Extended Framework (NF) December 2014 Introduction The Framework (NF) for medical graduat dcrib four knowledge and five skill based competenci that demonstrate: Understanding the basic scienc in relation to nutrition (K1) Knowledge the interactive role nutrition in health and the prevention disease (K2) Knowledge evidence-based dietary for prevention and treatment disease (K3) Awarens food sourc nutrients food habits and the cultural and social importance food (K4) kills in the identification risk deficits and excs (1) Ability to interpret nutrition evidence in a critical and scientific manner and apply it appropriately in clinical practice (2) Ability to apply basic dietary for prevention and treatment medical conditions and disease and trauma with recognition that many issu require specialist management by a dietitian (3) Ability to apply principl ethics related to management (4) Ability to work effectively in a team with other health prsionals to deliver optimal nutrition care (5). This NF has been developed over three years by a team medical and nutrition prsionals. The nutrition competenci have been mapped to the current Australian edical ouncil (A) Graduate Outcome tatements (www.amc.org.au). We have undertaken extensive consultation with key bodi and refined our NF as a rult this feedback. Recently we have extended the NF to provide exampl the range relevant topics with learning outcom that could be included together with exampl as part the Web-based Implementation Toolkit (WNIT) project which has been funded through the Federal Government s Office for Learning and Teaching. It is hoped that the NF will provide a useful reference point for entry-level medical cours throughout Australia. We are interted in any feedback you may wish to provide on this framework. Please contact Pr. aryl Nowson caryl.nowson@deakin.edu.au Explanatory Not The NF dcrib the learning outcom for each the knowledge- and skill-based competenci for medical graduat. A relevant range variabl provide contexts and environments in which competency could be demonstrated. Important explanatory not to the NF include: Owing to the breadth contextual variabl some learning outcom may be repeated as applicable across many contexts and/or environments to demonstrate competency. Asssment have been included in this extended version the NF. A medical graduate should demonstrate all competenci by the end medical training. Due to various medical training models time periods (e.g. end year 1) have not been specified. The terms tudent Learning Outcome Graduate ompetenci and/or Graduate Attribut may be used across various institutions to dcribe the skills and knowledge students will achieve. K = knowledge = skill 1
K1 1.1 understanding the basic scienc in relation to nutrition tudent Learning Objectiv (LOs) 1. Dcribe the functions sential nutrients and the basis for the biochemical demand for energy and nutrients 2. Dcribe the integrative normal procs appetite eating inttinal function digtion absorption and nutrient utilisation and common disorders that affect them 3. Differentiate the energy and nutrient requirements across the lifpan for normal growth structure and function subject matter to addrs LOs Anthropometric standards and reference rang for individuals/groups linical/biochemical standards and reference rang for individuals/groups acronutrient and micronutrient requirements (e.g. energy protein HO fat iron calcium vitamin D zinc) and biochemical functions in individuals and/or population groups and disorders which may affect digtion absorption and requirements for the Gastrointtinal tract structure function; digtive and absorptive procs Fuel metabolism and homeostasis carbohydrat fats and protein Hormonal control hunger and satiety Biochemical demand and contributors to energy intake and energy expenditure in the body across the life course al requirements across the lifpan including infancy childhood adolcence adulthood pregnancy lactation and later life trategi to addrs nutrition requirements clients in a range settings e.g. acute care rehabilitation nursing home community primary care settings LOs that could be incorporated into existing Identify key macronutrients and micronutrients understand their biochemical functions and dcribe individual requirements for different population groups Dcribe fuel metabolism and homeostasis carbohydrat fats and protein; explain the impacts on biochemical demand and contributors to energy intake and energy expenditure in the body across the life course Dcribe gastrointtinal tract structure and function; dcribe the procs digtion and identify major sit where absorption nutrients occurs Dcribe the mechanisms hunger and satiety control Dcribe how different disease procs impact status Differentiate the requirements across the lifpan including infancy through to end life and pregnancy and lactation Identify appropriate to addrs nutrition requirements clients at different life stag and in different settings (e.g. acute care rehabilitation nursing home community) ource and identify the most appropriate anthropometric standards and reference rang for individuals/groups Recognise and identify clinical/biochemical standards and reference rang Written exam/q OE ase Individual or communitybased 2
K2 1.3 2.1 3. 33.5 3.2 1.1 1.2 1.4 1.5 3.2 knowledge the interactive role nutrition in health and the prevention disease tudent Learning Objectiv (LOs) 1. Dcribe the common nutritionrelated caus mortality and morbidity in the population 2. Explain the biochemical basis how nutrition affects health and risk factors for disease 3. Translate how disease can affect status subject matter to addrs LOs Dietary links with non-communicable diseas e.g. diabet obity VD (including hypertension) cancer osteoporosis nutrient deficienci (e.g. vitamin D iron folate) -related risk factors across the lifecourse for various disease and predictors mortality including: a) Dyslipidaemia (high trans and saturated fat) b) Hypertension (high sodium) c) Overweight/obity (excs energy intake/low energy expenditure) d) Osteoporosis (low calcium intake) e) NTDs (low folate intake) f) alnutrition/failure to thrive (insufficient macro and/or micronutrients) g) icronutrient deficiency (eg: iron deficiency aneamia and vegetarianism) h) urgical/trauma/infection (macro and micronutrient deficiency) Diseas/disease procs and their impact on status including: a) alnutrition associated with increased requirements and/or decreased intake in common conditions including rpiratory disease F gastrointtinal disorders including those related to surgery #NOF cancer and associated treatments neurological impairment including dementia b) Gastrointtinal disease and micronutrient deficienci e.g. coeliac disease rohn s Disease short gut c) Eating disorders and weight loss/malnutrition/deficienci d) Increased macro/micronutrient requirements for healing prsure areas (e.g. long-term institutionalised) e) hronic renal and end-stage renal failure and energy protein fluid Na + K + PO 4 requirements f) tarvation and refeeding syndrome g) ystic fibrosis/inborn errors metabolism and child growth/development h) Food allergy/intolerance and other practic requiring dietary rtriction omplex cas which require outside referral; therefor LOs that could be incorporated into existing Identify the most common caus morbidity and mortality that have dietary links e.g. diabet obity VD (including hypertension) cancer osteoporosis nutrient deficienci (e.g. Vitamin D iron folate) Dcribe the nutrition-related risk factors for various diseas and predictors mortality Dcribe which dietary factors may impact on cardiovascular disease including those that affect lipids hypertension and weight Dcribe the impact a low-calcium intake on osteoporosis Dcribe the dietary patterns that may impact on cancer development Dcribe the impact malnutrition and failure to thrive on health Identify the impact obity on those at risk type 2 diabet Dcribe the reasons for altered nutrient requirements in inflammatory bowel disease and coeliac disease Dcribe the possible reasons for increas in the risk malnutrition in rpiratory disease Identify what body composition chang can occur in long-term eating disorder patients Dcribe the effects that dementia may have on patients in aged care Written exam/qs OEs ase Individual or communitybased Referral letter 3
tudent Learning Objectiv (LOs) subject matter to addrs LOs a) Identify relevant dietetic servic provide referral and appropriate documentation (e.g. biochemistry medications history) b) Effectively communicate to patients regarding disease procs and plans for referral to nutrition and dietetics prsional LOs that could be incorporated into existing K3 1.3 2.7 2.1 2 knowledge evidence-based dietary for prevention and treatment disease 1. Dcribe the role nutrition in treatment disease 2. Dcribe the dietary management for relevant medical conditions and disease 3. an appreciation nutrient/drug interactions Evidence-based dietary management and medical conditions: a) ardiovascular risk factors: o Hypercholterolemia (trans and saturated fats fibre plant sterols omega 3 PUFAs UFAs) o Hypertension (sodium alcohol obity) o Overweight/obity (energy) o Diabet (energy protein HO intake physical inactivity GI) b) etabolic/endocrine disorders: o Diabet (energy protein HO intake physical inactivity GI) o PO (obity physical inactivity GI) c) Gastrointtinal disorders: o Gall bladder disease (obity saturated fat) o oeliac disease (gluten) o onstipation/diarrhoea/diverticular disease (soluble and insoluble fibre fluids microbiome) o Inflammatory Bowel Disease (energy protein fluid electrolyt) o Dietary intolerance (fructose lactose fructans oligosaccharid) d) Renal disease o ARF (electrolyt fluid energy protein) o RF (protein fluid electrolyt) o ERF (energy protein fluids) o Electrolyt (phosphate potassium sodium) e) Oncology o alnutrition/weight loss (protein/ energy) f) Burns o Wound healing (protein energy fluid micronutrients e.g. zinc g) Pulmonary disorders Outline the major medical conditions where dietary management is particular importance Dcribe the dietary management in treating food allergy Dcribe the dietary management in treating cardiovascular disease Dcribe the dietary management in treating polycystic ovarian syndrome Dcribe the dietary management in treating type 2 diabet Dcribe the dietary management in treating coeliac disease Dcribe the dietary management in treating inflammatory bowel disease Dcribe the dietary management in treating malnutrition Dcribe the dietary management in treating burns Dcribe the dietary management in treating pulmonary disorders Dcribe drugs/treatments used that may affect status and dietary requirements Qs hort answer qutions ase OEs 4
tudent Learning Objectiv (LOs) subject matter to addrs LOs o alnutrition/weight loss (protein/energy) o Fluid overload (fluid and sodium) Drugs/treatments that may affect status and dietary requirements such as: a) ardiovascular (e.g. warfarin and Vitamin K) b) Endocrinology (e.g. thyroid radiation and iodine; metformin and vitamin B12) c) Renal (e.g. dialysis and electrolyt protein) d) Psychiatric (e.g. AO inhibiters and tyramine; medications associated with weight gain) LOs that could be incorporated into existing 5
K4 3.2 3.4 3.8 3.9 1.1 1.2 1.4 1.5 awarens food sourc nutrients food habits and the cultural and social importance food tudent Learning Objectiv (LOs) 1. List the food sourc major nutrients 2. Dcribe how the social determinants health influence food consumption patterns and the consequenc this 3. Appreciate the social and cultural importance food subject matter to addrs LOs acro and micronutrients provided by each food group in the Australian Guide to Healthy Eating (http://www.eatforhealth.gov.au/) The Australian Dietary Guidelin (http://www.eatforhealth.gov.au/) as promoted by the Department Health and Ageing The food groups as outlined by the Australian Guide to Healthy Eating as promoted by the ommonwealth Department Health and Ageing (http://www.eatforhealth.gov.au/) Foods providing high amounts carbohydrate protein fats (including high poly- and monounsaturated fats) and dietary fibre that are protective against disease e.g. VD overweight some cancers diabet hypertension Foods that contain high amounts micronutrients pecially iron zinc B group vitamins calcium Procsed takeaways and other discretionary foods that contain high saturated and trans fats sodium and sugar that are linked to disease (as noted in K2) Food labels - to determine the major macro and micronutrient pril foods ommunity groups vulnerable to food insecurity and factors contributing to food insecurity (individual household community and state/federal levels) ocial and cultural interactions impacting food availability dietary intak individuals and populations e.g. cultural cuisine impact occupational environment LOs that could be incorporated into existing Identify food sourc the major macro and micronutrients Identify community groups vulnerable to food insecurity Identify factors contributing to food insecurity at an individual household government level Dcribe how social and cultural interactions impact the dietary intak individuals and populations Qs hort answer qutions ase Referrals OEs 6
1 2.2 2.4 skills in the identification risk deficits and excs tudent Learning Objectiv (LOs) 1. Asss nutrition risk factors pertaining to over- and undernutrition 2. Integrate nutrition in the medical history and physical examination 3. Interpret and integrate findings from the to define problems subject matter to addrs LOs * as part the overall medical in all patients including: a) Food/nutrition-related history (e.g. food intake medication complementary/alternative medicine use food knowledge/beliefs and availability physical activity mental health status) b) Anthropometry asss and utilise anthropometric data using recognised methods (height weight weight history BI waist circumference growth charts) c) Biochemical data tts procedur identify requt and interpret rults relevant tts that are clinically applicable to asss status (e.g. UE P FB iron studi hormon micronutrients) d) -focused physical findings physical appearance muscle and fat wasting swallow function appetite and affect e) lient history medical/health/family history treatments therapy occupational and social history Validated nutrition screening and tools (e.g. T UT NR NA-F NA GAPG-GA); evaluating data for relevance/significance and validating information collected where possible Referring to dietetics prsional (APD) a) dietetic servic providing referrasl and appropriate case documentation including history rults invtigations and previous management plans b) Formulating to accs expertise in a range settings including rural city and remote locations LOs that could be incorporated into existing skills in identification clients who may need further assistance in managing their diet the use anthropometric measur such as BI waist circumference and use growth charts awarens the importance nutritionrelated factors in the medical and physical Display incorporation nutrition-related findings into and management plan where appropriate; develop plans for clients and appropriate referrals to other agenci/servic Qs hort answer qutions ase OEs * Adapted from Academy and Dietetics IDNT anual 4 th Edition 2013. 7
2 1.1 1.2 1.4 1.5 2.1 5 3.5 4. 2 ability to interpret nutrition evidence in a critical and scientific manner and apply appropriately in clinical practice tudent Learning Objectiv (LOs) 1. Locate and critically appraise literature on nutrition related to prevention and treatment disease 2. Apply an evidence-based approach in the delivery appropriate nutrition management in clinical practice subject matter to addrs LOs Rourc related to nutrition management patients: rearch databas prsional associations (e.g. Dietitians Association Australia Diabet Australia Baker IDI National Heart Foundation ancer ouncil) and dietetic prsionals with APD credentials Rearch analysis: a) Differenc between clinical versus statistical significance in nutrition management patients b) onfounding variabl that can impact nutrition-related rearch c) Non-evidence-based materials including some complementary and alternative therapi (A) and practitioners cientific evidence and nutrition management patients; practic relevant to current evidence LOs that could be incorporated into existing Displays the use current evidence based information in the management clients with nutrition related issu use relevant evidence-based nutrition rourc and apply them in patient management Qs hort answer qutions ase Referrals OEs 8
3 2.7 2.1 2 2.7 2.9 3.2 2.7 2.8 2.9 ability to apply basic dietary for prevention and treatment medical conditions disease and trauma with recognition that many issu require specialist management by a dietitian tudent Learning Objectiv (LOs) 1. Apply clinical reasoning to prioritise management 2. Explain risk factors for common diseas to patients and their famili 3. Provide basic evidence-based advice on nutrition to patients 4. Where appropriate integrate nutrition goals into patients care plans including referral to other prsionals as required (particularly dietitians) 5. Recognise that dietary may include those for noncommunicable diseas subject matter to addrs LOs Risk factors including: a) Low fibre and wholegrain cereals related to constipation diverticular disease b) Fruit and vegetable intake and cancer c) Low calcium intake and osteoporosis d) Weight gain and inactivity and type 2 diabet e) High saturated fat intake sodium and VD f) weetened drinks and weight gain ADGs that relate to the individual client Appropriate nutrition management such as: a) To improve type 2 diabet control suggt weight loss/maintenance b) To treat VD reduce saturated fat/increase UFA AND PUFA to improve lipid prile c) To assist failure to thrive children suggt increased energy using supplements with specialist input form a dietitian d) For coeliac disease suggt strict gluten avoidance with specialist input form a dietitian e) For malnourished nursing home patients suggt increased eating frequency energy dense foods and specialist dietitian input d) Provide referrals to dietetic-trained prsionals; work as a team to ensure all aspects patients care plans are regularly addrsed; keep in close touch with the allied health staff and ask for details treatment as a self-learning vehicle LOs that could be incorporated into existing skills in the identification risk deficits and excs prioritisation issu depending on the broader prile/life circumstanc the patient the ability to communicate common risk factors that could be modified to prevent/treat disease the ability to apply different management for clients in a range settings the ability to provide basic evidencebased nutrition advice to patients with common diseas such as type 2 diabet VD malnutrition the ability to recognise in what situations referral to a dietitian is appropriate Literature review ase 9
4 2.1 3 4.4 4.4 the ability to apply principl ethics related to management tudent Learning Objectiv (LOs) 1. Apply ethical and legal requirements to the decisionmaking procs concerning nutrition subject matter to addrs LOs Decisions regarding: a) withholding or withdrawing nutrition or hydration support b) deciding when enteral or parenteral nutrition is required and seek specialised advice c) seek medicolegal advice when indicated for example in chronic eating disorders child malnourishment meal provision in aged care servic Rpecting patients choic in decisions related to provision nutrition via oral enteral or parenteral rout LOs that could be incorporated into existing the ability to recognise the nutritionrelated ethical issu that may be involved in end life situations OEs ase reports/stu di Referrals 5 3.6 3. 7 4.8 ability to work effectively in a team with other health prsionals to deliver optimal nutrition care 1. Recognise the limitations own knowledge and skill and refer or consult with another health practitioner appropriately 2. Understand rpect incorporate and support the rol other health prsionals in management patients ultidisciplinary team approach to and management individuals and groups Engaging rpectfully and effectively with multidisciplinary team members Utilising servic community-based organisations and Ns that promote health and nutrition (e.g. the Red ross eals on Wheels community health centr) Providing written referrals (including relevant and diagnostic information) or newer technologi to communicate with other allied health prsionals ounselling individuals and groups regarding non-evidence-based practic that may be harmful to health nutrition or financial status for an individual ability to engage rpectfully and effectively with multidisciplinary team members skills in locating and utilising servic community-based organisations and Ns that promote health and nutrition (e.g. the Red ross eals on Wheels community health centr) the importance using a multidisciplinary team approach to and management individuals and groups the importance communication via referral including relevant and diagnostic information OEs ase reports/stu di Referrals 10
bbreviations ADGs A APD ARF A F HO P RF VD ERF FB Fe 2+ GI K + AO Q NA NA-F T UFAs UT Na + NDs Ns #NOF NR NTDs OE PO PG-GA PO 4 PUFAs GA UE Australian Dietary Guidelin Accredited Practising Dietitian omplementary and Alternative Therapi ongtive ardiac Failure arbohydrate alcium/agnium/phosphate (blood tt) Full Blood ount Iron Glycaemic Index Potassium onoamine Oxidase ini Asssment alnutrition creening Tool alnutrition Universal creening Tool odium Non ommunicable Diseas Fracture Neck Femur Risk creening Tool Neural Tube Defects Polycystic Ovary yndrome Patient Generated ubjective Global Asssment Phosphate ubjective Global Asssment Urea/Electrolyte/reatinine (blood tt)