Data transparency is critically important: the Academy joins forces with the World Cancer Research Fund

The Academy of Nutrition Sciences (ANS) and the leading cancer charity, World Cancer Research Fund (WCRF), have recently joined forces to respond to a letter from Stanton and colleagues, published in The Lancet, which called for the Global Burden of Disease 2019  (GBD 2019) investigators to reconsider the measurements they were using to draw conclusions about the links between dietary risk factors and diseases, including cancer, and to increase the transparency around the decisions they make when drawing conclusions. For over 30 years, WCRF has been at the forefront of exploring the links between diet, nutrition, physical activity, body weight and cancer. The Academy of Nutrition Sciences  was established in 2019 to provide a collective voice for the nutrition science discipline, including those engaged in research, education and training, clinical practice, and nutrition science communication. As explained later, the Academy has a particular interest in the nature of the evidence base used in nutrition science and the frameworks underpinning dietary recommendations.

Our joint letter in The Lancet

For the diet-related recommendations made by governments and organisations, such as WCRF, to be trusted by everyone who uses them, it is essential that the underlying studies, used to inform these recommendations, appropriately and effectively analyse the available data. At the same time, these methods need to be clearly documented by the study investigators, and any changes to them clearly explained. Transparency about the assumptions made in arriving at the published findings is critically important.

Recently WCRF and the Academy worked together to publish a letter in The Lancet about the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD 2019). https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01283-1/fulltext

Our letter joined calls from other scientists (see here) asking the GBD investigators to reconsider the measurements they were using to draw conclusions about the links between dietary risk factors and diseases, including cancer. Of particular interest to us was the dramatic change in the reported impact of eating unprocessed meat upon health. In 2019 the GBD study reported that 896,000 deaths were caused by a diet high in red meat, a dramatic change from only 25,000 deaths in 2017. It seemed to us that this change had more to do with the method used to estimate risky levels of meat eating, rather than change in how eating it was impacting health. For both the Academy and WCRF, our biggest concern is that many users of the valuable data provided by GBD will not be aware of the technical details which underlie this change, with risk of unintentional misinterpretation. It is very important that challenges such as those made in the Lancet letter from the scientific community are quickly and openly addressed so that the public, scientific community and policy-makers can have faith in the results of published research. This is particularly true for studies like GBD because they play a key role in establishing the scientific base for public health policy and disease prevention efforts round the world. 

It is therefore pleasing to note that, at the time of this blog going online, the GBD investigators have already responded to the concerns from the scientific community by publishing a letter detailing how they intend to change and improve their methods for GBD 2020 (see here). The Academy and WCRF recognise the increasingly complex body of evidence demonstrating links between diet and health outcomes. We look forward to reading the results of GBD 2020, which incorporate adjustments to the methodology, and welcome the investigators’ transparency.

The Academy of Nutrition Sciences’ perspective on translating research into dietary recommendations

The Academy of Nutrition Sciences (ANS) was established in 2019 to provide a collective voice for the nutrition science discipline, including those engaged in research, education and training, clinical practice, and nutrition science communication. It is a result of a longstanding collaboration between four organisations:  the Association for Nutrition, the British Dietetic Association, the British Nutrition Foundation, and the Nutrition Society. The Academy also seeks to reduce the levels of misinformation about nutrition and health and improve the public’s understanding of how evidence is scrutinised and evaluated by organisations, such as WCRF, to produce recommendations.

The Academy has a strong interest in nutrition research excellence, development of the nutrition science discipline and application of the outcomes of rigorous nutrition science for public benefit. Its first Position Paper, published in December 2020 in the British Journal of Nutrition (see here) focused on the nature of the evidence base used in nutrition science and frameworks underpinning dietary recommendations for prevention of non-communicable diseases such as cancers and cardiovascular diseases. The paper considers methodological advances made in nutritional epidemiology and frameworks used by expert groups to support objective, rigorous and transparent translation of the evidence into dietary recommendations, and the innate challenges in this complex area of science.  Alongside an emphasis on the fundamental importance of transparency and systematic rigour, the Academy makes three recommendations: (i) the development of methodologies and criteria for selection of relevant experimental data; (ii) further development of innovative approaches for measuring human dietary intake and reducing confounding in long-term cohort studies and; (iii) retention of national nutrition surveillance programmes needed for extrapolating global research findings to UK populations. The Position Paper is accompanied by an editorial, published in both Nutrition Bulletin and the Journal of Human Nutrition and Dietetics, which focuses on synthesising nutrition science into dietary guidelines for populations amidst the challenge of fake news (see here).

An accompanying blog post from WCRF can be found here https://www.wcrf.org/how-do-we-know-what-cancer-prevention-information-to-trust/

Prof Judy Buttriss, Chair of Trustees, Academy of Nutrition Sciences

Dr Vanessa Gordon-Dseagu, World Cancer Research Fund

Prof Christine Williams, Trustee, Academy of Nutrition Sciences

How can nutrition organisations support the teaching of nutrition to student doctors?

We’d like doctors to learn more about nutrition – here’s how we can help.

The importance of nutrition for health is widely recognised, and poor nutrition is associated with an increased risk of ill health[1],[2]. Public Health England acknowledged the need to develop training in diet and health for non-nutritionists[3] and the NHS long-term plan commits to ensuring that “nutrition has a greater place in professional education training.”[4]  Yet nutrition has not been well covered in medical training, with reports suggesting there is only between 2 and 19 hours of teaching devoted to nutrition over a 5-year medical degree programme[5] [6]. The Academy of Nutrition Sciences and its member organisations, the Association for Nutrition (AfN), British Dietetic Association, British Nutrition Foundation and The Nutrition Society, are committed to championing nutrition science, enhancing its impact on policy and health for public benefit.  Improving the coverage of nutrition within the medical curriculum is, therefore, a key concern.

Understanding the reasons for this lack of nutrition coverage in the medical curriculum is important.  When the AfN, surveyed medical schools they found that one reported reason is the time pressure on an already crowded curriculum. Another is the need for nutrition expertise within teaching staff.  Medical schools wanted to see how nutrition teaching would map against the General Medical Council  (GMC) Outcomes for Graduates and the Medical Licensing Assessment (MLA), and asked for evidence-based resources.  Examples that demonstrate how to integrate nutrition into the curriculum have also been identified as useful. An important factor is that medical schools have a great deal of freedom in what they teach.  Although the GMC articulates “graduate fundamentals” and sets the Medical Licensing Assessment, medical schools determine the detail of their syllabus – it is in this detail where nutrition should sit. 

AfN became the custodians of the nutrition curriculum for undergraduate medical training in 2018, building on the work of the Academy of Medical Royal Colleges[7] who published their nutrition curriculum guidance in 2013.  The challenge was not just to create a modern, competency-based curriculum, but also to understand these barriers and to encourage greater inclusion of nutrition in the syllabus.  The task was to design a curriculum which would provide the basic nutrition knowledge which doctors need on “day 1”, which would provide a foundation for later learning within specialities and which would help newly qualified doctors to understand when specialist nutrition support would benefit their patients.  But it was also about providing a curriculum which makes sense to medical schools, which can be integrated into their existing syllabus in a coherent way, and which can be assessed as part of the existing assessment structures.

In 2021, AfN published the updated Undergraduate Curriculum in Nutrition for Medical Doctors[8], the work of an Interprofessional Group which included representatives from a range of nutrition, dietetic and medical organisations. This was a multidisciplinary piece of work which demonstrated what is possible when professional associations, learned societies, practitioners, academics and policy makers work together.  It will take the joint efforts of these organisations to promote, encourage and enable uptake of the curriculum by medical schools.

It is this joint working model which the Academy is well placed to promote.  All of the Academy founding members are members of the Interprofessional Group and all have a role to play in supporting implementation.  One of the benefits of the Academy is that it provides a forum where nutrition organisations can co-ordinate their activities on issues which matter to all of us, and bring together their strengths to work for public benefit.  

The curriculum has been designed to provide doctors with an understanding of key principles in nutrition.  The intention is not to make doctors nutrition professionals, but rather to give them the knowledge they need to support their medical practice, to provide basic nutrition advice and to understand how and when to refer patients for specialist nutrition support.  The curriculum was mapped against the GMC Outcomes for Graduates and the Medical Licensing Assessment, so that medical schools can see where nutrition teaching can be usefully added to their existing teaching and, indeed, where it may already be covered without being explicitly identified as nutrition.  Assessment drives learning, so the Interprofessional Group is also developing questions to contribute to the MLA question bank.

The Interprofessional Group identified three areas of activity to support implementation of the curriculum – communications, resource development and quality assurance.  These areas require the support of all member organisations of the IPG and, indeed, the nutrition and dietetic community more widely, to maximise the impact of the curriculum on initial medical training.  A scoping exercise has been conducted to identify the current capabilities and resources of the IPG members, which could support implementation of the curriculum. 

We believe that medical schools should be supported to easily identify resources that will support them in delivering the nutrition curriculum, so a quality assurance scheme has been established that endorses the resources developed by the nutrition and dietetic community against the curriculum, identifying the teaching points that are supported.  AfN has launched a web page to provide a “one stop” point of access to the resources and CPD opportunities available, ready for promotion to medical schools as they are encouraged to implement the nutrition curriculum.  Work is ongoing to publish academic papers about the curriculum, and other promotional activity has been undertaken including a social media campaign and direct communications with medical schools.  

Ultimately, the success of the nutrition curriculum depends on the ability of medical schools to integrate its teaching points into the detail of their syllabus.  Doing so will require support and expertise, which the Academy of Nutrition Sciences, and its member organisations, are well placed to provide through the development of resources to support teaching points, CPD opportunities for medical educators and the promotion of examples of good practice which already exist.  

Helen Clark

Chief Executive, Association for Nutrition
Academy of Nutrition Sciences Operational Support Group Member

[1] Public Health England, “Calorie reduction: The scope and ambition for action,” March 2018. [Online]. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/800675/Calories_Evidence_Document.pdf.

[2] Development Initiatives, “2020 Global Nutrition Report: Action on equity to end malnutrition,” July 2020. [Online]. Available: https://globalnutritionreport.org/documents/566/2020_Global_Nutrition_Report_2hrssKo.pdf.

[3] Public Health England, “Sugar Reduction: The evidence for action,” October 2015. [Online]. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/470179/Sugar_reduction_The_evidence_for_action.pdf.

[4] NHS Digital, “The NHS Long Term Plan,” 7 January 2019. [Online]. Available: https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/. [Accessed September 2020].

[5] Macaninch E, Buckner L, Amin P, Broadley I, Crocombe D, Herath D, et al. Time for nutrition in medical education York Teaching Hospital NHS Foundation Trust. 2020 [cited 2022 Mar 10];0. Available from: http://dx.doi.org/10.1136/bmjnph-2019-000049

[6] Broad J, Wallace M. Nutrition and public health in medical education in the UK: reflections and next steps. Public health nutrition [Internet]. 2018 Sep 1 [cited 2022 Mar 11];21(13):2523–5. Available from: https://pubmed.ncbi.nlm.nih.gov/29708088/

[7] https://www.aomrc.org.uk/reports-guidance/uk-undergraduate-curriculum-nutrition/

[8] https://www.associationfornutrition.org/careers-nutrition/wider-workforce/nutrition-training-for-medical-doctors