Training Standards for Physician Nutrition Specialists®

To be eligible to enter fellowship training in the subspecialty of clinical nutrition, a physician must have completed categorical residency training. Although this will generally be in pediatrics, family medicine, internal medicine, or general surgery, physicians with other training backgrounds may be considered. Elective schedules permitting, physicians who are enrolled in fellowship programs in subspecialties such as adult or pediatric gastroenterology, endocrinology, critical care, nephrology, or cardiology may pursue nutrition training integrated within their major subspecialty fellowship program.

A subspecialty education program in clinical nutrition must provide training and experience at a sufficient level for the fellow to acquire competency as a specialist in the field. Training must comprise a minimum of 6 months of mentored clinical experience and formal instruction, either as a block or as an equivalent amount of time (1000 hours) integrated among other duties over a longer time period. No less than 20% of the clinical experience should be gained in inpatient settings and no less than 20% in outpatient settings (e.g., 1 day per week over 6 months or ½ day per week over a 1-year period).

Modern facilities and services, including inpatient, ambulatory care, and laboratory resources, must be available and functioning. Specifically, there must be a complete biochemistry laboratory, interdisciplinary nutrition support service, indirect calorimetry equipment, body composition facility, dietary service, and medical and surgical intensive care units.

1. The training program must provide opportunities for fellows to develop clinical competence in the field of clinical nutrition.
2. Clinical experience must include opportunities to observe and manage a sufficient number of new and follow-up inpatients and outpatients of all ages including children and older adults, of both sexes, and with a wide variety of common and uncommon nutrition-related disorders. It must be supervised by physicians and care must be provided by an interdisciplinary team such as a Nutrition Support Service, including Registered Dietitians and/or other appropriate health care professionals. The program must include opportunities to function in the role of a clinical nutrition consultant for other physicians and services in both inpatient and outpatient settings.
3. Fellows should have formal instruction, clinical experience, or opportunities to acquire expertise in the evaluation, nutritional management, and prevention of the following disorders:

Malnutrition
Obesity and eating disorders
Diabetes mellitus
Hypertension and cardiovascular diseases
Dyslipidemias
Gastrointestinal and liver disorders
Cancer
Renal disorders
Osteoporosis
Hematologic disorders
Pulmonary disorders
Immune disorders (HIV, transplant)

4. Fellows should have formal instruction, clinical experience, or opportunities to acquire expertise in the evaluation, management, and prevention of the following clinical problems:

Stress states
Hypometabolic/starvation states
Refeeding syndrome
Drug-nutrient interactions
Fluid and electrolyte management
Interpretation of laboratory values
Nutritional access device problems

The program must provide for instruction in the indications, contraindications, complications, limitations and, where applicable, interpretation of the following diagnostic and therapeutic techniques and procedures:

Nutritional assessment (history including diet; physical examination; and laboratory interpretation)
Methods for assessing energy expenditure and body composition
Dietary counseling
Feeding devices
Enteral and parenteral nutrition support in both inpatient and outpatient settings

The program must, as a minimum, insure that fellows receive formal instruction in the areas below. This instruction may be in the form of lectures, conferences, seminars, or formal self-study programs or in other settings or locations, including previous or concomitant dietetic or graduate training in nutrition.

Nutritional assessment and interventions/therapies, including complementary and alternative nutrition therapies
Macro- and micronutrients in health and disease:

Metabolism, absorption, utilization
Signs, symptoms, and management of deficiencies and excesses

Nutrition through the life cycle
Health promotion and disease prevention
Ethical issues in nutrition