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Open access Review
Reference to nutrition in medical BMJNPH: first published as 10.1136/bmjnph-2021-000234 on 8 March 2021. Downloaded from
accreditation and curriculum guidance:
a comparative analysis
1,2 1 2 1
Breanna Lepre , Kylie J Mansfield, Sumantra Ray, Eleanor Beck
To cite: Lepre B, Mansfield KJ, ABSTRACT What this paper adds
Ray S, et al. Reference to Objective Poor diet is a leading cause of death worldwide.
nutrition in medical accreditation Doctors are well placed to provide dietary advice, yet
and curriculum guidance: nutrition remains insufficiently integrated into medical ► Doctors are well- placed to provide dietary advice,
a comparative analysis. education. Enforcement of curriculum or accreditation yet nutrition remains insufficiently integrated into
BMJ Nutrition, Prevention & requirements such as nutrition requires relevant regulatory medical education.
Health 2021;0. doi:10.1136/ frameworks. The aim of this review was to identify ► Despite an emphasis on meeting the needs of the
bmjnph-2021-000234 community and the demands of the labour market,
1School of Medicine, University nutrition content or requirements for nutrition education in review of global medical regulation identified less
of Wollongong, Wollongong, New accreditation standards or formal curriculum guidance for than half of accreditation and curriculum guidance
South Wales, Australia medical education internationally. included nutrition.
2NNEdPro Global Centre for Design Non- systematic comparative analysis. ► To incentivise inclusion of nutrition in medical ed-
Nutrition and Health, Cambridge, Data sources An internet search using the Google ucation, it must be embedded within curriculum or
UK Search engine, the WHO Directory of Medical Schools accreditation requirements, and part of relevant reg-
and Foundation for Advancement of International Medical ulatory frameworks.
Correspondence to Education and Research Directory of Organizations that ► This top-do wn approach may be necessary to finally
Breanna Lepre, School of Recognise/Accredit Medical Schools was conducted
Medicine, University of through September 2020 to identify government and make progress to increase nutrition knowledge and
Wollongong, Wollongong, NSW organisational reports as well as publications from skills in medical professionals.
2522, Australia; regulatory and professional bodies relevant to medical
bl778@ uowmail. edu. au education.
Eligibility criteria Eligible publications included (A) non- communicable diseases could be prevented
Received 11 January 2021 accreditation standards, (B) competency standards or a by following a healthy diet, staying physically http://nutrition.bmj.com/
Revised 10 February 2021 framework, (C) curricula, and (D) assessment content. active, avoiding tobacco and consuming alcohol
Accepted 17 February 2021 2
Data extraction and synthesis We stratified findings in moderation. The United Nations (UN)
by country or region and both preregistration and Decade of Action on Nutrition and the ICN2
postregistration education. Findings were synthesised Framework for Action underscore the need for
based on the existence of nutrition content or scalable health workforce capacity in nutrition
requirements for nutrition education within systems used 3 4
to end malnutrition in all its forms. Doctors
to guide medical education internationally. are well placed to provide dietary advice and
Results This review found that despite an emphasis on are perceived by those in their care to provide on September 30, 2022 by guest. Protected by copyright.
meeting the needs of the community and the demands of trustworthy and individualised nutrition
the labour market, only 44% of accreditation and curriculum care.5 6 General practitioners, in particular, have
guidance included nutrition. Nutrition remains inadequately the potential to elicit improvements in nutrition
represented in accreditation and curriculum guidance for behaviour and risk factors in individuals with
medical education at all levels internationally. Accreditation lifestyle- related chronic disease, and are powerful
standards provide a mandated framework for curricula and 5
inclusion of nutrition in accreditation frameworks provides an role models. Their regular contact with large
incentive for the integration of nutrition into medical education. numbers of individuals also provides opportuni-
Conclusions This review is a call to action for the medical ties for referral to other nutrition services, such
profession including government, health agencies and as dietitians, where further expertise is required.
educational and accreditation entities. The inclusion of nutrition Despite this, there is evidence that physicians
in medical education has appeared throughout medical are not capitalising on opportunities to provide
education literature for more than five decades, yet without nutrition care to patients with chronic disease.
consensus standards there is little likelihood of uniform For example, obese patients reported receiving
© Author(s) (or their adoption. dietary counselling during only 25% of clinic
employer(s)) 2021. Re- use 7
visits and a Centers for Disease Control and
permitted under CC BY- NC. No INTRODUCTION Prevention report has noted a 10% decrease
commercial re- use. See rights 1
and permissions. Published by Poor diet is a leading cause of death worldwide. in the frequency of preventive counselling
The WHO estimates that approximately 80% of 8
BMJ. provided between 1996–1997 and 2007–2008.
Lepre B, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2021-000234 1
BMJ Nutrition, Prevention & Health
In order to provide nutrition care as part of routine clinical it will always be difficult to implement. Fundamental to BMJNPH: first published as 10.1136/bmjnph-2021-000234 on 8 March 2021. Downloaded from
practice, doctors require the relevant nutrition knowledge, improvements in medical nutrition education and subse-
skills and attitudes (competence). However, despite the quent nutrition practice behaviour is the need to first
centrality of nutrition to health, it remains insufficiently inte- identify any formal expectations for nutrition education
grated into medical education, regardless of country, setting by regulatory bodies including accrediting bodies, and
9
or year of medical education. Deficits in medical nutrition representatives of the medical profession. Accreditation
education present an ongoing barrier to the provision of standards (regulations) provide an incentivised blue-
9
nutrition care in practice. print for curricula, by setting a benchmark for outcomes,
According to the World Directory of Medical Schools, the process of educational delivery and in some cases
13
a joint initiative of the World Federation for Medical required programme content. Amending accredita-
Education (WFME) and the Foundation for Advance- tion standards to require nutrition education as a formal
ment of International Medical Education and Research outcome would provide incentive to include nutrition in
(FAIMER), there are 3387 medical schools currently oper- medical education programmes in order to receive and
10
ational internationally. Accreditation systems are used maintain accreditation. Therefore, the aim of this review
to ensure the quality of medical education, facilitated was to identify nutrition content or requirements for
by medical schools, and can be institutional or program- nutrition education in accreditation standards or formal
11
matic and voluntary or mandatory. Accreditation has curriculum guidance for medical education internation-
11
been linked to improved medical student outcomes. ally. It is anticipated that the results of this review will
According to the WHO and WFME, the purpose of accred- provide insight into formal opportunities to integrate
itation and quality improvement in medical education is nutrition into medical education.
to ‘adjust medical education to changing conditions in
the health care delivery system and to prepare doctors
12
for the needs and expectations of society’. A limitation METHODS
of the accreditation process is the potential for mismatch For the purposes of this review, we initially defined key
between the agreed- upon content of medical education concepts and terms based on published definitions and
12 14
and community needs. author experience (table 1).
Our previous research has highlighted potential This review took a pragmatic approach to search and
competencies for nutrition in medical education. identify literature. An internet search using the Google
However, without a regulatory framework to enforce this, Search engine was conducted through September 2020
Table 1 Definitions of key concepts and terms related to medical education used within this review
Term Definition or description http://nutrition.bmj.com/
Accreditation Recognition of the compliance of educational services (ie, institutional accreditation) or programme
(ie, programmatic accreditation) with pre- established standards (accreditation standards or
regulations) of accreditation to provide an objective measure of the quality of the educational
programme or institution and the existence of quality assurance mechanisms.
Competency standards Defines the major roles or domains within a profession and the knowledge, skills and attributes
75
or frameworks underlying their performance.
Curriculum or curricula Broadly defines the totality of student experiences that take place in the educational process. This on September 30, 2022 by guest. Protected by copyright.
may include topics or subjects taught and the educational programme, assessment and other
methods used to evaluate student learning (eg, placement or mentorship).
Preregistration For the purposes of this review, this includes education which begins with medical school and
continues to graduation with the awarding of a degree. This may be undergraduate or postgraduate
depending on the jurisdiction but might also be termed as ‘pre- entry’.
Postregistration For the purpose of this review, this includes any education during provisional registration, vocational/
professional training, specialist and subspecialist training as well as other forms of training/education
obtained after graduating from medical school.76
Clinical rotation/ A fixed period of clinical practice during education (preregistration).
placement
Internship First postgraduate year of practice. In some countries, internship is used to indicate the first year of
residency (part of postregistration training).
Intern An individual with restricted registration, who is legally qualified to practise medicine with
supervision.
Residency A period of postgraduate training in a medical specialty.
Physician/medical An individual who is legally qualified to practise medicine without supervision.
clinician
2 Lepre B, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2021-000234
BMJ Nutrition, Prevention & Health
to identify non- peer- reviewed government and organ- 20 countries and 40 organisations were included and BMJNPH: first published as 10.1136/bmjnph-2021-000234 on 8 March 2021. Downloaded from
isational reports as well as publications from regulatory grouped into eight regions for review (table 2).
and professional bodies relevant to medical education Although similar numbers of documents were sought
and training. The WHO Directory of Medical Schools across continents, only two documents were obtained
and FAIMER Directory of Organizations that Recognise/ from South America, and only two documents were
Accredit Medical Schools were used to identify relevant included from all of Asia (two from China) (table 3).
literature for this review.15 16 Specifically, we identified Less than half (25/57) of the documents in this review
regulatory bodies in medicine in each continent, and included nutrition (table 3). There was no pattern
in specific countries, and searched for standards (typi- regarding the amount or scope of nutrition in medical
cally identified as accreditation standards) or curriculum accreditation and curriculum guidance between indi-
policy (including competency standards or a framework vidual organisations, countries or regions. Generally,
and guidelines for curricula and assessment) for medical the number of documents that included any reference
education and training using keywords related to medical to nutrition was less in Europe (31%) compared with
education, accreditation and regulation. Keywords the African region (4/7; 57%) and India, Sri Lanka,
included terms of ‘medical education’, ‘standards’, Nepal and Bangladesh (5/9; 56%). Accreditation and
‘regulation(s)’, ‘accreditation’, ‘competencies’ and curricula policy and guidance for medical education
‘curriculum’. Eligible types of publications included the and training in South America did not include any
following: (A) accreditation standards, (B) competency reference to nutrition.
standards or a framework, (C) curricula, and (D) assess- Just over half of the documents included in this review
ment content. Where a publication was not available in (n=30/57) were accreditation standards or regulations,
English, the Google Translate website (https://translate. with a relatively even split between preregistration
google. com. au) was used to translate the information to (30/57) and postregistration (27/57) medical education
17
the English language. (table 4). Only two documents outlined assessment.
We examined key professional medical documents, Twenty- five of the documents included any reference
namely guidelines for accreditation and curricula, to to nutrition, with 14 of these related to preregistration
identify the existence of nutrition within these systems (table 4). Requirements for nutrition education were
for medical education and training internationally. For most frequently found in a curriculum framework or
the purposes of this review, nutrition was defined as any syllabus (n=11/25) followed by a competency framework
explicit or implicit reference to ‘nutrition processes as well or educational outcomes (8/25). The two documents
as the components of food, their actions, interaction and referring to assessment included requirements for inclu-
balance in relation to health and disease’.18 The search sion of nutrition education in this assessment (2/25)
function in Microsoft Office was used to identify explicit (table 4). http://nutrition.bmj.com/
terms such as ‘diet’, ‘nutrition’ and ‘food’. Following
this, each document was reviewed in full to identify other Accreditation standards
(implicit) references to nutrition. For example, concepts Many of the accreditation standards included in this review
related to food hygiene, breast feeding and fluid and were limited to academic and professional outcomes such
electrolyte balance, and skills such as anthropometric as purpose, criteria for admission, faculty requirements,
assessment were considered a reference to nutrition. administration and evaluation. National accreditation
For reporting of results, at least one exemplar country standards for preregistration in China, India and Nigeria
was selected from a group of countries or regions, which included requirements for nutrition education (table 5). on September 30, 2022 by guest. Protected by copyright.
represent a similar model of medical education. All find- Four accreditation standards included nutrition, and
ings were stratified by country or region following the as these standards form part of a formal regulatory
typical chronological career path of a medical student. framework, the nutrition education in these countries
Findings were synthesised based on the type of guidance is mandated. Requirements for nutrition education in
(accreditation standards, competency standards or a accreditation standards and regulation were stipulated
19
framework and guidelines for curricula and assessment) (A) competencies or (B) an education programme
to identify the existence of nutrition content or require- or curriculum20–22 for medical education. Nutrition was
ments for nutrition education in systems used to guide integrated into subjects (eg, human anatomy)19–21 or by
medical education. medical specialty (postregistration) (eg, surgery).22
In China, the Working Committee for the Accredita-
Patient and public involvement tion of Medical Education provides mandatory accredi-
There are no patient and public involved in the study. tation of undergraduate (basic) medical programmes
under the authority of the Ministry of Education and
former Ministry of Health. The Accreditation Standards for
RESULTS Basic Medical Education in China stipulate that the medical
Accreditation standards and curriculum guidance school must, in the curriculum, ‘identify and incorporate
(including competency standards or a framework and the contributions of public health sciences’, including
guidelines for curricula and assessment) (n=57) from nutrition and food hygiene, ‘to develop students’
Lepre B, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2021-000234 3
BMJ Nutrition, Prevention & Health
BMJNPH: first published as 10.1136/bmjnph-2021-000234 on 8 March 2021. Downloaded from
Table 2 Organisations involved in guidance for medical Table 2 Continued
education for each region included in this review Region Organisation(s)
Region Organisation(s) North America Liaison Committee on Medical Education
Africa (Egypt, National Authority for Quality Assurance and Canada (LCME)
Ethiopia, Nigeria) and Accreditation of Education (Egyptian American Association of Medical
Cabinet) Colleges (AAMC)
Higher Education Relevance and Quality Federation of State Medical Boards
Agency (HERQA) (FSMB)
Medical and Dental Council of Nigeria National Board of Medical Examiners
National Postgraduate Medical College of (NBME)
Nigeria (NPMCN) Accreditation Council for Graduate
Australia and Australian Medical Council (AMC) Medical Education (ACGME)
New Zealand Medical Deans Australia and New American Academy of Family Physicians
Zealand (AAFP)
Medical Board of Australia The College of Family Physicians of
Confederation of Postgraduate Medical Canada
Education Councils South America Council for the Accreditation of Higher
The Royal Australian College of General (Mexico) Learning (El Consejo para la Acreditación
Practitioners (RACGP) de la Educación Superior, AC; COPAES)
The Royal New Zealand College of Mexican Board for Accreditation of
General Practitioners (RNZCGP) Medical Education (Consejo Mexicano
China Working Committee for the Accreditation para la Acreditación de la Educación
of Medical Education Médica; COMAEM)
National Health and Family Planning UK and Northern General Medical Council (GMC)
Commission (NHFPC) Ireland (England, The Scottish Deans’ Medical Curriculum
Scotland, Group
Chinese Medical Doctor Association Northern Ireland)
India, Sri Lanka, Medical Council of India* Academy of Medical Royal Colleges
Nepal and (AoMRC), Northern Ireland Medical and
Bangladesh Sri Lanka Medical Council Dental Training Agency (MDTA), Cardiff
Nepal Medical Council and Vale University Health Board, NHS http://nutrition.bmj.com/
Bangladesh Medical and Dental Council Health Education England, Department
Europe (Germany, of Health
MEDINE (Thematic Network for Medical Royal College of General Practitioners
Kazakhstan, Education in Europe) (RCGP)
Russian Independent Agency for Accreditation
Federation, and Rating (IAAR) *The Medical Council of India was superseded by the National
Spain, Sweden, Medical Commission on 26 September 2018.
Turkey) Swedish Higher Education Authority
Federal Ministry of Justice and Consumer awareness of population health and disease prevention on September 30, 2022 by guest. Protected by copyright.
Protection, Germany strategies, allowing them to function well in health educa-
The Turkish National Accreditation tion, promotion and management efforts’ and ‘introduce
Council for Medical Education’s complementary medicine and their roles’, such as food
(UTEAK) Association for Evaluation and and food therapies.21
Accreditation of Medical Education Medical education in India is regulated by the Medical
Programs (TEPDAD) Council of India (MCI), which makes accreditation recom-
The National Agency for Quality mendations to the Indian government. To fulfil the roles
Assessment and Accreditation (Agencia of the profession, this council stipulates that the Indian
Nacional de Evaluación de la Calidad y Medical Graduate would have obtained a set of compe-
Acreditación; ANECA)
The German Medical Association tencies delineated by domain (roles) at the time of grad-
uation. This includes the ability to ‘prescribe and safely
The National Centre for Public administer appropriate therapies including nutritional
Accreditation, Russia interventions…’ across the care spectrum and demon-
Turkish Medical Association strate an understanding of the ‘importance of nutrition
National Commission for the Specialty of 19
in health and disease…’. Regulation for undergraduate
Endocrinology and Nutrition, Spain medical education in India also includes items on how
Continued to integrate competencies horizontally and vertically to
19
‘enable students to make clinical correlations…’.
4 Lepre B, et al. bmjnph 2021;0. doi:10.1136/bmjnph-2021-000234
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