Physician Nutrition Specialists Research Articles

Dietary recommendations in the prevention and treatment of osteoporosis.

This article presents the initial recommendations of the French Rheumatology Society (Société Française de Rhumatologie - SFR) and the Osteoporosis Research and Information Group (Groupe de Recherche et d'Informations sur les Ostéoporoses - GRIO) on the role of diet in the prevention and treatment of osteoporosis. The recommendations were produced by a working group composed of rheumatologists, physician nutrition specialists and a geriatrician. Fifteen (15) questions pertaining to "daily practices" were preselected by the working group. For the literature review, the working group focussed mainly on the effects of diet on bone mineral density (BMD) and fractures, and primarily on meta-analyses of longitudinal studies and dietary intervention studies. A Mediterranean-type diet and the daily consumption of 2 to 3 dairy products are recommended. Together, these provide the calcium and "high quality" protein required to maintain a normal calcium-phosphorus balance and bone metabolism, and are associated with lower fracture risk. Conversely, unbalanced Western diets, vegan diets, weight-loss diets in non-overweight individuals, alcohol consumption and daily consumption of sodas are advised against. In terms of the beneficial effects on bone mineral density and fracture risk, current scientific data are either insufficient or too divergent to recommend increasing or restricting the consumption of tea or coffee, vitamins other than vitamin D, vitamin D-enriched or phytoestrogen-rich foods, calcium-enriched plant-based beverages, oral nutritional supplements, or dietary sources of prebiotics and probiotics. These are the first set of recommendations addressing the role of diet in the prevention and treatment of osteoporosis. More research is necessary to direct and support guidelines.

Dietary recommendations of the French Society for Rheumatology for patients with chronic inflammatory rheumatic diseases.

This article presents the 1st set of dietary recommendations of the French Society for Rheumatology for patients suffering from chronic inflammatory rheumatic diseases (IRD) made by a working group consisting of 12 rheumatology experts, 3 physician nutrition specialists, 1 internal medicine specialist, 1 registered dietician and 3 representatives from patient associations. This group relied on a systematic literature review and on expert opinions, while taking into consideration not only the joint effects of diet in IRD but also the extra-articular ones. Eight general principles and nine recommendations were established. The general principles emphasize that nutritional advice is not a substitute for pharmacological treatment of IRD and that it is an integral part of the patients' overall care, which could help the patient actively participate in their care. The recommendations propose supporting weight loss in subjects who are overweight or obese, a Mediterranean-type diet and supplementation in polyunsaturated fatty acids, mainly omega-3. Conversely, gluten-free diets (in the absence of celiac disease), vegetarian/vegan diets, fasting and elimination of dairy products should not be proposed. Supplementation with vitamins or trace elements is not indicated for controlling chronic IRD activity, while the use of probiotics or spices is not recommended given the limited or disparate data.

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Are housestaff identifying malnourished hospitalized medicine patients?

Clinical nutrition and nutritional assessment are often a neglected component of medical school curriculums despite the high prevalence of malnutrition in hospitalized patients. This study found that medical housestaff performed nutritional assessments in only 4% of admitted patients despite a high rate of malnutrition (57%). Survey results show housestaff lack knowledge in the area of malnutrition. Medical schools and training programs must place greater emphasis of providing qualified physician nutrition specialists to implement effective nutrition instruction.

Residency and specialties training in nutrition: a call for action

Despite evidence that nutrition interventions reduce morbidity and mortality, malnutrition, including obesity, remains highly prevalent in hospitals and plays a major role in nearly every major chronic disease that afflicts patients. Physicians recognize that they lack the education and training in medical nutrition needed to counsel their patients and to ensure continuity of nutrition care in collaboration with other health care professionals. Nutrition education and training in specialty and subspecialty areas are inadequate, physician nutrition specialists are not recognized by the American Board of Medical Specialties, and nutrition care coverage by third payers remains woefully limited. This article focuses on residency and fellowship education and training in the United States and provides recommendations for improving medical nutrition education and practice.

Physician Nutrition Education

Nutrition education for physicians in the United States is limited in scope, quality, and duration due to a variety of factors. As new data and quality improvement initiatives highlight the importance of nutrition and a generation of nutrition experts retire, there is a need for new physician educators and leaders in clinical nutrition. Traditional nutrition fellowships and increased didactic lecture time in school and postgraduate training are not feasible strategies to develop the next generation of physician nutrition specialists in the current environment. One strategy is the development of short immersion courses for advanced trainees and junior attendings. The most promising courses include a combination of close mentorship and adult learning techniques such as lectures, clinical experiences, literature review, curricular development, research and writing, multidisciplinary interactions, and extensive group discussion. These courses also allow the opportunity for advanced discourse, development of long-term collaborative relationships, and continued longitudinal career development for alumni after the course ends. Despite these curricular developments, ultimately the field of nutrition will not mature until the American Board of Medical Specialties recognizes nutrition medicine with specialty board certification.

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The Intersociety Professional Nutrition Education Consortium and American Board of Physician Nutrition Specialists

A significant obstacle to nutrition literacy among physicians is a paucity of physician nutrition specialists (PNSs) on medical school faculties who can effectively advocate for change in medical school and residency curricula, and who can serve as role models for incorporating nutrition into patient care. To address these issues, the Intersociety Professional Nutrition Education Consortium (IPNEC) developed a paradigm for PNSs that is designed to attract more physicians into the field; promulgated educational standards for fellowship training of PNSs; and established a unified mechanism for certifying PNSs, the American Board of Physician Nutrition Specialists (ABPNS). With a board of directors consisting of members nominated by 7 professional nutrition societies in addition to at-large members, the ABPNS incorporates broad participation by all professional nutrition societies that have substantial physician members. The ABPNS certificate is intended to be the premier comprehensive credential for physicians who wish to identify nutrition as an area of expertise. Certification is equally accessible to physicians with backgrounds in any of the specialties and subspecialties relevant to clinical nutrition. This article outlines the history and features of IPNEC and ABPNS and the consensus paradigm, training standards, and certification process they developed. We discuss achievements, opportunities, and challenges facing the maintenance of a consensus-based certification body in order to inform future initiatives designed to expand the number of physician nutrition specialists.

Professional Outcomes of Completing a Clinical Nutrition Fellowship

Cleveland Clinic has trained 17 physician nutrition specialists since the establishment of its clinical nutrition fellowship (CNF) in 1994. The paths taken by the graduates and whether they continue to practice clinical nutrition are largely unknown. To investigate the professional outcomes of completing a CNF, a survey of graduates was conducted. Fifty-seven percent of respondents (n = 8) applied to another fellowship prior to applying to a CNF. The 2 most common reasons for applying to a CNF were to increase knowledge of clinical nutrition and increase the chance of acquiring a gastroenterology fellowship. Eighty-five percent (n = 10) of graduates found the CNF to be valuable. Eighty-six percent (n = 12) went on to complete a gastroenterology fellowship, and 67% (n = 8) of graduates believed that completing a CNF increased their chances of gaining acceptance to a gastroenterology fellowship. Only 42% (n = 6) of the graduates currently hold professions that specifically dictate the use of clinical nutrition, but 61% (n = 8) reported using clinical nutrition in their daily or weekly practice. Fifty percent (n = 7) of graduates believed that completing a CNF made them more competitive job candidates, but only 21% (n = 3) said that their extra training is reflected in their current salary. It appears that CNFs are being used as a method of subsequently acquiring a gastroenterology or other medical fellowships. Although not working in defined clinical nutrition professions, >50% of graduates continue to apply their CNF skills after completing their training. A small percentage have found dedicated nutrition-based clinical professions.

Developing an Education Program for Nutrition Support Teams

Focused training and continuing medical education are necessary for nutrition support clinicians to acquire new skills, maintain competence, and keep abreast of advancements in the field. Unfortunately, there is a lack of physician-nutrition specialists to act as teachers and role models. One solution is to have members of a multidisciplinary nutrition support team, regardless of discipline, share their expertise with others. This is best accomplished within the framework of a formal education program that can accommodate the knowledge and skill level of each instructor and educational goals of each student. Developing an education program should include the following steps: formulate general goals of the program, specify learning objectives, assess each student's current level of knowledge and educational goals, determine educational strategies and learning activities that will best meet the goals of each student and the program, and devise a method to evaluate the performance of each student and the program as a whole.

Professional Outcomes of Completing a Clinical Nutrition Fellowship: Cleveland Clinicʼs 16-Year Experience

Purpose: Clinical Nutrition Fellowships (CNF) were established in the early 1990s with the intent increasing the number of physician nutrition specialists (PNS). Cleveland Clinic has trained 15 PNS since the start of its CNF in 1994. The paths taken by our graduates and whether they continue to practice clinical nutrition are largely unknown. Methods: A survey of our graduates was conducted to investigate the professional outcomes of completing a CNF. This was a descriptive, cohort, IRB approved study. Results: 15 electronic surveys were sent and 12 were returned for an 80% response rate. Our results show that 50% (6) of graduates applied to another fellowship prior to applying to a CNF. The two most common reasons for applying to a CNF were to increase their knowledge of clinical nutrition and to increase chances of acquiring a GI fellowship. 81% (9) of graduates found our CNF to be valuable. 92% (11) went on to complete a gastroenterology fellowship. 70% (7) of graduates believed that completing a CNF increased their chances of getting acceptance to a gastroenterology fellowship. Only 33% (4) of our graduates currently hold professions that specifically dictate the use of clinical nutrition, however, 33% (4) and 25% (3) reported the use of clinical nutrition in their daily and weekly practice, respectively. 50% (6) of graduates believed that completing a CNF made them more competitive job candidates but only 17% (2) said that their extra training is reflected on their current salary. 80% (8) of CNF graduates said that clinical nutrition training needs to be improved in GI fellowships. Conclusion: It appears that CNF are being used as a method of subsequently acquiring gastroenterology or other medical fellowships. Over 50% of graduates continue to apply their CNF skills after completing their training although not in defined clinical nutrition professions.Figure

Training and certifying Physician Nutrition Specialists: the American Board of Physician Nutrition Specialists (ABPNS) –4

A significant obstacle to nutrition literacy among physicians is a paucity of Physician Nutrition Specialists (PNSs) on medical school faculties who can effectively advocate for change in medical school and residency curricula and who can serve as role models for incorporating nutrition into patient care. To address these issues, the Intersociety Professional Nutrition Education Consortium developed a paradigm for PNSs that is designed attract more physicians into the field; promulgated educational standards for fellowship training of PNSs; and established a unified mechanism for certifying PNSs, the American Board of Physician Nutrition Specialists (ABPNS). This article details the consensus paradigm and specific training standards and outlines the features and history of the ABPNS. The ABPNS certificate is intended to be the premier comprehensive credential for physicians who wish to identify nutrition as an area of expertise. Certification is equally accessible to physicians with backgrounds in any of the specialties relevant to clinical nutrition. It is hoped that more physicians will identify nutrition as a specialty interest if training opportunities are available in a variety of settings and are merged with their other professional interests. ABPNS invites input and feedback from colleagues around the world.

Training and certifying gastroenterologists as physician nutrition specialists.

Because nutrition is an integral aspect of the science and practice of gastroenterology, all gastroenterology fellows should receive training in core aspects of nutrition (level 1 training). Some gastroenterologists also wish to train more extensively in nutrition (level 2) and become physician nutrition specialists. The Intersociety Professional Nutrition Education Consortium, composed of representatives from eight national societies with significant nutrition interests, including the American Gastroenterological Association, and three credentialing bodies, has developed a paradigm and training requirements for physician-nutrition specialists that recognizes their varied backgrounds and areas of interest. Opportunities exist for gastroenterology fellows to obtain physician nutrition specialist training within their gastroenterology fellowships and to be eligible to take the Certification Examination for Physician Nutrition Specialists offered by the new American Board of Physician Nutrition Specialists.* This article reviews the development of consensus on subspecialty training for physicians in nutrition; it also encourages directors of gastroenterology fellowships to develop training opportunities and gastroenterology fellows to consider identifying nutrition as an area of emphasis for their careers.

Integrating nutrition as a theme throughout the medical school curriculum

More than one-third of adult Americans are obese. A major portion of the diseases that cause the highest morbidity and mortality, eg, heart disease, cancer, diabetes, stroke, and hypertension, can be attributed to diet. Yet, despite the demand for more nutrition education, few medical schools have an adequate nutrition curriculum. Many medical schools are reducing the number of lecture hours in favor of problem-based tutorial discussions, so an addition of another mandatory lecture course is not likely. The organization of nutrition as a theme throughout the 4-y medical school curriculum can pull together many hours of nutrition information taught during various courses, eg, biochemistry, physiology, pathophysiology, clinical clerkships, and electives. Emphasis should be placed on the identification of available resources (eg, faculty throughout the medical school and affiliated hospitals, textbooks, research, and clinical experiences) and applied to practical clinical situations so that students are able to identify, assess, and appropriately manage the frequent nutritional problems seen in outpatients and inpatients. Strategies and techniques such as curriculum analysis, computer-aided instruction modules, Internet Web sites, case-based tutorial discussions, use of physician nutrition specialists and dietitians, administratively separate nutrition units, observed structured clinical examinations, and faculty development are listed and discussed in this article.

Physician-nutrition-specialist track: if we build it, will they come?

The Intersociety Professional Nutrition Education Consortium (IPNEC) has made substantial progress in its first 2 y. With support from 9 participating nutrition societies and certification organizations and with funding from the National Institutes of Health and several nutrition industry partners, a sustained, functioning consortium has been established. The consortium's 2 principal aims are to establish educational standards for fellowship training of physician nutrition specialists (PNSs) and to create a unified mechanism for certifying physicians who are so trained. Its long-term goals are to increase the pool of PNSs to enable every US medical school to have at least one PNS on its faculty and to surmount obstacles that currently impede the incorporation of nutrition education into the curricula of medical schools and residency programs. The consortium formulated and refined a paradigm for PNSs, conducted a national role delineation survey to define the scope of the discipline of clinical nutrition, and developed a preliminary curriculum template for training PNSs that can be completed in a minimum of 6 mo. IPNEC and its sponsoring societies are strategically positioned to play an important long-term role in nutrition education for physicians. We intend to continue soliciting broad input, especially from directors of fellowship training programs in nutrition and closely related subspecialties; to develop the core content for fellowships in nutrition and related subspecialties; and to initiate a unified PNS certification examination.