsylvania that includes general education for both college students and the lay public; education of medical and health professionals; education for elementary school children and teachers; and activities of a nutrition resource and information centre. University courses have been developed to meet needs of these several groups, and have been subjected to critical evaluation in order to modify and evolve effective instructional materials that can then be used by other institutions. Manuals for teachers and students have been developed that are available through the Nutrition Foundation. Four 15-minute television tapes have been prepared and are utilized by six of the stations in Pennsylvania.

A unique feature of the Pennsylvania state programme is the co-operation between curriculum specialists and evaluation experts in the College of Education and nutritionists from the Nutrition Program in designing and introducing nutrition education into the public schools.

A programme in nutrition at Boston University School of Medicine consists of lectures and seminars interspersed throughout the first two years, taught during the most relevant portions of the pre-clinical curriculum. During the clinical years there are in-service educational programmes.

Information can be obtained directly from the Nutrition Foundation (489 Fifth Avenue, New York, N.Y. 10016) from Dr. W. Darby, president of the foundation, who can also provide excellent educational material. Darby has suggested, "Obligatory or required nutrition content may be in the curriculum as a required course designated as nutrition, or as coordinated nutrition subject matter in lectures, laboratory, or clinical experience within several offerings throughout the curriculum. The former is regarded by many as the more effective.

"Electives vary from an organized consideration of basic nutrition concepts to opportunities for supervised clinical, field, or research experiences or participation in seminars. The important unifying feature is that responsible faculty leaders and curriculum planners recognize that an opportunity to learn nutrition concepts and their application must be properly incorporated in the learning experience of the student and that there is coordinated planning for presenting these in an interesting and useful manner."

The incorporation of principles of nutrition into the treatment and management of patients and disease is clearly of great importance. For schools of dentistry, according to a survey in the US and Canada in 1967 - 68, while nutritional biochemistry was included either as a required course or as a lecture unit by 74 per cent of the dental schools, the teaching of clinical nutrition and the implementation of an applied nutrition service was limited to only 15 per cent of the schools responding.

TABLE 2. Teaching Nutrition in Schools of Medicine and Pharmacy

Europe

Western Europe

France (G. Debry). When nutrition education is included at all, it is taught within the context of metabolic diseases or as part of endocrinology, gastroenterology, preventive medicine, nephrology, and cardiology.

Germany, Federal Republic (H. Cremer). Of the eight chairs in human nutrition, only three are in a faculty of medicine (Giessen), two in a faculty of science (Hohenheim), and the remaining in agriculture (Bonn, Kiel, Munich).

Spain (G. Varela). The subject of nutrition is not included in the curricula of medical schools; a few classes in nutrition are given in biochemistry and physiology.

Sweden (B. Isaksson). Recently, the highest education authorities have decided that nutrition will be included in the curriculum for medical students. It is, however, not stated how many hours should be devoted to nutrition, or what should be covered. It is up to each university to decide individually. Of the six medical faculties in Sweden, four have a chair in nutrition.

Yugoslavia (R. Buzina). The present knowledge of nutrition by physicians is unsatisfactory, nor is it adequate among dentists and pharmacists.

Eastern Europe (T. Tashev).

In Bulgaria, Czechoslovakia, Hungary, Rumania, and the Soviet Union, basic nutrition is taught in schools of medicine within biochemistry, physiology, physiopathology, and public health. Clinical nutrition is taught in association with gastroenterology, cardiology, etc. The system of teaching nutrition is considered to be unsatisfactory. No teaching in nutrition is provided to students of dentistry and pharmacy.

European Sub-Committee Meeting

The European sub-committee of the IUNS, with the participation of J.E. Dutra de Oliveira, J. Mauron (host), and other experts met in Vevey, Switzerland, on 12 - 13 May 1977, and reached the following conclusions, which are of value worldwide.

1. There is inadequate knowledge of basic and applied nutrition among most physicians in the world.

Consumers are becoming more and more aware of the role of correct nutrition in health, and they generally consider physicians as the most knowledgeable advisers in the field. There was, however, unanimous consensus among the members of the panel that most physicians (and dentists and pharmacists) do not have sufficient knowledge of nutrition in clinical and preventive medicine, bearing in mind that they should be advisers in the prophylaxis and therapy of the many nutrition-linked diseases.

2. Proposals for the improvement of knowledge by better nutrition training.

a. Medical Faculties

Each faculty should have a person whose primary responsibility is nutrition, possibly a holder of a chair in nutrition. International and national organizations, such as the ministries concerned, or academic institutions, might help to implement such plans. Nutrition teaching at faculties of medicine should include the following. (i) The presentation of biological facts related to nutrition in the basic sciences. This could be carried out through liaison between the professor in nutrition and his colleagues in related fields. (ii) The teaching of clinical science and public health could be handled in the same way, especially where preventive and therapeutic diets are required. (iii) It would be an advantage if professors of nutrition personally taught the nature of metabolic diseases and nutrition in general. (iv) Nutrition questions must be included in examinations in order to determine whether the teaching has been effective.

There are several ways of teaching nutrition. The extent to which professors of internal medicine, pediatrics, and preventive medicine share the subject (jointly with their pre-clinical colleagues) is of secondary importance. The best possible solution probably depends on the local situation. The single system (one department or chair of nutrition) as well as the joint venture (multidisciplinary co-operation) both have their advantages and snags. Most Important is that the bulk of nutrition be taught by the scientist who is the best qualified and most motivated, i.e., the one who "sells" the subject best.

In order to facilitate the implementation of the above, the panel put forward the following proposals:
(i) general practitioners should be made more aware of the value of nutrition in medicine;
(ii) clinicians should be persuaded to include a nutrition question in final examinations;
(iii) clinical nutrition research in medical schools should be encouraged, and clinicians made aware of the importance and usefulness of nutrition.

b. Dentistry

Up to now, teaching nutrition in most dental schools has not been compulsory, and examinations in nutrition generally not mandatory for obtaining a diploma or degree. Obviously, in the control of dental caries, improve nutrition will have an enormous preventive effect. Nutrition teaching should therefore also be made compulsory for dental students, using official bodies, governments, etc., to bring about this change.

c. Pharmacy

A pharmacist who is well trained in nutrition will be of significant help to hospital physicians and general practitioners in the proper use of dietary foods and nutrient supplements. Nutrition training at an academic level will also prevent pharmacists from giving advice outside their competence. The introduction of nutrition in the curriculum of schools of pharmacy should therefore be encouraged, at least in those countries where pharmacists obtain academic training.

3. Recommendations

Long-term plans should be devoted to actions that:

a. change the attitudes toward, and the knowledge of, nutrition among all health professionals with whom the medical, dental, and pharmacy students come into contact during their studies;
b. stimulate the practical application of scientifically based nutritional principles within the environment of the medical students (e.g., nurses, kitchen staff, etc);
c. encourage public debate so that it will promote the development of healthy habits;
d. stimulate increased scientific research, in co-operation with clinicians, on the relationship between diet and disease and the possibilities of preventing, alleviating, and curing diseases with the aid of diet;
e. develop programmes that consider not only the students' curricula, but that also deal with measures required to make the curricula applicable to the studies; everyday lives as physicians, dentists, or pharmacists;
f. encourage the nutrition scientist to disseminate his knowledge to laymen in very simple but correct terms, not only through personal contact, but also via the mass media. Some control over what is disseminated can be obtained through Nutrition Foundations or other similar organizations such as Nutrition Councils.

References

1. F. Aylward, "Food and Nutrition Education and Training," UNESCO-ED/WS/353, pp. 23 - 24, Paris, 1972.

2. Teachers College, Columbia University, Proceedings of a Conference on Nutrition Education, The Nutrition Foundation, New York, 1974.

3. W.J. Darby, "The Renaissance of Nutrition Education," Nutr. Rev., 35: 33 - 38,1977.

4. J.E. Dutra de Oliveira, "Teaching Nutrition in Medical Schools: Past, Present and Future," Wld. Rev. Nutr. Dietet., 25: 142 - 165, 1976

5. C.K. Cyborski, "Nutrition Content in Medical Curricula," J. Nutr. Ed., 9: 17 - 18 (1977).

6. R.T. Frankle, Nutrition Education in the Medical School: A Curriculum Design, The Nutrition Foundation, New York, 1976.

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