Currently browsing posts about: Nutrition-education

Some comments on three recent developments in the field of nurition.

I.  Nutrition in medical education

I’ve been teaching , researching, and writing about nutrition since 1976 when I was on the faculty at Brandeis and assigned my first class.  I then went to the USCF School of Medicine where I taught nutrition to health professions student for the next ten years.

While there, I wrote my first book, Nutrition in Clinical Practice, in which I briefly summarized what all of us at the time thought medical students needed to know.  The book was published in 1985, and is long out of print.  In 2020, a used copy was available on Amazon for $930 (even more surprising, it is no longer on that site).

Consequently, I was amazed to see: Eisenberg DM, Cole A, Maile EJ, et al. Proposed Nutrition Competencies for Medical Students and Physician Trainees: A Consensus Statement. JAMA Netw Open. 2024;7(9):e2435425. doi:10.1001/jamanetworkopen.2024.35425

As one of the authors , Emily Broad Leib, wrote in a Tweet (X), “This article shares the consensus of 37 medical education leaders on what all physicians-in-training should know about nutrition. With this start, I hope we can achieve a future where all drs. are armed with this knowledge!”

Well, wouldn’t that be nice.  When I arrived at UCSF in 1976, it was already nearly 20 years since the first conference on nutrition in medical education called for more nutrition instruction.  It has now been 70 years since then, with little change.

The structural barriers are insurmountable, apparently.

• The focus on treatment, not prevention
• Lack of qualified instructors
• Time in the curriculum
• Time in office visits (anyone seen a doctor lately for more than 15 minutes)
• The complexity of the field

Still, let’s hear applause for this consensus effort, starting with recommendation #1:

Provides evidence-based, culturally sensitive nutrition and food recommendations to patients for the prevention and treatment of disease.

Tomorrow: The need for leadership on precisely that point.

Two examples of  beef-industry attempted influence:

I.  Science teachers

This one comes from Wired: Inside the Beef Industry’s Campaign to Influence Kids

Big Beef is wooing science teachers with webinars and lesson plans in an attempt to change kids’ perceptions of the industry.

A beef industry group is running a campaign to influence science teachers and other educators in the US. Over the past eight years, the American Farm Bureau Foundation for Agriculture (AFBFA) has produced industry-backed lesson plans, learning resources, in-person events, and webinars as part of a program to boost the cattle industry’s reputation.

What is the AFBFA?

The AFBFA is a contractor to Beef Checkoff, a US-wide program in which beef producers and importers pay a per-animal fee that funds programs to boost beef demand in the US and abroad. In 2024, Beef Checkoff has approximately $42 million to disperse across its initiatives, and a funding request reveals that the AFBFA’s campaign for 2024 is projected to cost $800,000. The allocation of Beef Checkoff funding to programs like this is approved by members of the Cattlemen’s Beef Board and the Federation of State Beef Councils, two groups that represent the cattle industry in the US.

What does this program teach?

One lesson plan provided as part of the program directs students to beef industry resources to help devise a school menu. In another lesson plan students are directed to create a presentation for a conservation agency regarding the introduction of cattle into their ecological preserve. A worksheet aimed at younger students has them practice their sums by adding up the acreage of cow pastures. Another worksheet based around a bingo game aimed at 8- to 11-year-olds asks teachers to “remind students that lean beef is a nutritions source of protein that can be incorporated in daily meals.”

As for the answer to my question yesterday about whether this kind of training works:

According to survey data included in these documents, educators who attended at least one of the AFBFA’s programs were 8 percent more likely to trust positive statements about the beef industry. Some 82 percent of educators who participated in a program had a positive perception of how cattle are raised, and 85 percent believed that the beef industry is “very important” to society.

Again, this is a USDA-sponsored checkoff program.  The US Dietary Guidelines on beef call for it to be lean and unprocessed.  The checkoff does not.

II.  Public health professionals

I received this e-mailed message from a reader who wishes to remain anonymous.

I am a member of the Kentucky Public Health Association and so receive their email newsletters. The Beef Council promotion is fairly new. It is interesting to watch an industry PR campaign with health professionals happen in real time. I’ve also just realized that I don’t believe the Association has policies around sponsorships, something I had not worried about until the past few months.

She forwarded two messages sent to her from the Kentucky Public Health Association.  These are announcements from the Kentucky Beef Council: “Happy Nationl Nutrition Month,” and “Fueling Tween and Teens with Strong Minds and Bodies.”

The second is labeled as an advertisement; the first is not.

Both encourage visits to the Beef Nutrition Education Hub to get free continuing education credits and other resources.

Both say:

Thank you to our 38,000 Kentucky Beef Farmers! Fun Fact: Kentucky is the largest beef-producing state East of the Mississippi River

This email was sent on behalf of KY Beef Council and the content within shall be attributed to the sponsor. This email shall not indicate an endorsement on behalf of KPHA.

Copyright © 2023  Kentucky Public Health Association

Comment:  The Kentucky Beef Checkoff at work!   Regardless of the Kentucky Public Health Association’s protestations, these messages give the appearance of endorsement.  It should not be doing this.

A report, Science Education in an Age of Misinformation, from Stanford University and written by a distinguished group of scientists addresses a question I get asked all the time: how do you know whom to trust when reading articles about food and nutrition.

It presents a decision tree for evaluating information sources.

Although most of the report is focused on other science topics, it includes one nutrition example (Example 3, pages 34 and 35).

Example 3 presents two websites, one from the Partnership for a Healthier America, the other from ILSI, the International Life Sciences Institute.

The suggested lesson asks students to use the decision tree to evaluate the credibility of the information on the websites.

For this example,

if students search for ‘Partnership for a Healthier America,’ they will find that one of the first links to appear in the search results is from Wikipedia…they may decide to start with the Wikipedia page to get a broad sense of what other information is available about the organization. There students will read that PHA is a nonprofit organization focused on health and nutrition. Its president and CEO is Nancy Roman, who has years of experience working for world food programs, food banks, and nutrition non-profit organizations.

On the other hand, when students apply the same strategy to the ISLI web page, they are also likely to begin with the Wikipedia entry. This tells a very different story. While ISLI is also a nonprofit organization, the Wikipedia entry shows it was funded by a Coca-Cola executive and has numerous ties to food and chemical companies, such as McDonald’s and Pepsi. Such ties represent a clear conflict of interest and would strongly suggest that ISLI is not a credible source of information.

A good start?  I think yes.  Take a look and decide for yourself.

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I’ve just had a book review published in the American Journal of Public Health: “Public health nutrition deserves more attention.”

It’s for a textbook on public health nutrition but doing it gave me the opportunity to say some things I want public health professionals to know.  I started the review like this:

Public Health Nutrition deserves more attention

Food and nutrition deserve much more attention from public health professionals.  On the grounds of prevalence alone, diet-related conditions affect enormous numbers of people.  Everybody eats.  Everybody is at risk of eating too little for health or survival, or too much to the point of weight gain and increased prevalence of non-communicable diseases (NCDs).  By the latest count, nearly 700 million people in the world do not get enough to eat on a daily basis, a number that has increased by tens of millions over the past five years and will surely increase by many millions more as a result of the Coronavirus pandemic.[i]   At the same time, about two billion adults are overweight or obese, and few countries are prepared to deal with the resulting onslaught of type 2 diabetes and heart disease.[ii]  Beyond that, food production, distribution, consumption, and disposal—collectively food systems—are responsible for a quarter or more of greenhouse gas emissions; climate change affects the health of everyone on the planet.[iii]

The same social, behavioral, economic, and structural determinants that affect health also affect nutritional health, and it is no accident that food choices are flash points for arguments about culture, identity, social class, inequity, and power, as well as about the role of government, private enterprise, and civil society in food systems.   From a public health standpoint, everyone–regardless of income, class, race, gender, or age—should have the power to choose diets that meet nutritional needs, promote health and longevity, protect the environment, and are affordable, culturally appropriate, and delicious.

Nutrition in 2021

For people in high-income countries, dietary prescriptions for health and sustainability advise eating less meat but more foods from plant sources.[iv]  Optimal diets should minimize consumption of ultra-processed foods, those that are industrially produced, bear little resemblance to the basic foods from which they were derived, cannot be prepared in home kitchens, and are now compellingly associated with NCD risk and mortality.[v]  We now know that ultra-processed foods encourage people to unwittingly take in more calories and gain weight.[vi]

Agenda for 2021

Today, a book for researchers and practitioners of public health nutrition needs to emphasize coordinated—triple-duty—recommendations and interventions to deal with hunger and food insecurity, obesity and its consequences, and the effects of food production and dietary choices on the environment.  Such approaches, as described by a Lancet Commission early in 2019,⁴ should encourage populations of high-income countries to eat less meat but more vegetables, those in lower- and middle-income countries (LMICs) to consume a greater variety of foods, and everyone, everywhere to reduce intake of ultra-processed foods.  As that Commission argued, public health nutritionists must recognize that attempts to improve diets, nutritional status, nutritional inequities, and food systems face daunting barriers from governments captured by corporations, civil society too weak to demand more democratic institutions, and food companies granted far too much power to prioritize profits at the expense of public health.  Nutritionists need knowledge and the tools to resist food company marketing and lobbying, to advocate for regulatory controls of those practices, and to promote civil society actions to demand healthier and more sustainable food systems.[vii]

I then go on to talk about the book itself, which alas, did not have much to say about this agenda.

References to the first part of this review

[i] The World Bank.  Brief: Food Security and COVID-19. December 14, 2020. https://www.worldbank.org/en/topic/agriculture/brief/food-security-and-covid-19#:~:text=In%20November%202020%2C%20the%20U.N.,insecure%20people%20in%20the%20world. Accessed January 2, 2021.

[ii] WHO.  Obesity and overweight: Key facts.  Geneva: WHO.  April 1, 2020. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed January 2, 2021.

[iii] International Panel of Experts on Sustainable Food Systems. COVID-19 and the crisis in food systems: symptoms, causes, and potential solutions. IPES-Food, April 2020. www.ipesfood.org/pages/covid19. Accessed January 2, 2021.

[iv] Swinburn BA, Kraak V, Allender S, et al. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet. 2019;393:791–846.

[v]  Monteiro CA, Cannon G, Levy RB, et al.  Ultra-processed foods: what they are and how to identify them. Public Health Nutr. 2019;22(5):936–941.

[vi] Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake. Cell Metab. 2019;30, 67–77.

[vii]  Jayaraman S, De Master K, eds.  Bite Back: People Taking On Corporate Food and Winning.  Oakland, CA: University of California Press; 2020.

 

 

I was astounded to learn that the USDA spends more than $900 million a year on nutrition education since I can hardly recall seeing any of it.

But now we have a Government Accountability Office (GAO) analysis of USDA’s expenditures on nutrition education.

The GAO says that USDA does not:

• Coordinate its nutrition education efforts
• Use the expertise of USDA nutritionists
• Make nutrition education a priority
• Have leadership with responsibility for nutrition education
• Share information across sub-agencies and avoid duplicating efforts
• Assign nutrition education experts to appropriate sub-agencies

No big surprise here—I’ve been hearing such complaints since I worked for the government in the late 1980s—but it’s good to see them documented.

Most of the report is about nutrition education for participants in WIC, SNAP, and other nutrition assistance programs.

Note that there is no line budget for promotion of the Dietary Guidelines for Americans, a statement of of federal nutrition policy, or for MyPlate, a food guide directed at the general public.  Funds to promote these documents have to be authorized by Congress.

Note also that while $900 million seems like a lot of money, it is considerably below what companies like McDonald’s and Coca-Cola each spend on advertising every year.

I was fascinated to see this FoodNavigator account of the recent United Nations’ call for action on nutrition.

The lengthy new UN resolution on “a healthier world through better nutrition” begins with pages of preliminary comments before getting to bland admonitions that member states should improve nutrition, health conditions, and living standards; address hunger and malnutrition; and promote food security, food safety, and sustainable, resilient, and diverse food systems.

The resolution encourages member states to strengthen nutrition policies that promote breastfeeding and control the marketing of breast-milk substitutes.

It also promotes physical activity. It

Calls upon Member States to develop actions to promote physical activity in the entire population and for all ages, through the provision of safe public environments and recreational spaces, the promotion of sports, physical education programmes in schools and urban planning which encourages active transport.

What got FoodNavigator’s—and my—attention, however, was its encouragement of member nations to:

develop health- and nutrition-promoting environments, including through nutrition education in schools and other education institutions, as appropriate.

Nutrition education?  That’s it on improving the nutrition environment?

Nothing about curbs on food industry marketing practices, front-of-package food labels, soda or sugar taxes, or other policies established to be effective in improving nutritional health (see, for example, the policies listed on the World Health Organization’s database, or the NOURISHING database of The World Cancer Research Fund).

The UN’s own Food and Agriculture Organization issued a report on the value of education in improving the food environment.  Its author, Corinna Hawkes, makes it clear that education is useful, but is far more effective when it thoroughly involves policies to change the food environment.

nutrition education actions are more likely to yield positive results…when actions are implemented as part of large, multi-component interventions, rather than information provision or direct education alone. It is notable that governments have been taking an increasing number of actions involving multiple components, such as combining policies on nutrition labels with education campaigns, public awareness campaigns with food product reformulation, and school food standards with educational initiatives in schools.

The resolution says none of this.  Even so, it did not pass unanimously.  The vote:

• Yes:       157 countries
• No:           2 (Libya and the United States)
• Abstain:    1 (Hungary)

And why did the United States vote no?  The US mission to the UN explains its position on the grounds—and I am not making this up—that the resolution:

• Favors abortion:  “We do not recognize abortion as a method of family planning, nor do we support abortion in our reproductive health assistance.”​
• Promotes free trade in medicines: “This could lead to misinterpretation of international trade obligations in a manner which may negatively affect countries’ abilities to incentivise new drug development and expand access to medicines.”​
• Promotes migration: “we believe [the resolution represents]…an effort by the United Nations to advance global governance at the expense of the sovereign rights of States to manage their immigration systems in accordance with their national laws and interests.”​

To be clear: UN resolutions are non-binding.  The UN cannot tell member countries what to do.  All it can do is exert leadership and moral force.

When it comes to the food environment these days, we need all the moral force we can get.  We didn’t get it here.

Vanessa Domine.  Healthy Teens, Healthy Schools: How Media Literacy Can Renew Education in the United States.  Rowman & Littlefield, 2015.

Here’s my blurb:

If you are not concerned about the effects of exposure to electronic media on the health of teenagers, you should be.   This book presents a well-researched, highly compelling case for the urgent need for media literacy education to be incorporated into school wellness programs as soon as possible.

For information about how online marketing affects kids’ food choices, take a look at the work of the Berkeley Media Studies Group, particularly in media advocacy training.

Center for Science in the Public Interest (CSPI) also has resources about online marketing to kids (scroll down for a list).

JAMA Internal Medicine invited me to comment on an article about the lack of nutrition education in medical schools.  This was written by Nathanial Morris, a second-year medical student at Harvard, who complains about the paucity of nutrition instruction in his curriculum.

Yet the course spanned just 3 afternoons, for a total of 9 hours of instruction…The course directors told us it would be the only time for dedicated nutrition education during our 4 years as medical students. There were no examinations nor interactions with patients. The 1 lecture on obesity lasted 45 minutes…As a medical student, I cannot fathom why medical schools continue to neglect nutrition education.

When I read his article, I didn’t know whether to laugh or cry.  I wrote almost identical articles in the 1980s based on my experience at UCSF (here’s one).

I asked a former UCSF colleague, Dr. Robert Baron, to co-author the commentary with me: Nutrition in Medical Education:  From Counting Hours to Measuring Competence.

Some help from Congress?

It is interesting in this context that various members of Congress are introducing bills to improve nutrition education for medical professionals, for example, the EAT for Health Act and the ENRICH Act.  Thanks to Jamie Berger for alerting me to this legislation and for sending some fact sheets about the bills: EAT for Health / ENRICH.

It’s been nearly 40 years since my involvement in this issue.  Ever optimistic, I’m happy to see some progress at last.

And this just in.

The current issue of the American Journal of Clinical Nutrition has papers from a symposium on nutrition in medical education.  The first was in 1962, so the half-century saga continues.

• Title page, program participants, and TOC:  Am J Clin Nutr 2014;99 1145S-1149S
• Introduction to Nutrition Education in Training Medical and Other Health Care Professionals. Penny M Kris-Etherton, Charlotte A Pratt, Edward Saltzman, and Linda Van Horn. Am J Clin Nutr 2014;99 1151S-1152S
• The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. Penny M Kris-Etherton, Sharon R Akabas, Connie W Bales, Bruce Bistrian, Lynne Braun, Marilyn S Edwards, Celia Laur, Carine M Lenders, Matthew D Levy, Carole A Palmer, Charlotte A Pratt, Sumantra Ray, Cheryl L Rock, Edward Saltzman, Douglas L Seidner, and Linda Van Horn. Am J Clin Nutr 2014;99 1153S-1166S
• Nutrition education in medical school: a time of opportunity. Robert F Kushner, Linda Van Horn, Cheryl L Rock, Marilyn S Edwards, Connie W Bales, Martin Kohlmeier, and Sharon R Akabas. Am J Clin Nutr 2014;99 1167S-1173S
• Residency and specialties training in nutrition: a call for action. Carine M Lenders, Darwin D Deen, Bruce Bistrian, Marilyn S Edwards, Douglas L Seidner, M Molly McMahon, Martin Kohlmeier, and Nancy F Krebs. Am J Clin Nutr 2014;99 1174S-1183S 
• Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. Rose Ann DiMaria-Ghalili, Jay M Mirtallo, Brian W Tobin, Lisa Hark, Linda Van Horn, and Carole A Palmer. Am J Clin Nutr 2014;99 1184S-1193S
• Policy approach to nutrition and physical activity education in health care professional training. Matthew D Levy, Lisel Loy, and Laura Y Zatz.  Am J Clin Nutr 2014;99 1194S-1201S.