Clinical nutrition education in medical schools: Results of an ESPEN survey

Clinical nutrition in primary care: ESPEN position paper

Primary care healthcare professionals (PCHPs) are pivotal in managing chronic diseases and present a unique opportunity for nutrition-related disease prevention. However, the active involvement of PCHPs in nutritional care is limited, influenced by factors like insufficient education, lack of resources, and time constraints. In this position paper The European Society for Clinical Nutrition and Metabolism (ESPEN) promotes the active engagement of PCHPs in nutritional care. We emphasize the importance of early detection of malnutrition by screening and diagnosis, particularly in all individuals presenting with risk factors such as older age, chronic disease, post-acute disease conditions and after hospitalization for any cause. ESPEN proposes a strategic roadmap to empower PCHPs in clinical nutrition, focusing on education, tools, and multidisciplinary collaboration. The aim is to integrate nutrition into medical curricula, provide simple screening tools for primary care, and establish referral pathways to address malnutrition systematically. In conclusion, we urge for collaboration with PCHP organizations to raise awareness, enhance nutrition skills, facilitate dietitian accessibility, establish multidisciplinary teams, and promote referral pathways, thereby addressing the underestimated clinical challenge of malnutrition in primary care.

Development and evaluation of a Massive Open Online Course (MOOC) for healthcare professionals on malnutrition in older adults

BACKGROUND

Education about malnutrition in older adults is often lacking in the curricula of healthcare professionals. Massive open online courses (MOOCs) are an innovative form of education that can potentially improve the knowledge of healthcare professionals.

OBJECTIVES

(1) to describe the development of a MOOC on malnutrition in older adults and (2) to evaluate the MOOC on the basis of knowledge gained.

DESIGN

The MOOC was developed by following a structured approach. For the evaluation of the MOOC, a cross-sectional descriptive study was conducted.

PARTICIPANTS

Overall, 1288 nurses, dietitians, medical doctors and other healthcare professionals participated in the evaluation study.

METHODS

After performing a comprehensive literature review, two dietitians specialised in geriatrics developed a summary of potentially important content of the MOOC. Nine European malnutrition experts from different professional areas were then asked to contribute their expertise. The specific MOOC content was developed based on the recent literature and evidence-based guidelines. For the evaluation of the MOOC, a questionnaire with 41 questions was developed. Results were analysed using descriptive statistics and chi-square tests.

RESULTS

The final MOOC consists of five modules with 15 learning videos and supplementary material. The percentage of persons with good malnutrition knowledge increased from 76.1 % to 89.9 % (p < 0.001), while the percentage of persons with fair or little malnutrition knowledge decreased (p < 0.001). The course significantly improved the participants' knowledge of specific malnutrition topics, namely, methods and instruments to determine the nutritional status of older people, interventions to improve oral intake, medical nutrition and multidisciplinary cooperation (p < 0.001). Overall, 91.5 % of the participants rated the quality of the course as very good or good.

CONCLUSION

MOOCs may be an effective tool that can be used to improve knowledge in healthcare professionals. This provides new opportunities for successful multidisciplinary malnutrition management in clinical practice.

Nutrition care is an integral part of patient-centred medical care: a European consensus

While healthcare is becoming more patient-centred, evidence-based nutrition interventions are still not accessible to all patients with cancer. As nutrition interventions directly improve clinical and socioeconomic outcomes, patient-centred care is not complete without nutrition care. While awareness of the negative impact of malnutrition on clinical outcomes, quality of life, and functional and emotional wellbeing in cancer is growing, there is relatively poor awareness amongst patients, clinicians, policymakers, and payers that nutrition interventions -particularly those begun in the early stages of the disease course- are an effective method for improving such outcomes. The European Beating Cancer Plan recognises the need for a holistic approach to cancer but lacks actionable recommendations to implement integrated nutrition cancer care at member state level. When considering nutrition care as a human right, the impact on quality of life and functional status must be prioritized, as these may be equally as important to patients, especially in advanced cancer where improvements in clinical outcomes such as survival or tumour burden may not be attainable. We formulate actions needed at the regional and the European level to ensure integrated nutrition care for all patients with cancer. The 4 main Take Home Messages are as follows: 1. The goals of Europe's Beating Cancer Plan cannot be achieved without integrating nutrition across the cancer care continuum. 2. Malnutrition negatively impacts clinical outcomes and has socioeconomic consequences for patients and healthcare systems. 3. Championing integrating nutrition care into cancer care is therefore the duty and ethical responsibility of clinicians (Hippocratic Oath-primum non nocere) and 4. Nutrition care is a cost effective, evidence-based therapy.

Nutrition education in medical schools (NEMS) project: Promoting clinical nutrition in medical schools - Perspectives from different actors

BACKGROUND & AIMS

Nutrition education is not adequately represented in the medical curriculum, and this prompted the European Society for Clinical Nutrition and Metabolism (ESPEN) to launch the Nutrition Education in Medical Schools (NEMS) Project in 2017. The aim of this original paper was to describe the perspectives of different actors in the promotion of nutrition education in medical schools.

METHODS

On 11 November 2021, an online meeting was held on this topic, where nine representatives from different backgrounds participated in the scientific programme. More than 640 participants registered to this webinar.

RESULTS

The different models of Nutrition Education in Medical Schools were introduced by Prof. Cristina Cuerda (Spain) and Prof. Maurizio Muscaritoli (Italy). The students' perspective was given by Ms. Alexandra Archodoulakis (Germany) and Ms. Sila Gürbüz (Turkey), representing the European Medical Students' Association. The dietitian's perspective was given by Dr. Kirsten Berk (The Netherlands), whereas Dr. Matti Aapro (Switzerland) gave the medical doctor (oncology)'s perspective. Ms. Clare Farrand (Australia) gave the WHO perspective and Dr. Kristiina Patja (Finland) explained the healthy lifestyle teaching to medical students. Lastly, Prof. Michael Chourdakis (Greece) and Prof. Zeljko Krznaric (Croatia) hosted the round-table discussion.

CONCLUSIONS

There was strong agreement among the representatives from different settings joining this ESPEN initiative that increasing nutritional knowledge and skills of young doctors is now possible and will launch a virtuous cycle that will proactively involve all the other healthcare professionals working in the nutritional field.

Transgender data collection in the electronic health record: Current concepts and issues

There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.

Clinical Nutrition and Human Rights. An International Position Paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Nutrition in medical education in Latin America: Results of a cross-sectional survey

RATIONALE

The gap between the nutrition education provided to medical students and the nutrition competences and attitudes needed for doctors to provide effective nutrition care is a global concern. The goal of this study was to investigate the curricular content on nutrition education in Latin American medical schools and to evaluate the self-perceived knowledge, attitudes, and barriers to nutrition practice of final-year medical students.

METHODS

Eighty-five public and private medical schools from 17 Latin American countries were invited to participate in the study. Two close-ended online questionnaires consisting of 25 and 43 questions were sent to medical school directors. Quantitative variables were expressed as frequencies, percentages, mean ± standard deviation, medians, and ranges.

RESULTS

A total of 22 (26%) medical school directors responded, of which 11 schools (50%) offered stand-alone mandatory nutrition courses in preclinical and 8 (36%) in clinical years. The mean hours dedicated to nutrition education was 47 (range: 0-150). A total of 1530 of 1630 (94%) students from 12 countries responded. Students' average age was 25 ± 3 years, and 59% were female. Most students agreed that improving patients' health through nutrition (91%) is important and that nutrition counseling and assessment should be part of routine care provided by all physicians (89%), but they lack the level of education and training required to address nutrition-related issues.

CONCLUSIONS

Positive attitude and interest in nutrition among final-year medical students is high, but nutrition education is not perceived as sufficient to adequately prepare doctors in the field of nutrition.

Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view

BACKGROUND & AIMS

Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN).

METHODS

On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives.

RESULTS

This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum.

CONCLUSION

The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

Nutrition training in residency and fellowship programme: time for a change

Background:

Despite several measures, the nutrition education during undergraduate and postgraduate training has been identified to be suboptimal. The objective of this study was to assess the nutrition knowledge, attitudes and practice of residents, fellows and teaching faculties, following a reformation in the training curriculum, in a tertiary teaching hospital.

Method:

We conducted an anonymous survey involving residents, fellows and teaching faculties in medical and surgical speciality. We assessed four domains: (a) recognition, (b) knowledge, (c) application of basic principles of nutritional and (d) attitude towards clinical nutrition during residency and fellowship training. Each domain had five multiple choice questions and the attitude section was assessed using a five-point Likert scale.

Result:

We distributed the survey to 305 doctors: 265 completed the first three domains and 259 completed all the domains. The overall mean ± SD score between residents (6.5 ± 1.9), fellows (6.8 ± 1.8) and teaching faculties (6.5 ± 2.2) was similar. All scored similarly in the recognition, knowledge and application domain of the questionnaire. When subcategorised, the gastroenterology sub-speciality scored significantly higher than the rest (8.1 ± 2.2 vs. 6.4 ± 1.9, p = 0.001). Sixty-three per cent and 44% of the responders felt there was lack of adequate focus on clinical nutrition training in residency and during daily ward round, respectively. Only 10% of responders felt confident in providing nutritional counselling and treatment for malnourished patients.

Conclusion:

Our study shows the current nutritional education during residency and fellowship training is still inadequate and falls short in achieving the recommended goals.

Self-Completion of the Patient-Generated Subjective Global Assessment Short Form Is Feasible and Is Associated With Increased Awareness on Malnutrition Risk in Patients With Head and Neck Cancer

BACKGROUND

We aimed to assess feasibility of self-completion of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) by head and neck cancer patients, and to assess self-reported increased awareness regarding malnutrition risk after self-completion.

METHODS

Participants were randomized to complete the PG-SGA SF by paper or app. Feasibility was assessed by time needed to complete the PG-SGA SF, perceived difficulty, and help needed during completion. Participants were asked if they knew what malnutrition was (yes/no) and if they could define "malnutrition." They were also asked 9 questions on whether they perceived increased awareness of malnutrition risk after having completed the PG-SGA SF and 2 on their intention to change lifestyle habits.

RESULTS

Of all participants (n = 59; 65.9 ± 12.6 years; 73% male), 55% completed the PG-SGA SF paper version and 46% the Pt-Global app. Median time needed for self-completion of the PG-SGA SF was 2 minutes 41 seconds (interquartile range: 1 minute 49 seconds-3 minutes 50 seconds). Forty-eight percent needed help with completion, indicating acceptable feasibility. Participants who completed the Pt-Global app needed help significantly more often (66%; 21/32) than those who completed the PG-SGA SF paper version (26%; 7/27) (P = 0.005). All difficulty scores were excellent. For 7/9 questions on malnutrition risk awareness, >50% of the participants answered positively.

CONCLUSION

The results of this study show that self-completion of the PG-SGA SF by head and neck cancer patients is feasible and that awareness regarding malnutrition risk may increase after completing the PG-SGA SF.

Dietary measures among patients with coronary heart disease in Europe. ESC EORP Euroaspire V

OBJECTIVE

Assess the dietary recommendations provided to patients hospitalized for a coronary heart disease (CHD) event.

DESIGN

Cross-sectional, multicentre observational study (ESC EORP Euroaspire V).

METHODS

8261 participants (25.8% women, 9.3% aged<50 years) from 27 countries, 6 to 24 months after hospitalization for a CHD event were included. Participants were asked if they had been advised to reduce salt, fat or sugar intake, change type of fat consumed, and increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish. Self-reported changes were recorded.

RESULTS

Advice to reduce energy intake, salt, fat and sugar was provided to 64.5% [range: 9.2-90.5], 73.2% [38.6-95.2], 77.3% [42.3-95.6] and 67.0% [39.4-93.3] of patients, respectively. Advice to change fat type, increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish was provided to 68.3% [33.7-92.3], 36.7% [0.6-75.2], 73.2% [39.2-93.6], 66.5% [8.0-90.8] and 53.5% [3.7-83.3] of patients, respectively. Advices were more frequently provided to patients aged 50 to 69, with a high educational level, or obesity. One-eighth [0-55.0] of patients reported having consulted a dietician. Reductions in energy intake, salt, fat and sugar were reported by 57.7% [4.9-81.0], 69.9% [32.1-85.9], 71.8% [40.4-88.4] and 61.2% [29.0-84.0] of patients, respectively. Changes in fat type and increased consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish were reported by 60.9% [4.9-81.0], 25.8% [0.6-54.1], 69.2% [27.7-88.4], 54.8% [4.0-80.1] and 40.4% [2.0-66.8] of patients, respectively.

CONCLUSION

Dietary advice is not systematically provided to patients with CHD, and considerable differences exist between European countries.

Golden Age of Medicine 2.0: Lifestyle Medicine and Planetary Health Prioritized

The 'golden age of medicine' - the first half of the 20th century, reaching its zenith with Jonas Salk's 1955 polio vaccine - was a time of profound advances in surgical techniques, immunization, drug discovery, and the control of infectious disease; however, when the burden of disease shifted to lifestyle-driven, chronic, non-communicable diseases, the golden era slipped away. Although modifiable lifestyle practices now account for some 80% of premature mortality, medicine remains loathe to embrace lifestyle interventions as medicine Here, we argue that a 21st century golden age of medicine can be realized; the path to this era requires a transformation of medical school recruitment and training in ways that prioritize a broad view of lifestyle medicine. Moving beyond the basic principles of modifiable lifestyle practices as therapeutic interventions, each person/community should be viewed as a biological manifestation of accumulated experiences (and choices) made within the dynamic social, political, economic and cultural ecosystems that comprise their total life history. This requires an understanding that powerful forces operate within these ecosystems; marketing and neoliberal forces push an exclusive 'personal responsibility' view of health - blaming the individual, and deflecting from the large-scale influences that maintain health inequalities and threaten planetary health. The latter term denotes the interconnections between the sustainable vitality of person and place at all scales. We emphasize that barriers to planetary health and the clinical application of lifestyle medicine - including authoritarianism and social dominance orientation - are maintaining an unhealthy status quo.

Is continuing medical education sufficient? Assessing the clinical nutrition knowledge of medical doctors

OBJECTIVES

Provision of nutritional support (NS) can improve disease outcome and shorten hospital length of stay. NS, often prescribed by medical doctors, requires adequate clinical nutrition (CN) expertise. The aim of this study was to investigate self-perceived and actual CN knowledge among medical doctors in Greece.

METHODS

Internal medicine physicians and surgical specialties (residents and specialized) were asked to self-evaluate their CN expertise, via a seven-item questionnaire and to complete a 20-question multiple-choice test on CN topics, with the aim of evaluating their actual CN knowledge. Participants were discouraged from accessing literature/information during the completion of either questionnaire.

RESULTS

Of 182 invited medical doctors, 115 (50.4% surgical specialties) participated in the study (63.2% response rate). The majority of participants (65.2%) demonstrated inadequate CN knowledge, with 30.4% of those scoring low having a high self-perception of their CN expertise. Comparison of perceived and actual CN knowledge revealed that only 56.5% of the participants estimated their knowledge correctly. Those who had participated in CN continuous medical education courses demonstrated increased related expertise (P = 0.002).

CONCLUSIONS

Medical doctors in Greece demonstrate low knowledge of fundamental CN principles, jeopardizing the provision of high-quality and efficient NS. Most importantly, the majority of participants overestimated their CN knowledge and prescribe artificial nutrition or participate in related decision making. Physicians' CN knowledge should be enhanced accordingly, either by attending CN modules during their studies, by participating in basic and advanced courses or CN-specific continuous medical education, or both.

A Survey of Home Enteral Nutrition Practices and Reimbursement in the Asia Pacific Region

Literature regarding the use of home enteral nutrition (HEN) and how it is reimbursed in the Asia Pacific region is limited. This research survey aims to determine the availability of HEN, the type of feeds and enteral access used, national reimbursement policies, the presence of nutrition support teams (NSTs), and clinical nutrition education in this region. An electronic questionnaire was sent to 20 clinical nutrition societies and leaders in the Asia Pacific region in August 2017, where thirteen countries responded. Comparison of HEN reimbursement and practice between countries of different income groups based on the World Bank’s data was investigated. Financial support for HEN is only available in 40% of the countries. An association was found between availability of financial support for HEN and health expenditure (r = 0.63, p = 0.021). High and middle-upper income countries use mainly commercial supplements for HEN, while lower-middle income countries use mainly blenderized diet. The presence of NSTs is limited, and only present mainly in acute settings. Sixty percent of the countries indicated an urgent need for funding and reimbursement of HEN. This survey demonstrates the varied clinical and economic situation in the Asia Pacific region. There is a lack of reimbursement, clinical support, and inadequate educational opportunities, especially for the lower-middle income countries.