Clinical Nutrition ESPEN 52 (2022) 377e380

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Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Short Communication

Starving for knowledge. Addressing the place of clinical nutrition

within undergraduate and postgraduate clinical training: A national
survey of practicing clinicians
Karen Boland a, b, c, *, Kathryn Allen a, Adam James d, Cara Dunne c, e
a
Department of Gastroenterology and Hepatology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
b
School of Medicine, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
c
Irish Society for Parenteral and Enteral Nutrition, Dublin, Ireland
d
Department of Cardiology, CHI at Crumlin, Dublin, Ireland
e
Department of Gastroenterology, St James' Hospital, James' Street, Dublin 8, Ireland

a r t i c l e i n f o s u m m a r y

Article history: Introduction: Clinical Nutrition is finding its place within medical training. In response to IrSPEN's ob-
Received 30 April 2022 jectives and ESPEN's manifesto, IrSPEN distributed an electronic survey investigating attitudes to Clinical
Accepted 19 September 2022 Nutrition and unmet educational needs.
Methods: A 35-part questionnaire was designed and distributed to clinicians in Ireland. Questions eli-
Keywords: cited clinician demographics, education history and experience assessing and managing malnutrition.
Education
Descriptive statistics were reported, comparisons analysed using Chi-squared test and correlation be-
Clinical nutrition
tween experience and confidence analysed with Spearman correlation coefficient.
Curriculum
Results: Of 168 respondents, 41% (n ¼ 58) were male and most practice medicine in an academic centre
(87.5%). Fifty-eight (34.7%) were regularly involved in nutrition support. Despite 20% (n ¼ 33) of re-
spondents regularly managing patients on parenteral nutrition (PN) and a fifth (n ¼ 34) regularly
managing complications of obesity, few had confidence in assessment for artificial nutrition (15.7%
(n ¼ 26), enteral nutrition; 8% (n ¼ 13), PN). Trainees were less confident than attending staff in assessing
and managing artificial enteral feeding (p ¼ 0.022) and complications of PN (p ¼ 0.01). Over 70% re-
spondents reported they received <2 h clinical nutrition education. Only 32% (n ¼ 52) received any
formal training within postgraduate training (PGT), more often GI trainees (p ¼ 0.01). A striking 98% felt
additional focus on nutrition education in PGT is required.
Conclusion: This survey elicits physician attitudes on nutrition education in undergraduate and post-
graduate curricula in Ireland. Practicing physicians identify the need to increase clinical nutrition edu-
cation. IrSPEN are actively engaging with Irish medical schools and training bodies to address these
deficits with multidisciplinary engagement from expert physicians and allied dietetic colleagues.
© 2022 The Authors. Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and
Metabolism. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction
The power and potential for clinical nutrition to impact patient
health far exceeds the expectations of patients and many clinicians.
Slow progress in tackling disease-related malnutrition indicates
that our current approach is not working and current messaging on
* Corresponding author. Department of Gastroenterology, Beaumont Hospital,
Beaumont Road, Dublin 9, Ireland.
E-mail address: karenboland2@beaumont.ie (K. Boland).
how to maintain a healthy diet and nutrition status are missing the
mark with the population. The World Health Organisation (WHO)
has sounded the alarm about the prevalence of obesity and asso-
ciated complications with rising mortality rates of cardiovascular
diseases, cancer, and diabetes. In particular, the double burden of
malnutrition and coexistence of undernutrition and overnutrition
within lifespans, families and societies is of concern [1]. A global
action plan was published in 2019 by the WHO aiming to attain a
25% relative reduction in premature mortality from non-
communicable diseases by 2025, and acknowledging the central
role of lifestyle and nutrition [2].

https://doi.org/10.1016/j.clnesp.2022.09.020
2405-4577/© 2022 The Authors. Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
K. Boland, K. Allen, A. James et al. Clinical Nutrition ESPEN 52 (2022) 377e380

The importance of nutrition as a cornerstone for maintenance of
health is self-evident. We ask doctors to apply nutrition knowledge
in practice to support patients in managing chronic diseases and
other conditions for which malnutrition is a risk factor. Yet, there
remain reports that nutrition education in medical schools falls
short of recommendations initially from ASPEN of a minimum 22 h
throughout the undergraduate curriculum, and subsequently from
ESPEN. There is an evidence-practice gap between the nutrition
education in medical schools and the knowledge and skills required
for doctors to affect high quality care in this area with only 25% of
medical schools in the US providing a dedicated course in nutrition
[3] and similarly, 69% European medical schools in another survey
required provision of nutrition education [4]. Jennifer Crowley and
colleagues completed a systematic review of 24 studies throughout
USA, Europa, Africa, Middle East, Australia, and Latin America. They
concluded that despite the centrality of nutrition to a healthy life-
style, medical students are not supported in providing high-quality
and effective nutritional care [5]. ESPEN launched the Nutrition
Education in Medical Schools project in 2017 [6], subsequently
proposing minimum curriculum content for nutrition education in
European Universities. They identified key factors for successful
implementation, adopting novel methods of medical education
including small group teaching and self-directed learning, and
horizontal and vertical integration of nutritional content in context
when teaching other subjects. The Council members alongside the
university representatives developed an example of how this could
be achieved over a 6-year programme [7]. The model for imple-
mentation is aspirational, fully integrating nutrition into the med-
ical curriculum.
For at least 3 decades, several efforts have been made to improve
medical nutrition education without substantial success. What is
required to move nutrition education in medical schools forward in
Ireland? The Irish Society for Clinical Nutrition and Metabolism
(IrSPEN) have established a goal to facilitate integration of nutrition
education into the postgraduate and undergraduate curricula. As
part of our next step in this process, we distributed a survey of
practicing clinicians in Ireland to identify attitudes and unmet
needs in this area.
2. Materials and methods
was performed with univariate Chi-squared analysis and Spearman
correlation coefficient using Stata.
3. Results
3.1. Demographics
The survey was distributed through social media platforms and
society membership, and 168 responses received with a response
rate of 21%. Respondent demographics are depicted in Table 1.
Forty-one per cent of respondents (n ¼ 58) were male, and the
majority worked full-time in academic centres (87.5%). Almost
three-quarters of physicians who responded were still in post-
graduate training, with 47% working at registrar level, with at least
3 years of experience.
3.2. Nutrition-related knowledge
We investigated the degree of confidence of respondents in
managing nutrition-related clinical care. Fifty-eight doctors
(34.7%) recorded that they are regularly involved in nutrition
support, but almost a quarter (n ¼ 40) were rarely or never.
Further enquiry demonstrated that 20% (n ¼ 33) regularly
assessed or managed patients on parenteral nutrition (PN), 65%
(n ¼ 108) regularly managed electrolyte abnormalities, 20.3%
(n ¼ 34) regularly managed complications of obesity. Despite this,
76 respondents (n ¼ 45.5%) give nutrition advice to patients less
than once per month. When we enquired about confidence in
managing artificial feeding supports or related complications, the
proportion of respondents’ confidence in assessment of need or
artificial enteral feeding was 15.7% (n ¼ 26) and for parenteral
nutrition, only 8% (n ¼ 13). Furthermore, 32% (n ¼ 54) did not
believe they had sufficient knowledge to manage complications
including the refeeding syndrome, line sepsis and line thrombosis.
We compared attitudes and beliefs of doctors in training and
compared with consultants and independent practitioners. We
found that while they had comparable confidence in their ability
to give nutrition advice (p ¼ 1) and assessment of need for
parenteral feeding (p ¼ 0.43), trainee doctors were significantly

We generated an online survey for distribution amount qual- Table 1

ified and practicing medical professionals in Ireland. Both Demographics of surveyed medical practitioners.
consultant and non-consultant hospital doctors from various Demographic N ¼ 168 (%)
specialities and across all levels of training were targeted. The
Male 58 (34.7%)
survey instrument used was anonymous and information about Age: 20e30 years 86 (51.5%)
the purpose of the study was provided. There was little likelihood 31e40 years 59 (35.3%)
of response bias, as there were no systematic differences between 41e50 years 12 (7.2%)
responders and non-responders. Questions were generated based >50 years 10 (6%)
Work Setting: Full time academic centre 146 (87.4%)
on previously published studies and commentary on the need to
Part time academic centre 10 (6%)
amend nutrition education within the undergraduate medical Community Practice 11 (6.6%)
curriculum [6,7] and were tested on three non-gastroenterology Grade: Intern 8 (4.8%)
clinicians to ensure clarity. Thirty-five questions were scored on Senior House Officer 42 (25%)
a 5-point Likert scale. The final contents of the survey were Registrar 81 (48.5%)
Consultant/Attending 36 (21.6%)
reviewed by a panel of nutrition experts from IrSPEN and deemed Speciality: Gastroenterology 43 (25.75%)
valid. Respondent demographics, clinical specialty, and daily Surgery 12 (7%)
management of issues relating to Clinical Nutrition were recorded. Respiratory 12 (7%)
In addition, we enquired about subjective experience and atti- Paediatrics 37 (22%)
Medicine for the Elderly 11 (6.6%)
tudes to education in Clinical Nutrition within the undergraduate
Oncology 9 (5.4%)
curriculum and postgraduate training of physicians and surgeons General Practice 9 (5.6%)
in Ireland. Endocrinology 5 (3%)
Responses were collected and analysed, and descriptive statis- Anaesthetics/Critical Care 4 (6.7%)
tics recorded. Comparison between clinician grades and correlation Cardiology 3 (1.8%)
Other 16 (12%)
between self-rated nutrition knowledge and years of experience
378
K. Boland, K. Allen, A. James et al.
less confident in assessment of need for and management of
artificial enteral feeding (p ¼ 0.022) and management of the
complications of parenteral nutrition (p ¼ 0.01). We also assessed
knowledge and attitudes around assessment of nutrition status by
clinicians. Two-thirds of trainee doctors (n ¼ 131) identified the
malnutrition universal screening tool (MUST) as the best method
to objectively measure risk of malnutrition. Many clinicians
believed that dietitians are best placed to assess need for nutrition
intervention and a non-statistically significant proportion of
trainee doctors felt that junior medical staff should be primarily
responsible for this (p ¼ 0.21, 8% trainees vs 3% consultants). Self-
rated knowledge of nutrition assessment, prescription of sup-
plementation, micronutrient requirements and obesity did not
correlate with clinical experience (p ¼ 0.9, r ¼ .1).
3.3. Physicians attitude towards education in clinical nutrition
within the undergraduate medical curriculum and postgraduate
training when addressing patients’ needs in clinical practice
We posed several questions relating to clinicians’ experience of
nutrition education in the undergraduate medical curriculum and
during postgraduate training. Seventy percent of respondents
believed their undergraduate training failed to prepare them for
their clinical practice and 92% reported that more focus and pro-
vision of education in this discipline was required (Fig. 1). This is
illustrated by the fact that 70% of those surveyed indicated that
they received <2 h of training in clinical nutrition within the
undergraduate medical curriculum. Almost one-third (n ¼ 50)
reported that no training in clinical nutrition was received as part
of their undergraduate training, to their recollection. There were
similar attitudes to the provision of training within the post-
graduate curriculum. Only 32% (n ¼ 52) received any specific
training in the form of lectures, tutorials, or course modules
within postgraduate training schemes, although gastroenterology
trainees were more likely to report that there was some provision
(p ¼ 0.01). A striking 98% of respondents felt that additional focus
on nutrition education in postgraduate training was needed to
adequately educate patients and manage complications of
malnutrition or obesity (Fig. 1). Specific comments included the
need for advice and education in the areas of complications of
Fig. 1. Attitudes and beliefs regarding Clinical Nutrition education in the undergraduate and postgraduate curricula. Responses depicted as percentage of the total respondents.
379
Clinical Nutrition ESPEN 52 (2022) 377e380
artificial tube feeding, parenteral nutrition, surgical interventions
in management of obesity and particularly the area of nutrition
and outcomes in liver disease and cirrhosis.
4. Discussion
We report that 92% respondents believe that increased focus on
clinical nutrition within the undergraduate and 98% believed
additional education for physicians within the postgraduate cur-
riculum is required (Fig. 1). These data compare with surveys
among internal medicine residents where 90% believed additional
education is required in this area [8]. Only 5.6% of our respondents
were working in general practice, however a previous analysis of
attitudes of over 3400 primary care physicians found clinical
practices relating to nutrition below the expected standard [9].
Within the Irish adult healthcare system in the absence of
nutrition support teams, the responsibility lies with general med-
ical, gastroenterology and surgical teams with support from allied
dietetic colleagues. These survey results highlight a deficit in
knowledge among physicians and the need for a multidisciplinary
approach to address malnutrition within our hospitals and among
our patients. Improved education in this area and funding of
nutrition support teams have been shown to improve patient care,
reduce complications [10] and are cost effective [11] in the context
of the complications of malnutrition and artificial nutrition itself.
The lack of dedicated nutrition support teams means that the
provision of high quality educational tools for healthcare workers
and increased awareness of the impact of disease-related malnu-
trition on chronic disease outcomes is important to address this
aspect of care for our patients.
Positioning clinical nutrition at the centre of patient care within
primary and secondary care teams requires a fundamental shift in
attitudes and the recognition of the impact of disease-related
malnutrition in patient with acute and chronic disease. Disease-
related malnutrition has clear and defined physiological and eco-
nomic burdens [12] responsible for approximately 10% of the total
health-care budget in Ireland in 2012. A fundamental change of
approach is required to successfully embed consideration of clinical
nutrition alongside pharmaceutical interventions in the manage-
ment of acute and chronic disease. In order to do achieve this, it is
K. Boland, K. Allen, A. James et al.
important to acknowledge the pressures of a knowledge-heavy
medical curriculum and develop innovative ways to amalgamate
Clinical Nutrition and other topics or modules. Over the last three
decades the medical curriculum has evolved to more integrated
systems-based approaches with increasing innovation in how ed-
ucation is delivered, incorporating group teaching and self-directed
learning [13]. These are valuable tools that can be used to teach
cornerstones of nutrition assessment and management alongside
other principles of disease management within postgraduate and
undergraduate training.
This survey elicits attitudes relating to nutrition education in the
undergraduate curriculum in Ireland from the perspective of
practicing clinicians within disparate specialities and grades.
Despite use of a multimodal recruitment strategy, there is potential
bias in that clinicians with a greater interest in nutrition may have
been more likely to respond. While there is theoretical bias in using
algorithm based social media it has been studied as an efficient
strategy to encourage clinician engagement [14]. We identify areas
where respondents reported lower self-rated levels of confidence.
IrSPEN has committed to addressing education in clinical nutrition
in medical schools in Ireland, drawing on the stated objectives of
ESPEN in this area [6,7] and have developed in-person training days
and written reference materials, focussing to date on gastroenter-
ology trainees and interns. These efforts will be expanded across
further disciplines, but crucially also to undergraduate pro-
grammes. We hope to work collaboratively with stakeholders to
develop appropriate materials for lecturing and self-directed
learning within undergraduate curricula.
Authors statement of contribution
Karen Boland and Cara Dunne conceived of the project as
IrSPEN members and wrote the questions. Karen Boland, Adam
James and Kathryn Allen developed and distributed the ques-
tionnaire. Karen Boland analyzed the data and was the primary
author of the manuscript which had contributions and edits from
all authors.
Funding
No funding disclosures
380
Clinical Nutrition ESPEN 52 (2022) 377e380
Declaration of Competing Interest
The authors have no conflict of interest to declare
Acknowledgements
We acknowledge the support of our dietetic colleagues and
colleagues at the Irish Society for Clinical Nutrition and Metabolism
in the development of an education programme for Clinical
Nutrition in Ireland.
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