Nutrition

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

Nutrition plays a major role in both health promotion and disease prevention, in addition to being a therapeutic tool in the treatment of medical, surgical and emotional illness. Physicians should develop the basic skills necessary to assess nutritional status and provide nutrition therapy.

Attitudes

The resident should develop attitudes that recognize the following:

Nutrition is an integral part of:
1. Health promotion and disease prevention-Mortality and morbidity could be significantly reduced through primary prevention targeting dietary risk factors throughout the life cycle.
2. Medical treatment of disease-nutritional status has a large impact on the ability to respond to medical interventions.
3. Diagnosis and role-appropriate management of:
Dietary intake is influenced by a variety of patient factors, including:
1. Culture (family, community, ethnicity, religion)
2. Socioeconomic (ability to purchase food, living situation)
3. Psychosocial and mental health (depression, anorexia, dementia, bulimia)
4. Knowledge
5. General health and lifestyle (co-morbid conditions, diseases, habits)
Nutrition consultants should be utilized when appropriate to help provide counseling for at-risk patients. Nutritionists, registered dieticians and licensed dieticians have specialized training in public health nutrition, wellness and disease prevention, medical nutrition therapy, and nutrition education and counseling for patients and the general public

Knowledge

The resident should develop knowledge of:

General principles of nutrition, including:
1. The roles of dietary components: carbohydrates, fats, proteins, vitamins, minerals, water and fiber
2. Dietary reference intakes
3. Nutritional content of foods
4. Dietary recommendations, e.g., dietary guidelines for Americans, food pyramid, DASH diet, Step I and II diets
Nutritional assessment
1. Medical/social history and physical examination
2. Anthropometrics (height/weight, body mass index [BMI], head circumference, body-fat distribution)
3. Ordering and evaluating laboratory tests (inpatient and outpatient)
Nutritional issues of different stages of the life cycle
1. Infancy-e.g., breastfeeding, bottle-feeding, adding solids, allergy prevention
2. Children-e.g., picky eating, pica, snacks
3. Adolescents-e.g., healthy choices, eating disorders
4. Adults-e.g., portion size, habits, convenience foods
5. Pregnancy-e.g., weight gain, folic acid, iron, calcium
6. Lactation-e.g., nutritional needs, support, counseling
7. Elderly-e.g., psychosocial issues, co-morbid conditions, swallowing disorders
The role of nutrition in the prevention and treatment of specific diseases
1. Cancer
2. Cardiovascular disease
3. Dental disease
4. Diabetes
5. Gastrointestinal disorders
6. Hematologic disorders
7. Hypertension
8. Liver disease
9. Obesity
10. Osteoporosis
11. Renal disease
Secondary malnutrition caused by systemic diseases
1. Alcoholism
2. Cancer
3. HIV/AIDS
4. Malabsorption
5. Pulmonary disease
Weight loss strategies and counseling
1. Behavior modification and goal setting
2. Diet drugs (prescription, herbal and over-the-counter)
3. Popular diets and supplements
4. Surgical approaches
Disordered eating
1. Anorexia nervosa
2. Binge eating
3. Bulimia
Use of dietary supplements, including:
1. Vitamin and mineral deficiency, toxicity, and recommended intakes
2. Guidelines for herbal, alternative and other supplements, including drug interactions, safety and efficacy
3. Evidence-based nutrition resources and signs of quackery
Preventing and recognizing and treating foodborne illness
Allergies and food intolerance
Physical activity and sports
1. Recommendations for health and weight loss
2. Nutritional needs for various levels of activity (i.e., elite athletes) and for different ages
3. Hydration
Enteral and parenteral nutrition
Community nutrition resources, e.g., food bank, Meals on Wheels, Women, Infants and Children (WIC) supplemental food program

Skills

The resident should develop skills in:

Integrating nutrition assessment and intervention into the medical history, review of systems, physical examination, laboratory evaluation and plan of care.
Assessing the nutritional status and writing diet prescriptions for inpatients, e.g., hospitals, nursing homes and other supervised living situations.
Ordering and interpreting laboratory and metabolic studies related to nutritional assessment.
Ordering and managing oral supplements and tube feeding, and understanding when and how to order and monitor total parental nutrition.
Counseling patients and family members about specific nutritional needs related to stages of the life cycle, lifestyle and habits, disease prevention and/or disease.
Counseling patients on safe lifestyle approaches to weight management and balancing caloric intake and physical activity.
Advising patients about appropriate use of and, when needed, prescribing vitamin, mineral and other dietary and botanic supplements.
Collaborating with registered dieticians and certified diabetes educators, and referring patients to community nutrition resources, including Internet sites.

Implementation

The implementation of these curriculum guidelines should be longitudinal and integrated into patient care, didactic conferences, and experimental learning activities. Nutritional status of the patient should be an integral part of case presentation, staffing, rounds and other clinical activities. Qualified nutrition professionals should teach nutrition and mentor residents: All faculty should model and teach nutrition and ways to integrate nutrition information into patient care.

Resources

Physician's curriculum in clinical nutrition- A competency based approach for primary care, Kansas City, MO: Group on Nutrition Education, Society of Teachers of Family Medicine, 1995.
Manual of Clinical Dietetics, 5th edition. Chicago, IL: The American Dietetic Association, 1996.
Mahan LK and Escott-Stump S. Krause's Food, nutrition and diet therapy, 10th ed. Harcourt, Brace and Co. 1999.
Modern Nutrition in Health and Disease, 9th Edition, Williams and Wickins, 1999.
Medical Nutrition and Disease, Blackwell Science Inc., 1996.

Web Sources

American Dietetic Association: http://www.eatright.org
Arbor Nutrition Guide: http://www.arborcom.com
National Center for Complementary and Alternative Medicine: http://nccam.nih.gov
Office of Disease Prevention and Health Promotion: http://www.odphp.osophs.dhhs.gov
USDA Center for Nutrition Policy and Promotion: http://www.usda.gov/cnpp
CNN health-related site: http://www.cnn.com/HEALTH