A 13-year journey towards implementing improved medical nutrition education in the UK and beyond
Authors: Elaine MacAninach RD and Prof Sumantra Ray RNutr | Editors: Dr Kathy Martyn RN, RNutr and Dr Minha Rajput-Ray | Reviewers: Sally Ayyad ANutr, James Bradfield RD and Dr Luke Buckner
Digital Design: Matheus Abrantes | With special thanks: The AIM Foundation for current support to the Nutrition Education Policy for Healthcare Practice (NEPHELP) initiative and the NEPHELP Project Team
As we mark the launch of the new Association for Nutrition (AfN) convened Curriculum in Nutrition for medical graduates (co-created with a nationally representative Inter-Professional Group in the UK), we reflect on the NNEdPro journey bringing together a selection of 18 key publications we have been involved in producing over the past 13 years. During this time, we have witnessed truly collaborative and progressive efforts that have led to this landmark moment.
Following a formal call to action in the 2007 Department of Health Nutrition Action Plan, the Need for Nutrition Education Project (NNEdPro), as it was then termed, was born back in 2008 to improve medical and healthcare nutrition training as well as practice and associated research. The first NNEdPro output took the form of a policy paper on the potential impact a medical doctor can have on individual and population nutrition, especially in UK healthcare: Ray S, Gandy J, Landman J (2008) The Doctor as a Nutritionist, A Discussion Paper on Nutrition in Medical Careers. Westminster Forum Projects.
Having identified nutrition as a gap in medical training, a series of nutrition education interventions were piloted across UK medical students (in over 15 medical schools) as well as UK junior doctors (Foundation Years). NNEdPro training programmes were well received and have continued to evolve to date, demonstrating an ongoing need for training and evaluation data to understand how nutrition knowledge is translated to clinical practice through action, advocacy, and leadership. The following papers provide a snapshot of insights:
Gandy, J; Douglas, P; Thompson, B; Rajput-Ray, M; Sharma, P; Lodge, K; Broughton, R; Smart, S; Wilson, R; Ray, S; The impact of a nutritional education intervention on undergraduate medical students (2010). Journal of Human Nutrition and Dietetics.
Ray, S., Laur, C., Rajput-Ray, M., Gandy, J., & Schofield, S. (2012). Planning Nutrition Education Interventions for the Medical Workforce: ‘Nutrition Education Workshop for Tayside Doctors’(NEWTayDoc) - A pilot project to inform development of the Need for Nutrition Education Programme (NNEdPro).
Laur, C., Thompson, B., & Ray, S. (2012). Short but effective educational interventions in medicine and healthcare–lessons learnt from the ‘Need for Nutrition Education Programme’. In MedEdWorld (pp. 1-15).
Ray S, Udumyan R, Rajput-Ray M, Thompson B, Lodge KM, Douglas P, Sharma P, Broughton R, Smart S, Wilson R, Gillam S. Evaluation of a novel nutrition education intervention for medical students from across England. BMJ open. 2012 Jan 1;2(1): e000417
Ball, L., Crowley, J., Laur, C., Rajput-Ray, M., Gillam, S., & Ray, S. (2014). Nutrition in medical education: reflections from an initiative at the University of Cambridge. Journal of multidisciplinary healthcare, 7, 209.
Ray S, Laur C, Douglas P, Rajput-Ray M, van der Es M, Redmond J, Eden T, Sayegh M, Minns L, Griffin K, McMillan C. Nutrition education and leadership for improved clinical outcomes: training and supporting junior doctors to run ‘Nutrition Awareness Weeks’ in three NHS hospitals across England. BMC medical education. 2014 May 29;14(1):1.
The early-stage ‘on the ground’ efforts of NNEdPro were contemporaneous with national curriculum recommendations at that time by the Intercollegiate Group on Human Nutrition of the Academy of Medical Royal Colleges (UK and Ireland).
As the work of NNEdPro progressed, it became clear that the lack of nutrition education for medical doctors was not just a UK problem. Linking with collaborators across the globe, NNEdPro shifted focus internationally to become a Global Centre and began to consider the most important nutrition competencies for good medical and healthcare practice as well as how to implement effective training.
Following on from case studies in the USA, India, and Australia, in a 2015 six-country comparison of the UK, Canada, USA, Australia, New Zealand and the Republic of Ireland, all countries were noted to have a visible curriculum on what must be taught to medical students.However, the UK was identified as the only country to mandate that all doctors should be able to complete a basic nutrition assessment. This requirement was unfortunately removed in the 2018 update of the UK Learning Outcomes for Medical Graduates.
Common themes emerging over 2014-17 included the importance of multi- and inter-disciplinary approaches with a unified voice across borders as well as the role of clinical leadership in effective implementation. The following papers highlight some of the key points in support of international and interprofessional approaches:
Kris-Etherton PM, Akabas SR, Bales CW, Bistrian B, Braun L, Edwards MS, Laur C, Lenders CM, Levy MD, Palmer CA, Pratt CA. The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. The American journal of clinical nutrition. 2014 May 1;99(5):1153S-66S.
Ray S, Rajput-Ray M, Ball L, Crowley J, Laur C, Roy S, Agarwal S, Ray S. (2015). Confidence and Attitudes of Doctors and Dietitians towards Nutrition Care and Nutrition Advocacy for Hospital Patients in Kolkata, India. Journal of Biomedical Education.
Kris-Etherton PM, Akabas SR, Douglas P, Kohlmeier M, Laur C, Lenders CM, Levy MD, Nowson C, Ray S, Pratt CA, Seidner DL. (2015). Nutrition competencies in health professionals’ education and training: a new paradigm. Advances in Nutrition: An International Review Journal.
Crowley, J., Ball, L., Laur, C., Wall, C., Arroll, B., Poole, P., & Ray, S. (2015). Nutrition guidelines for undergraduate medical curricula: a six-country comparison. Advances in medical education and practice, 6, 127.
Ball, L., Barnes, K., Laur, C., Crowley, J., Ray, S. (2016) Setting Priorities for Research in Medical Nutrition Education: A Global Approach. BMJ Open.
Burch, E., Crowley, J., Laur, C., Ray, S., Ball, L. Dietitians' Perspectives on Teaching Nutrition to Medical Students. Journal of the American College of Nutrition. 2017.
Bhat, S., Kohlmeier, M., Ray, S. (2017). Bridging Research, Education and Practice Across Disciplines: Need for Nutrition Education/Innovation Programme (NNEdPro). Journal of Nutrition Education and Behaviour.
S Ray. The NNEdPro Global Centre for Nutrition and Health: A Consolidated Review of Global Efforts Towards Medical and Healthcare-Related Nutrition Education (2019). Nestlé Nutr Inst Workshop Ser. Nestlé Nutrition Institute, Switzerland/S. Karger AG., Basel, © 2020, vol 92, pp 143–150.
THE ‘NEPHELP’ INITIATIVE
The core aim of NEPHELP is to develop, test, improve, implement, and evaluate nutrition education resources for doctors and associated health professionals in hospitals as well as community settings. This supports the development of learning resources and toolkits for practitioners.
Dr Minha Rajput-Ray and Dr Harrison Carter receiving the MNI-ESPEN award in the Hague (2017) enabling the establishment of NEPHELP
The first phase of NEPHELP focussed on junior doctors whilst the second phase looks deeper into both primary and secondary care. Through this initiative, doctors can be empowered with greater nutrition training to become champions for nutrition within local teams, coordinating the key roles that nurses and other healthcare professionals make in nutrition care. Ultimately the goal is to improve nutritional care utilising a whole team approach to improve screening, early detection, and integration into care pathways; examples include reducing cardiovascular risk, managing type 2 diabetes, gastrointestinal problems, undernutrition, or signposting patients to nutrition resources with consideration of age, medical conditions, cultural preferences, financial and environmental circumstances. This supports the implementation of rapid first-line nutrition advice as well as appropriate referrals to dietitians and nutritionists. Alongside this, we continue to advocate for adequate nutrition training for medical and healthcare students as well as professionals, with those we have taught then providing guidance in future to their trainees.
The NEPHELP Team (Dr Luke Buckner, Elaine MacAninch RD, Emily Fallon ANutr and Prof Sumantra Ray RNutr, launching the second phase of NEPHELP at the BMJ Safety and Quality in Healthcare Conference in Glasgow (2019)
Our vision is to facilitate the development of a nutrition-trained healthcare workforce, to work seamlessly between hospitals and the community in the prevention and treatment of disease, improving the lives of those we care for and protecting scarce NHS and social care resources.
Whilst several papers from NEPHELP are currently under development and review, a key publication from the first phase of the initiative led to a collaboration with the medical student-led group ‘Nutritank’ resulting in the ‘Time for Nutrition’ survey:
Macaninch, E., Buckner, L., Amin, P., Broadley, I., Crocombe, D., Ray, S. Herath, D., Jaffee, A., et al. (2020). Time for nutrition in medical education. https://doi.org/10.1136/bmjnph-2019-000049
Since 2019, building on the bedrock of the NEPHELP initiative, doctoral research at the University of Wollongong Australia undertaken in collaboration with NNEdPro, has added further global insights through detailed analyses and syntheses around curricula as well as competencies, providing a sound basis for the development of guidance for medical nutrition educators. Furthermore, the development of 12 Regional Networks spanning over 35 countriesacross six continents provides opportunities for the adaptation and scaling of medical nutritioneducation efforts which can be supported by a centrally curated evidence collection hosted bythe ‘International Knowledge Application Network Hub in Nutrition’ (iKANN). Collaborative work undertaken recently with the World Health Organization has also resulted in a blueprint (Lepre et al 2021; in press) for nutrition training and capacity building amongst health professionals in the wake of Universal Health Coverage.
Lepre B, Mansfield KJ, Ray S, et al. (2021) Reference to nutrition in medical accreditation and curriculum guidance: a comparative analysis. BMJ Nutrition, Prevention & Health 2021; bmjnph-2021-000234. doi: 10.1136/bmjnph-2021-000234
Lepre B, Mansfield KJ, Ray S, et al (2021). Nutrition competencies for medicine: an integrative review and critical synthesis. BMJ Open 2021;11: e043066. doi: 10.1136/bmjopen-2020-043066.
THE NUTRITION IMPLEMENTATION COALITION
Furthermore, based on mutually productive collaborations with Nutritank and the Brighton-based ‘Education and Research in medical Nutrition Network’ (ERimNN) over 2017/18, the UK Nutrition Implementation Coalition was formed in 2019 as a collaborative group convened by NNEdPro and including Nutritank, ERimNN and additionally, Culinary Medicine UK, as core members.
The coalition brings together a variety of educational, professional and research experiences, who share the same vision regarding the need to advocate for nutrition education for healthcare professionals and bridge the gap between knowledge and practice to improve the ability of doctors, nurses, health, and social care professionals to deliver effective nutrition care. This coalition fully supports the implementation of the newly launched national nutrition curriculum in the UK.
“We believe better nutrition educated health and social care workforce improves patient outcomes and holds benefit for population health.”
THE NUTRITION CURRICULUM AND NEXT STEPS
Central to the implementation of improved nutrition training and practice is the need for consensus and commitment across different organisations. Alongside other members of the UK Nutrition Implementation Coalition, NNEdPro was honoured to have been involved in the consultative Inter-Professional Group convened by the AfN and leading to the 2021 launch of the new national nutrition curriculum for medical students and graduates. This is a truly critical and very timely blueprint to develop sound conceptual foundations underpinning the relationships between nutrition, health, and disease and to help equip medical professionals and the healthcare workforce with the skills to deliver nutrition care within the multi-professional team.
EMERGING OPPORTUNITIES TO PIOT IMPLEMENTATION
Over the Autumn term of 2021 the NNEdPro Chair, Professor Sumantra Ray, as a member of faculty at both the Nutrition Innovation Centre for Food and Health (NICHE) and the newly established Medical School at Ulster University, will have the opportunity to deliver a series of five medical nutrition education lectures to the first intake of graduate medical students in Northern Ireland.
Furthermore, ERimNN, working with Brighton and Sussex Medical School (BSMS) are developing a strategy for mapping the new AfN Curriculum against existing curricula that highlights gaps and opportunities for continued curriculum development.
These timely opportunities to begin implementation of the newly launched nutrition curriculum in real-time can provide potentially useful insights for medical nutrition educators atlarge.
You can learn more and download the AfN Nutrition Curriculum here.