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Directory
changes
New
IUNS publications
Nutrition and cancer: a committee report
Nutrition education for medical students and
practitioners: report of a workshop
The following further changes have occurred in the directory of the International Union of Nutritional Sciences since the last Newsletter.
Liaison Representatives
Dr. D. A. T. Southgate has resigned as IUNS liaison representative to COGENE. The IUNS Council has decided not to appoint another representative to this body.
Adhering Bodies-Change of Address-New Members
China:
Chinese Nutrition Society
Dr. Shen Zhiping, President
c/o Institute of Health
China National Center for Preventive Medicine
29 Nan Wei Road
Beijing, China
Korea: The Korean Nutrition Society
Prof. Nak Eung Sung, President
Dean, College of Medicine
Ewha Women's University
Seoul 120, Korea
Nigeria:
Nutrition Society of Nigeria
Dr. Chuna D. Muogbo, General Secretary
College of Medicine
University of Benin Teaching Hospital
Benin City, Nigeria
Committee Chairmen
Committee III/4: Dr. D. Picou has retired and has not
been replaced.
Committee III/6: Professor Olfat Darwish has succeeded
Professor J . D. Naismith.
A7,1978
Notes on Workshop on Nutrition Education for Medical and Other
Health Sciences, held by Commission V in Rio de Janeiro, 27
Aug. - 1 Sept. 1978, during XI Congress. 8 pp., xeroxed. Material
presented at workshop published as Nutrition Education and
Training for Health Science Professionals. F. Fidanza, E. F.
P. Jelliffe, K. Bagchi, A. Valyasevi, J. S. Ju, T. N.
Maltetnlema, E. Sarakikya, H. D. Cremer, E. Morava, R. Tarian, W.
A. Krehl, K. B. Taylor, N. Sooza, M. Vannucchi, J. E. Dutra de
Oliveira, A. Hendrikx. Wrld. Rev. Nutr. Dietet., 38:
153-225 (1981).
B43,1981
Advanced Degrees in Nutrition Science. Report of a V/8
working meeting held in Wageningen, Netherlands, 30 Mar, - 1 Apr.
1981, sponsored by UNU and the International Course in Food
Science and Nutrition (NUFFIC). Food Nutr. Bull., 3 (4):
49-51 (1981), and 7 pp. + appendices, xeroxed. The Inventory
of International and Regional Training Courses in Human Nutrition
was produced and published in Food Nutr. Bull., 5 (2): 81-92
(1983).
B46,1982.
I/5 Recommended Dietary Intakes around the World The
introductory chapter is published in Food Nutr. Bull. 4 (41:
34-45 (1982), and the full report in Nutr. Abstr. Rev.,
53: 939-1015, 1075-1119 (1983).
B48,1983 V/1 & V/14
"Training in Clinical Nutrition: Undergraduate and
Postgraduate." Mark L. Wahlqvist and Bjorn Isaksson, Lancet,
ii: 1295-1297 (1983).
The following publications have appeared since Newsletter 10:
B51,1983 WGI
Proposed Outline for en International Handbook of Methodology
for the Study of Food Consumption, by Wija van Staveren and
Jean Henderson (members of IUNS Working Group 1 on Methodology
for Evaluation of Dietary Intakes), in EURO-NUT Report 1 on The
Diet Factor in Epidemiological Research, ed. J. G. A. J.
Hautvast and W. Klaver (1982), pp. 143-147,
B52,1983 VI/8
International Nutrition Standards for Poultry, by R.
Blair, H. Morimoto, V. Peter and T. G. Taylor. Nutr. Abstr. Rev.,
53: 670-713 (1983).
B53,1983 I/4
Report of the Second Workshop on Nutritional Quality in Food
Standards and Guidelines, 22-23 May 1983 at the Ministry of
Agriculture and Fisheries, The Hague, Netherlands. 37 pp.
xeroxed.
B54,1983 II/12
Report of a WHO/IONS Workshop on Nutritional Consequences of
Developmental Programmes, 30-31 Oct. 1983, Bangkok, Thailand.
C. Gopalan. 19 pp. xeroxed.
B55,1984 II/6
Energy Expenditure under Field Conditions. Report of an
international workshop held at Charles University, Prague, 6-8
Apr. 1981, with the assistance of UNU, IUNS, and the
Czechoslovakian National committee on Nutrition Published by
Universitas Carolina Press, Prague.
B56,1984 I/11
Protein-Energy Requirement Studies in Developing Countries:
Results of International Research. Report of an IUNS workshop
held in Berkeley, Calif.,SA, 10-14 Aug. 1981. Ed. W. M Rand, R.
Uauy, and N. S. Scrimshaw. UNU Food and Nutrition Bulletin
Supplement 10 (1984). 369 pp.
C46,1983
Fibre in Human and Animal Nutrition. Proceedings of an
international symposium held in Palmerston North, New Zealand,
23-28 May 1982, cosponsored by IUNS. Ed. G. Wallace and L. sell.
Published by the Royal Society of New Zealand, Bulletin 20 (
1983) . 249 pp.
Nutrition and cancer: a committee report
In recent years, much evidence has accumulated to indicate that nutrition has an influence on cancer incidence and mortality. This led to the establishment by IUNS, in 1979, of a committee on nutrition and cancer. This committee held a workshop in Cambridge, England, in 1980, and a report of the proceedings was subsequently published in Nutrition and Cancer (vol.2, no. 4 [1981] I. At that time, the committee felt that no dietary recommendations should be made to the public, but that the results of research on nutrition and cancer should be disseminated in a balanced way to provide the public with as much up-to-date knowledge as possible.
Meanwhile, concern in the United States regarding nutrition and cancer resulted in the establishment by the National Research Council of a committee on diet, nutrition, and cancer. This committee has now issued two reports that are available from the National Academy Press, 2101 Constitution Ave. NW, Washington, D.C. 20418, USA.
The first report, issued in 1982, contains a comprehensive
survey of epidemiological and experimental evidence related to
nutrition and cancer. Based on that evidence, the committee
recommended the following interim dietary guidelines:
- that consumption of dietary fat (both saturated and
unsaturated) be reduced from approximately 40 per cent to 30 per
cent of total calories;
- that the importance of including fruits (especially citrus
fruits), vegetables (especially carotene-rich and cruciferous
vegetables), and whole-grain cereal products in the daily diet be
emphasized;
- that consumption of food preserved by salt-curing (including
salt-pickling) or smoking be minimized;
- that contamination of foods by carcinogens be minimized;
- that, where feasible and prudent, mutagens be removed from the
diet or their concentrations minimized;
- that, if alcoholic beverages are consumed, it be done in
moderation.
The second report has been discussed in a number of review articles (e.g. T. H. Maugh II,Science, 217: 36-37 [1982]; Council for Agricultural Science and Technology, Special Publication No. 13 [Ames, Iowa, USA, 1982]; A. I. Mendeloff, Amer. J. Clin. Nutr., 37: 495-498 [1983]; E. Wynder, Cancer Res., 43: 3024-3027 [1983]; S. Palmer and K. Bakshi, JNCI, 70: 1153-1170 [1983] ). Detailed reviews have also been prepared by the US Department of Health and Human Services and Department of Agriculture and may be obtained from the Office of the Assistant Secretary for Health, US Public Health Service, Washington, D.C. 20201. In general, the committee has been praised for preparing such a comprehensive review of the subject, but the guidelines have received a mixed reaction of approval and criticism.
Much information on nutrition and cancer has also been published in recent books and proceedings of workshops or symposia on the subject (e.g. Nutrition and Cancer: Etiology and Treatment, ed. G. R. Newell and N. M. Ellison [Raven Press, New York, 1981]; Molecular Interrelations of Nutrition and Cancer, ed. M. S. Arnott, J. van Eys, and Y-M. Wang [Raven Press, New York, 1982]; Carcinogens and Mutagens in the Environment, vol. 1, Food Products, ed. H. Stich [CRC Press, Boca Raton, Fla., USA, 1982]; Environmental Aspects of Cancer: The Role of Macro and Micro Components of Foods, ed. E. L. Wynder, G. A. Leveille, J. H. Weisburger, and G. E. Livingston [Food and Nutrition Press, Westport, Conn., USA, 1983]; "Workshop on Fat and Cancer," Cancer Res., 41: 3677-3826 [1981]; "Workshop Conference on Nutrition in Cancer Causation and Prevention," Cancer Res., 43: 2385s-2519s [1983] ).
Many components of the diet have been implicated in carcinogenesis, including fat, protein, vitamins, salt, trace elements, fibres, alcohol, and food additives. Some of the effects are related to carcinogenic or mutagenic compounds in the food supply, but there is also ample evidence that diet can either promote or hinder the proliferation of tumour cells during later stages of tumorigenesis. We will hope to provide more information in future issues of the IUNS Newsletter on epidemiological and experimental evidence related to nutrition and cancer and to indicate possible ways in which diets might be modified to lessen the risk of developing cancer and to improve the prognosis of cancer patients.
"Diet and Human Carcinogenesis" will be the theme of the third symposium of the European Organization for Cooperation in Cancer Prevention Studies (ECP), to be held in Aarhus, Denmark, 19-21 June 1985. Plans are also being made to hold a workshop, sponsored jointly by ECP and IUNS, immediately prior to the symposium at the same location. The aim of the workshop would be to develop recommendations for the public regarding their dietary life. style, for the medical profession regarding primary prevention of cancer, and for the food industry regarding food constituents and additives. Further details of the symposium and workshop may be obtained from Dr. J. Geboers, Secretary-General, Organizing Committee, c/o Division of Epidemiology, St. Rafael University Hospital, Capucijnenvoer 30, B-3000, Leuven, Belgium.
A colloquium on nutrition and cancer will also be held as part of the scientific programme of the Thirteenth International Congress of Nutrition at Brighton, UK, in August 1985. This will consist of presentations on the role of different dietary constituents in carcinogenesis, with opportunities for discussion.
The current membership of the IUNS Committee on Nutrition and Cancer consists of J. H. Cummings (Cambridge, UK), J. A. Gustafsson (Stockholm, Sweden), J. Higginson (Bethesda, Md., USA), T. Hirayama (Tokyo, Japan), O. M. Jensen (Copenhagen, Denmark), J. V. Joossens (Leuven, Belgium), D. Kromhout (Leiden, Netherlands), R. McLennan (Brisbane, Australia), R. Siassi (Teheran, Iran), M. P. Sporn (Bethesda, Md., USA), H. Tulinius (Reykjavik, Iceland), D. Xu (Shanghai, China), D. G. Zaridze (Lyon, France), and K. K. Carroll, Chairman (London, Ont., Canada). The committee would welcome enquiries or comments on the subject of nutrition and cancer.
-K. K. Carroll, Chairman, IUNS Committee IV/8
Nutrition education for medical students and practitioners: report of a workshop
IUNS held a workshop on Nutrition Education for Medical Students and Practitioners, 13 March 1984, at the Royal College of Physicians, London, during the annual meeting of the IUNS Council. Members of the Council, the chairmen of the IUNS committees on Clinical Nutrition (V/14) and Schools of Medicine (V/1), and additional invited experts reviewed and discussed nutrition education for medical students and medical practitioners as it is now conducted and as might be recommended. Postgraduate and continuing education were considered as parts of a continuum together with undergraduate medical education.
Undergraduate Medical Schools
Topics making up the core of medical nutrition
The core of nutrition for teaching medical undergraduates has been considered and suggested in several reports and articles in the last 12 years, e.g.:
- P. L. White, L. K. Mahan, and M. E. Moore. Conference on
Guidelines for Nutrition Education in Medical Schools and
Postdoctoral Training Programs, Williamburg, Va., USA, 25-27 June
1972. American Medical Association and the Nutrition Foundation.
- R. T. Frankle. Nutrition Foundation, Washington, D.C., 1975.
- R. E. Olson. "Nutrition as a Theme for the Study and
Practice of Medicine." Nutr. Reviews, 37: 1-5 (1979).
- C. R. Gallagher and V. M. Vivian. "Nutrition Concepts
Essential in the Education of the Medical Student." Amer. J.
Clin. Nutr., 32: 1330-1333 (1979).
- IUNS Committee V/1 "Nutrition Education and Training in
Schools of Medicine, Pharmacy, and Dentistry." Food Nutr.
Bull., 1 (4): 52-56 (1979).
- R. E. Olson. "Integrating Nutrition into Medical and
Public Health Programs." Food Technology, Dec. 1980, pp.
58-61.
- National Health and Medical Research Council of Australia.
"Check List of Nutrition Topics for Medical Schools,"
in chapter by M. L. Wahlqvist. In A. N. Howard and I. M. Baird,
eds., Recent Advances in Clinical Nutrition, no. 1, pp. 275-279.
John Libbey, London, 1981.
- J. Grey, ed. Nutrition in Medical Education British Nutrition
Foundation, London, 1983.
- M. L. Wahlqvist and B. Isaksson. "Training in Clinical
Nutrition: Undergraduate and Postgraduate." Lancet, ii:
1295-1297 (1983).
Integration with other subjects, or an identifiable nutrition course?
How can medical schools be sure that appropriate material on nutrition is being taught? It may be included under biochemistry, paediatrics, medicine, surgery, public health, psychiatry, etc. One option is to have a nutrition coordinator for the medical school who tries to see that, whatever the name of the subject, the topics recommended in the materials in the preceding paragraph are being taught. But those who have tried report that doing this required a great deal of time and negotiation, and with every change of teaching staff in departments the task may start again.
The alternative view is that the core of nutrition should be labelled as such. If it is not, the faculty cannot be sure that the elements of nutrition are being taught nor can the students, and medical students then do not see nutrition as a subject in which they would like to specialize.
A co-ordinator of nutrition teaching for the medical school
All these who have looked into nutrition teaching in medical schools agree that there needs to be one staff member who has a special interest in nutrition and is given the responsibility by the dean or curriculum committee to coordinate the nutrition teaching where this is integrated into other subjects, and to organize a course of core lectures on useful topics in nutrition that are not dealt with by the major teaching departments. This staff member might be an endocrinologist, gastro-enterologist, paediatrician, etc. To function effectively, the co-ordinator (even if senior) should undergo re-training in nutrition (e.g. a postgraduate course or time spent in a nutrition centre) and will need to keep up to date (e.g. by maintaining regular contacts with a nutrition centre). The coordinator should stimulate and/or supervise research in nutrition in the hospital or medical school.
A full-time lecturer or professor of nutrition
With present resources and priorities, most medical schools are not able to have a full-time lecturer in or professor of nutrition. But they are needed as a national resource, and a minority of medical schools (a majority of those in Sweden) do have professors of nutrition. They are often appointed to a university rather than just the medical school. These individuals ought to be able to attract a critical mass of research students, research workers on grants, and collaborating colleagues and to develop a teaching and research centre in nutrition. This should be a resource not only for the local medical school but for other schools in the area or country. Such groups should be recognized by international agencies and supported as training centres.
Different nutrition teaching for different places
Nutrition teaching for hospital practice has to be different from that for community work. There are also considerable differences between useful nutrition teaching for developed countries and that for Third World countries.
More emphasis needed on clinical teaching
Most medical schools are better at providing some nutrition teaching at the pre-clinical stage. It tends to fit comfortably as identifiable parts of lecture courses in biochemistry and physiology. But there are more gaps and more needs for strengthening teaching in nutrition at the clinical stage. Ideally, teachers at this stage should be clinicians. Science graduates can teach nutrition at the pre-clinical stage or even for public health, but not as a rule at the bedside. For science graduates to be effective teachers in a medical school they need to learn the vocabulary of medicine and try to make their teaching and research clinically related.
More food science needed at the pre-clinical stage
One of the biggest weaknesses of medical graduates and students is their lack of knowledge about food-food composition, food habits, etc. Food is a primary point of contact when diagnosing nutritional disorders or advising on nutritional therapy. Biochemistry departments should be encouraged to include some food science in their course to medical students and to have one of their lecturers specialize in the biochemistry of foods.
Good food the first nutritional support in hospital
Hippocrates, the father of medicine, stressed the importance of the diet in treating disease. In clinical teaching as much emphasis should be given to nutritional therapy as to drug therapy.
The basic nutritional care in hospital-the food service and feeding-lacks glamour and has low status compared with other treatments such as surgery. In general, doctors are not interested; ward rounds are timed not to overlap with patients' meals. But patients' feeding should be considered and discussed on ward rounds. Only if respected clinical teachers show a scientific interest in their patients' feeding can students and junior hospital doctors be expected to do so.
Bad feeding can be a major negative influence for patients in hospital. Doctors should know their hospital food system. Some patients get their last meal of the day at 3.00 p.m. It is irrational to set high standards of surgery and precise timing of drug administration and accept poor and badly timed feeding in hospitals.
A practical on student's own food intake
It is reported that a practical on the students" own food intakes, with subsequent calculation of nutrients consumed, stimulates interest and deepens understanding of food composition and habits.
Nutrition needs to be seen to be useful
Students are often interested in nutrition at the pre-clinical stage, but their motivation wanes later on. This may be partly because clinicians under-emphasize nutrition, partly because a knowledge of nutrition may not seem to be useful for treating patients or making money in private practice. But (in developed countries) obesity, hyperlipidaemias, diabetes, and malnutrition secondary to disease are common, while enteral and parenteral nutritional support and dietotherapy are important in management. Nutrition teachers should concentrate on topics of practical value and perhaps ask what students and doctors perceive as the topics they need to know more about.
Need for nutritional counselling in general practice
General practitioners in developed countries do not seem able to cope with the growing public demand for nutritional counselling. Unorthodox "alternative practitioners" (not medically qualified) are filling the vacuum and flourishing. Such practitioners-chiropractors, naturopaths, acupuncturists, faith healers, and the like-do not have a systematic scientific knowledge of physiology or medicine, and their nutritional advice is often unsound, sometimes dangerous. Medical students should be trained in nutritional counselling.
A little knowledge is a dangerous thing
Alternative, unscientific ideas on nutrition are so pervasive in developed countries at present that medical students come in contact with them through friends or what patients say. The smaller a new graduate's understanding of nutritional science, the greater the risk that he may incorporate some of the popular nutritional mythology into his practice.
Practical familiarity with malnutrition in Third World countries
In Third World countries the major nutritional disorders are malnutrition, protein-energy malnutrition everywhere, and, in different regions, various vitamin and element deficiency diseases. Nutrition is the first component of primary health care in rural areas. A period in which the student works in a rural area (with good teaching and support) is a most important part of the curriculum. Patients with malnutrition will not be seen in private practice, but they are a national challenge that should appeal to the more idealistic students.
Nutrition questions in major examinations
Because graduates will need a knowledge of nutrition in their hospital or community practice (discussed above), the lecturer co-ordinating nutrition teaching should ensure that there are questions on nutrition in the major medical school examinations.
Where the curriculum is already full
Where it is difficult to find any extra time for newer subjects like nutrition, one solution that has worked is to offer interesting evening lectures in the medical school on such topics as national nutrition policy, the world food crisis, and religion, culture, and nutrition.
Tape-slide packs on the major topics in nutrition that students can run through in their free time have a place. They should, of course, be attractively produced, not commercially biased, and kept up to date. One of the international agencies, e.g. an IUNS committee, might consider reviewing the existing tape-slide packs available on nutrition, indicating which are recommended and should be more widely distributed and arranging for new ones to be made to fill the gaps.
Suitable books
Where medical schools find it difficult to provide enough time
for teaching newer subjects like nutrition, reliable and readable
books should be available in the library and in bookshops so that
students can read on their own to supplement what they are
taught. Suitable books for undergraduates are of two types:
- inexpensive, fairly small books with plenty of figures and
tables for the student to buy and own (e.g. R. L. Weinsier and C.
E. Butterworth, Handbook of Clinical Nutrition [C. V. Mosby,
1981]; D. S. McLaren, Nutrition and Its Disorders, 3rd ed.
[Churchill Livingstone]; D. Morley, Paediatric Priorities in the
Developing World [Butterworth]);
- reference books, which should certainly include local and
international food-composition tables and some up-to-date
systematic textbooks of human nutrition and dietetics.
Elective periods
Elective periods dealing with nutrition appear to have been quite popular with students in some medical schools. Medical schools should try to arrange to have one or more such electives available locally or that can be arranged at another university.
Students from developed countries who spend a term in a Third World country inevitably have their nutritional (and other) perspectives broadened.
At a few universities it is possible for medical students to specialize in nutrition courses and projects over a full academic year for an intercalated B.Sc Such a course is running well at Queen Elizabeth College for the medical schools of London University.
Conclusion
Those who say that doctors know nothing about nutrition because they never learnt it at medical school are wrong on three counts:
1. There is some teaching of nutrition in all medical schools, but it often goes under other labels, e.g. biochemistry or paediatrics. In varying degrees it appears that medical schools are tending to increase the amount of identifiable undergraduate teaching in nutrition, and medical students are asking for more.
2. Medical education does not finish with the first qualifying degree (M.B., Ch.B., etc. in the British system). Doctors continue their training in junior hospital posts, GP training schemes, postgraduate specialist courses, regular journal reading and short refresher courses. Many of these, where appropriate, include some teaching or experience in nutrition.
3. Because medical graduates are the only professionals who have made a systematic, scientific study of anatomy, physiology, biochemistry, pathology, medicine, surgery, obstetrics, and psychiatry, they are in the best position of all non-specialists to understand and advise on human nutrition.
IUNS will do all it can to stimulate and help with undergraduate training of medical students in nutritional science.
Postgraduate Medical Education
Postgraduate education deserves more emphasis
Medical graduates have become increasingly aware of their need for nutritional information-hospital doctors because of recognition of hospital malnutrition and options for nutritional support; general practitioners in industrial countries because some of their patients have read more about nutrition than they have; in developing countries nutrition is central in the care of the majority of people in rural areas. Graduates know what they need and their motivation to learn may be higher than that of undergraduates.
There are many more qualified doctors than undergraduates. What they are taught has more immediate impact in practice, which then reaches down to undergraduates. Knowledge is continually changing. Doctors cannot rest with what they learnt as undergraduates. It is necessary for graduates to learn or be taught on the job to keep their knowledge up to date.
Courses of different lengths
Postgraduate courses in nutrition range in length from three years (usually leading to a Ph.D.) through one or two years (usually leading to a master's degree), or five months (e.g. the International Course in Food Science and Nutrition in the Netherlands and Belgium), down to occasional one-day (or weekend) courses.
Medium-short courses
There are, however, very few medium-short courses of about six weeks. The workshop considered that courses of this length could be very cost-beneficial and that trial courses should be encouraged and supported. Such a course should teach appropriate practical methods and should serve one country or a small group of neighbouring countries to minimize travel expenses.
Medium-short courses would be suitable for doctors who want to know and understand nutrition better for use in their practice but do not intend to dedicate themselves full time to nutrition work. In each hospital, the workshop thought, there should be at least one doctor with a special and continuing interest in nutrition.
One medium-short course is being set up jointly by Professor Isaksson (Gothenburg) and Professor Hautvast (Wageningen). Two or more nutrition training centres will participate. Students will rotate through these so that they are taught at a high level by specialists. This course is new and to some extent experimental but should serve as a model for others.
Support and recognition for medium-short courses
For courses like this to succeed, they will have to be not too expensive for the participant (e.g. largely paid for by the universities involved or by the Ministry of Health), and some recognition and certificate is desirable. This is partly as a reward, partly to ensure the scientific and medical orthodoxy of the teaching (there are, of course, already intermediate-length courses in unorthodox, unscientific human nutrition). IUNS could play a valuable role by approving such six-week courses-where justified by the content and the practical teachers.
Medium-short courses in developing countries
In developing countries courses of similar length can be designed and should be most valuable. The subject matter here should emphasize the local nutritional deficiency diseases, diarrhoea, and methods of preventing these.
Long courses
Long courses exist for more extensive training of small numbers of doctors who are considering or intending to be nutrition experts. These are offered at academic nutrition centres. There are very few of these in any country and none in some. A critical mass of specialists and research workers is necessary for a good postgraduate training centre. There must be active programmes of research in which the trainee can participate, alongside and integrated with advanced postgraduate teaching. Maintenance and support of these nutrition training centres by international, government, and/or charitable agencies (provided they are functioning well) is essential, for these are the foci from which all nutritional knowledge ultimately spreads.
The United Nations University supports advanced training in nutrition for graduates (some of them medical) from Third World countries. A selected list of centres are recognized for this training, in Jamaica, in Thailand, and a small number in the United States, the Netherlands, and the United Kingdom:
Career structure for medical specialists in nutrition
There is no great prospect of more than a tiny number of jobs in any country for full-time senior medical nutritionists or consultants in clinical nutrition. The career structure is a big problem for those who would like to be medical specialists in nutrition. There are some university pre clinical posts (in biochemistry or physiology departments) and rare research jobs or even rarer chairs of nutrition. There is not (or very seldom) the sequence through senior house officer, registrar, and senior registrar for nutrition that provides continuity in the major clinical specialities.
There are, however, opportunities which we must encourage for hospital consultants and community physicians with a partial special interest in, and maintained knowledge of, nutrition.
The Royal College of Physicians and other similar bodies permit trainee clinical specialists to spend a year or two in relevant studies away from the mainline. This could include nutrition research.
Clinical nutrition not yet a recognized speciality
Attempts up to now to have (clinical) nutrition recognized as a clinical (sub-)speciality in the United Kingdom and the United States have not been successful. But clinical pharmacologists, immunologists, and medical physicists, all of whom are recognized in Britain, can serve as useful analogies. Even proctologists are recognized clinical specialists in some countries.
The case for nutrition as a clinical speciality is now being assembled in the United States (see L. Howard, "Certification of Clinical Nutrition Specialists: The Current Role of the American Board of Nutrition," Amer. d. Clin. Nutrition, 38: 811-812 [1983] ). In the United Kingdom, the workshop was informed, the Royal College of
Physicians will be asked again to consider clinical nutrition as a speciality for consultant physicians.
A clinical speciality needs a defined clinical responsibility. This might be certain diseases (obesity would be constant; others such as hyperlipidaemia and deficiency diseases might vary in different countries) and certain treatments (enteral and parenteral nutrition and consultant on therapeutic diets).
Nutrition reports from the Royal Colleges
There is a seeming paradox that, while the Royal College of Physicians doesn't yet recognize clinical nutrition as a speciality, it has had more working parties that have produced more reports on nutrition than any other branch of medicine-viz. Fluoride, Teeth, and Health (1976); Prevention of Coronary Heart Disease (1976); Medical Aspects of Dietary Fibre (1980); Obesity (1983); and Food Intolerance and Food Aversion (1984).
The Royal College of Obstetrics too devoted its tenth study group to Nutrition in Pregnancy. This was published as a 280-page report by the College (1983).
Danger of separation of clinical nutrition from general human nutrition
There may be a danger of separation of "clinical nutrition" from general "human nutrition." Clinical nutrition is a newer subject; its practitioners have mostly had their primary training and experience in clinical subjects like surgery or gastroenterology. They have adopted some techniques that derive from nutrition research in developing countries in the 1960s. The more general human nutritionists tend to have a public-health orientation and may not have everyday familiarity with some of the practical technology of clinical nutrition. Clinical nutritionists are tending to develop their own societies. It would be a great mistake to divide nutrition for health from nutrition for disease.
Short courses
For introducing doctors to modern nutrition five-day courses have been used (5 x 7 hours = 35 hours) or a series of evening lectures (e.g., 4 x 2 hours = 8 hours). Where run by experienced teachers these have been well taken up and received.
For continuing education, one-day courses are useful, e.g. all day Saturday. This could be with an expert visiting speaker on the programme. The chief reason there are not more courses like this is the shortage of experienced medical nutritionists; hence the importance of building up centres of excellence in nutrition (cf. the paragraph on long courses above).
Tapes
For general practitioners, professionally recorded and well-edited tapes of experts speaking to an audience of other general practitioners can extend the coverage of short courses to places without them. Doctors can listen to these in their cars or in their spare time while relaxing. Essential slides should be converted to figures and tables on sheets of paper to accompany and clarify the tapes. There are medical postgraduate organizations that make tapes like this.
Content of tapes and short courses
Tapes and brief courses must be up to date. In some developed countries general practitioners can't keep up with the demand for nutrition counselling, so unorthodox, "alternative," unscientific practitioners are tending to take over this role. Doctors would like information about the pros and cons of various popular and unorthodox diets that their patients may ask about. Before putting on a short course about nutrition, it is helpful to send doctors a brief questionnaire, through the postgraduate medical education organization or college of general practitioners, asking them to indicate the nutrition topics that are giving them trouble and that they would really like to hear about and discuss. Ordinary practitioners are more likely to turn out for talks about things that worry them than to come and listen to an academic selling his latest research hypotheses.
How can nutrition be made more useful for ordinary doctors?
Academic and research centres of nutrition should ask themselves, "How can we help to make nutritional science more useful and more accessible to ordinary medical practitioners?"
One weakness in our present equipment is the unreliability and incompleteness of food tables and the inability of doctors or their patients to convert food-intake records into calories and relevant nutrients. The usefulness of nutrition in medical practice-in hospital and at the grassroots -would be greatly increased by better food tables and well-designed software by which a patient's nutrient intake can be determined rapidly and reliably with a microcomputer. The workshop noted that this is one of the main aims of the new INFOODS organization. It deserves high priority.
Other simpler projects can make nutritional knowledge more generally available, e.g. straightforward agreed-on modern tables of normal weights for height for adults, and nutrition education material and therapeutic diet programmes that are not commercially biased.
Suitable books and articles
With the right books and articles, practicing doctors can keep themselves up to date, look up and work out particular problems in their patients, and increase their knowledge of and expertise in nutrition. There are some useful books for this purpose and the best of them should be more widely known and available.
A useful annotated list of books on nutrition was compiled by the Committee on Education of the American Society for Clinical Nutrition (M. S. Read, Amer. J. Clin. Nutrition, 38: 775-794 [1983]).
Some suitable books and articles recommended by this workshop include:
- R. L. Weinsier, and C. E. Butterworth. Handbook of Clinical
Nutrition. C. V. Mosby, 1981.
- J. S. Garrow. Treat Obesity Seriously. Churchill Livingstone,
1981.
- D. S. McLaren and D. Burman, eds. Textbook of Paediatric
Nutrition, 2nd ed. Churchill Livingstone.
- S. Davidson, R. Passmore, J. F. Brock, and A. S. Truswell.
Human Nutrition and Dietetics, 7th ed. Churchill Livingstone,
1979.
- A. Paul and D. A. T. Southgate, McCance and Widdowson's The
Composition of Foods, 4th rev. ed. H.M. Stationery Office,
London, 1978.
- the nutrition chapters in Harrison's and in Davidson's and in
the Oxford textbooks of medicine, which are written by good
medical nutritionists and are all kept up to date;
- the reports from the Royal College of Physicians (see the
paragraph on nutrition reports from the Royal Colleges above);
- a series of 16 practical articles, "The ABC of
Nutrition," to be published in the British Medical Journal
starting at the end of 1984 or the beginning of 1985, which are
written for general practitioners and will be gathered in a short
book;
- a book of illustrative cases of nutritional disorders being
prepared by Committee V/1 of IUNS, to be published in late 1985.
Possibly IUNS, through one of its committees, might maintain an up-to-date short list of books and articles like these which could be useful on the bookshelf of the average medical practitioner.
Wider distribution of authoritative statements
Everyone is his or her own expert on nutrition, there are many false prophets, and there are some genuine advances in nutritional science from time to time. Interested people outside the main centres of nutrition often complain that they are confused, they don't know what or whom to believe. New scientific concepts or correction of old misunderstandings take a long time to reach the great majority of non-specialist medical practitioners round the world, especially in Third World countries.
It was suggested at the workshop that IUNS might play a useful role by collection and wider distribution of authoritative statements on nutrition that appear from time to time in journals and official documents (like the American Medical Association's statements on nutrition). These could be shortened and put in a news" letter as abstracts with the references supplied to the full statements.
Participants
Dr. R. Buzina (Yugoslavia), President, IUNS
Sir Douglas Black (UK), representing the Royal College of
Physicians
Dr. A. Pradilla, Head of Nutrition Unit, WHO, Geneva
Professor Emeritus Nevin Scrimshaw (USA), representing the United
Nations University, and Past President, IUNS
Professor M. K. Gabr (Egypt), President designate, IUNS
Professor Dutra d'Oliveira (Brazil), Vice-President, IUNS
Professor J. A. G. Hautvast (Netherlands), Vice-President, IUNS
Professor A. Valyasevi (Thailand), Vice-President, IUNS
Professor Emeritus J. C. Waterlow (UK)
Professor D. J. Naismith (UK), Chairman, Organizing Committee,
Thirteenth International Nutrition Congress
Professor B. Isaksson (Sweden). Chairman, IUNS Committee V/14,
Clinical Nutrition
Professor M. Wahlqvist (Australia), Chairman, IUNS Committee
V/1, Undergraduate Medical Schools
Dr. Derek Shrimpton (UK) Director-General, British Nutrition
Foundation
Professor L. Hambraeus (Sweden)
Dr. Carmen Intengan (Philippines!, Council member, IUNS
Professor T. A. Tashev (Bulgaria), Council member, IUNS
Dr. Barbara Underwood (USA), Council member, IUNS
Ms. Dorothy Hollingsworth (UK), Secretary-General, IUNS
Professor A. S. Truswell (Australia), Council member, IUNS,
Rapporteur
Mrs. Joyce Harrison (UK) Executive Secretary, IUNS