ࡱ>   #` Wbjbj5G5G W-W-&IBBBBdCdCdC(DlMlMlM@NQ(D.hUbf(fffsxە|~~~~~~$)hQdCrsBBff# HJJJBfdCf|J|JJ/9C^dCf\U plMh0L;vTdCEJKR(D(D(DD lM(D(D(DlM(D(D(DBBBBBB SOCIETY OF TEACHERS OF FAMILY MEDICINE Group on Nutrition  SOCIETY OF TEACHERS OF FAMILY MEDICINE GROUP ON NUTRITION Physicians Curriculum in Clinical Nutrition: Primary Care Third Edition ( 2001, The Group on Nutrition, Society of Teachers of Family Medicine. Reproduction permitted for educational purposes only. Not for resale Updated April 2007 Table of Contents  TOC \h \z \t "Heading 1,4,Heading 2,5,Chapter Title,2,Chapter Subtitle,3,Section Label,1" Introduction 7 About the Group on Nutrition  PAGEREF _Toc517736881 \h 10 Editors 13 Authors contributing to at least one edition 13 Contributors and Reviewers contributing to at least one edition 14 NUTRITION TRAINING IN FAMILY MEDICINE RESIDENCY 17 Nutrition Issues at Different Stages of the Life Cycle 21 Infants 21 Children and Adolescents 22 Adults 24 Pregnancy and Lactation 25 Elderly 26 Nutrition Care Skills for Prevention and Treatment of Disease 27 Cancer 27 Cardiovascular Disease, Dyslipidemias, Diabetes Metabolic Syndrome, and Hypertension 27 Gastrointestinal Disorders  PAGEREF _Toc517736895 \h 29 Hematologic Disorders--Nutritional Anemias  PAGEREF _Toc517736896 \h 30 Osteoporosis 30 Renal Disease 29 Secondary Malnutrition Caused by Systemic Diseases 31 Alcoholism and Liver Disease 31 Cancer 31 HIV-AIDS 32 Pulmonary Disease 32 Obesity-Weight Loss Strategies and Counseling 33 Eating Disorders 35 Use of Dietary Supplements 35 Foodborne Illness 36 Food Allergy and Intolerance 36 Physical Activity and Sports 37 Nutrition Support 37 Community Nutrition Resources 38 METHODS 41 Responsibility for Curriculum 41 Setting Goals and Objectives 41 Getting Started 42 Building Faculty Support 42 Creating a Supportive Environment 43 Nutrition Bulletin Board(s) 43 Brochure Rack 43 March Nutrition Month 43 Taste Tests 44 Reference Material 44 Conferences 44 Nutrition Assessment & Referral Forms 44 Patient Education Materials 45 Supporting the Nutrition Program Financially 45 Integrating Nutrition Education into Patient Care 46 Nutrition Consultation 46 Clinical Resources 47 Nutrition Handbook 47 PDA Programs 47 Teaching Opportunities: Inpatient Setting, Nursing Home, and Home Visit 47 Screening and Assessment 47 Morning Rounds 48 Teaching Opportunities: Ambulatory Setting 48 Nutrition Screening 48 Co-Counseling 49 Diet Referrals 49 Computer Assessment Programs 49 Observation 50 Precepting 50 Increase Awareness 50 Chart Review and Quality Assurance 51 Patient Education Material 51 Clinic Newsletter 52 Patient Education Classes and Group Visits 52 Nursing Home 52 Community Activities 52 Diadactic Teaching Opportunities 53 Grand Rounds, Lectures, Conferences, and Small Groups 53 Grand Rounds 53 Guest Lectures 54 Slide Shows 54 Integrate Nutrition with Other Topics 54 Small Group Seminars 54 Games 54 Case Studies 54 Self-Assessment 55 Fat Intake Scale 55 Rate Your Plate 55 Plant Food Screener 55 Simulated Learning 55 Standardized Patients and Simulated Patients 56 Case Conferences 56 Physician Conference Meal 56 Field Trips 57 Teaching Practical Nutrition 57 Community Resources 57 Opportunities for Independent Study 57 Self-study learning modules 57 Books 58 Journal Articles 58 Computer Programs 58 Video Resources 58 Journal Club 58 Literature Review 58 Evidence-Based Medicine (EBM) 59 Related Curriculum 59 Evaluation Tools and Strategies 59 Direct Observation 59 Objective Structured Clinical Examinations (OSCE) and Clinical Practice Examinations (CPX) 60 Rotation Evaluation 60 Competency Checklists 60 Board Review Questions 60 Surveys of Graduates 60 BEST PRACTICES 61 Mentors 72 Textbooks 78 Handbooks 78 Cookbooks 79 Web-Based Dietary Analysis Tools 79 Nutrition-Specific Journals 79 Newsletters 80 Organizations 80 Computer-Based Education 81 Websites for Physician Education 81 Websites for Nutrition Education for Patients 82 Evidence-Based Medicine 83 Geriatrics 83 Handheld Computer Software 84 Journal Articles 85 APPENDIX 87 Appendix I: Recommended Core Educational Guidelines for Family Practice Residents AAFP Reprint No. 275 88 Appendix II: Rotation Planning: Nutrition in Medicine Needs Questionnaire 92 Appendix III: Nutrition and ACGME Competencies 94 Appendix IV: Family Medicine Resident Evaluation ~ Community Medicine Nutrition Rotation100 Appendix V: Family Medicine Resident Evaluation ~ Nutrition Didactic Session..102  Introduction W hile estimates vary, there is a nutrition related reason for at least 25% of all visits to primary care providers (Kolasa 1999). The Residency Review Committee for the American Academy of Family Physicians (AAFP) has required nutrition education since 1982 and published Recommended Core Educational Guidelines in Nutrition (AAFP Reprint No. 275) in 1989 (http://www.aafp.org). The Guidelines have been updated with input from the Group on Nutrition in 1995 and 2000. The Group on Nutrition also has published earlier versions of detailed curriculum guides (Michener and Rasmann-Nuhlicek, 1987; and Sitorius and Rasmann-Nuhlicek, 1995; Kolasa and Deen, 2001; updated 2002 and 2005). Though guidelines exist, there is no consensus on minimal nutrition training a graduating family physician should have. Over the years, many family medicine residency programs have provided training on attitudes, knowledge, and skills in nutrition, but there is still work to be done. In 2000, the Group on Nutrition (GON) surveyed 100 randomly selected family medicine residency programs about their efforts in nutrition. Few programs have full time nutrition educators (Deen, et al, 2003). However, most have a faculty member with responsibility for the nutrition curriculum. More than 50% of the programs responding to the survey feel that nutrition is an important component of their residency programs. Most programs feel that time is a significant barrier to effective nutrition education, and almost half feel that effective evaluation is lacking. Support for trained nutrition faculty is also an important barrier. Since the training is quite variable, it is not surprising that virtually every published study on the subject shows family physicians are supportive of, but do not feel competent at delivering nutrition services to patients. More than 90% of primary care physicians report nutrition is their responsibility. Consumers continue to identify the physician as the trusted source of nutrition information. Even so, the recurring theme through the published literature is that physicians report lack of confidence in nutrition assessment and counseling skills, and only a small percentage of physicians report that they find personal gratification in counseling about diet issues. The Group on Nutrition believes that incorporating nutrition into the training of primary care residents can help boost their confidence and skill in ensuring patients receive adequate nutrition care, both from the physician and with appropriate referral, in collaboration with other professionals with nutrition training. To that end, the Group has again updated the Physician's Curriculum in Clinical Nutrition, with a focus on the nutrition interventions that are high yield and tools that are office friendly. In 2005 GON updated this curriculum and its members were engaged in discussions about the future of residency education in family medicine Unfortunately retirements and budget cuts have reduced the nutrition activity in some practices. Other residencies are putting a focus on child and adult obesity management. Earlier editions of this manual had many best practices described. There are fewer in this 2007 edition. The focus of this monograph is primary care residency training. Many medical nutrition educators teach in both residency and medical school settings. Improving nutrition training in medical schools would have an impact on residency training. Medical students report that they receive inadequate nutrition training. The American Association of Medical Colleges (AAMC) annually queries graduating medical students about the adequacy of their training. Since 1994 more than 50% of the graduating medical students have ranked their nutrition training as "inadequate." In an attempt to understand this poor ranking, the AAMC added some specific questions to the survey in 2000. Student responses are important in planning nutrition curriculum for primary care residents. In the year 2000, only 20.3% of the students ranked their nutrition-related experience as "adequate. Only 20% said that their clerkship preceptors served as appropriate role models for the practice of nutrition assessment and intervention. There has been no significant change in the student responses in 2001 and 2002. In 2003, 51.8% of US medical school graduates ranked nutrition preparation inadequate. It has been estimated by the Nutrition in Medicine program at University of North Carolina at Chapel Hill, that medical schools teach between 2 and 70 hours of nutrition with an average of 23.9 hours. Most of that teaching is done in the first and second year of training. The National Board of Medical Examiners (NBME) who administers the USMLE Step 1, 2 and 3 exams developed a nutrition sub-score for the Step 1 exam. The impact of this on nutrition curriculum has not been assessed. In a country where obesity is considered epidemic among adults and children, only 23% of the students felt prepared to assess the patient's status for obesity and undernutrition. A recent study showed physicians rarely included in their advice about weight loss, components that could increase health behavior change (Flocke et al, 2005). The AAFP lists top reasons for office visits at its Web site. Many of those reasons have nutrition implications: hypertension (#1), general medical exam (#3), diabetes mellitus (#8), heart disease (#11), asthma (#12), abdominal pain (#18), and pregnancy care (#21). Although medical nutrition therapy is considered part of first-line management for each of these diagnoses only 39% of the medical students reported adequate training to assess and treat patients with Type 2 diabetes mellitus; 45% to treat cardiovascular disease; and 40% to use appropriate complementary medicine strategies. The lack of medical school curriculum in nutrition has been discussed for many years. A variety of curriculum guides have been published. This monograph does not focus on medical school nutrition curriculum, but we refer readers to the Nutrition Academic Award Program (NAA) The Nutrition Academic Award program sponsored by NHLBI (1997-2005) published a curriculum guide ( HYPERLINK "http://www.nhlbi.nih.gov/funding/training.naa" www.nhlbi.nih.gov/funding/training.naa) for training physicians. There are several links from this site that still have good tools although some appear to be dated. The purpose of this curriculum is to distill the skills needed by primary care clinicians for their patient care efforts and to provide resources for faculty charged with the development of those skills in their learners. GON welcomes your suggestions. Kathryn M. Kolasa, PhD, RD, LDN Darwin Deen, MD, MS Co-editor Co-editor Literature Cited Deen D, Spencer E, Kolasa KM. Nutrition Education in Family Practice Residency Programs. Family Medicine. 2003;35(2):105-11. Deen D, Kolasa KM (eds). Physicians Curriculum in Clinical Nutrition. Society for Teachers of Family Medicine. 2001; updated 2002. http://www.stfm.org/pdfs/GroupOnNutrition.pdf Flocke SA, Clark A, Schlessman K, Pomiecko G. Exercise, diet and weight loss advice in the Family Medicine outpatient setting. Fam Med. 2005;37(6):415-21. Kolasa KM, Developments and challenges in family practice nutrition education for residents and practicing physicians: an overview of the North American experience. Euro J Clin Nutr. 1999:53(52):89-96. Michener L, Rasmann-Nuhlicek D, Kahn A. Curriculum in Nutrition. Kansas City: Society of Teachers of Family Medicine, 1987 Sitorius M, Rashmann-Nuhlicek D (eds). Physicians Curriculum in Clinical Nutrition. Kansas City: Society of Teachers of Family Medicine, 1995 Editorial Assistance The first edition of the monograph was edited by Jerri Harris, MPH, Department of Family Medicine, Brody School of Medicine at East Carolina University, Greenville, North Carolina, with support from Rosemarie Colt and Jennifer Levine. Support for the 2002 Update by Vickie Best. Support for the 2005 update by Rebecca Rawl and Tasha Mebane. Support for the 2007 update was provided by student assistants in the Department of Family Medicine at the Brody School of Medicine at East Carolina University. Funding The Group on Nutrition members and reviewers provided their efforts as volunteers. A grant from Weight Watchers International Foundation, Inc. and Ross Laboratories funded production of the monograph and Web site. Unrestricted funding from the Council for Biotechnology Information also helped support the Blackboard course for two years. . The 2005 and 2007 updates were completed without funding. Dedication This monograph is dedicated to the memory and work of Dale N. Rasmann-Nuhlicek, MS, RD, who inspired the work of the Group on Nutrition for many years. About the Group on Nutrition T he Group on Nutrition (GON) was established in 1983 as an approved group of the Society of Teachers of Family Medicine (STFM). It has formal liaison with the American Academy of Family Physicians (AAFP) and the American Dietetic Association (ADA). GON is also represented on the American Academy of Family Physicians Foundation Resource Committee for Nutrition Education. The mission is to facilitate communication among those involved in nutrition education for medical students and family medicine residents. Since its inception, the GON has been co-chaired by a physician and a nutritionist. The Group works toward the development and implementation of nutrition curriculum in medical school, residency programs, and CME (see  HYPERLINK "http://stfm.org" http://stfm.org). It has published an edition of this curriculum in 1995, 2001 2002, 2005 and a previous curriculum guide. GON members share their experiences through annual newsletters, paper presentations, and publications at STFM and AAFP sponsored meetings. . The University of South Dakota and Roger Shewmake have supported an active listerve since 1999. The 1995 edition of the nutrition curriculum was distributed to every U.S. and Canadian medical school and all family medicine residency programs. Partial funding for this effort came from Ross Products Division, Abbott Laboratories. STFM has sold an additional 300 copies. In February 1999 the guide was on the top 10-seller list from the STFM bookstore. Since 2001 it has been available on the STFM web site; in 2006 it was peer reviewed and accepted for the Family Medicine Digital Library (www.fmdrl.org/138) and the AAMCs MedPortal (www.aamc.org) The 1995 manual was an update of the Curriculum in Nutrition, published in 1987. Lloyd Michener, MD, Dale Rasmann-Nuhlicek, MS, RD, and Arlo Kahn, MD, edited the first edition of the Curriculum Guide. Partial funding came from a faculty development grant to Dr. Michener at Duke University. These guides were prepared in response to the educators need for guidance on implementing the AAFPs Recommended Core Educational Guidelines for Family Practice Residents (approved in 1989 and updated in 1995 and 2000). An STFM-GON Task Force, co-chaired by Elizabeth Spencer and Darwin Deen, developed the guidelines adopted in 2000 and also surveyed the nutrition teaching practices of 100 randomly selected Family Medicine Residency Programs. A listserv to facilitate the curriculum work has been supported by the Eau Claire, Wisconsin, family medicine program. Darwin Deen and Kathy Kolasa edited this 2001 edition with support from a $50,000 competitive grant awarded by Weight Watchers International Foundation (WWIF), Inc., and other support from Ross Laboratories. . In addition to preparing the curriculum guide, the GON has been active in training faculty to use the guide. In 1989, Sylvia Moore and John Nagle presented nutrition workshops at all six STFM regional meetings. After this, regional teams that included a physician, a registered dietitian, and a behavioral scientist, were trained to conduct additional workshops in their regions. In 1990, STFM co-sponsored and published the proceedings of a workshop on Nutrition in Family Medicine, supported by the National Dairy Council. GON, under the leadership of Dale Nuhlicek (now deceased) and Michael Sitorius, annually offered workshops on nutrition education at the STFM annual meetings. In 1997 the Group presented an entire STFM Theme Day on Nutrition, attended by more than 100 family medicine educators. In 1998, STFM and the Society for General Internal Medicine (SGIM) met concurrently in Chicago. GON invited interested SGIM members, led by Elizabeth Ross, to work together on common interests. In 1999, GON co-sponsored a Virtual Seminar on nutrition curriculum hosted by East Carolina University. The seminar demonstrated a strategy to provide support for medical nutrition educators throughout the country whose travel is constrained by time or money, or both. In Spring 2001, GON held a pre-conference at STFM with about 60 registrants. From May 2001- February 2007, the GON used a Blackboard course (Physicians Curriculum in Clinical Nutrition at http://ecu.blackboard.com/ to share materials and discussions. Support for this effort previously was provided in part by the Council on Biotechnology Information and in 2002 from Ross Laboratories, Abbott Labs. Much of the material became dated and the course was taken down. Nutrition educators with curriculum materials to share are encouraged to upload them to either the Family Medicine Digital Resource Library ( HYPERLINK "http://www.fmdrl.org" www.fmdrl.org) and/or the medical education portal of the American Association of Medical Colleges ( HYPERLINK "http://www.aamc.org" www.aamc.org). Efforts to identify grant funding for the activities of the Group on Nutrition in recent years have not been successful.. The NEHP-ADA and GON-STFM jointly select the Dale Rasmann Nutrition Education Award recipient. The recipient must be actively involved in nutrition education in medical school, residency, or a related health care professional discipline; have demonstrated leadership in the area of nutrition education and mentoring of medical, residency, nutrition, or pharmacy students; and be a member of STFM or ADA. The award is presented bi-annually. See the American Dietetic Association Foundation web site for information and nomination forms ( HYPERLINK "http://www.adaf.org/" http://www.adaf.org special awards). Since 2005 Darwin Deen, MD, MS, and Roger Shewmake have co-chaired GON. . Previous chairs include Lloyd Michener, Dale Rasmann-Nuhlicek, Mike Sitorius, Karen Lazarus, Sam Grief MD, Rebecca Kirby, and Kathy Kolasa. *STFM Group on Nutrition Education This listserv is intended to serve as a resource for family medicine educators in communicating ideas and strategies to enhance nutrition education. To subscribe: send a message to:  HYPERLINK "mailto:dbehan@usd.edu" dbehan@usd.edu or  HYPERLINK "mailto:rshewmake@usd.edu" rshewmake@usd.edu. Subject: (leave blank) Message: "subscribe to nutrition education listserv Contact: Roger Shewmake at  HYPERLINK "mailto:rshewmake@usd.edu" rshewmake@usd.edu or Darlene Behan at  HYPERLINK "mailto:dbehan@usd.edu" dbehan@usd.edu Editors Darwin Deen, MD, MS Professor Department of Family Medicine and Social Medicine Albert Einstein College of Medicine Bronx, New York Kathryn M Kolasa PhD, RD, LDN Professor and Section Head Nutrition Education and Services Department of Family Medicine Department of Pediatrics Brody School of Medicine at East Carolina University Greenville, North Carolina Dorothy DeLessio, MS, LDN, CDE Graduate Nutrition Specialist/Senior Clinical Teaching Associate Department of Family Medicine Memorial Hospital/ of RI/Brown Medical School Pawtucket, RI 02860 Co-editor Third Edition, April 2007 Authors contributing to at least one edition (Affiliation at time of contribution) Kirsten Black, MPH, RD University of Colorado Health Sciences Center Department of Family Medicine Denver, Colorado Nanna Cross, PhD, RD Family Medicine Residency Program at Cheyenne Cheyenne, Wyoming Darwin Deen, MD, MS Department of Family Medicine and Community Health Albert Einstein College of Medicine Bronx, New York Kathryn Kolasa, PhD, RD Department of Family Medicine Brody School of Medicine at East Carolina University Greenville, North Carolina Roger Shewmake, PhD, LN Professor and Director, Section of Nutrition Department of Family Medicine University of South Dakota School of Medicine Sioux Falls, South Dakota Elizabeth Spencer, RD, MS, CDE Eau Claire Family Medicine Residency University of Wisconsin Department of Family Medicine Eau Claire, Wisconsin Contributors and Reviewers contributing to at least one edition (affiliation at time of contribution) David Brechtelsbauer, MD Sioux Falls Family Medicine Residency Sioux Falls, South Dakota Lisa Brown, MD Sioux Falls Family Medicine Resident Sioux Falls, South Dakota Carla Boyes, MS, RD, CDE Oakwood Family Medicine Residency Program Westland, Michigan Katherine Chauncey, PhD, RD, FADA Department of Family & Community Medicine Texas Tech University Health Sciences Center Lubbock, Texas Kathleen Decker, MS, RN, CS Sioux Falls Family Medicine Residents Sioux Falls, South Dakota Mary Dundas, PhD, RD Department of Health & Nutrition Sciences Idaho State University Pocatello, Idaho Bruce Flareau MD, FAAFP Director Medical Education, Morton Plant Mease Program Director, USF Family Medicine Residency University of South Florida Patrick Fahey, MD Ohio State University Columbus, Ohio Paula M Gardiner MD Tufts Family Medicine Residency 100 Hospital Road Malden MA Gary Gianini MSW, MS Coordinator Behavioral Science Family Medicine Residency Middlesex Hospital Middletown, CT 06457 Robert Hall, MBBS, FRACGP Clinical Associate Professor Monash University School of Medicine Victoria, Australia Pat Hennessey MS, RD Helena, Mt 59601 Rebecca Kirby, MD, RD El Paso, Texas Stacie Lenssen, MD Sioux Falls Family Medicine Resident Sioux Falls, South Dakota Desiree Lie, MD, MSEd Department of Family Medicine University of California, Irvine Orange, California Stephen L. McKernan, BS Pharm, ND, DO, FAAFP Lone Star Family Health Center and Conroe Family Medicine Residency Program Conroe, TX Bas Maiburg GP vocational training Maastricht University Netherlands Steven Masley, MD Turley Family Health Center University of South Florida Clearwater, Florida Treavor Meaney, MD Sioux Falls Family Medicine Residents Sioux Falls, South Dakota Albert Rees, MD Lousiana State University University Medical Center Lafayette, LA Frank Repka, PhD, RD Department of Family Medicine Medical College of Ohio Toledo, Ohio Kimberly Shafer, MS, RD, LD HealthPartners-Center for Health Promotion Minneapolis, Minnesota Lynn Thomas, DrPH, RD, CNSD Department of Family and Preventive Medicine USC School of Medicine Columbia, South Carolina Sheryl Rosenberg Thouin MPH, RD, CDE Northridge Famly Medicine Residency Program Northridge, CA Gail Underbakke RD, MS Preventive Cardiology, Cardiovascular Medicine University of Wisconsin Madison, Wisconsin Kristin Westin MS, RD, LDN Chicago, Illinois Section 1 Nutrition Training for Family Medicine Residents T he purpose of the Nutrition Training section is to expand the Recommended Core Educational Guidelines for Family Practice Residents: Nutrition (AAFP Reprint No. 275, http://www.aafp.org). The training provides sufficient detail for faculty at family medicine residencies to develop a nutrition curriculum or improve their existing nutrition curriculum. The STFM Group on Nutrition (GON) targeted the training to the discipline of family medicine. We reviewed reports and recommendations for nutrition training for physicians from several sources to help us define the scope of training applicable to family medicine at the residency training level. These included the basic principles defined in the Nutrition Curriculum Guide for Physicians, developed for medical students by recipients of the National Heart, Lung, and Blood Institutes Nutrition Academic Awards. We also reviewed the recommendations for nutrition curricula for physicians of the American Medical Student Association and the American College of Nutrition. Recommendations are intended to promote the need for and demonstrate a more consistent approach to nutrition teaching at family medicine residencies and third year clerkships. Several factors make consistency difficult. First, medical students entering residency vary in their knowledge, clinical background, and experience in nutrition due to variation in nutrition teaching in medical schools and students previous life experiences. Some residents may need remedial work in the general principles of nutrition to achieve the level of knowledge expected by the first year of residency. Second, we recognize that not all residencies will be able to implement the curriculum in its entirety. The GON considered prioritizing the training but we decided each residency should determine its own priorities if all topics cannot be covered. The topics have been included because nutrition educators with experience working in primary care settings believe that family physicians need to be familiar with all these areas in order to integrate nutrition into clinical care and make appropriate referrals. The faculty responsible for nutrition education can select topics based on those most relevant to their patient population and the needs of residents in their program. Residents can use this document to evaluate the scope of their nutrition knowledge and work with faculty to fill in perceived areas of deficiency. Finally, the STFM GON acknowledges that the level of involvement of family physicians in some aspects of nutrition care, such as renal disease and nutrition support, will vary with practice location and local resources. As a result, some variation in nutrition curricula among residencies is inevitable. While we acknowledge these sources of local variability, the goal of this section is to provide a model nutrition curriculum by which nutrition education in family medicine residency programs can be evaluated. Several barriers exist that make implementation of a nutrition curriculum difficult. One limitation frequently cited is lack of knowledgeable faculty. Several programs have had success with a physician faculty member knowledgeable in nutrition working in collaboration with a registered dietitian to share the teaching responsibilities. Another barrier is finding a way to fit nutrition into an already crowded curriculum. The training can be integrated into routine care of residents own patients, which is where they learn best. It is designed for the full range of family medicine: all stages of the life cycle, all settings from inpatient to outpatient to community, all levels of care from prevention counseling of healthy patients to ongoing management of chronic conditions. The Appendix of this (2007) update includes discussion the ACGME domains of competency based evaluation, the rationale for using the provision of nutritional care as a method of documenting resident progress in achieving competence in specific domains, and how to practically assess resident progress in achieving selected nutritional care competencies.  Nutrition Assessment and Counseling 1. Include nutrition and physical activity in the history-taking process. In addition to asking about prescribed medications, ask about the use of and rationale for using overthecounter dietary supplements, herbs and other nutritional products (e.g. power bars, meal replacements, shakes) Include questions in social history about access to food, occupation, and living situation. Ask about weight changes, gains and losses Use 24-hour recall, food record, or food frequency to obtain diet history. Ask about physical activity using the FITT model--frequency, intensity, type, time, and consider patients limitations. Use tools like WAVE ( HYPERLINK "http://bms.brown.edu/nutrition/acrobat/wave.pdf" http://bms.brown.edu/nutrition/acrobat/wave.pdf), DETERMINE checklist ( HYPERLINK "http://www.aafp.org/x17367.xml" http://www.aafp.org/x17367.xml ), Healthy Eating Index ( HYPERLINK "http://www.forcevbc.com/good/food.htm" http://www.forcevbc.com/good/food.htm) or My Pyramid Tracker ( HYPERLINK "http://www.mypyramidtracker.gov/" http://www.mypyramidtracker.gov/) 2. Integrate nutrition assessment in the physical exam. Examples of nutrition risks may be signs of vitamin and mineral deficiency or toxicity, eating disorders, obesity, compromised oral health, xanthomas, acanthosis nigricans, poor wound healing. . 3. Determine body mass index (BMI) from weight and height measurements for all over the age of 2 years and advise on weight to decrease disease risk  HYPERLINK "http://www.nhlbi.nih.gov/" http://www.nhlbi.nih.gov for adults;  HYPERLINK "http://www.cdc.gov" http://www.cdc.gov for children and teens. 4. Order, interpret the clinical significance of, and take appropriate action to correct laboratory measurements pertinent to assessment of nutritional status. Examples of nutritional assessment in patients with or at risk of chronic illness can be found in the Univesity of Wisconsin Medical Schools Medical Nutrition Handbook at: http:www.medicine.wisc.edu. A review of inpatient nutrition assessment can be found at http://medscapecom/viewarticle/474066_3. HYPERLINK "http://www.med.upenn.edu/nutrimed/surg_guideline.pdf" http://www.med.upenn.edu/nutrimed/surg_guideline.pdf 5. Estimate calorie requirement according to age, gender, and activity, or metabolic condition or illness. Use tables found in MyPyraid Tracker ( HYPERLINK "http://www.mypyramidtracker.gov" http://www.mypyramidtracker.gov). Use the Miflin St Jeor equation to calculate calorie needs of obese adults. (Men) 10 x wt (kg) + 6.25x ht(cm) - 5 x age + 5; (Women)10 x wt(kg) + 6.25 x ht(cm) - 5 x age 161. Add Activity Factors: Confined to bed, use 1.2; out of bed, use 1.3 . Subtract 500 calories/day for weight loss 6. Integrate individualized diet and physical activity counseling into the plan of care: Tailor diet and activity counseling messages to each patient s readiness for behavior change and health beliefs. Provide advice specific to the patient s age, gender, family history, chronic conditions and activity level, food intolerance or allergies. Use Dietary Guidelines for Americans or the My Food Guide Pyramid as the foundation for nutrition counseling. Evaluate adequacy of dietary intake and advise ways to improve diet considering food groups and portion sizes  HYPERLINK "http://www.usda.gov" http://www.usda.gov Consider family and economic issues and cultural diversity in nutrition counseling. Advise about dietary supplements, including metabolic, herbal and botanical products. ( HYPERLINK "http://ods.od.nih.gov/databases/ibids.html" http://ods.od.nih.gov/databases/ibids.html Consider Dietary Reference Intake (DRI) and Tolerable Upper Intake Level for nutrients, as well as evidence for indications, efficacy, interactions with other medications, and safety  HYPERLINK "http://www.nap.edu/books/0309072794/html/related.html" http://www.nap.edu/books/0309072794/html/related.html. Recognize potential adverse interactions between medications and food intake or nutrient metabolism, and adjust either diet or medication as needed. Make appropriate recommendations for vegetarian nutrition, if indicated. ( HYPERLINK "http://www.vrg.org/" http://www.vrg.org)  Advise physical activity commensurate with patient s ability. Make specific recommendations for physical activity using activity guidelines from the American College of Sports Medicine  HYPERLINK "http://www.acsm.org/" http://www.acsm.org/. and the Centers for Disease Control and Prevention. Also see the recommendations from the National Academy of Sciences, Dietary Reference Committee  HYPERLINK "http://www.nap.edu/books/0309085373/html" http://www.nap.edu/books/0309085373/html 7. Write diet orders based on nutrition assessment of institutionalized patients (hospital, long-term care, etc). Prescribe nutrition therapy for patients undergoing surgeryboth pre and postconsidering the appropriate progression of food intake to maintain optimum nutritional status. 8. Collaborate with Registered Dietitians and refer to community nutrition resources when appropriate  HYPERLINK "http://www.eatright.org" http://www.eatright.org Infants Routinely assess nutritional status at well child appointments, considering he following: Compare length, weight, head circumference to Centers for Disease Control and Prevention growth charts (http:// HYPERLINK "http://www.cdc.gov/growthcharts/" www.cdc.gov/growthcharts/). Consider using the World Health Organization charts for breastfed babies. Measure hemoglobin or hematocrit and perform lead risk assessment at recommended intervals. Obtain and evaluate diet history from caregiver, including dietary intake and self-feeding skills. Diagnose nutrition problems such as failure to thrive, anemia, and follow-up as appropriate. 2. Prescribe nutrition supplements, assessing the need for fluoride, vitamin D, iron, Trivisol, and others if indicated. 3.Recommend that all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for about the first six months of life. Breastfeeding should continue with the addition of complementary foods throughout the second half of the first year. Family physicians should have the knowledge to promote, protect, and support breastfeeding Encourage breastfeeding, when possible, or use of iron fortified formula to one year and intake of iron rich foods when solid foods are introduced. Be able to discuss reasonable intakes and troubleshoot problems.  HYPERLINK "http://www.aafp.org/x6633.xml" http://www.aafp.org/x6633.xml 4. Recommend appropriate diet for age, including feeding skills development such as weaning to cup, progression of solid foods. (See  HYPERLINK "http://www.brightfutures.org" http://www.brightfutures.org). Consider economic and culturally appropriate information. http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/wic_fam3.htm#fa10 5. Assess for common feeding problems and provide guidance when needed. Examples of common feeding problems are spittingup, colic, constipation, nursing bottle caries, and delayed weaning.There is a nice interactive chart on feeding problems for infants and children at  HYPERLINK "http://family" http://familydoctor.org/x2577.xml 6. Recommend preventive oral health care that includes dietary management and routine dental care beginning at 1 year of age. http://www.brightfutures.org Children and Adolescents 1. Routinely assess nutritional status at well child and routine appointments, considering the following: Compare height, weight, and body mass index (BMI) to growth charts from the Centers for Disease Control and Prevention. http://www.cdc.gov/growthcharts/. (Note under and over weight and children crossing percentile lines)). Monitor on annual basis. Note rate of weight gain as well as total weight gain.  HYPERLINK "http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424" http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424 Perform screening tests when indicated. Examples are cholesterol in children with high risk family history, blood pressure, lead, hemoglobin or hematocrit. Take diet history and compare diet intake to My Food Guide Pyramid considering food groups with servings adjusted for age http://www.cnpp.usda.gov/MPyramidforKids.htm 2. Use Dietary Guidelines for Americans ( HYPERLINK "http://www.healthierus.gov/dietaryguidelines" http://www.healthierus.gov/dietaryguidelines) as the foundation for nutrition counseling. Assess for common feeding concerns and provide guidance, considering the following: High intake of sweetened beverages Total amount of food (How Much Are You Eating?) Discretionary calories Nutritional quality of snacks Frequent meals from fast food restaurants Frequency of family meals Diets inadequate in calcium or iron Potential for eating disorder and overly restrictive weight loss diet Excessively restricted vegetarian diet Special nutritional needs of teen athletes 3. Encourage physical activity and assess for excess television/computer (screen time) use. (< 2 hours/day) 4. Counsel for reduction of risk for coronary artery disease and atherosclerosis, cancer, osteoporosis, and obesity in high risk children. Provide diet counseling and refer to Registered Dietitian for medical conditions with a nutrition component. Examples are failure to thrive, chronic diarrhea, iron deficiency anemia, developmental disabilities adversely affecting food intake, severe dental caries or malocclusion, obesity, bariatric surgery For less serious feeding issues recommend interactive site: htpp://familydoctor.org/x2577.xml? Recommend 60 minutes physical activity per day (30 at home and 30 at school) Recommend web sites such as:  HYPERLINK "http://www.cdc.gov/youthcampaign" http://www.cdc.gov/youthcampaign;  HYPERLINK "http://www.kidnetic.com" http://www.kidnetic.com;  HYPERLINK "http://www.kidshealth.org" http://www.kidshealth.org Recommend active video and computer games such as Dance Dance Revolution or Nictoons Movin Adults 1. Routinely assess nutritional status at physical exams, and routine gynecologic exams for women, including the following: Measure height and weight and consider weight distribution (waist circumference). Determine body mass index (BMI) and goal BMI to reduce disease risk. Perform screening tests when indicated. Examples are cholesterol, blood pressure, hemoglobin or hematocrit, bone density scans, C-reactive protein. Take diet history and compare diet intake to My Food Guide Pyramids considering food groups and portion sizes. Ask about physical activity, considering frequency, intensity, type, time, and patients limitations. 2. Use Dietary Guidelines for Americans as the foundation for diet counseling and the Nutrition Facts label as a teaching tool  HYPERLINK "http://vm.cfsan.fda.gov/~dms/flg-5-1.html" http://vm.cfsan.fda.gov/~dms/flg-5-1.html. Advise supplements as needed to meet Dietary Reference Intake for age. Consider special dietary needs for folic acid and iron for women of childbearing age, and for supplemental calcium and vitamin D and other nutrients throughout the adult years. See DRI tables at:  HYPERLINK "http://www.nal.usda.gov/fnic/etext/000105.html" http://www.nal.usda.gov/fnic/etext/000105.html or 3. Assess intake of over-the-counter vitamin mineral supplements, herbs, and other dietary supplements and provide appropriate advice on safety and efficacy  HYPERLINK "http://dietary-supplements.info.nih.gov/" http://dietary-supplements.info.nih.gov and  HYPERLINK "http://consumerlab.com/" http://consumerlab.com. 4. Provide diet counseling for patients at risk for osteoporosis, coronary artery disease, atherosclerosis, stroke, hypertension, lipid metabolism disorders, diabetes, obesity, periodontal disease and diet-related cancers. See the University of Wisconsin Medical Schools Medical Nutrition Handbook at: http://www.medicine.wisc.edu 5. Encourage physical activity according to American College of Sports Medicine and Centers for Disease Control guidelines, considering patients limitations. Use the FITT model for exercise prescriptionsfrequency, intensity, type, and time. Pregnancy and Lactation 1. Routinely assess nutritional status and provide guidance at prenatal appointments considering the following potential nutrition risks: Prepregnancy weight Maternal age Parity Short interconceptual period Obstetric history of premature, small-for-age or large-for-age babies Hemoglobin or hematocrit Socioeconomic status Post-pregnancy weight loss 2. Use National Academy of Sciences Institute of Medicine guidelines to determine and discuss weight gain goals for underweight, normal weight, and overweight pregnant women  HYPERLINK "http://www.nap.edu" http://www.nap.edu and recommend portion size and food groups to meet special needs of pregnant and lactating women with special attention to dietary intake of folic acid, iron, calcium, protein, dietary fiber, and alcoholic beverages. 3 Recommend appropriate diet supplementation for folic acid, iron, calcium and other nutrients.  HYPERLINK "http://books.nap.edu/catalog/1451.html" http://books.nap.edu/catalog/1451.html;  HYPERLINK "http://www.nal.usda.gov/wicworks/Sharing_Center/NJ/eating_right_pregnancy.pdf" http://www.nal.usda.gov/wicworks/Sharing_Center/NJ/eating_right_pregnancy.pdf; or  HYPERLINK "http://www.nal.usda.gov/wicworks/Sharing_CenterWA/9_months.pdf" http://www.nal.usda.gov/wicworks/Sharing_CenterWA/9_months.pdf. Also see The American College of Obstetricians and Gynecologists: www.acog.org. 4.. Routinely ask about prenatal vitamin and iron intake, encourage patient adherence and counsel about side effects and benefits. Also discuss need for continuation after delivery. 6. Screen and counsel patients on harmful lifestyle behaviors, including tobacco use, alcohol, excessive caffeine intake, pica, restricted vegetarian diet, and excessive intake of dietary supplements or herbs or herbs and teas contraindicated in pregnancy and lactation. Discuss any fish advisories for methyl mercury or PCB contamination. See http://cfsan.fda.gov/%7Epregnant/whilmeth.html 7. Make referrals to Registered Dietitian for nutrition therapy for complications of pregnancy. Examples are inappropriate weight gain, anemia, severe constipation, hyperemesis gravidarum, and gestational diabetes.  HYPERLINK "http://www.eatright.org" www.eatright.org 8. Recommend breastfeeding to one year.  HYPERLINK "http://www.aafp.org/x6633.xml" http://www.aafp.org/x6633.xml  HYPERLINK "http://www.aap.org/policy/re9729.html" http://www.aap.org/policy/re9729.html and  HYPERLINK "http://www.lalecheleague.org/" http://www.lalecheleague.org/;  HYPERLINK "http://www.nal.usda.gov/wicworks/Sharing_Center/Breastfeeding_educational.html" http://www.nal.usda.gov/wicworks/Sharing_Center/Breastfeeding_educational.html 9. Provide anticipatory guidance for breastfeeding with emphasis on preventing or treating common problems, considering Proper latch and positioning to breast Maintaining adequate milk supply and frequency of nursing Sore nipples Low weight gain Pumping breastmilk Supplemental feedings and weaning Mastitis or yeast infections Vitamin and mineral supplementation (e.g. Trivsol) Elderly Note: Several standardized tools are available to assess nutritional status of the elderly, such as the Nutrition Screening Initiative  HYPERLINK "http://aafp.org/PreBuilt/NSI_newbookletSmaller.pdf" http://aafp.org/PreBuilt/NSI_newbookletSmaller.pdf and the Mini-Nutritional Assessment  HYPERLINK "http://www.mna-elderly.com/" http://www.mna-elderly.com/. 1. As part of the history, evaluate age-related physiologic or psychological factors that influence food intake and nutritional status: Living environment Functional status Mental/cognitive screening Depression screening Oral health status 2. As part of the physical exam, Evaluate height annually for losses secondary to osteoporosis of the spine. Measure weight at each visit. Further evaluate weight changes >5 pounds per year. Observe for signs of malnutrition. Evaluate oral health and dentition. Determine weight, height, and goal BMI for optimum health. Assess mobility and physical activity. 3. Conduct screening or diagnostic tests when indicated. Examples are lipid profile, blood pressure, hemoglobin or hematocrit, bone density scans, vitamin B-12, etc. 4. Take a diet history and compare diet intake to Food Guide Pyramid such as the Tufts University Food Pyramid for 70+, considering food groups and portion sizes. Note excessive intake of low nutrient density foods, alcohol use, adequacy of fluid intake, and food sources of fiber, calcium, vitamin D, protein, vitamin B-12, and folic acid  HYPERLINK "http://commentator.tufts.edu/archive/nutrition/pyramid.html" http://commentator.tufts.edu/archive/nutrition/pyramid.html. 5. Use the Dietary Guidelines for Americans as the foundation for nutrition counseling  HYPERLINK "http://www.healthierus.gov/dietaryguidelines/" http://www.healthierus.gov/dietaryguidelines/ 6. Prescribe nutrient supplements such as vitamin B-12, calcium, vitamin D and others as needed to meet the DRI for patients over 70 years of age. 7. Considering limitations, prescribe physical activity to include strength and flexibility training as well as aerobic activity. For appropriate exercises see  HYPERLINK "http://nihseniorhealth.gov" http://nihseniorhealth.gov 8. Evaluate the potential food-drug and nutrient-drug interactions for those taking several prescriptions, over-the-counter vitamin-mineral supplements, herbs, and other dietary supplements. 9. Prescribe appropriate diets for patients in long term care or assisted living facilities and coordinate nutritional care plan with Registered Dietitian in these facilities. Cancer Incorporate dietary guidelines for cancer prevention from the National Cancer Institute into prevention diet counseling.  HYPERLINK "http://nci.nih.gov/" http://nci.nih.gov and  HYPERLINK "http://www.aicr.org" http://www.aicr.org and Cardiovascular Disease, Dyslipidemias, Diabetes, Metabolic Syndrome, and Hypertension The chronic diseases of diabetes, dyslipidemia, cardiovascular disease, metabolic syndrome or insulin resistance, and hypertension are interrelated and often present in the same individual. The prevention of and treatment for all these conditions require similar lifestyle and diet modifications. The process of nutrition assessment and patient education and support is similar and nutrition therapy will include similar elements of lifestyle and diet modification. However, there may be a different focus depending upon the individual patients diagnosis(es). To avoid repetition, the nutrition assessment and care for these conditions have been combined. As part of the history, obtain a focused nutrition history to assess dietary, social, and lifestyle factors related to the patients diagnoses. This is best accomplished by having the patient record several days of food intake and physical activity. Assess for: Physical activityfrequency, intensity, type, and time Smoking history Alcohol usekinds, amount, frequency Diet, considering eating patterns and portion sizes; beverages; sources of dietary fats, carbohydrates, and proteins (and relative percentage of intake); sodium intake; sources and amounts of fiber from fruits, vegetables, and grains; and use of vitamin mineral supplements, herbal products, and plant stanol or plant sterol esters. See guides for 5 and 15 minute consultations on metabolic syndrome at  HYPERLINK "https://piratemail.ecu.edu/exchweb/bin/redir.asp?URL=http://www.medicine.wisc.edu/mainweb/includes/viewfile.php?fileid=895%26viewtype=inline%26section=naa" \t "_blank" http://www.medicine.wisc.edu/mainweb/includes/viewfile.php?fileid=895&viewtype=inline§ion=naa Periodically order and monitor appropriate lab and other measurements to determine effectiveness of treatmentblood pressure, blood lipid levels, hemoglobin A1C, weight, BMI, waist circumference, C-reactive protein. Educate patients and family about the relationship between diet, physical activity, excess body weight if obese, and excessive alcohol use in the management of their disease. Prescribe appropriate nutrition therapy based on national standards: American Heart Association  HYPERLINK "http://circ.ahajournals.org/cgi/content/full/102/18/2284" http://circ.ahajournals.org/cgi/content/full/102/18/2284 and/or National Cholesterol Education Program  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm" http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm, for dyslipidemias and cardiovascular diseases, Portfolio diet for individuals willing to be vegetarian.  HYPERLINK "http://www.portfolioeatingplan.com/" http://www.portfolioeatingplan.com/ American Diabetes Association for diabetes  HYPERLINK "http://www.diabetes.org" http://www.diabetes.org, DASH-Sodium Diet for hypertension, NHLBI guidelines  HYPERLINK "http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm" http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm Weight loss, if indicated, using the NHLBI obesity treatment guidelines  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm" http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm and being aware of the 2001 Surgeon General Call for Action  HYPERLINK "http://www.surgeongeneral.gov/topics/obesity/" http://www.surgeongeneral.gov/topics/obesity/ Prescribe physical activity, considering patients readiness for changing behavior related to exercise, limitations, and preferences. A prescription should include frequency, intensity, type, and time (FITT). Refer to Registered Dietitian for medical nutrition therapy to help patients prioritize dietary and lifestyle modifications, especially when multiple dietary changes are indicated. (www.eatright.org) Refer patients with diabetes to a Registered Dietitian and/or Certified Diabetes Educator for self-management education to help patients assume responsibility for their own care. Refer patients to community resources such as support groups, fitness clubs, weight loss programs, etc. Gastrointestinal Disorders As part of the history and physical exam of patients suspected of having a gastrointestinal (GI) disorder, identify symptoms and differentiate among problems that affect transit time and motility, cause irritation of the mucosa, or affect gastric acid secretion. Identify diet and lifestyle factors that contribute to symptoms. Consider the following: Use of alcohol, caffeine, carbonated beverages, tobacco Meal patternssize and spacing of food intake Types and variety of foodsfiber from whole grains, fruits, and vegetables and consumption of dairy products, amount of fat and fatty foods Medications that alter GI function History of GI surgery Changes in bowel habits and use of laxatives Life stressors and ways of dealing with stress. Provide diet counseling for gastrointestinal problems commonly encountered in family medicine: celiac disease (gluten intolerance), constipation, diarrhea, gastroesophageal reflux disease, peptic ulcer disease, irritable bowel syndrome, gallstones, esophagitis, pancreatitis, and lactose intolerance. Refer to the National Institute of Diabetes & Digestive & Kidney Disease ( HYPERLINK "http://www.niddk.nih.gov/" http://www.niddk.nih.gov/ ). For the patient with identified liver disease, refer for nutrition therapy to improve nutritional status, enhance regeneration, and prevent or alleviate encephalopathy and other metabolic disturbances amenable to nutrition therapy. Identify the underlying cause of malnutrition to guide nutrition therapy for appropriate patient management. Consider nutrition therapy to alter mechanical defects of digestion and absorption, impairments in enzymatic secretion, impairment in activity of bile salts, or impairment of absorption. Make referrals to Registered Dietitian for patients with severe gastrointestinal disease affecting nutritional status, such as inflammatory bowel diseases, gluten intolerance, malabsorption syndromes, etc. Hematologic Disorders--Nutritional Anemias Recognize patients at risk for nutritional anemia caused by deficiencies of iron, folate, and vitamin B-12, and differentiate nutritional from non-nutritional causes with appropriate history and lab measurements: Iron deficiencywomen during reproductive years, infants and children Folatewomen during reproductive years, chronic alcoholics, chronic use of anti-seizure medications, Vitamin B-12vegans, elderly, post gastric or small bowel surgery. Provide diet counseling to increase food sources of deficient nutrients and prescribe supplements in treating the anemia when needed. Osteoporosis Routinely assess for risk factors of osteoporosis beginning in the teen years at well appointments, such as physicals, pap and pelvic exams. See Surgeon Generals Report on Bone Health and Osteoporosis, 2004 http://www.surgeongeneral.gov/library/bonehealth Routinely assess diet for calcium and vitamin D and overall diet. Advise patients to increase food sources of calcium and vitamin D to meet the Dietary Reference Intake for age and gender and recommend supplements if patient is unable to meet the DRI by diet. Assess weight bearing physical activity. Routinely assess for physical activity and recommend weight-bearing exercise, flexibility and weight training to improve strength and balance in patients at risk. Evaluate height yearly for losses secondary to osteoporosis of the spine of patients over 65 years of age. Use available technology to monitor bone mineral density in high risk patients (DEXA, x-ray, etc.). Renal Disease Acute renal failure and end stage renal disease are usually cared for by specialists in medical management and nutrition therapy. Nephrolithiasis is more common in primary care. Provide diet counseling for patients diagnosed with kidney stones or those who have a history of forming stones, considering fluid intake, dietary calcium, protein, potassium, and sodium. Alcoholism and Liver Disease Prescribe nutrition therapy in collaboration with Registered Dietitian for alcohol related liver disease to provide adequate but not excessive protein and calories and other diet modifications to correct malnutrition and support liver regeneration. Cancer As part of the history and physical, determine the following: Weight changes or edema secondary to disease or treatment. Difficulties with appetite, taste changes, stomatitis, esophagitis, swallowing, nausea, vomiting, diarrhea, or constipation. Assessment of dietary intake with emphasis on total calories, fruits, vegetables, and whole grains, carotenoids Use of nutritional supplements, herbs, and nutritional therapies with limited or no evidence. BMI based on weight and height. Provide diet counseling when indicated for nutritional inadequacy or weight loss Provide counseling on safety and efficacy of nutritional supplements and other therapies.  HYPERLINK "http://ods.od.nih.gov/databases/ibids.html" http://ods.od.nih.gov/databases/ibids.html;  HYPERLINK "http://nccam.nih.gov" http://nccam.nih.gov;  HYPERLINK "http://www.cfsan.fda.gov/~dms/ds-prod.html" http://www.cfsan.fda.gov/~dms/ds-prod.html ;  HYPERLINK "http://www.nal.usda.gov/fnic/etext/000015.html" http://www.nal.usda.gov/fnic/etext/000015.html;  HYPERLINK "http://www.consumerlab.com" http://www.consumerlab.com Refer to Registered Dietitian for nutrition therapy for patients with significant weight loss, those who are immunocompromised, and for those who have eating difficulties and malnutrition secondary to the cancer or treatment. Counsel cancer survivors on other chronic conditions affected by diet. HIV-AIDS As part of the history and physical of HIV-AIDS infected patients, screen for nutrition problems, including Baseline laboratory measurements of nutritional status Weight changes Psychosocial factors affecting food intake Diet history with attention to nutrients involved in immune function Use of nontraditional therapies. Provide diet counseling and education, considering the following: Adequate calories and optimum diet for immune function Before adding fat calories, rule out fat malabsorption. Vitamin mineral supplements, again rule out fat malabsorption Safe food handling practices to protect against food- or water-borne illness Eating plan for symptom management if needed. Benefits and risks of nutrition related complementary therapies. See: The care of women with HIV living in limited resources settings for a good overeview. Found at http://aidsinfo.nih.gov Refer to Registered Dietitian for early and on-going nutrition therapy to maximize immune function. Pulmonary Disease As part of the history and physical exam, determine nutritional status considering weight changes and edema, anorexia, difficulties with eating such as shortness of breath and fear of choking, availability of easy to eat foods, safe food handling, and use of nutritional supplements. Provide diet counseling for patients with chronic obstructive pulmonary disease, considering BMI, ability to consume an adequate diet to maintain lean body mass with food or supplements if needed, and potential food-drug interactions. For patients with sleep apnea and obesity, educate patients about relationship between sleep apnea and obesity, and work with patient to determine a plan for weight loss. Refer to Registered Dietitian for nutrition therapy to achieve optimum weight, dietary intake, and nutritional status. Obesity-Weight Loss Strategies and Counseling See: AAFP monograph: Practical Advice for Family Physicians to Help Overweight Patients.  HYPERLINK "http://www.aafp.org/x24060.xml" http://www.aafp.org/x24060.xml;  HYPERLINK "http://www.aafp.org/afp/20030115/tips/7.html" www.aafp.org/afp/20030115/tips/7.html;  HYPERLINK "http://www.aafp.org/afp/20060515/putting.html" www.aafp.org/afp/20060515/putting.html. For childhood overweight screening see http://www.aafp.org/afp/20060101/usc/pdf For adult obesity see:  HYPERLINK "http://www.aafp.org/online/en/home/clinical/publichealth/aim/cmeaim/podcast/aimpodcast/podcastreferences.html" www.aafp.org/online/en/home/clinical/publichealth/aim/cmeaim/podcast/aimpodcast/podcastreferences.html. As part of the history, assess risk factors that led to obesity. Consider the following: Family history of obesity and obesity related diseases Weight history and age of onset History of weight loss attempts Dietary intake including meal spacing, food groups, amount of carbohydrate and portion sizes, use of sweetened beverages and alcohol Mental health status Medications that affect weight Physical activity and limitations Social support Interest and appropriateness of bariatric surgery As part of the physical exam, determine BMI for adults and children over 2 years of age. Use BMI charts for adults and Centers for Disease Control and Prevention BMI charts for children.  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm" http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm and  HYPERLINK "http://www.cdc.gov/growthcharts/" www.cdc.gov/growthcharts/. http:/aafp.org/afp/20060515/putting.html; jtt[://www.nhlbi.nih.gov/health/public/heart/obesity/wecan Use national guidelines, such as those from the National Heart Lung and Blood Institute, to classify obesity and health risk based on patients weight. Consider co-morbidities that increase health risk related to weight. Consider the small step program for weight loss:  HYPERLINK "http://www.smallsteps.gov/the" http://www.smallsteps.gov/thesmall stepsprogramforthepreventionoftype2diabetes. See  HYPERLINK "http://ndep.nih.gov/campaigns/SmallSteps/SmallSteps_overview.htm" http://ndep.nih.gov/campaigns/SmallSteps/SmallSteps_overview.htm; Pediatric obesity see:  HYPERLINK "http://www.smallsteps.gov/kids/flash/index.html" www.smallsteps.gov/kids/flash/index.html and  HYPERLINK "http://www.healthiergeneration.org/default.aspx" http://www.healthiergeneration.org/default.aspx Discuss the effect of obesity on present and future health and personalize risk to each patient. Ascertain each patients readiness and ability to work on weight loss or prevention of weight gain according to health beliefs and stage of behavior change. Assess use of over the counter weight loss aids and dietary products for weight loss, popular diet books, commercial weight loss programs, herbs, and prescription drugs. Advise patient on safety and efficacy. See http://www.aafp.org/afp/20041101/1731.html Collaborate with patient to choose treatment modality. Consider referral to Registered Dietitian for individual nutrition therapy, multi-disciplinary programs based on scientific principles of weight loss, and support groups. Consider other options as an adjunct to diet and activity, depending on weight and health riskprescription drugs, surgery, and mental health referral. Warn against fads and frauds.  HYPERLINK "http://www.ftc.gov/opa/2004/11/bigfatliesweep.htm" http://www.ftc.gov/opa/2004/11/bigfatliesweep.htm; http://win.niddk.nih.gov/publications/index.htm#health Design plan for follow up and support. Assist patient in setting realistic goals for weight loss, and in making permanent lifestyle changes to maintain weight loss or prevent further gain. Consider using materials from links mentioned in this section. Aslo see  HYPERLINK "http://www.heartage.com" http://www.heartage.com for the Plate Method diet basics and goal setting for weight loss. See Calories Count Approach to Obesity. At  HYPERLINK "http://www.fda.gov/oc/initiatives/obesity" http://www.fda.gov/oc/initiatives/obesity ; also National Weight-control Network (WIN). HYPERLINK "http://win.niddk.nih.gov/index.htm" http://win.niddk.nih.gov/index.htm Support local community and national public health initiatives to increase physical activity and improve diet to decrease the prevalence of obesity. Assess appropriateness for Bariatric Surgery. If following patient after surgery, be aware of life long nutrition supplementation needs and portion size control. Eating Disorders (Anorexia, Bulimia, and Binge Eating Disorder) Incorporate screening for subtle signs of eating disorders into history, review of systems and physical exam of patients at risk for eating disorders. (Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorder. BMJ 1999;319:1467-1468.), ( HYPERLINK "http://www.anred.com" http://www.anred.com ). Make referral for treatment to multi-disciplinary team or professional qualified to treat eating disorders. May coordinate treatment plan depending upon local resources. Determine healthy weight goal and monitor weight. Manage medical complications of eating disorders. Provide supportive counseling to patient and family in collaboration with the treatment team. Be an advocate for the patient to assure getting needed care and access to local resources. Use of Dietary Supplements and Functional Foods Note: This includes vitamins, minerals, herbs, botanicals, over the counter weight loss aids, metabolic products, and other dietary supplements. Functional foods are foods that have been developed for a medicinal purpose such as a margarine with an added plant stanol ester to lower LDL-cholesterol. Use Dietary Reference Intake recommendations, including Upper Tolerable Intake levels, when assessing diets for vitamin and mineral deficiencies and potential toxicity from excess intake of supplements. ( HYPERLINK "http://www.nal.usda.gov/fnic/etext/000105.html" http://www.nal.usda.gov/fnic/etext/000105.html and  HYPERLINK "http://consumerlab.com" http://consumerlab.com) Keep abreast of nutrition-related lay literature for popular diets, dietary supplements and herbs and assist patients in making informed decisions about dietary supplements. Warn patients about use of those that are potentially harmful (including those not available in U.S. but through Internet) , such as ephedra, PPA that interact with other drugs, such as St. Johns Wort, antioxidant vitamins for prevention of heart disease. Advise about risks and benefits, such as popular weight loss diets not based on currently accepted sound nutrition principles, or not evidence based. Promote use of those known to be safe and efficacious, such as vitamin B-12, vitamin D for elderly, folic acid for reproductive age women. Vitamin D for breastfed babies; iron for children and pregnant women. Be familiar with regulations governing the labeling, marketing, and sale of dietary supplements, herbs, and over the counter metabolic products and functional food ingredients. Foodborne Illness Recognize the presenting signs and symptoms of foodborne illnesses caused by common microbial pathogens. Provide education for patients, especially those who are elderly, pregnant, infants or otherwise immune compromised, on safe food handling practices to prevent foodborne illness.  HYPERLINK "http://www.foodsafety.gov" http://www.foodsafety.gov Provide supportive nutrition therapy if needed in identified cases of foodborne illness. Be familiar with the National Food Safety Initiative and other national and local public education campaigns to decrease the incidence of foodborne illness.  HYPERLINK "http://fightbac.org/" http://fightbac.org. and the AMA primer on food safety  HYPERLINK "http://www.ama-assn.org/ama/pub/category/3629.html" http://www.ama-assn.org/ama/pub/category/3629.html Food Allergy and Intolerance Consider common food allergens when taking diet history, especially those labeled on US food products ( i.e., cows milk, soy, eggs, wheat, peanuts and tree nuts, fish, and shellfish. Recognize common symptoms of food allergies and food intolerance, and ask about family history of food allergies and asthma. Eliminate the suspected food allergen from the diet and observe for changes in symptoms. Refer for diagnostic testing if indicated. Differentiate between food allergy and food intolerance and provide patient education, considering patients and family perceptions of suspected allergens.  HYPERLINK "http://www.foodallergy.org/" http://www.foodallergy.org/. Prescribe diet supplements if diet is compromised by elimination of offending foods. Refer to Registered Dietitian when major food groups are eliminated from diet. Physical Activity and Sports Assess current level of physical activity and provide guidance for physical activity for the non-athlete according to recommendations of the Dietary Guidelines for Americans, the American College of Sports Medicine and the Centers for Disease Control and Prevention for optimum health, treatment of disease, and prevention of obesity. Refer to http://familydoctor.org/288.xml Consider the sedentary patients readiness for behavior change to increase physical activity. Consider the small steps program and Heartage.com goal setting for activity . See  HYPERLINK "http://www.cdc.gov/nccdphp.dnpa/physicl/index.htm" http://www.cdc.gov/nccdphp.dnpa/physicl/index.htm. For kids see http://www.kdishealth.org/parent/nutrition_fit/index.html Use the FITT model for exercise prescriptionsfrequency, intensity, type, and time. Provide diet counseling at sports physicals to include optimum diet to enhance athletic performance, including hydration, adequate calories and carbohydrate, adequate calcium, avoidance of rapid weight changes, use of ergonomic aids and diet supplements. For dietitians in sport see http://www.disen.org/index.htm Recognize and refer patients with eating disorders. Be aware of the possibility of women athletes with the triad of amenorrhea, excessive exercise, and disordered eating patterns. Nutrition Support Perform nutrition assessment of malnourished, critically ill, ventilator-dependent and post surgery patients, including physical exam, laboratory studies, BMI and weight changes, speech and swallowing evaluation, and ability to meet nutrition needs via the oral route. Recognize when alternate forms of nutrition are needed.  HYPERLINK "http://clinnutr.org/" http://clinnutr.org. Consider contraindications for nutrition support in consultation with patient and family. If available, review living will and advance directives for patients wishes. Discuss care with family and patient, if possible, to consider end of life care vs. nutrition support for recovery. For patients unable to consume adequate amounts of food orally, provide nutrition support, if appropriate. Consider the following: Collaborate with others to write nutrition prescription, such as Registered Dietitian, pharmacist, speech therapists, nurses, and follow local protocols. Monitor patients tolerance and make adjustments as needed. Select the most appropriate means of nutrition supportoral supplement, tube feeding, or parenteral nutrition. Monitor effectiveness with physical exam and appropriate laboratory measurements, and weight. Wean from enteral and parenteral nutrition support to usual diet in a timely manner. Consult nutrition support team if available. Community Nutrition Resources Be familiar with and make referrals to local and community-based national food and nutrition resource programs when needed. Some examples are the following: The Supplemental Food Program for Women, Infants, and Children (WIC)  HYPERLINK "http://www.fns.usda.gov/fns/" http://www.fns.usda.gov/fns/ Lactation consultants, other support groups such as Le Leche League  HYPERLINK "http://www.lalecheleague.org/" http://www.lalecheleague.org/ Child Nutrition Programs including National School Lunch and Breakfast Program  HYPERLINK "http://www.fns.usda.gov/fns/" http://www.fns.usda.gov/fns/ Food Stamps and local emergency food assistance programs providing meals or groceries  HYPERLINK "http://www.fns.usda.gov/fns/" http://www.fns.usda.gov/fns/ Weight loss programs that are based on sound nutrition principles such as Weight Watchers or programs offered by hospitals or clinics or private practice Registered Dietitians The Administration on Aging, through the National Aging Network, provides congregate and home delivered meals, health promotion/disease prevention programs, transportation, information and assistance, in-home services, caregiver support, legal and guardianship, Alzheimer's services, etc. Information can be found at  HYPERLINK "http://www.aoa.gov" www.aoa.gov. In addition, information on local services to help support older adults at home and in the community can be found through the Eldercare Locator at  HYPERLINK "http://www.eldercare.gov/Eldercare/Public/Home.asp" \o "http://www.eldercare.gov/Eldercare/Public/Home.asp" http://www.eldercare.gov/Eldercare/Public/Home.asp. Information on health issues at:  HYPERLINK "http://nihseniorhealth.gov" http://nihseniorhealth.gov;  HYPERLINK "http://www.maoclinic.com/health/senior-health/HA00066" http://www.maoclinic.com/health/senior-health/HA00066; http://www.nlm.nih.gov/medlineplus/nutritionforseniors.html#cat1. Cooperative Extension Service that provides nutrition education http://www.csrees.usda.gov/  HYPERLINK "http://www.aoa.gov/youcan" http://www.aoa.gov/youcan; Check own state for local programming Home care programs for in-home assistance with meal preparation. Other local community nutrition resources and food programs including food banks, health department State specific nutrition and physical activity resources. Some examples are included: California California Department of Health Services: California Nutrition Network for Healthy, Active Families and the California 5 a DayFor Better Health Campaign:  HYPERLINK "http://www.dhs.ca.gov" www.dhs.ca.gov CANFit: California Adolescent Nutrition and Fitness Program:  HYPERLINK "http://www.canfit.org" www.canfit.org Prevention institute:  HYPERLINK "http://www.preventioninstitute.org" www.preventioninstitute.org Massachusetts Massachusetts Department of Public Health: Healthy Choices:  HYPERLINK "http://www.jumpupandgo.com" www.jumpupandgo.com Boston Steps:  HYPERLINK "http://www.bphc.org" www.bphc.org Michigan Intertribal Council of Michigans Healthy Anishinaabe:  HYPERLINK "http://www.itcmi.org" www.itcmi.org Minnesota Minnesota Department of Health: Office of Minority and Multicultural Health:  HYPERLINK "http://www.health.state.mn.us/ommh" www.health.state.mn.us/ommh North Carolina North Carolina Division of Public Health: Eat Smart, Move MoreNorth Carolina:  HYPERLINK "http://www.eatsmartmovemorenc.org" www.eatsmartmovemorenc.org East Carolina University: KIDPOWER and Pediatric Healthy Weight Care Management Program:  HYPERLINK "http://www.ecu.edu/pedsweightcenter" www.ecu.edu/pedsweightcenter FitTogether:  HYPERLINK "http://www.fittogethernc.org/" www.fittogethernc.org North Carolina Healthy Weight Initiative:  HYPERLINK "http://www.nchealthyweight.com/" http://www.nchealthyweight.com/ North Carolina Winners Circle:  HYPERLINK "http://www.ncwinnerscircle.com/" http://www.ncwinnerscircle.com/ North Carolina 5 A Day:  HYPERLINK "http://www.nc5aday.com/" http://www.nc5aday.com/ Healthy Carolinians:  HYPERLINK "http://www.healthycarolinians.org/" http://www.healthycarolinians.org/ Pennsylvania The Food Trust:  HYPERLINK "http://www.thefoodtrust.org" www.thefoodtrust.org Wyoming Valley Wellness Trails Partnership:  HYPERLINK "http://www.activelivingbydesign.org/cgi-bin/albd.org/view_services.cgi?request=show_public_home&dept_id=124" http://www.activelivingbydesign.org/cgi-bin/albd.org/view_services.cgi?request=show_public_home&dept_id=124 Texas Steps to a Healthier Austin:  HYPERLINK "http://www.healthierus.gov/steps/grantees/Austin.html" www.healthierus.gov/steps/grantees/Austin.html Washington State City of Moses Lake Healthy Communities:  HYPERLINK "http://depts.washington.edu/dohuwnps/MosesLake/" http://depts.washington.edu/dohuwnps/MosesLake/ Washington, D.C. D.C. Hunger Solutions:  HYPERLINK "http://www.dchunger.org" www.dchunger.org Nationwide Resources (some examples are cited): National Academy for State Health Policy:  HYPERLINK "http://www.nashp.org/" www.nashp.org Syndemics Prevention Network: http://www.cdc.gov/syndemics/ Food Research and Action Center:  HYPERLINK "http://www.frac.org/" http://www.frac.org/ Action for Healthy Kids:  HYPERLINK "http://www.actionforhealthykids.org/" www.actionforhealthykids.org Steps to a Healthier US Initiative:  HYPERLINK "http://www.healthierus.gov/steps/" http://www.healthierus.gov/steps/ National Park Service Northeast Region Philadelphia Office; Rivers, Trails, and Conservation Assistance Program; Community Toolbox:  HYPERLINK "http://www.nps.gov/phso/rtcatoolbox/" http://www.nps.gov/phso/rtcatoolbox/ Section 2 METHODS T he nutrition training outlined in the previous chapter provides the framework for developing and implementing a nutrition curriculum. Section 2 provides ideas and methods for teaching nutrition that have been compiled from family medicine residency programs across the country. The information is organized into four categories. 1. Program elements that help support a strong nutrition curriculum. 2. Teaching opportunities in ambulatory and inpatient settings. 3. Strategies for didactic teaching. 4. Methods of evaluation.  Certain elements are crucial for any programs success. These include assigning responsibility for curriculum, setting goals and objectives, enlisting faculty support, and creating an environment that supports nutrition. Responsibility for Curriculum A successful program depends on the commitment of a qualified faculty member who can assume responsibility for developing and implementing the curriculum. If available, a physician trained in nutrition is an ideal candidate for this responsibility. Alternatively, a dietitian/nutritionist, at least masters level trained, serves as the curriculum coordinator in many residency programs. Optimally, this person will work with physician faculty who can assist in curriculum development by providing direction and support. Many residencies do not have a dedicated curriculum coordinator, but have nevertheless found creative ways of implementing a modified nutrition curriculum. Often this involves integrating nutrition education into other areas of the curriculum. Another strategy is to set up individualized learning plans for residents (discussed later in this chapter). Setting Goals and Objectives The AAFP document, Core Educational Guidelines for Family Practice Residents: Nutrition (AAFP Reprint no. 275, http://www.aafp.org/edu/guide/rep275.html), provides a comprehensive list of attitudes, knowledge, and skills. The list serves as a framework for developing specific goals and objectives. These may vary, based on residency program characteristics such as residency focus, finances, populations served, staffing and other resources. Residencies with many resources and strong nutrition programs may attempt to cover all training. However, other programs may have to limit their focus to training in specific areas. The Family Medicine Curriculum Resource Project Clerkship Resources included Nutrition . See  HYPERLINK "http://www.fmdrl.org" http://www.fmdrl.org Getting Started A tool that helps an individual assess the current state of nutrition in the residency curriculum is found in the Appendix. The tool lists the main topics and potential places where the topic might be currently taught or could be taught. Residents interested in strengthening their nutrition training can assist in completing this checklist. Building Faculty Support An essential element of a successful nutrition curriculum is faculty support. Nutrition should be integrated across the curriculum and involve all areas of patient care. A knowledgeable and supportive faculty can greatly enhance the curriculum by modeling behaviors and addressing nutritional issues during teaching times. One of the most effective ways of reaching faculty who have had limited exposure to nutrition is through residents. Resident education about nutrition can lead to new attitudes and behaviors among faculty about the utility of nutrition. Similarly, physician faculty who are knowledgeable about nutrition can help promote nutrition among their peers. Faculty also can learn about nutrition concurrently with residents through participation in workshops, conferences, and other activities mentioned below. In the hospital setting, registered dietitians may be available to present topics or discuss nutritional aspects of cases during morning rounds. Support for nutrition can also come from other allied health professionals such as health educators, nurses, and pharmacists. Some residencies cross-train these providers, giving them knowledge and skills in basic nutrition. This enables them to model behaviors that support the nutrition objectives of the program. Creating a Supportive Environment A variety of activities and resources can enhance the visibility of nutrition as well as provide necessary education for both patients and residents. Nutrition Bulletin Board(s) A nutrition bulletin board can be used for either patients or residents. The display should be eye catching and changed regularly to maintain interest. Patient focus: Monthly themes of seasonal interest; articles and columns from local sources (e.g., newspapers, cooperative extension, state health departments, cooperative extension service, or the dairy council); addressing misinformation in the media. Resident focus: A nutrition question of the week; recent nutrition related journal articles; new patient education materials; information that has personal relevance. Brochure Rack A brochure rack is an effective way to provide nutrition education material because patients can choose the topics that they are interested in. Also, patients can read over material while they are waiting and then follow up by asking questions during their office visit. To enhance interest, change the materials regularly and keep the racks looking tidy. The federal government, state health departments, non-profit agencies, and pharmaceutical companies often provide materials free of charge. Before ordering or using free materials, evaluate the content of the material for accuracy, readability, and applicability for the patient population. Screen materials for product promotion. March Nutrition Month March is designated as nutrition month, with special events in the community and increased visibility for nutrition in the media. Highlight local events for patients and encourage residents to become involved. To find out whether special activities are being organized in your community and for information about resources available to promote nutrition, you can contact the state or local chapter of the American Dietetic Association (http://www.eatright.org). Other months during the year are associated with different health concerns, such as diabetes and heart disease. Often there are special activities and media attention to increase awareness of these diseases. Theme months can provide additional opportunities for teaching about nutrition. Taste Tests Taste tests can stimulate interest and increase practical knowledge. They can be easily integrated into many different teaching topics. Ideas for taste testing include sampling different enteral formulas, trying new products (e.g., comparing sugar substitutes, learning about different soy foods, evaluating sports drinks and sports nutrition bars), evaluating low-fat or low-sodium foods, tasting exotic fruits and vegetables, sampling foods prepared by different cooking techniques. Reference Material The residents room or library should contain nutrition resources for patient care. Some general ideas are discussed below. A comprehensive list of recommended reference materials is provided in the Resources section. Books: Basic nutrition texts, good quality lay-literature, and other types of resources. CD ROMs: Software for food analysis and food and medication interactions, and educational CD ROMs for self-study. Bookmarked Web pages: Evidence-based medicine sites, patient education sites, non-profit organizations, and on-line nutrition journals. Software for PDAs: Assessment tools, guidelines, and other nutrition programs available to download from the internet as freeware, shareware, or demonstration programs. Conferences Nutrition topics should be included regularly in the conference schedule. Additionally, having a nutritionist attend conferences provides the opportunity to more frequently address nutritional issues. Significant evidence that nutrition can be used for prevention and treatment should be incorporated into EBM conferences. Nutrition Assessment & Referral Forms Ensure that forms such as diet assessment, food frequency, BMI screening, and nutrition referral are readily accessible by placing them in the exam rooms. Patient Education Materials Patient education materials should be readily available for residents to use. Some programs are moving toward computer-based resources. It may be useful to keep some of the most commonly used resources in the exam rooms. Residents should become familiar with commonly used patient education materials. Encourage residents to highlight important points for patients. One way to do this is to post new materials or distribute copies to residents. You can also bring relevant patient education material to discuss when presenting a lecture or facilitating a small group discussion. Supporting the Nutrition Program Financially There are a variety of methods used to support nutrition programs in family medicine residency settings. Most, however, are not completely self-supporting and therefore require that the program's administrators have a commitment to excellent nutrition care for their patients. In some programs, physician faculty assume responsibility for the nutrition curriculum as they do for other areas of interest, such as sports medicine. Many programs employ registered dietitians who provide medical nutrition therapy for patients to generate part of the salary. The dietitian may free attending physicians from the time required to counsel patients on prenatal nutrition, Type 2 diabetes, weight management or other chronic conditions, in addition to generating a fee for service consultations. The program then supports the remaining salary to allow the dietitian to teach, provide service, and perhaps do research. Reimbursement for medical nutrition therapy and weight management is improving. The dietitian needs to be responsible for following developments in reimbursement. (http://www.eatright.org). Programs that employ doctoral level dietitians may expect nutrition faculty to obtain research or other grant funding to help support the nutrition program of the residency. Many residency programs depend on the volunteer efforts of faculty in other disciplines to provide education for their residents. Registered dietitians employed in hospital, wellness, and HMO settings may be eager to participate in the teaching of primary care residents. Nutrition faculty at nearby colleges and universities may be available to teach in return for an adjunct clinical professor appointment. These appointments usually do not include payment. Faculty in dietetics programs may welcome the opportunity to collaborate with family physicians in research and educational efforts. Invitations should be extended. Integrating Nutrition Education into Patient Care The primary method of teaching during residency is through patient care. Because nutrition is an essential component of care, it should be included in both inpatient and ambulatory settings. Often as residents assume greater responsibility for the care and management of their patients, their interest in nutrition grows. It is important to realize that residents need to acquire both academic knowledge and skills for communicating that knowledge to patients. There is growing literature describing nutrition education interventions that are successful in the office setting. Unfortunately, these evidence-based reports may be difficult to find using typical search procedures Nutrition should be included as part of first-year resident orientation. Nutrition Consultation Remind residents that nutrition assessment and counseling are part of the plan for each patient. Review the WAVE tool ( HYPERLINK "http://brown.edu//nutrition" http://brown.edu//nutrition) or the REAP tool  HYPERLINK "http://brown.edu/nutrition" http://brown.edu/nutrition Review the current evidence based Dietary Guidelines for Americans (USDA-CNPP Web site: http://www.usda.gov/cnpp Review current evidence based standards for Body Mass Index (BMI) for adults (http://www.nhlbi.nih.gov) and for children ( HYPERLINK "http://www.cdc.gov/growthcharts/" http://www.cdc.gov/growthcharts/). Review current evidence for prenatal weight gain, supplementation and nutrition during lactation ( HYPERLINK "http://books.nap.edu" http://books.nap.edu) Address cost and reimbursement for nutrition services. Information in this area is constantly changing and it is important to make residents (and faculty) aware of the services provided by a dietitian that can be reimbursed. It is also important to address the issue of cost and benefits for services that must be paid out of pocket. Residents may be reluctant to mention nutrition referral to low-income or elderly patients because they feel that the patient will not be able to afford the service. Keep in mind that nutrition services may be available at the local health department at no cost or on a sliding fee scale. At least two issues can be used to help change this attitude. One is that many of these patients are willing to spend a significant amount of money at health food stores on supplements, as well as on alternative therapies. This demonstrates their desire to try to manage their disease. Also, there is good evidence to show that the cost of nutrition consultation is a small investment that can reduce management costs in the long run. Encourage residents to offer the nutrition consultation and let the patient decide if they have the desire and will pay for the consultation. Patients often save money after a consultation because they avoid buying needless expensive foods and supplements. Clinical Resources Programs can help residents feel more comfortable handling nutrition issues by providing them good nutrition resources. Some programs provide handbooks. Nutrition software for use on hand-held computers is becoming increasingly popular. Nutrition Handbook Many programs distribute clinical nutrition handbooks for evaluating nutritional status, initiating a care plan, and making appropriate referral. Separate handbooks have been developed to address issues of prevention, therapeutic nutrition, and special needs in obstetrics, surgery, and geriatrics (see the resources section). The University of Wisconsins handbook is found at  HYPERLINK "http://www.medicine.wisc.edu/" http://www.medicine.wisc.edu/ PDA Programs As the popularity of hand-held computers grows, many nutrition programs are becoming available. Programs for downloading or purchase can be found in the resources section. Teaching Opportunities The inpatient service, the nursing home, and even home visits provide many opportunities for nutrition education. A dietitian from the hospital, the family medicine faculty, or the nursing home can help provide teaching. Some strategies include: Screening and Assessment Nutrition screening on admission: Screening all patients at the time of admission provides an excellent opportunity for teaching about identification and follow-up for high-risk patients. Every patient admitted to an accredited hospital receives a nutrition screen. Review the policy and charting used at the hospitals where the residents practice. This may be a function of the nursing department or the nutrition department. Patients who are identified as at risk can be discussed during morning rounds. Identification of at-risk patients: In programs in which nutritional status is assessed at admission, residents may be assigned responsibility for identifying at-risk patients for discussion during morning rounds. Bedside assessment: After residents (typically R1s and medical students) have learned how to conduct nutrition assessments, they can be assigned a bedside assessment. They select a patient, complete an assessment, and discuss it with the nutrition faculty. Resident and faculty may decide to visit the patient together. The assessment can include anthropometric measurements, biochemical evaluation, electrical impedance, and metabolic cart measurements. (http://www.med.upenn.edu/nutrimed/) Morning Rounds Faculty dietitians, hospital dietitians, and other faculty with knowledge of nutrition should be encouraged to participate in morning rounds so that nutrition issues can be identified and addressed. % Provide structured teaching on subjects of interest in the inpatient setting. % Have residents identify one patient each week for chart review and teaching. % Invite the hospital dietary staff to explain their role in patient care and their charting protocol for obtaining a dietary consult. Review the hospital's Diet Manual. Review the hospital's nutrition formulary. Review the role of the Nutrition Support Team. Ambulatory Setting In the ambulatory setting residents often have the opportunity to work with clinical dietitians who can assist in the identification and long-term management of patients who have nutritional problems. Nutrition Screening Nutrition screening consists of a brief evaluation to identify patients who are at high risk for nutritional problems. The tools and questions used for screening vary depending on the characteristics of the population screened and the objectives of the screening. A number of screening tools are available (see resources section). Some strategies for teaching about screening: % Have residents practice using various screening tools during patient care or as a separate activity. % Require residents to complete a screening protocol on a certain number of patients or to administer a screening tool to all patients over the age of 65. Review the Nutrition Screening Initiative's tools (American Academy of Family Physician's Web site: http://www.aafp.org/nsi/). Review the WAVE or REAP tool ( HYPERLINK "http://brown.edu//nutrition" http://brown.edu//nutrition) . Co-Counseling Most programs use co-counseling as a teaching strategy, but scheduling can be challenging. Some programs use co-consultation with clinical dietitians/nutrition faculty both for teaching and evaluation. Required Co-consultations: Co-consultations can be used both to teach and evaluate resident skills. During the first year of training, residents can be required to schedule a specific number of co-consultations for patients with particular types of nutrition problems. First-year residents mainly observe faculty. Second-year residents are expected to play a more active role in the counseling. By the third year, residents are expected to demonstrate specific competencies. Getting the most of co-consultation: The resident and clinical dietitian should meet prior to the co-consult to discuss the goals for the counseling session, the residents learning objectives, and the specific behaviors that the resident should exhibit. Afterwards, the resident and dietitian should debrief the session. Patients for co-consultation: Overweight/obese, taking medications for weight management, sports medicine, HTN, high blood cholesterol, diabetes, well child, prenatal care, and geriatric. Diet Referrals Dietitians use a diet referral as a teaching opportunity by communicating to the referring physician about the patients treatment plan. One problem to avoid is residents referring patients because they do not know or are not interested in learning how to do nutrition counseling. To ensure that residents are learning about nutrition and not simply passing off patients, it is recommended that they be required to do one co-consult for a specific disease before they are eligible to make a referral. Computer Assessment Programs Several types of programs are available for diet and nutrition assessment, to aid in managing weight loss, diabetes mellitus, hyperlipidemia, and to evaluate drug-nutrient interactions (see resources). If computer assessment programs are available, residents should become familiar with how these tools can be used in clinical practice. Web sites: USDA's MyPyramidTracker (http://mypyramidtracker.gov); CYBERDIET http://www.cyberdiet.com/; NHLBI Interactive Meal Planner: http://hin.nhlbi.nih.gov/cvd_frameset.htm. Observation Direct observation with a two-way mirror or by videotape enables faculty to accurately evaluate the resident during a patient encounter. Residents should review audio or videotape and do a self-critique. The value of taping can be enhanced when faculty (physician, behavioral science, and/or clinical nutrition) work together to review tapes and provide feedback. Programs that use direct observation often have checklists for evaluating specific skills and level of knowledge. Since this method is often used in behavioral science, nutrition faculty should look for ways to collaborate. For example, the nutritionist may review the checklists and suggest ways to include nutrition-related items. Another idea is to cross-train faculty so they can identify and critique specific skills such as the residents ability to identify and follow through on opportunities to provide nutrition information or counseling. Precepting Precepting can be a useful teaching time, particularly when physician preceptors encourage residents to pursue nutritional issues. Having a clinical nutrition faculty member as a co-preceptor will encourage discussion of nutrition topics. The nutritionist can identify issues, suggest resources, and help plan interventions. Precepting is also a good opportunity to teach locating and using various patient education materials, and how and when to make a diet referral. Increase Awareness The following suggestions are designed to increase awareness of the value of nutrition during patient visits: % Post a list of patients who are at nutritional risk so they receive appropriate follow-up care. % Provide nutrition in-service to faculty preceptors. % Maintain files of commonly used nutrition education materials in the preceptor/workroom. % Maintain nutrition links on computer desktops. % Ensure that nutrition texts, handbooks, and patient education materials are readily available in the preceptor/workroom. Physicians who obtain knowledge from nutrition-specific resources such as nutrition journals have a more favorable attitude about nutrition and provide nutrition assessment and counseling to their patients more often than those who obtain information from popular magazines. Chart Review and Quality Assurance Chart reviews have been shown to increase knowledge and nutrition interventions among residents. Additionally, the results can be used to evaluate both learners and the curriculum. A nutrition chart review may be conducted as part of a larger chart review/quality assurance program or as a separate activity. Faculty and residents should review charts together, paying close attention to nutrition assessments and therapy. A specific form for chart review or quality assurance based on faculty consensus of minimum patient care requirements is helpful. Since nutrition assessment is an important part of good patient care, each patients chart should contain a nutrition assessment form. Special assessment forms can be used for prenatal patients. In addition to weight grids, a Diet Score helps providers determine whether the patient is at nutritional risk and in need of a nutrition referral. Residents and students can attend instructional sessions to learn how and when to use this form appropriately. As forms become computerized, nutrition faculty will need to identify minimum information to be entered, types of quality assurance review, and flags or rules to be incorporated. Patient Education Material Many physicians rely on printed materials, audiovisuals, and multimedia resources for patient education. Some programs, therefore, take time during residency to help residents evaluate and/or prepare patient education materials. Third-year residents may also choose to devote elective time to developing materials and organizing their own set of patient education materials before going out into private practice. Residents may find it useful to explore some of the self-help patient education sites on the Internet. There are sites designed to assist patients with weight management (Shape-Up-America Web site: http://www.shapeup.org) or heart disease risk reduction (American Heart Association XE "American Heart Association"  Web site: http://www.onelife.americanheart.org/). Sites that require subscription may be willing to offer a free trial period if they are contacted indicating the physician wants to review the site before recommending it to patients. Evaluating materials: Patients are increasingly using the Internet as a source of medical information, residents also need to learn how to evaluate different medical Web sites. It is time consuming and may be difficult to determine whether a Web site has accurate food, nutrition and physical activity information. Writing materials: Developing patient education materials such as brochures, handouts, and newsletters can be useful for residents who enjoy writing. Often materials are available that can be rewritten or adapted. Clinic Newsletter If the clinic publishes a newsletter, residents can help write a regular nutrition column. This emphasizes the importance of nutrition in family medicine, provides information on specific topics, and may lead to increased dialogue about nutrition between patients and physicians. Patient Education Classes and Group Visits Group classes in the clinic are a cost-effective way to teach patients about topics such as weight loss, diabetes, prenatal nutrition, and low-fat, low-cholesterol diets. Residents should be encouraged to attend classes they routinely refer patients to so they understand what is taught in the classes and can experience the class dynamic. Residents can also help teach classes. Some practices offer group visits that allow time for patient education. Plan to include a nutrition teaching point in each group visit. Nursing Home When possible, a clinical dietitian can attend rounds on the residents nursing home rotations to help review nutrition assessment and planning. Some programs offer a rotation designed to teach skills in long-term care nutrition support. Components of the rotation may include patient interviews, assessment and care planning, and prescribing diet orders. Residents should meet with the dietitian who reviews the nutritional quality of the menus for the nursing home. A home visit is an appropriate time to learn about food safety. Using a tool to assess the safety of the food supply in the home is an eye-opening experience.. Community Activities Residents should be encouraged to participate in community events. Nutrition faculty can help facilitate participation by contacting community organizations and acting as a conduit for information. Because scheduling is a barrier, faculty should disseminate information (e-mail or on a bulletin board) as early as possible. Health Fairs: Residents and students can conduct nutrition assessments (e.g., obtain heights and weights, evaluate diet histories, etc.), and provide nutrition education. Cholesterol and breast cancer screenings: Residents and students can discuss nutrition recommendations for primary and secondary prevention. Speaking Engagements: Some residencies have established ties with school groups, service clubs, and other organized groups who welcome nutrition discussions. Non-profit organizations such as the American Heart Association XE "American Heart Association"  often need volunteers to present talks as part of their speakers bureau. Media Coverage: Nutrition faculty can promote their residencies by providing media training for residents and arranging for them to appear on local TV talk or news shows.  Residencies differ considerably with regard to opportunities for didactic teaching. The STFM Group on Nutrition assessed nutrition teaching in residencies. See results in: Deen D, Spencer E, Kolasa K. Nutrition education in Family Practice Residency Programs. Fam Medicine. 2002. The following section outlines strategies that have been used successfully. Programs need not attempt to apply all these strategies, but should use those that fit with their resources and overall teaching objectives. Grand Rounds, Lectures, Conferences, and Small Groups Lectures, conferences, and grand rounds provide opportunities for structured learning. While most residencies use these formats, there is considerable variation in the extent to which they are used for teaching nutrition. Some programs hold monthly conferences where nutrition is taught, while others have as few as six (or fewer) per year. Grand Rounds Some programs report that this is not the most useful method for presenting nutrition topics. Others suggest that Grand Rounds confers status to the topic and should be done several times per year. Family medicine faculty or other nutrition or medical faculty can present an in-depth conference on specific nutrition topics. Guest Lectures Guest lectures can stimulate interest in nutritional subjects. Volunteer speakers and funding to support such activities are often available through various national and local health organizations and food commodity groups. Slide Shows PowerPoint slide presentations can be downloaded without cost from various Internet sites. For example, the use of Body Mass Index and BMI based growth charts are provided at http:128.248.232.56/CDCGrowth/presentation. Or cholesterol guidelines  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm" http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm; or weight management guidelines  HYPERLINK "http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/profmats.htm" http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/profmats.htm Integrate Nutrition with Other Topics One way to increase exposure to nutrition is to incorporate nutritional themes into conferences on other subjects. For instance, in a conference on osteoporosis include a presentation on nutrition issues such as calcium requirements, exercise, and soy, in addition to medical management. Integrating nutritional issues helps to reinforce the concept that nutrition is an integral part of prevention and treatment. Small Group Seminars Small group seminars or lectures are a cost/time effective way to cover material that residents need to master. There are a variety of ways to make small group learning interesting and enjoyable for residents. Games Games frequently are used to stimulate interest and reinforce nutrition knowledge. Various games are available. Case Studies Case studies are an effective way of covering nutrition topics. Although patient cases can be used, resources that provide cases studies have been developed for teaching. Some case studies have been posted to the Family Medicine Digital Library (www.fmdrl.org) Self-Assessment Self-assessment has become a popular method of teaching applied nutrition to physicians. It has been shown to be an effective means of changing physician behavior with regard to nutrition. Self-assessments can be done independently or incorporated into conference formats. Some examples of self-assessment methods: Diet Comparison: Have residents complete a 24-hour diet history and compare it to a standard recommendation. Use MyPyramidTracker.gov. or http://www.forcevbc.com/good/food.htm; Interactive Meal Planner (http://hin.nhlbi.nih.gov/cvd_frameset.htm.). Diet and Lipids: Have residents analyze their own diets, perform their own lipid profiles, and complete various health risk appraisal forms. One successful program in cholesterol screening and management included diet assessment, counseling, and frequent feedback to residents regarding their cholesterol screening activities. Fat Intake Scale (http://depts.washington.edu/~nwlrc/fis.html) The Northwest Lipid Research Centers Fat Intake Scale has been used successfully during a physicians conference meal. Physicians enjoy the opportunity to assess their own fat intake and familiarize themselves with educational tools and methods used by dietitians. Others have used fat gram counting as a reference tool. Rate Your Plate This is a food-frequency questionnaire that has been used in a number of settings as part of a workshop or discussion of nutrition counseling. (http://depts.washington.edu/~nwlrc/fis.html). Plant Food Screener This is a tool to help assess whether an individual is getting enough dietary fiber, fruits, and vegetables. (http://www.nutritionquest.com/fv_screener.html). Simulated Learning Residents can learn about the practical issues their patients face through simulated experiences. Faculty participation can enhance the learning experience. One commonly used scenario is to experience being diabetic for a day. Residents can also be given instructions to follow different diets (e.g., low fat, reduced calories, etc.). Standardized Patients and Simulated Patients Standardized patients (an actual patient trained to present an illness in a standardized way) and simulated patients (a well person trained to simulate a patients illness in a standardized way) can be used in a variety of ways for teaching and assessment. More than 70% of medical schools use standardized patients. For example, an encounter can be videotaped and reviewed with the resident. Alternatively, brief, taped vignettes of patients with nutrition problems can be used to stimulate interest and discussion in a lecture or small-group setting. Each vignette should have specific teaching points, and be followed by a case discussion reviewing each point. Faculty must make sure scripts and checklists include appropriate nutrition information. Case Conferences One of the benefits of case conferences is that different types of providers are involved, leading to a more holistic approach to care. This is an excellent opportunity to teach about the role of nutrition in patient care. Nutrition may be covered in these conferences, either directly by presenting patients with interesting or difficult nutrition-related problems, or indirectly by integrating nutrition issues into other aspects of patient care. It is appropriate to devote a few minutes of each conference to discussion of nutrition as it relates to the patients condition. Several programs have developed vignettes from real patient cases. Physician Conference Meal Meals can be used in conjunction with lectures to reinforce nutrition topics. For example, a talk on nutrition interventions in hyperlipidemia may be accompanied by a meal emphasizing low-fat foods. Another way that meals can be used is to give each participant an index card, which lists the parameters of a specific diet (e.g., Therapeutic Lifestyle Change Diet (TLC), DASH, low calories, etc). Display food buffet style and list the nutrition content of each food. The participant must then make food choices according to his or her diet prescription. Topics that lend themselves to this format include obesity, diabetes mellitus, hypertension, and hyperlipidemia. Develop guidelines for health promoting meals and snacks. Provide these guidelines to caterers and others who provide food and beverages to the family medicine center. A guide for healthy meals at conferences can be found at www.eatsmartmovemorenc.com Field Trips Field trips can teach practical aspects of nutrition or introduce community resources to residents. Teaching Practical Nutrition It is often helpful to teach nutrition outside the clinic; for example, in grocery stores, health food stores, farmers markets, dietary departments of the hospital, weight-loss clinics, and specialty programs for bulimic and anorexic patients, public health clinics, nursing homes, nutrition programs for the elderly, La Leche League meetings and other community resources. Each trip should have specific learning objectives and activities in which residents interact with the environment. For instance, residents who visit a grocery store may be given a worksheet to compare nutritional content of different products. Community Resources Target sites that residents are most likely to refer patients and schedule appointments with the program coordinator. If possible, have the coordinator describe the programs services and how physicians can help their patients receive services. Discuss the services provided. Community resources may include the WIC clinic, school breakfast, lunch and after school programs, Nutrition Program for the Elderly, Food Stamp Office, Cooperative Extension Service Office including the Expanded Food and Nutrition Education Program (EFNEP), public health nutrition office, and Food Pantry and/or soup kitchen. Non-governmental community resources, such as La Leche League should also be considered. Involving students and residents in a homeless shelter can enhance sensitivity to the barriers to nutrition faced by this population. One resource for learning about local community resources, including nutrition, is the United Way (http://www.unitedway.org). Independent Study Independent study is often done in conjunction with a nutrition rotation, a nutrition elective, or for personal interest. Nutrition faculty can help residents clarify learning objectives and identify appropriate educational materials, taking into account the residents individual learning style. Using a variety of formats can help maintain interest. Some of the different types of resources available include: Self-study learning modules These can be used alone or as a part of a nutrition rotation. Books Provide a bibliography of books that are concise, reasonably priced, and directed toward primary care. Also, consider using clinical guidelines and books in the lay literature. Journal Articles Select recent articles and reviews. Introduce residents to update services they can subscribe to during and after residency. Computer Programs Nutrition CD ROMs are an excellent way for residents to learn about nutrition using an interactive format. Nutrition in Medicine from the University of North Carolina, Chapel Hill (http://www.med.unc.edu/nutr/nim/Welcome.htm) is a series of CD-ROM and web based programs designed for nutrition medical education. Each module contains a review of basic nutritional sciences and an applicable case, and Board-like test questions. A large advisory committee has reviewed these programs. The programs are also available on the web. Nutrition Principles and Clinical Nutrition courses from Stanford University are available on CD for those medical schools who wish to use them. Terms of Use require mounting the courses on local password protected servers and complying with copyright. Contact  HYPERLINK "mailto:stanford_nutrition@lists.stanford.edu" stanford_nutrition@lists.stanford.edu. Video Resources Tapes of lectures on nutrition topics can be useful learning tools. Often these are available from medical school libraries or universities that have a nutrition department. Journal Club Many residencies have a monthly journal club. Featuring articles on nutrition periodically teaches residents about the unique factors that must be considered when evaluating nutrition studies, as well as how to interpret new findings. For a comprehensive list of journals that could be used to find appropriate articles see the resources section. Literature Review Literature reviews can be a useful way for residents to learn about a specific nutrition topic. This format is applicable to independent study, especially when a resident has a specific area of interest. Residents can also be assigned to complete a comprehensive literature review to present to other residents in Journal Club or in conferences. Evidence-Based Medicine (EBM) As interest in EBM grows, it is important to demonstrate how nutrition is an evidence-based discipline. One way to do this is to maintain files of current articles that support recommended therapies. Post or distribute salient articles as they are published. Nutrition topics are also discussed on some EBM Web sites (e.g., Cochrane Library). Monitor the Journal of Family Practice for published nutrition related POEMS (http://www.jfampract.com). One Web site is dedicated to evidence-based nutrition (http://www.nutriwatch.org). The Family Practice Network (FPIN) has systematic reviews of questions posed by family physicians. There are nutrition related questions in the database. See www.fpin.org Related Curriculum Many of the skills needed for successful nutrition counseling are similar to office counseling techniques traditionally taught in the behavioral science curriculum. It may not be necessary to duplicate efforts. Rather, complement them by demonstrating how these skills apply to nutrition counseling. If some residents have difficulty learning these skills, it may be necessary to implement a counselor-training component in the nutrition curriculum. Evaluation A survey of residencies showed that there are more than 20 different ways evaluations are conducted. Significantly, the five most common methods (the American Board of Family Medicine In-training Examination, formative review sessions, resident chart reviews, lists of procedures performed, and family medicine conference attendance) have limited applicability for evaluating competency in nutrition. Following are six examples of tools and strategies useful in evaluating nutrition skills. Check the Nutrition Academic Award site for evaluation tools  HYPERLINK "http://www.nhlbi.nih.gov/funding/training/naa/schools.htm" http://www.nhlbi.nih.gov/funding/training/naa/schools.htm Direct Observation Direct observation of students and residents performing nutrition assessment and counseling during patient encounters is the standard for evaluating performance skills. Use reporting forms that list the skills being evaluated, with specific behavioral indicators for each skill to standardize these assessments. Objective Structured Clinical Examinations (OSCE) and Clinical Practice Examinations (CPX) The standardized patient is being used as an assessment tool for clinical competence in multi-station examinations. OSCEs for nutrition skills need to be developed for training such as diet assessment anthropometrics, and for identifying the need for appropriate nutrition interventions. Performance criteria can be incorporated into the overall performance criteria in CPXs. One program with extensive experience in post-clerkship examination incorporates aspects of nutrition into the exam, but always in the context of a clinical case. For example, a case dealing with a diabetic or hypertensive patient will elicit questions about the condition and how to manage it with nutrition intervention. Rotation Evaluation Some rotation evaluation forms include terms used in nutrition-related portions of the program. Pre- and post examinations reveal strengths and weaknesses of the nutritional knowledge base and progress of the individual learner. Evaluation of rotations by learners provides feedback on the usefulness of the activities and experiences to the residents and clerks. Samples are found in the Appendix. Competency Checklists Many behavioral medicine programs have competency checklists. These focus on 1) interviewing skills, 2) data gathering, 3) concern for the family as well as the patient, 4) office counseling, 5) identification of community resources, and 6) professional relationships. These checklists can serve as models for developing a nutrition checklist. Alternatively, nutrition-related points can be incorporated into the behavioral checklist. Board Review Questions Some programs report that residents enjoy Board review type questions at the end of a conference session. Surveys of Graduates Residency programs are required to survey their graduates, and can include questions about changes in beliefs about nutrition since entering practice; What they wish they had known then, and other questions. Most programs survey their residents periodically to evaluate the effectiveness of the residency program. Questions about nutrition counseling can be added to the survey to identify the types of office counseling skills used by the graduates, as well as their levels of comfort and confidence in performing those skills. Section 3 Best Practices T he GON was challenged to describe best practices in residency nutrition education. But, as noted earlier, each residency needs to consider its own priorities and resources. As an aid to faculty who are just getting started, or who want to approach nutrition in their programs, several community and university programs describe how they incorporate the previous nutrition competencies into their programs. The information most frequently requested of programs is type of program, number of residents and fellows, contact person and number of dietitians in the program, formal and informal opportunities for teaching, and funding sources for nutrition education. Nutrition in Family Medicine Residency Programs Oakwood Annapolis Hospital (Oakwood Healthcare System) Wayne, MI  HYPERLINK "http://www.oakwood.org" www.oakwood.org Type of Program Community Number of Residents 10 / year Number of Fellows 2 - Sports Medicine (starting July 2007) Nutrition Contact Carla B. Boyes, MS, RD, CDE Number of dietitians employed in program 0.7 FTE Total; 0.2 patient care; 0.5 education/research in nutrition and patient education Formal opportunities for nutrition education Half-day orientation in nutrition basics for new residents; includes general and diabetic survival skills nutrition Self-assessment. Weekly didactic lectures conferences (4-5 nutrition topics/year) Teaching Family case conferences. Grand Rounds (1-2 nutrition topics/year). Ambulatory pediatric rotation (readings). Medicine rotation (TPN). One-week rotation in lactation during OB (R2). Geriatric rotation: one-hour session and readings. Informal opportunities for nutrition education Inpatient rounds. Medical record notes by registered dietitian. Door-side consultations. Collaboration with behavioral science faculty in videotaping patient encounters. Collaboration with behavioral science during two half-day orientation sessions for new residents for patient education and cultural congruity. Community medicine rotation: health literacy with nutrition as an example; nutrition lecture for school children while rotating in hospital-affiliated, school-based clinic. Co-counseling with registered dietitian. Registered dietitian precepting with residents for practical application during patient visits. Funding Faculty position; nutrition consult income; grants. Faculty position; nutrition consult income; grants. Morehouse School of Medicine Atlanta, GA http://www.msm.edu/ Type of Program University based Number of Residents 5/year Number of Fellows N/A Nutrition Contact Laurita M. Burley, PhD, RD, LD Number of dietitians employed in program 1 full time Formal opportunities for nutrition education In conjunction with behavioral medicine rotation: Observe dietitian, participate in joint counseling or patient group sessions on diabetes, hyperlipidemia, weight management, hypertension. Four to six nutrition topics/year at weekly half-day conferences including maternal, pediatric, geriatric, sports, diabetes, cardiovascular disease, obesity management, eating disorders, alternatives and dietary supplements, and critical care cases. Nutrition Board Review. Informal opportunities for nutrition education Dietitian available for consultations during clinic operation. Self-study. Assessment and consultation on personal nutrition. Community group presentations and exhibits. Funding Federal- and state-funded faculty position and grants. Type of Program University based Texas Tech University Health Sciences Center Lubbock, TX http://www.ttuhsc.edu/ Type of Program University based Number of Residents 26; 10/ first year; 2-R1 residents go to Abilene for 2 &3 years; 8/2 & 3 years in Lubbock Number of Fellows Sports Medicine Fellow - 1 Nutrition Contact Katherine Chauncey PhD, RD, LD Number of dietitians employed in program 1 FTE faculty member Formal opportunities for nutrition education One office rotation per year per resident. Review nutrition-related patient education materials; allow time to observe dietitian; joint counseling of patients; provide time for nutrition self-study; personal nutrition assessment; rounds with hospital dietitian and nutrition support team; one-to-one discussions of nutrition and chronic illness; work on nutrition related research project, if applicable. Precept R1s in clinic. Grand Rounds (2-3 nutrition topics/year). Bi-annual Therapeutic Luncheon with dietitian in teaching hospital. Informal opportunities for nutrition education Medical record documentation. Hallway consultations. Resident assisting family medicine third-year clerks with nutrition case presentation, if requested; resident role-modeling nutrition intervention for third- and fourth-year clerks. Funding State-supported university faculty position; medical practice income plan; grants; nutrition consultation income East Carolina University Greenville, NC http://www.ecu.edu/med/ Type of Program University Number of Residents 30 (10/year) Number of Fellows 1 Womens Health, 1 Sports Medicine, 2 Geriatric Nutrition Contact Kathryn M Kolasa, PhD, RD, LDN Number of dietitians employed in program 2.0 FTE ; additional RDs as grants allow Formal opportunities for nutrition education Scheduled didactic and workshops in each of 6 family medicine months; Integration of relevant nutrition in weekly academic afternoon Presentations in evidence based medicine conference (clinical jazz) Breastfeeding rounds during family medicine month Geriatric nutrition didactic during Geri Rotation Inpatient nutrition during family medicine service month; enteral formula tasting during orientation month Grand Rounds (2-3x/year for nutrition) Informal opportunities for nutrition education Observation/team counseling with dietitian in first year Door side consults with RD Electronic medical record chart notes Emails assessments; problem screening and intervention planning; and provides patient-focused nutrition counseling involving the patient in order to development a more effective nutrition plan. Nutrition ElectiveFMC 3 Residents may choose to complete a nutrition elective. A specific nutrition topic of interest is selected by the resident. Supporting clinical field experiences are coordinated by the family medicine nutritionist and additional one-on-one tutorials are set up for the resident and nutritionist. Past electives have focused on Type 2 Diabetes Nutrition Management; Weight Management Programs in the Community; and Eating Disorders. Informal opportunities for nutrition education Precepting in the Family Medicine Center Medical record documentation of nutrition consultations Hallway consultations Community group presentations Co-counseling with clinic nutritionist Supermarket Safari nutrition education tours Food demonstrations Nutrition resource file of problem management protocols and patient-focused counseling materials are available and accessible for all residents to use with patients. Develop patient education materials for departmental web site:  HYPERLINK "http://www.ecu.edu/fammed/" http://www.ecu.edu/fammed/ see For Patients Funding Nutrition consultation income, grants, faculty salary University of Illinois Chicago, IL http://www.uillinois.edu/ Type of Program University based Number of Residents 18 Number of Fellows 0 Nutrition Contact Samuel Grief, MD Number of dietitians employed in program 0 Formal opportunities for nutrition education Wellness Nutrition Center: 2-4 weeks rotation work with Dr. Grief seeing patients for weight management. Also, see patients with dietitians, watching a nutrition intake. Some other opportunities exist to see patients with GI disorders. Lectures on integrating nutrition assessment into clinical practice; drug/nutrient interaction; osteoporosis. Funding University Sioux Falls Family Medicine Residency Sioux Falls, SD http://www.siouxfallsfpr.org/ Type of Program Community based Number of Residents 8/8/8 Number of Fellows AOC Sports Medicine 4/year Nutrition Contact Roger A. Shewmake, PhD, LN Number of dietitians employed in program 1 FTE Formal opportunities for nutrition education All first year residents, during their orientation, participate in a Super Market tour with small group nutritional assignments related to healthy shopping. Nutrition Rotation (3rd year elective) 4 week rotation Offered several times per year Components Community Health Geriatrics Nutrition support Diabetes education Noon conference presentation Ambulatory/hospital experiences Sports Medicine Rotation 10 hours didactic sessions 2 hours nutritional analysis 2 hours informal nutrition related topics presented by resident at monthly AOC educational meetings Diabetes Education Week (workshop 5 hours) Dietitian/Nutritionist is Grand Rounds Case Discussant (4-8 X per year) Elective time individually designed Grand Rounds usually 6-8 topics on nutrition per year Informal opportunities for nutrition education Co-consults with dietitian/nutritionist Precepting/Staff desk (8 hours/week) Nutritionist (attends 5 noon conferences/week) provides nutritional aspects of cases/topics Noon conference meals/analysis frequently used as teachable moment Funding Faculty position, nutrition consultation income, grants Brown Medical School Providence, RI Type of Program Community based program in an urban setting Number of Residents 13-13-13 Number of Fellows Family Medicine Leadership Fellows 4 Nutrition Contact Dorothy DeLessio, RD, LDN, CDE Number of dietitians employed in program 0.5 FTE Formal opportunities for nutrition education conferences, workshops, rounds, nutrition elective or nutrition related COPC project. Sessions with an RD and MD/RD team in the Family Medicine Outpatient Clinic and Heart Disease Prevention Clinic. Work with a team composed of a group of patients, a physician, nurse, social worker, pharmacist, and dietitian in conducting Diabetes group medical visits Personal lifestyle assessment/diet evaluation and plan Didactic sessions and half day workshops in all three years and with fellows Geriatric case management and home visits with a team , physician, NP, MSW,RD Patient simulation project: assume the role of a person with diabetes and self manage for 3 days during PGY1 Nutrition support didactic and supplement tasting session Informal opportunities for nutrition education Precepting in the Family Practice Center Medical record documentation of nutrition consultations and communication through the EMR system Hallway consultations and consults with Graduate Nutrition Specialist and with hospital dietitians particularly nutrition support dietitians Nursing home, assisted living and home visits Community group presentations, COPC projects Case management meetings with clinic nutritionist for high risk pregnancy clinic Patient-focused counseling materials and nutrition resources are available electronically on all clinic and hospital computers and within the electronic medical record system for all residents to use with patients. Computer based interactive tutorials and nutrition assessment programs are available in resident resource areas. A continuing nutrition education program for the department web page is under development. Funding Faculty salary, Grants Mentors Each of the individuals below has agreed to mentor others seeking to teach nutrition in medical schools or residency programs. They are willing to correspond by phone or e-mail. They are eager to share materials. Please feel free to contact them. Boyes, Carla, MS, RD, CDE Clinical Educator Oakwood Family Medicine Residency 2001 S. Merriman, Suite 100 Westland, MI 48186 Phone: 734- 727-1061 FAX: 734-727-1045 e-mail:  HYPERLINK "mailto:boyesc@oakwood.org" \o "mailto:boyesc@oakwood.org" boyesc@oakwood.org Clinical expertise: Principles of nutrition education, prenatal nutrition, lactation, infant/child nutrition, nutrition for women, geriatric nutrition, diabetes, hypertension, hyperlipidemias, obesity Populations: Hispanic, African American, Arabic/Middle Eastern, suburban Teaching Tips: 1) Teach a 2-3 minute practical application of a nutrition concept as part of a 15 minute physician patient contact; 2) Precept residents and interns for practical application of nutrition and other patient education in precepting room during patient visits; 3) Collaborate with other rotations/disciplines to enhance delivery of nutrition education to residents; 4) Be innovative in seeking opportunities to expand nutrition education in resident experience; 5) Present a half day nutrition basics during first month orientation in conjunction with a nutrition self-assessment. DeLessio, Dorothy, MS, LDN, CDE Graduate Nutrition Specialist/Senior Clinical Teaching Associate Department of Family Medicine Memorial Hospital/ of RI/Brown Medical School 111 Brewster St. Pawtucket, RI 02860 Phone: 401-729-2759 Fax: 401-729-2923 e-mail:  HYPERLINK "mailto:Dorothy_DeLessio@mhri.org" Dorothy_DeLessio@mhri.org Burley, Laurita M., PhD, RD, LD Department of Family Medicine Morehouse School of Medicine 1513 East Cleveland Avenue, Bldg 100, Suite 300A East Point, GA 30344 lburley@msm.edu Clinical Expertise: Diabetes, hypertension, hyperlipidemias, obesity Populations: Urban, African American Teaching Tips: Use the medical interview as an instrument for behavioral change. Chauncey, Katherine PhD, RD, FADA Associate Professor Dept of Family & Community Medicine Texas TechMedical Center 3601 - 4th Street Lubbock, TX 79430 Phone: 806-743-1100 x258 e-mail: HYPERLINK "mailto:kathy.chauncey@ttuhsc.edu" \o "mailto:kathy.chauncey@ttuhsc.edu" kathy.chauncey@ttuhsc.edu Clinical expertise:Metabolic syndrome and its associated health problems; lifecycle nutrition-infants, OB, geriatrics; evaluation of patient's dietary supplement and herbal use. Population: Suburban,Rural, White, Hispanic,African American Teaching tips: One-to-one and small group are the most effective for me, although Ienjoy doing interactivelectures. Case consults result in instant learning with good retention. Residents like personalized nutrition (e.g., self-assessment or interventions with family members). Use hospital dietitians as teachers; don't make it burdensome on the resident or the dietitian; results in improved relations between dietitians and physicians. Deen, Darwin, Jr. MD, MS Dept of Family and Social Medicine Albert Einstein College of Medicine 1300 Morris Park Avenue Bronx, NY 10461 Phone: 718-430-2900 FAX: 718-430-8816 e-mail: deen@aecom.yu.edu website: HYPERLINK www.nutritionforlifebooks.com www.nutritionforlifebooks.com Clinical Expertise: Nutritional assessment, principles of nutrition education, sports nutrition, geriatric nutrition, herbal medicine, dietary supplements, obesity, hyperlipidmias, Populations: Urban, Hispanic, African American. Teaching Tips: expertise in curriculum design and evaluation, nutrition precepting, competency-based evaluation Hark, Lisa, PhD, RD, RD Director, Nutrition Education & Prevention Program University of Pennsylvania School of Medicine Stemmler Hall Suite 100 36th & Hamilton Walk Philadelphia, PA 19104-6087 Phone: 215-349-5795 FAX: 215-573-7075 e-mail:lhark@mail.med.upenn.edu website:  HYPERLINK "http://www.nutritionforlifebook.com" www.nutritionforlifebook.com ; www.lisahark.com Clinical expertise: Nutrition assessment, principles of nutrition education, nutrition for women, lactation, infant/child nutrition, geriatric nutrition, diabetes, hypertension, hyperlipidemias, obesity, supplements Kolasa, Kathryn, PhD, RD Department of Family Medicine The Brody School of Medicine at East Carolina University Greenville, NC 27834 Phone: 252-744-1358 FAX: 252-744-3040 e-mail: kolasaka@ecu.edu Clinical expertise: Nutrition assessment, principles of nutrition education, prenatal nutrition, infant/child nutrition, nutrition for women, geriatric nutrition, eating disorders, sports nutrition, diabetes, hypertension, hyperlipidemias, adult and pediatric obesity, supplements, herbals; environmental and policy changes to support health eating Populations: Rural, urban, African American Teaching tips: 1) Write a nutrition column for local newspaper that is widely read by patients who then ask their doctor about it. 2) Self-dietary assessment and prescription by first-year residents. Lindseth, Glenda, Ph.D, RD 2018 Belmont Rd. Grand Forks, ND 58201-7314 Phone: 701-777-4506 FAX: 701-777-4096 e-mail: glendalindseth@mail.und.nodak.edu Clinical Expertise: Principles of nutrition education, Prenatal nutrition, nutrition for women, Populations: Native American, rural, suburban Teaching Tips: Interactive course delivery, internet research. Masley, Steven MD, FAAFP, CNS Medical Director, Carillon Executive Health and Ten Years Younger, Trimmer, Fitter Program Assistant Professor, University South Florida 900 Carillon Parkway, Suite 108 St Petersburg, FL 33716 (727) 561-2424 (727) 561-2400 (fax)  HYPERLINK "mailto:steven.masley@baycare.org" \o "mailto:steven.masley@baycare.org" steven.masley@baycare.org Clinical expertise: Nutrition for anti-aging, women, geriatric nutrition, hyperlipidemia, obesity, diabetes, congestive heart failure, sports nutrition, supplements, herbals; chef Populations: All Teaching Tips: Challenging people to become younger, trimmer, and fitter through lifestyle changes. Moore, Sylvia - PhD, RD, FADA University of Wyoming Professor/Director,Division of Medical Education & Public Health [University of Washington School of Medicine Assistant Dean, WWAMI Academic/Regional Affairs] 1000 East University, Department 4238 Laramie, WY 82071 Phone: (307) 766-2496 Fax: (307) 766-2492  HYPERLINK "mailto:moores@uwyo.edu" \o "mailto:moores@uwyo.edu" moores@uwyo.edu Clinical expertise: Obesity prevention& management; principles of nutrition education; nutrition for women; sports nutrition; dyslipidemias; hypertension; supplements & herbals. Populations: Rural Rock, Cheryl, Ph.D, RD, FADA Professor Dept Family & Preventive Medicine University of California San Diego Dept 0901 9500 Gilman Drive La Jolla, CA 92093-0901 Phone: 858-822-1126 FAX: 858-822-1497 e-mail: clrock@ucsd.edu Clinical expertise: Nutrition for women, eating disorders, oncology, obesity Populations: Urban, suburban Shewmake, Roger, PhD, LN Director, Section of Nutrition USD School of Medicine Department of Family Medicine 1400 W. 22nd Street Sioux Falls, SD 57105-1570 Phone: 605-357-1500 FAX: 605-357-1510 e-mail:  HYPERLINK "mailto:rshewmak@usd.edu" \o "mailto:rshewmak@usd.edu" rshewmak@usd.edu Clinical expertise: Nutrition assessment, principles of nutrition education, nutrition for women, geriatric nutrition, diabetes, obesity, hypertension, hyperlipidemias, sports nutrition Populations: Urban, rural, suburban. African American, Asian American Teaching Tips: Diabetes Week Training Experience, nutrition rotation, group breakfast at fast food restaurant St. Jeor, Sachiko Ph.D., R.D. Professor and Chief Division of Medical Nutrition and Director, Center for Nutrition and Metabolic Disorders Department of Internal Medicine University of Nevada School of Medicine Redfield Bldg/153 Reno, NV 89557 Phone: 775 784-4474 FAX: 775 784-4468 email: sach@med.unr.edu Clinical Expertise: Weight management, renal nutrition, nutrition assessment, CVD Populations: Medical Clinics, clinical research and trials, epidemiological research studies Teaching Tips: Relate science to practice (poster presentations). Self- assessments are popular for residents, medical students, etc. Thomas, Lynn, DrPH, RD, CNSD Assistant Dean for Preclinical Curriculum Office of Curricular Affairs and Faculty Support School of Medicine University of South Carolina Medical Library Bldg. 101/306 Columbia, SC 29208 Phone: (803) 733-3367 FAX: (803) 733-1513 e-mail:  HYPERLINK "mailto:lthomas@gw.med.sc.edu" \o "mailto:lthomas@gw.med.sc.edu" lthomas@gw.med.sc.edu Clinical Expertise: Nutrition assessment, principles of nutrition education, nutrition for women, geriatric nutrition, tube feeding, TPN, kidney failure, and teaching through technology. Populations: Rural Teaching Tips: 1) Quick bedside assessment using rule of thumb calculations to write diet orders. 2) Three Web sites:  HYPERLINK "http://www.med.sc.edu/nutrition" \o "http://www.med.sc.edu/nutrition" www.med.sc.edu/nutrition  HYPERLINK "http://www.med.sc.edu/foodtools" \o "http://www.med.sc.edu/foodtools" www.med.sc.edu/foodtools and  HYPERLINK "http://www.med.sc.edu/diabetesmanagement" \o "http://www.med.sc.edu/diabetesmanagement" www.med.sc.edu/diabetesmanagement White, Jane Ph.D., RD Department of Family Medicine University of Tennessee 1924 Alcoa Highway Knoxville, TN 37920 Phone: 865-544-9352 FAX: 865-544-6532 e-mail: jwhite13@utk.edu Clinical Expertise: Nutrition assessment, principles of nutrition education, prenatal nutrition, lactation, infant/child nutrition, geriatric nutrition, nutrition for women, hypertension, hyperlipidemias, diabetes, obesity, eating disorders, congestive heart failure, alcoholism, supplements, herbals Populations: Urban, rural, suburban, African American, Asian American Teaching Tips: 1) 2 week nutrition elective 2) Teaching nutrition specific information in the exam room in a 1-2 minute intervention 3) Teaching on in-patient service roundsinformation specific to the patient. Resources This monograph can be found on the Society of Teachers of Family Medicine Web site ( HYPERLINK "http://fmdrl.org" http://fmdrl.org) with a detailed and current list of resources. The following resources were recommended by members of the Group on Nutrition and were active/available spring 2007. The faculty found these resources helpful in teaching nutrition at their program. This is not a comprehensive list. It seems an almost impossible task to keep web addresses current. Textbooks Bendich A, Deckelbaum RJ, eds. Preventive nutrition: a comprehensive guide for health professionals, 3rd ed. Totowa, NJ: Humana Press, 2005. Available at  HYPERLINK "http://www.humanapress.com" http://www.humanapress.com Mahan KL, Escott-Stump S, eds. Krauses food, nutrition, and diet therapy, 11th ed. St. Louis, MO: W. B. Saunders Company, 2004. Available at  HYPERLINK "http://www.us.elsevierhealth.com/" http://www.us.elsevierhealth.com/ Morrison G, Hark L. Medical nutrition & disease, 3rd ed. Oxford: Blackwell Science, 2003. Available at  HYPERLINK "http://www.blackwellpublishing.com/" http://www.blackwellpublishing.com/ Update expected in 2007 Shils ME. Modern nutrition in health and disease, 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005. Available in August 2005 at  HYPERLINK "http://www.lww.com" http://www.lww.com Wolinsky I. Nutrition in exercise and sport, 3rd ed. London: CRC Press, Inc., 1998. Available at  HYPERLINK "http://www.crcpress.com" http://www.crcpress.com Handbooks Moore S. Physician's guide to outpatient nutrition. Available through the AAFP Web site:  HYPERLINK "http://www.aafp.org" http://www.aafp.org Heimburger, DC. Handbook of clinical nutrition, 3rd ed. St. Louis, MO: Mosby, 1997. Available at  HYPERLINK "http://www.mosby.com" http://www.mosby.com Bartlett, S. Geriatric Nutrition Handbook, 5th ed. Chapman & Hall Publishers. Available at  HYPERLINK "http://www.jbpub.com" http://www.jbpub.com Watson RR. Handbook of nutrition in the aged, 3rd ed. London: CRC Press, 2000. Available at  HYPERLINK "http://www.crcpress.com" http://www.crcpress.com Chernoff, R. Geriatric nutrition: the health professionals handbook, 2nd ed. New York: Aspen Publishers, 1999. Available at  HYPERLINK "http://www.jbpub.com" http://www.jbpub.com. 3rd edition available in 2006. American Academy of Pediatrics: Pediatric nutrition handbook, 5th ed. Chicago, IL: American Academy of Pediatrics, 2003. Available at  HYPERLINK "http://www.aap.org" http://www.aap.org Trusswell, A Stewart. ABC of Nutrition, 4th ed. BMJ Books, 2003. Available at  HYPERLINK "http://www.bmjbookshop.com" http://www.bmjbookshop.com PACE (Patient-Centered Assessment and Counseling For Exercise and Nutrition) Program. Includes separate manuals for nutrition and physical activity with background information and counseling and patient education forms based on stages of behavior change. Order from San Diego State University, 55009 Campanile Dr., San Diego, CA 92182. Tel: (619) 594-5459; Fax: (619) 594-3639. Available at  HYPERLINK "http://www.paceproject.org/" http://www.paceproject.org. University of Wisconsin Medical Schools medical Nutrition Handbook. See  HYPERLINK "http://www.medicine.wisc.edu" www.medicine.wisc.edu BrightFutures. See. www.brightfutures.org Cookbooks American Heart Association Cookbook, 5th ed; Around the World Cookbook; Low-Fat, Low-Cholesterol Cookbook; Low-Salt Cookbook; And Quick & Easy Cookbook. Times Books, A Division Of Random House, Inc. Available at  HYPERLINK "http://www.amazon.com" http://www.amazon.com or  HYPERLINK "http://www.bn.com" http://www.bn.com BJ Ponichtera, RD. Quick and Healthy Recipes and Ideas (Volumes 1 and 2). Available from Scaledown Publishing, Inc. 1519 Hermits Way, The Dalles, Oregon 97058. Phone (541) 296-5859 and Web site  HYPERLINK "http://www.quickandhealthy.com" http://www.quickandhealthy.com Chauncey, K. Low Carb Dieting for Dummies. Hoboken, NJ: Wiley Publishing. 2004. Available at  HYPERLINK "http://www.fordummies.com" http://www.fordummies.com Web-Based Dietary Analysis Tools  HYPERLINK "http://www.mypyramidtracker.gov/" http://www.mypyramidtracker.gov/ Online dietary and physical activity assessment tool that provides information on diet quality, physical activity level, and relevant nutrition messages. Also contains links to nutrient and physical activity information.  HYPERLINK "http://www.cyberdiet.com/" http://www.cyberdiet.com Evaluates diet and physical activity and provides suggestions for making changes. Has a user fee with unlimited use for 3 months.  HYPERLINK "http://www.nal.usda.gov/fnic/foodcomp/" http://www.nal.usda.gov/fnic/foodcomp/ USDA Nutrient Data Laboratory website. Can search nutrient database for nutrient composition of individual foods. Does not analyze diets. Nutrition-Specific Journals American Journal of Clinical Nutrition: High quality research-oriented journal ( HYPERLINK "http://www.ajcn.org/" www.ajcn.org) Journal of The American College of Nutrition: Research and good review articles of interest to clinicians.  HYPERLINK "http://www.jacn.org/" http://www.jacn.org/ Journal of American Dietetic Association: publishes original research, review articles, practical applications and position statements of the ADA.  HYPERLINK "http://www.adajournal.org/" http://www.adajournal.org/ Nutrition in Clinical Care: target audience is primary care clinicians and those who teach them. Contains useful teaching material and patient education tools. ( HYPERLINK "http://www.blackwell-synergy.com/servlet/useragent?func=showIssues&code=ncc" http://www.blackwell-synergy.com/servlet/useragent?func=showIssues&code=ncc) Nutrition Reviews: timely reviews of topical research areas. http://www.ilsi.org Nutrition Today: reviews targeted to nutrition professionals.  HYPERLINK "http://www.lww.com/product/?0029-666X" http://www.lww.com/product/?0029-666X Newsletters Nutrition Action: Published by The Center for Science in the Public Interest Deals with issues important to consumers. Note: CSPI takes what some consider a very hard-line, anti-big business view. For the alternative view see  HYPERLINK "http://www.cspinot.com/" http://www.cspinot.com/. Environmental Nutrition Newsletter. Targeted for nutrition professionals. Provides brief accurate reviews of important nutrition topics. Available by subscription from Environmental Nutrition, 52 Riverside Drive, New York, NY 10024-6599.  HYPERLINK "http://www.environmentalnutrition.com/" www.environmentalnutrition.com Tufts University Health and Nutrition Letter.  HYPERLINK "http://www.healthletter.tufts.edu/" www.healthletter.tufts.edu. Organizations Society of Teachers of Family Medicine: Group on Nutrition.  HYPERLINK "http://www.stfm.org/" http://www.stfm.org. American College of Nutrition  HYPERLINK "http://www.am-coll-nutr.org/" http://www.am-coll-nutr.org/. American Society for Nutrition http://www.asn.org Awards the Roland Weinsier Award for Excellence in Medical/Dental Nutrition Education; hosts medical nutrition education symposia American Society of Parenteral and Enteral Nutrition.  HYPERLINK "http://www.clinnutr.org/" http://www.clinnutr.org/. American Dietetic Association.  HYPERLINK "http://www.eatright.org/" http://www.eatright.org American Diabetes Association.  HYPERLINK "http://www.diabetes.org/" http://www.diabetes.org/. American Heart Association.  HYPERLINK "http://www.americanheart.org/" http://www.americanheart.org/. American Gastroenterological Association.  HYPERLINK "http://www.gastro.org/" http://www.gastro.org/. National Lipid Education Council.  HYPERLINK "http://www.lipidhealth.org/" http://www.lipidhealth.org. National Cholesterol Education Program.  HYPERLINK "http://rover.nhlbi.nih.gov/chd/" http://rover.nhlbi.nih.gov/chd/. Centers for Obesity Research and Education.  HYPERLINK "http://www.uchsc.edu/core/" http://www.uchsc.edu/core/. National Diabetes Education Initiative.  HYPERLINK "http://www.ndei.org/" http://www.ndei.org. NIH Office of Dietary Supplements.  HYPERLINK "http://dietary-supplements.info.nih.gov/" http://dietary-supplements.info.nih.gov/. Center for Food Safety and Applied Nutrition, Food and Drug Administration. Dietary Supplements.  HYPERLINK "http://www.cfsan.fda.gov/~dms/ds-prod.html" http://www.cfsan.fda.gov/~dms/ds-prod.html Food & Nutrition Information Center.  HYPERLINK "http://www.nal.usda.gov/fnic/" http://www.nal.usda.gov/fnic/. National Center for Complementary and Alternative Medicine.  HYPERLINK "http://www.nccam.nih.gov/" www.nccam.nih.gov Grains Nutrition Information Center.  HYPERLINK "http://www.wheatfoods.org/" http://www.wheatfoods.org/. International Food Information Council Foundation. http://www.ific.org . Source of food information. Producer of many AAFP-F approved patient education materials on food ingredients. Also sponsor of interactive web site for Kids Healthy Weight  HYPERLINK "http://www.kidnetic.com" www.kidnetic.com Society for Nutrition Education and Behavior Change. www.sne.org Computer-Based Education Nutrition In Medicine Series: Nutrition & Cancer, Nutrition & Stress, Nutritional Anemias, Diet, Obesity and Cardiovascular Disease, Maternal And Infant Nutrition, Diabetes and Weight Managemen; Sports Nutriiton; Childhood Obesity. By Steven Zeisel. Educational Modules CD-ROM Windows & Macintosh. And moving to the Web in 2005-2006.  HYPERLINK "http://www.med.unc.edu/nutr/nim/" http://www.med.unc.edu/nutr/nim/ Nutrition Principles and Clinical Nutrition courses from Stanford University are available on CD for those medical schools who wish to use them. Terms of Use require mounting the courses on local password protected servers and complying with copyright. Contact  HYPERLINK "mailto:stanford_nutrition@lists.stanford.edu" stanford_nutrition@lists.stanford.edu. Cases on NAA sites. For example Nutri-case  HYPERLINK "http://www.alexor.com/nutricase/prototype/index2.htm" http://www.alexor.com/nutricase/prototype/index2.htm Computer training for growth charts.  HYPERLINK "http://depts.washington.edu/growth/" http://depts.washington.edu/growth/ Web sites for Physician Education  HYPERLINK "http://arborcom.com/" http://arborcom.com is the home of the Arbor Nutrition Guide that has a comprehensive listing of nutrition sites specifically suitable for health professionals, including a section for family physicians. An e-mail subscription service offering evidence-based updates on significant new nutrition articles is also available.  HYPERLINK "http://www.nal.usda.gov/fnic/etext/000023.html" http://www.nal.usda.gov/fnic/etext/000023.html lists food guide pyramids for ethnic diets and the Mediterranean diet.  HYPERLINK "http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm" http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm is the home page for the DASH diet. Those not familiar with the dietary approaches to stop hypertension trial need to review. Look here for patient education material.  HYPERLINK "http://www.almondsarein.com/" http://www.almondsarein.com/ is the Web site for the California Almond Board. Follow the links here to a printable Adobe Acrobat dietary assessment tool based on the DASH diet.  HYPERLINK "http://www.nutriwatch.org/" http://www.nutriwatch.org/ from the same people who brought you Quack Busters, a site dedicated to evidence-based nutrition advice.  HYPERLINK "http://www.pcrm.org/" www.pcrm.org contains information from the Physicians Committee for Responsible Medicine, a group that protests animal research and supports a vegetarian lifestyle. Contains interesting material on the health benefits of a vegetarian diet. Nutrition information is not always science based.  HYPERLINK "http://cancer.med.upenn.edu/" http://cancer.med.upenn.edu/ is the Web site of Oncolink: a University of Pennsylvania Cancer Center resource. This site gives information on the link between diet and cancer, as well as information on nutrition for people with cancer.  HYPERLINK "http://www.ag.ndsu.nodak.edu/foodlink.htm" http://www.ag.ndsu.nodak.edu/foodlink.htm is a page of links set up by the North Dakota Agricultural Extension Service.  HYPERLINK "http://www.calciuminfo.com/" http://www.calciuminfo.com/ sponsored by a pharmaceutical company, this site provides lots of good information (in both English and Spanish) about this important nutrient.  HYPERLINK "http://www.nhlbi.nih.gov/funding/training/naa/" http://www.nhlbi.nih.gov/funding/training/naa/. Nutrition Academic Award homepage with links to each of the awardees. Growing resource for nutrition education material.  HYPERLINK "http://www.med.upenn.edu/nutrimed/" http://www.med.upenn.edu/nutrimed/ University of Pennsylvania s Web site provides educational resources for health care professionals who teach nutrition. Web Sites for Nutrition Education for Patients  HYPERLINK "http://www.healthfinder.gov/" http://www.healthfinder.gov Search on nutrition for a comprehensive list of links to nutrition information and resources. Site maintained by the US Department of Health and Human Services.  HYPERLINK "http://www.usda.gov/" http://www.usda.gov Home page for the US Department of Agriculture. Wide range nutrition information for health professionals and the public.  HYPERLINK "http://www.nutrition.gov/home/index.php3" http://www.nutrition.gov/home/index.php3 US Department of Agriculture. Provides nutrition information for the public.  HYPERLINK "http://www.nal.usda.gov/fnic/etext/fnic.html" http://www.nal.usda.gov/fnic/etext/fnic.html US Department of Agriculture. Has links to Food and Nutrition Topics from A to Z.  HYPERLINK "http://www.niddk.nih.gov/health/nutrition.htm" http://www.niddk.nih.gov/health/nutrition.htm National Institute of Diabetes & Digestive & Kidney Diseases. Nutrition section of this web site has information for health professionals and the public.  HYPERLINK "http://www.nhlbi.nih.gov/health/public/heart/index.htm" http://www.nhlbi.nih.gov/health/public/heart/index.htm National Heart, Lung, and Blood Institute. Has information about diet for hypertension (DASH Diet and sodium), for cholesterol, and for obesity.  HYPERLINK "http://monarch.gsu.edu/multiculturalhealth" http://monarch.gsu.edu/multiculturalhealth Nutrition Education for New Americans Department of Anthropology and Geography at Georgia State University. Includes downloadable nutrition education materials in foreign languages, food pyramid guide, and order form. Provides resources for professionals who work with non-English speaking and low-income clients. Handouts are available for download.  HYPERLINK "http://extension.oregonstate.edu/fcd/nutrition/" http://extension.oregonstate.edu/fcd/nutrition/ Oregon State University Extension Family and Community Development. Has nutrition education resources for various cultures and information about teaching nutrition to low-income families.  HYPERLINK "http://www.eatright.org/" http://www.eatright.org American Dietetic Association. Healthy Lifestyles section has nutrition information and resources for the public. Evidence-Based Medicine www.nlm.nih.gov/ PubMed www.guideline.gov National Guideline Clearinghouse (NGC) http://cancernet.nci.nih.gov/ CancerNet  HYPERLINK "http://healthweb.org/browse.cfm?subjectid=39" http://healthweb.org/browse.cfm?subjectid=39 Health Web s Evidence-Based Medicine http://www.jfponline.com Family Practice Journal Club Online http://www.fpin.org http://www.cochrane.org The Cochrane Collaboration  HYPERLINK "http://www.cebm.net/" http://www.cebm.net/ Center for Evidence-Based Medicine http://www.usda.gov/fsis US Department of Agriculture Food Safety & Inspection Service http://vm.cfsan.fda.gov/list.html Center for Food Safety and Applied Nutrition http://www.cdc.gov/ Centers for Disease Control and Prevention http://foodsafety.org National Food Safety Database http://www.fightbac.org Partnership for Food Safety Education  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm" http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm National Cholesterol Education Program guidelines  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf" http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf National High Blood Pressure Education guidelines  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm" http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Obesity guidelines Geriatrics http://www.aoa.dhhs.gov/ Administration on Aging http://www.agingwithdignity.org/ Aging with Dignity http://www.alz.org Alzheimer s Association http://www.americangeriatrics.org American Geriatrics Society http://www.arthritis.org/ Arthritis Foundation http://www.asaging.org American Society on Aging http://www.niddk.nih.gov/ National Institute of Diabetes, Digestive, & Kidney Diseases Handheld Computer Software Many medical schools and health sciences libraries have created a Web site with links to PDA resources Sites with nutrition software  HYPERLINK "http://www.handago.com" www.handago.com Searchable. Contains 75+ entries related to nutrition including ideal height, weight, body frame and ideal target weight calculators; recipe managers; Kidnorms ($17.95); fitness planners and daily nutrition trackers; and nutrient databases for various foods. Some reviews available ICU-Fluids-Electrolytes-Nutrition by Pacific Primary Care 12.95). Includes nutritional and vitamin deficiencies, nutritional support, detailed work ups of electrolyte abnormalities, dehydration. Required full version of iSilo reader to run. No reviews available.  HYPERLINK "http://www.med-ia.ch/medcalc/" http://www.med-ia.ch/medcalc/ MedCalc is a medical calculator. Calculations relevant to nutrition include Body Mass Index (BMI), LDL cholesterol, Harris Benedict Equation for Basal Energy Expenditure, Ideal Body Weight, Total body surface. Free. Note: the Harris Benedict Equation does NOT ALLOW input of BOTH an injury factor and an activity factor. Resulting calculations may UNDERESTIMATE patient calorie needs.  HYPERLINK "http://www.healthetech.com/" www.healthetech.com BalanceLog. A weight management system that allows setting of personal nutrition goals, weight loss goals, tracking of daily food consumption. $49. No reviews available.  HYPERLINK "http://www.epocrates.com" www.epocrates.com Downloads for prescription medicine guidelines. Extent of drug-nutrient interaction information unknown. No reviews available.  HYPERLINK "http://www.healthypalmpilot.com/" www.healthypalmpilot.com Now part of pdaMD.com network. This site has a list of health related software (free and for a charge). There is a program Vitamins that uses the 1999 RDAs. There are several BMI calculators. There are several logs for patients to track progress. Some reviews.  HYPERLINK "http://www.dietarysoftware.com/" www.dietarysoftware.com BEE, IBW, enteral formulas, weight change, BMI, Catabolic Index, MeQ conversions. $229 for Palm and software, $99 software only.  HYPERLINK "http://www.hightechnutrition.com/" www.hightechnutrition.com Nutrition assessment software for the professional nutritionist. $149.99. No reviews available.  HYPERLINK "http://www.solutionsinhand.com/" www.solutionsinhand.com Use their spreadsheet MiniCalc to create a custom spreadsheet to calculate TPN.  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm" http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm Risk calculator for the cholesterol treatment guidelines; 2001 cholesterol treatment guidelines including the Therapeutic Lifestyle Change diet.  HYPERLINK "http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm" http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm BMI calculator. NOTE it does not calculate BMI for children or short individuals. Includes obesity assessment and treatment guidelines.  HYPERLINK "http://statcode.hypermart.net/growthcharts.htm" http://statcode.hypermart.net/growthcharts.htm CDC 2000 growth charts. Has graphic display. Gives percentiles and z-scores. Requires 130K. Free. Journal Articles Journal articles specific to nutrition in primary care are published in a variety of journals. Visit the AAFP Web site ( HYPERLINK "http://www.aafp.org/" www.aafp.org) and search on the keyword "Nutrition" to find articles published in the American Family Physician. Also good articles for primary care in Nutrition in Clinical Care  HYPERLINK "http://www.blackwell-synergy.com/servlet/useragent?func=showIssues&code=ncc" http://www.blackwell-synergy.com/servlet/useragent?func=showIssues&code=ncc Kolasa KM. Strategies to enhance effectiveness of individual based nutrition communication. 4th Heelsum Nutrition and Family Medicine conference. European J Clinical Nutr. 2005;59(8):s24-30. Deen D, Spencer E, Kolasa K. Nutrition education in Family Practice Residency Programs. Fam Medicine. . 2003; 35(2): 105-111. Deen D, Hark L. Taking a Nutrition History: A Practical Approach for Family Physicians March 15, 1999 - American Academy of Family Physicians  HYPERLINK "http://www.aafp.org/afp/990315ap/1521.html" http://www.aafp.org/afp/990315ap/1521.html . Flocke SA, Clark A, Schlessman K, Pomiecko G. Exercise, diet and weight loss advice in the Family Medicine outpatient setting. Fam Med. 2005;37(6):415-421. Kolasa KM. Developments and challenges in family practice nutrition education for residents and practicing physicians: an overview of North American experiences. European J. Clinical Nutrition, 1999;53(S2):S89-S96. Includes extensive reference list. Kolasa KM, Weismiller D. Prenatal care and nutrition. Am Fam Phys 1997; 56:205-212, 216-218. Kolasa K, Lasswell A. 1995. Dietitian as medical educator. Topics in Clin Nutr. 10(3):20-28. Includes extensive reference list. Appendix Recommended Core Education Guidelines for Family Practice Residents. AAFP Reprint No. 275. Rotation Planning: Nutrition in Medicine Needs Questionnaire Nutrition and ACGME Competencies by Darwin Deen IV. Evaluation form for Community Medicine Nutrition. Brown Medical School V Evaluation form for Nutrition Didactic. Brown Medical School APPENDIX I Recommended Core Educational Guidelines for Family Practice Residents AAFP Reprint No. 275 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 basic skills necessary to assess nutritional status and provide nutrition therapy. Attitudes The resident should develop attitudes that recognize the following: A. Nutrition is an integral part of: 1. Health promotion and disease preventionmortality 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. B. 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) C. Nutrition consultants should be used, 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: The roles of dietary components: carbohydrates, fats, proteins, vitamins, minerals, water and fiber Dietary reference intakes Nutritional content of foods Dietary recommendations (e.g., dietary guidelines for Americans, food pyramid, DASH diet, Step I and II diets) Nutritional assessment Medical/social history and physical examination Anthropometrics (e.g., height/weight, body mass index [BMI], head circumference, body-fat distribution) Ordering and evaluating laboratory tests (inpatient and outpatient) Nutritional issues of different stages of the life cycle Infancy (e.g., breastfeeding, bottle-feeding, adding solids, allergy prevention) Children (e.g., picky eating, pica, snacks) Adolescents (e.g., healthy choices, eating disorders) Adults (e.g., portion size, habits, and convenience foods) Pregnancy (e.g., weight gain, folic acid, iron, calcium) Lactation (e.g., nutritional needs, support, counseling) Elderly (e.g., psychosocial issues, co-morbid conditions, swallowing disorders) The role of nutrition in the prevention and treatment of specific diseases Cancer Cardiovascular disease Dental disease Diabetes Gastrointestinal disorders Hematologic disorders Hypertension Liver disease Obesity Osteoporosis Renal disease Secondary malnutrition caused by systemic diseases Alcoholism XE "Alcoholism"  Cancer HIV/AIDS Malabsorption Pulmonary disease Weight loss strategies and counseling Behavior modification and goal setting Diet drugs (prescription, herbal, and over-the-counter) Popular diets and supplements Surgical approaches Disordered eating Anorexia nervosa XE "Anorexia nervosa"  Binge eating Bulimia Use of dietary supplements, including: Vitamin and mineral deficiency, toxicity, and recommended intakes Guidelines for herbal, alternative, and other supplements, including drug interactions, safety and efficacy Evidence-based nutrition resources and signs of quackery Preventing and recognizing and treating foodborne illness Allergies and food intolerance Physical activity and sports Recommendations for health and weight loss Nutritional needs for various levels of activity (i.e., elite athletes) and for different ages 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 parenteral 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 vitamins and prescribing vitamins, minerals, and other dietary and botanic supplements when needed Collaborating with registered dietitians 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 experiential 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 find ways to integrate nutrition information into patient care. Resources Physicians 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 ed. Chicago, IL: The American Dietetic Association, 1996. Mahan LK and Escott-Stump S. Krauses Food, Nutrition and Diet Therapy, 10th ed. Harcourt, Brace and Co., 1999. Modern Nutrition in Health and Disease, 9th ed. Williams & Wilkins, 1999. Medical Nutrition and Disease, Blackwell Science Inc., 1996. Web sites American Dietetic Association: http://www.eatright.org Arbor Nutrition Guide:  HYPERLINK "http://www.arborcom.com" http://www.arborcom.com National Center for Complementary and Alternative Medicine:  HYPERLINK "http://nccam.nih.gov" http://nccam.nih.gov Office of Disease Prevention and Health Promotion:  HYPERLINK "http://www.odphp.osophs.dhhs.gov" www.odphp.osophs.dhhs.gov USDA Center for Nutrition Policy and Promotion:  HYPERLINK "http://www.usda.gov/cnpp" www.usda.gov/cnpp CNN health-related site:  HYPERLINK "http://www.cnn.com/HEALTH/diet.fitness" www.cnn.com/HEALTH/diet.fitness Published 8/89 Revised 7/95 Revised 06/00 APPENDIX II ROTATION PLANNING From: ________________________________________ (Nutrition Coordinator) Subject: Nutrition in Medicine Needs Questionnaire Name: ________________________________________Date: ___________ Help me meet your needs for nutrition information during your nutrition rotation as well as the rest of your residency. Rank the following list with OK or More: OK=Feel I know enough about this More=Feel I need to know more Put an * by your 3-4 top priorities for more. Knowledge _____Nutrition therapy for diabetes _____Nutrition therapy for heart disease: treatment and prevention _____Nutrition therapy for hypertension _____Nutrition for wasting diseasesCOPD, HIV and AIDS, cancer _____Nutrition therapy for various gastrointestinal diseases Nutrition for prevention throughout life cycle _____Infants _____Breastfeeding _____Childhood _____Adolescence _____Pregnancy and lactation _____Menopause _____Aging _____Vitamin and mineral supplements _____Weight loss diets, medications for weight loss, and obesity _____Selection and use of enteral supplements; e.g., Ensure, etc. _____Drug-nutrient and drug-food interactions _____Nutrition and alcoholism _____Management of eating disorders; e.g.,anorexia, bulimia, binge eating _____Nutrition problems in infancy- failure to thrive, anemia, obesity, diarrhea _____Popular and commercial diet businesses and health foods claims _____Allergies and food intolerances _____Specific nutrients and food sources; e.g., fiber, calcium, iron, protein, etc. _____Nutrition for sports and athletic performance _____Community nurtition resources; e.g., WIC, Meals on Wheels, etc. _____Determining calorie requirements based on growth, illness, weight loss, etc. Skills _____Integrating nutrition assessment into a complete history and physical in ambulatory setting _____Take diet history and give appropriate advice based on disease process _____Assess nutritional status of hospitalized patients _____Write appropriate diet orders for institutionalized patients, including enteral feedings _____Provide nutrition guidance for prevention based on gender, age, and risk of disease _____Monitor growth, weight changes; use of Body Mass Index _____Interpret lab tests for nutrition related conditions Have you had a college level course in nutrition? _____Yes _____No Did you have a nutrition course in medical school? _____Yes _____No Developed by Elizabeth Spencer, RD, MS, CDE, Eau Claire, Wisconsin APPENDIX III How Can Nutrition Education Contribute to Competency-based Resident Evaluation? Adapted from a presentation by Darwin Deen MD, MS The objectives of this section is to briefly review the ACGME domains of competency based evaluation, discuss the rationale for using the provision of nutritional care as a method of documenting resident progress in achieving competence in specific domains, demonstrate how the Nutrition Academic Award objectives can be used to measure resident competence, and discuss how to practically assess resident progress in achieving selected nutritional care competencies. Competency-based assessment of residents nutrition education is key for several reasons. Tests have a powerful influence on student learning, and as a result, the development tests that will further residents educational goals is important. The introduction of a hands-on clinical skills test drives students out of the library into the clinic, where they may seek help with their physical-exam skills. Conversely, the introduction of a test assessing only recall of isolated facts drives them to cram course review books. Finally, students paths toward mastery or even excellence will be less rocky if they receive ongoing feedback on their progress. It has been said that It is in the evaluation system that the real objectives of any program are displayed, and the truly important values become apparent (1) The dimensions of clinical competence include the relevant abilities of the physician, problem-solving tasks, the nature of the illness, and social and psychological aspects. Relevant abilities of the physician include knowledge, and interpersonal and technical skills. Problem solving tasks related to clinical competence include data gathering, diagnosis, and continuity of care. Scope of care and practice setting are elements vital to clinical competence related to the nature of the illness. Social and psychological skills are related to diagnosis and management. Within each discipline, faculty must determine the body of nutrition knowledge required for practice within their specific specialty. ACGME domains include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Competency-based nutritional care is at the forefront of resident education for several reasons. Physicians are increasingly recognizing the importance that diet and exercise play in influencing the prevention, risk and management of a variety of chronic diseases. Providing good nutritional care to patients is a part of the professional responsibility of every physician. Residency program faculty may seek to address the ACGME domains in their own nutritional care efforts. Demonstration of proficiency in nutritional care can be used to reflect competency in each of the ACGME domains. Nutrition education satisfies multiple ACGME competencies. The following is a brief description of the ACGME domains and the ways in which nutrition objectives can reflect each of those domains. The first ACGME competency to be discussed relates to patient care. It stipulates that patient care should be compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Nutrition objectives that relate to this competency include engaging patients in discussions about dietary change and the impact of lifestyle on health promotion and disease prevention. A second ACGME competency relates to medical knowledge. It requires that physicians be in command of medical knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and be able to apply this knowledge to patient care. 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hq5@CJ0\D&'xxe{f{}ij ^gdqutrition objectives that relate to the knowledge of appropriate nutritional interventions for specific disease states will demonstrate a physicians competency in medical knowledge. The practice-based learning and improvement competency involves the investigation and evaluation of a physicians own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. The use of best available evidence-based nutritional guidelines for patient care and incorporation of new information will demonstrate this competency. Evaluation of residents abilities to satisfy nutrition competencies will include, for example, feedback from preceptors regarding the frequency with which given nutrition competencies are achieved and will demonstrate practice-based learning if evaluations are tracked over time and used to document improvement. A fourth ACGME competency requires that physicians engage in effective interpersonal and communication skills that result in efficient information exchange when teaming with patients, their families, and other health professionals. Including nutritional care as part of health maintenance visits, use of the Stages of Change model to assess patients readiness to make changes, making appropriate referrals to dietitians (or others) to assist patients with lifestyle change goals will document interpersonal and communication skills in teaming with patients and with other health professionals. The ACGME professionalism competency is manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. By developing and maintaining nutrition knowledge, physicians are demonstrating professionalism, and by providing patients with evidence-based nutritional information, they are adhering to the ethical principles of the profession. Gaining knowledge about the various cultural aspects of their patients diets will allow residents to demonstrate cultural competence and professionalism. Nutritional care for patients demonstrates professionalism by acknowledging that it is the responsibility of the physician to prevent as well as treat disease and to help empower patients to take control of their health care and disease management. Residency programs have a responsibility to train residents in common cultural eating patterns of the diverse patient populations that they provide care for. The systems-based practice competency is evident through actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Use of community resources such as knowledge about and referral to Meals-on-Wheels and Senior Center congregate meals programs and WIC programs will demonstrate the systems-based practice competency as related to nutrition. Several NAA objectives have been rewritten as ACGME competencies. These include objectives in the areas of community and population health, behavioral principles, nutritional assessment, pediatrics, and hypertension. The first NAA community and population health objective involves the provision of effective preventive nutrition counseling appropriate for any well or diseased individual. The corresponding ACGME competencies require that the resident knows the food groups included in the Food Guide Pyramid and understand the limitations of the current Food Guide Pyramid and how to characterize a well-balanced diet. This competency addresses medical knowledge. Also related to medical knowledge and community and population health, residents must be able to state the TLC diet recommended by the NCEP-ATP III and state the DASH diet and lifestyle modifications recommended by JNC VII A second NAA community and population health objective involves residents ability to recognize the importance of nutrition and community nutrition services in health promotion, disease prevention, and disease management. To satisfy this ACGME competency, the resident must be able to use the health maintenance visit as an opportunity to assess patients diet and exercise habits and be able to make appropriate recommendations for modifying both. This also addresses patient care. In the arena of systems-based practice, a resident must be able to appropriately refer patients with identified nutritional needs to a Registered Dietitian. An NAA objective related to behavioral principles addresses the residents need to be competent in assessing a patient's readiness for change and matching the counseling intervention to the patients current stage in the continuum of change. A resident who satisfies the corresponding ACGME competency can state the stages of change and demonstrate what questions to ask to determine what stage the patient is at. This objective relates to the interpersonal and communication skills of the resident. A resident must also be able to give an explanation of what data caused them to formulate that opinion to satisfy medical knowledge requirements. A second NAA objective related to behavioral principles deals with the requirement that the resident be able to effectively counsel patients to set realistic nutritional goals and timelines for behavioral change. The complimentary ACGME competency stipulates that residents must be able to describe a stage-appropriate intervention considering the patients current diet. This competency particularly addresses the residents abilities in patient care and professionalism. In the areas of interpersonal and communication skills, a resident should be able to recognize when a patients goals are unrealistic and be able to provide appropriate guidance on realistic goals. The NAAs nutritional assessment objective specifies that residents be able to perform a complete nutritional assessment on all ambulatory and hospitalized patients, including those with acute or chronic disease as well as healthy individuals of all ages. Corresponding ACGME competencies relate to patient care and state that residents inquire about the dietary and exercise habits of patients with hypertension, diabetes, hyperlipidemia, etc. and, when appropriate, do a 24-hour dietary recall. Residents should also be expected to evaluate patients Ht, Wt, BMI, Waist Circumference, and Risk Factors. An NAA objective in pediatrics states that physicians must effectively counsel families with children to develop and maintain healthy eating habits. The compatible ACGME competencies require that residents asks age appropriate questions regarding the childs diet and provides accurate information to parents regarding healthy intake for children of different ages in addressing medical knowledge and interpersonal and communication skills. A second competency states that the resident must be aware of the prevalence of iron deficiency and other nutritionally-related pathology in the patient populations he or she serves. This competency falls within the domains of patient care and medical knowledge. An NAA objective related to hypertension states that a physician must be able to provide effective individualized dietary counseling for hypertensive patients, focusing on body weight, energy balance, and dietary intake of fruits, vegetables, sodium, potassium, calcium, magnesium, and total and saturated fat. The corresponding ACGME competencies require that when evaluating a patient with hypertension, the resident will evaluate the patients dietary intake (including alcohol) and activity level with sensitivity to cultural norms. This addresses patient care, medical knowledge and professionalism. A second competency states that a resident must be able to discuss dietary management with a patient with hypertension and be able to recognize the roles of the major important nutrients. This competency addresses medical knowledge. The standardized patient examination is a vital part of medical education. Standardized patients are trained to simulate a medical condition and used to assess history-taking and physical examination skills, communication skills, differential diagnosis, lab utilization, and treatment recommendations. In this situation, the raining of evaluators is critical (whether done by the SP or an observer) to the efficient and reliable appraisal of residents clinical skills. In the evaluation of overweight and/or obese children, adolescents, or adults, residents must be able to perform an appropriate physical examination, measure the patients body weight and waist circumference, determine the percent body fat, calculate the BMI, estimate the patients body fat distribution, and evaluate the patient for other signs and symptoms of weight related morbidity. The ACGME competencies required in the evaluation of overweight and/or obese individuals involve the resident being aware of the NHLBI practice guidelines for management of obesity and consideration of secondary effects of obesity when recommending weight management modalities. This competency addresses the issue of medical knowledge. Residents must also be able to effectively screen obese patients for cardiovascular disease and recommend appropriate therapy when identified to address issues of patient care. In addition, residents must utilize community resources to assist patients interested in weight loss as related to a systems-based practice. Finally, residents must be knowledgeable about the pharmacologic agents available to assist in the management of obesity, know the indications for bariatric surgery and effectively answer patients questions regarding obesity management. This is vital when evaluating the interpersonal and communication skills of residents. NAA objectives addressing contemporary trends require that physicians effectively communicate with patients the benefits and effects of various popular dietary supplements, complementary and alternative medicines, and commonly used weight reduction programs. Corresponding ACGME competencies stipulate that residents include questions about the use of dietary supplements in their routine histories, be prepared to answer questions that their patients ask about dietary supplements, and use evidence based approaches to determine the effectiveness of weight reduction programs and complementary and alternative medicines. Suggestions on how to incorporate these competencies into recorded observations in the residents evaluation folders include creating a checklist for different types of visits and including nutrition on a computer-based evaluation form with a drop-down menu by diagnosis. Suggestions for ensuring consistency in faculty expectations include observed precepting and requiring faculty development. 1. Neufeld VR Assessing Clinical Competence. Springer Pub NY 1985 p.7. APPENDIX 4 Brown Medical School Memorial Hospital of Rhode Island Family Medicine Resident Evaluation Community Medicine Nutrition. PGY3 Evaluator: ____________________________________________________ Resident: _____________________________________________________ Session Date: ____________________________________ CompetencyNeeds AttentionCompetent for level of trainingExceeds competence for level of trainingNot ObservedDemonstrates ability to apply knowledge of nutrition care in the outpatient setting through patient education and counseling using case studies and Nutricase computer program. Patient careDemonstrates the ability to problem solve around assessment of the stage of readiness to change, literacy level, and culture of patients. Patient careDemonstrates the ability to plan and initiate nutrition education and counseling, and referral to appropriate persons or agencies. Systems-Based PracticeDemonstrates the ability to evaluate, locate and use patient education tools appropriate to a patients ethnicity, stage of readiness and literacy level. Problem Based LearningDemonstrates the ability to identify appropriate resources or search tools for maintaining up to date knowledge of medical nutrition therapy for various diagnoses. Practice-Based Learning Comments: Signature of evaluator:___________________________________Date:____________________ Aug. 2006/deLessio APPENDIX 5 Brown Medical School Memorial Hospital of Rhode Island Resident evaluation Family Medicine PGY 1 Nutrition Didactic session Educator: _________________________________________________________ Resident: _________________________________________________________ Session Date: ______________________________________________________ Competency Needs AttentionCompetent for Level of TrainingExceeds Competence for Level of TrainingNot ObservedAble to define the classes of nutrients, give major functions of each, and recommend appropriate nutrient dense sources. Medical knowledgeAccurately discusses the requirements for and consequences of excess or deficiency of the various nutrients. Medical knowledgeKnowledgeably discusses the most recent Dietary Guidelines for Americans. Medical knowledgeDemonstrates the ability to apply the Dietary Guidelines for Americans and the ATP III guidelines to assess the residents own diet. Patient CareCorrectly explains the rationale for therapeutic diets for dyslipidemia, hypertension, obesity and diabetes. Medical knowledgeDemonstrates the ability to determine appropriate referrals to dietitians or appropriate nutrition related agencies. 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