Nutrition Education in Medical School, Residency Training, and Practice

The knowledge, attitudes, and perceptions towards a plant-based dietary pattern: a survey of obstetrician-gynecologists

Background

Obstetricians-gynecologists (OB/GYNs) play a critical role for their pregnant patients during their perinatal period, but research on OB/GYNs knowledge, attitudes, and perceptions regarding plant-based dietary patterns (PBDP) and how this may influence recommendations to patients is lacking. An online cross-sectional survey was conducted to examine OB/GYN's knowledge, attitudes, and perceptions towards a PBDP.

Methods

Postcards were mailed in June 2023 to a convenience sample of 5,000 OB/GYNs across the US using a mailing list provided by the American College of Obstetricians and Gynecologists. Postcards had a brief study description and a QR code that linked to an online survey asking questions about demographics, behavior (e.g., nutritional habits), and other factors that may influence knowledge, attitudes, and perceptions towards a PBDP for their patients.

Results

Ninety-six OB/GYNs completed the full questionnaire (~2% response rate). Most (92%) felt that it is within an OB/GYN's role to incorporate nutrition education and counseling within practice. However, 72% felt inadequately trained to discuss nutrition and diet-related issues with patients. Despite a perceived lack of nutrition training, 86% reported that a PBDP was safe and health-promoting, and 81% reported that a well-planned PBDP could adequately meet all nutritional needs of pregnant and lactating patients.

Conclusion

Findings suggest that OB/GYNs are generally knowledgeable about the components and health benefits of a plant-based diets. However, nutrient adequacy misconceptions and lack of sufficient training to discuss nutrition with patients may result in OB/GYNs not recommending PBDPs to patients. These findings underscore the need to enhance OB/GYN graduate medical education and training by integrating education on PBDPs, therefore improving a clinician's ability to confidently and effectively counsel pregnant persons on this aspect of perinatal care.

There and Back Again: A Forty-Year Perspective on Physician Nutrition Education

Medical education faces an urgent need for evidence-based physician nutrition education. Since the publication of the 1985 National Academies report "Nutrition Education in the United States Medical Schools," little has changed. Although several key efforts sought to increase nutrition content in undergraduate medical education over the past 40 y, most medical schools still fail to include the recommended minimum of 25 h of nutrition training. Without foundational concepts of nutrition in undergraduate medical education, graduate medical education unsurprisingly falls short of meeting patient needs for nutritional guidance in clinical practice. Meanwhile, diet-sensitive chronic diseases continue to escalate, although largely preventable and treatable by nutritional therapies and dietary lifestyle changes. Fortunately, recent recognition and adoption of Food is Medicine programs across the country increasingly connect patients with healthy food resources and nutrition education as core to their medical care, and physicians must be equipped to lead these efforts alongside their dietitian colleagues. Filling the gap in nutrition training will require an innovative and interprofessional approach that pairs nutrition with personal wellness, interprofessional practice, and community service learning. The intersectional benefits of connecting these domains will help prepare future physicians to address the social, behavioral, and lifestyle determinants of health in a way that recognizes nourishing food access as a core part of clinical practice. There are numerous strategies to integrate nutrition into education pathways, including didactic and experiential learning. Culinary medicine, an evidence-based field combining the culinary arts with nutritional science and medicine, is 1 promising educational framework with a hands-on, interprofessional approach that emphasizes community engagement. Advancing the critical need for widespread adoption of nutrition education for physicians will require support and engagement across societal stakeholders, including co-leadership from registered dietitian nutritionists, health system and payor reform, and opportunities for clinical innovation that bring this essential field to frontline patient care.

Nutrition Education and Nutrition Knowledge Among Obstetrics and Gynecology Residents

Background: Nutrition in pregnancy is a component of the Council on Resident Education in obstetrics and gynecology core curriculum; however, no studies currently examine adherence to this goal. Objectives: Our objective was to assess obstetrics and gynecology (Ob/Gyn) residents' education and knowledge surrounding nutrition in pregnancy, including (1) amount of dedicated didactic time to and attitudes toward, (2) subjective comfort in counseling patients on, and (3) objective knowledge of pregnancy-related nutrition. Materials and Methods: This is a cross-sectional electronic survey-based study. A 28-item questionnaire was distributed to residents enrolled in Ob/Gyn training programs across the United States in 2022. Results: From 247 Ob/Gyn residency programs, 218 residents across postgraduate years and from geographically diverse locations consented to participation and completed all survey questions. Almost half (48%) of participants reported 0 hours per year of dedicated nutrition-related education, 49% reported 1-2 hours, and 3% reported >2 hours. Most residents (92%) strongly agreed or agreed that education regarding pregnancy-related nutrition guidelines would be useful for clinical practice. However, less than one-third (31%) of residents reported feeling comfortable counseling patients on nutrition in pregnancy. On assessment of residents' objective knowledge of pregnancy-related nutrition, mean percentage of correct responses was 74%. Conclusions: This study identifies a gap in graduate medical education, specifically a disconnect between the recognized impact of nutrition on pregnancy outcomes and residents' ability to confidently and effectively counsel patients on nutrition in pregnancy. Results demonstrate a need to develop curriculum and interventions to educate Ob/Gyn residents about pregnancy-related nutrition.

Culinary Medicine Experiences for Medical Students and Residents in the U.S. and Canada: A Scoping Review

PHENOMENON

Despite the importance of diet in the prevention and management of many common chronic diseases, nutrition training in medicine is largely inadequate in medical school and residency. The emerging field of culinary medicine offers an experiential nutrition learning approach with the potential to address the need for improved nutrition training of physicians. Exploring this innovative nutrition training strategy, this scoping review describes the nature of culinary medicine experiences for medical students and resident physicians, their impact on the medical trainees, and barriers and facilitators to their implementation.

APPROACH

This scoping review used the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) checklist as guides. Eligible publications described the nature, impact, facilitators, and/or barriers of nutrition and food preparation learning experiences for medical students and/or residents. Additional inclusion criteria were location (U.S. or Canada), allopathic or osteopathic, English, human subjects, and publication year (2002 or later). The search strategy included 4 electronic databases. Two reviewers independently screened titles/abstracts and a third reviewer resolved discrepancies. The full-text review consisted of 2 independent reviews with discrepancies resolved by a third reviewer or by consensus if needed, and the research team extracted data from the included articles based on the nature, impact, barriers, and facilitators of culinary medicine experiences for medical trainees.

FINDINGS

The publication search resulted in 100 publications describing 116 experiences from 70 institutions. Thirty-seven publications described pilot experiences. Elective/extracurricular and medical student experiences were more common than required and resident experiences, respectively. Experiences varied in logistics, instruction, and curricula. Common themes of tailored culinary medicine experiences included community engagement/service-based learning, interprofessional education, attention to social determinants of health, trainee well-being, and cultural considerations. Program evaluations commonly reported the outcome of experiences on participant attitudes, knowledge, skills, confidence, and behaviors. Frequent barriers to implementation included time, faculty, cost/funding, kitchen space, and institutional support while common facilitators of experiences included funding/donations, collaboratives and partnerships, teaching kitchen access, faculty and institutional support, and trainee advocacy.

INSIGHTS

Culinary medicine is an innovative approach to address the need and increased demand for improved nutrition training in medicine. The findings from this review can guide medical education stakeholders interested in developing or modifying culinary medicine experiences. Despite barriers to implementation, culinary medicine experiences can be offered in a variety of ways during undergraduate and graduate medical education and can be creatively designed to fulfill some accreditation standards.

Mobile Application Increased Nutrition Knowledge Among Brazilian Physicians

OBJECTIVE

To assess whether using a Dietary Approaches to Stop Hypertension (DASH) diet recommendation application increases primary care physicians' knowledge and dietary counseling skills.

DESIGN

A randomized controlled trial.

SETTING

Brazilian public primary care service.

PARTICIPANTS

Two hundred and twenty-two physicians (intervention group: n = 111; control group: n = 111).

INTERVENTION

Thirty days of using the Dieta Dash application. The application provides information about nutritional recommendations for hypertension management.

MAIN OUTCOME MEASURES

Nutrition knowledge score.

SECONDARY OUTCOMES

self-assessment of knowledge, self-confidence, assessment of eating habits, and barriers to dietary counseling.

ANALYSIS

Linear mixed-effects models for repeated measures and generalized estimating equations for comparing changes between groups.

RESULTS

A total of 66.2% of participants completed the follow-up. There was no significant difference between the groups regarding the mean knowledge score (P = 0.15). The prevalence of high knowledge increased by 12% (prevalence ratio [PR] = 1.12; 95% confidence interval [CI], 1.00-1.25) in the intervention group and showed an improvement in the self-confidence assessment (PR = 1.21; 95% CI, 1.02-1.44), and increased assessment of eating habits (PR = 1.26; 95% CI, 1.10-1.55).

CONCLUSIONS AND IMPLICATIONS

The Dieta Dash application helped address dietary counseling, improving knowledge and self-confidence. However, innovative strategies are needed to minimize the primary care barriers.

Perception of Nutrition Education and Subjective Competency in Nutrition Topics among Korean Family Medicine Residents

BACKGROUND

Appropriate nutrition is necessary for maintaining good health in the general population. During primary physician training, it is important to educate residents on the basic concepts of nutrition and methods to manage nutritional aspects according to various disease. However, little is known about the perception of nutritional education among Korean family medicine residents. This study analyzed the recognition of the importance of nutritional education, the amount received, and satisfaction with it as well as self-perceived competency in various nutrition topics among residents.

METHODS

Web-based questionnaires were sent via mobile messages to all the residents registered with the Korean Academy of Family Medicine (KAFM). Out of 566 residents, 68 voluntarily participated in the study. The questionnaire consisted of 41 items related to perceptions of nutrition education, self-perceived competency in nutrition topics, and demographic characteristics.

RESULTS

The response rate was 12.01%. Residents rated their satisfaction with nutrition education at 4.78 out of 10, and 83.3% considered it important. However, only 13.24% of the participants felt that it was adequate. The most common training method for nutrition education was lectures at KAFM conferences. Among the 29 nutritional topics, the residents reported highest confidence in subjects related to chronic diseases such as obesity (77.94%), diabetes (75%), cardiovascular disease (67.65%), gastrointestinal disorders (67.65%), and weight loss management (67.65%). Conversely, topics related to women (36.76%), children and adolescents (38.23%), drug-nutrient interactions (39.7%), eating disorders (42.64%), and food labels (42.64%) showed low self-perceived confidence rates.

CONCLUSION

Korean family medicine residents value nutrition education but believe that more education is necessary and they demonstrate differences in self-perceived competency in various nutrition topics.

Don't forget the veggies! Identifying and addressing a lack of vegetable education in physiology

Ninety-five percent of Westerners do not consume the recommended daily vegetable intake, exacerbating the incidence of obesity, malnutrition, and nutritional deficiencies such as fiber. This article reviews the literature from PubMed, ERIC, and Web of Science, as well as Internet sites and government resources, to identify what should be considered important inclusions relating to dietary vegetable (including legumes and pulses) intake content in university physiology subjects. The primary aim is to advance the competency relating to good nutrition knowledge for future health professionals to enable them to guide and counsel patients and clients toward better health. A review of the literature provides scant nutritional content relating to vegetable intake, particularly across physiology subjects and health professional programs in general. A review of country dietary guidelines yielded discrepancies and ambiguity around recommended daily vegetable intake, including what constitutes essential vegetables. Educators responsible for embedding nutritional information in the curriculum would therefore be challenged to find reliable, evidence-based resources. Adding quality curriculum content on the importance of vegetable intake also promotes some of the Sustainable Development Goals (SDGs), including SDG 2 (Zero Hunger), thereby contributing to SDG 3 (Good Health and Well-Being). This article offers recommendations on how to embed content relating to the importance of dietary vegetables for good health and guidance for educators of health professions programs wanting to improve their curriculum content relating to adequate nutrition.NEW & NOTEWORTHY Is nutritional literacy an important concept in physiology? This article identifies a paucity of content and addresses the need for vegetable intake education.

Disseminating sleep education to graduate psychology programs online: a knowledge translation study to improve the management of insomnia

STUDY OBJECTIVES

Despite the negative impact of poor sleep on mental health, evidence-based insomnia management guidelines have not been translated into routine mental healthcare. Here, we evaluate a state-wide knowledge translation effort to disseminate sleep and insomnia education to graduate psychology programs online using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) evaluation framework.

METHODS

Using a non-randomized waitlist control design, graduate psychology students attended a validated 6-hour online sleep education workshop delivered live as part of their graduate psychology program in Victoria, Australia. Sleep knowledge, attitudes, and practice assessments were conducted pre- and post-program, with long-term feedback collected at 12 months.

RESULTS

Seven out of ten graduate psychology programs adopted the workshop (adoption rate = 70%). The workshop reached 313 graduate students, with a research participation rate of 81%. The workshop was effective at improving students' sleep knowledge and self-efficacy to manage sleep disturbances using cognitive behavioral therapy for insomnia (CBT-I), compared to the waitlist control with medium-to-large effect sizes (all p < .001). Implementation feedback was positive, with 96% of students rating the workshop as very good-to-excellent. Twelve-month maintenance data demonstrated that 83% of students had used the sleep knowledge/skills learned in the workshop in their clinical practice. However, more practical training is required to achieve CBT-I competency.

CONCLUSIONS

Online sleep education workshops can be scaled to deliver cost-effective foundational sleep training to graduate psychology students. This workshop will accelerate the translation of insomnia management guidelines into psychology practice to improve sleep and mental health outcomes nationwide.

Barriers to adequate nutrition care for child malnutrition in a low-resource setting: Perspectives of health care providers

Introduction

Several studies in developing countries found that more need-based training is required for health care providers (HCPs) in child malnutrition management.

Methods

An exploratory cross-sectional study was conducted to explore barriers to providing adequate nutrition care as perceived by the healthcare providers (HCPs) in the child malnutrition clinic at a Children's University Hospital in Egypt. Participants were selected using the purposive sampling technique. Five out of seven HCPs in the clinic were included (two male physicians, one female physician, and two female nurses). Qualitative data were collected through in-depth interviews. The interview guide consisted of semi-structured open-ended questions. Quantitative data were the resulting scores from the scoring system used to assess the understandability and actionability of the patient education materials (PEMs) that are available in the clinic. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) for the scoring. Statistical analysis: The thematic content analysis technique was employed for qualitative data. The percent score was generated for the PEM actionability and understandability for quantitative data.

Results

Most common child malnutrition conditions encountered by HCPs were nutritional deficiencies. Barriers to the delivery of adequate nutrition care to children were physician-centered: limited nutrition education in the medical school, health system-centered: an insufficient number of HCPs, lack of nutritional supplements, lack of patient education materials (PEMs) that suit the characteristics of the served community, lack of updated standard of practice (SOP) and guidelines, inadequate nutrition training of HCPs, and insufficient time for each patient, and caregivers-centered: the low socioeconomic status and false cultural, nutritional beliefs.

Conclusion

There are different barriers to adequate nutrition care for child malnutrition in low-resource healthcare settings. Mainly nutritional deficiencies. Most of the barriers were health system-related in the form of insufficient resources (shortage of workforce; concerning the high caseload, nutritional supplements, and PEMs) and inadequate management of resources (lack of skill-based training, lack of updated SOP and guidelines, and lack of properly designed PEMs that facilitate communication with the target caregivers).

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position on the Role of the Registered Dietitian Nutritionist in the Care of the Pediatric Patient With Chronic Gastrointestinal Diseases

The optimization of nutrition is essential for the growth and development of all children, including those with gastrointestinal (GI) conditions that can variably affect nutrient intake, absorption, or metabolism. Registered Dietitian Nutritionists (RDNs) are essential partners in delivering high quality care for pediatric GI disorders, but limited evidence is available to support the role of the RDN in the care of these patients. This position paper outlines the evidence supporting the role of the RDN in the management of chronic pediatric GI issues in both inpatient and outpatient settings. Gaps in the literature, opportunities for future research, and barriers to RDN access are discussed.

Culinary Medicine Training in Core Medical School Curriculum Improved Medical Student Nutrition Knowledge and Confidence in Providing Nutrition Counseling

Background: Elective culinary medicine education has become popular to help fill important gaps in physician nutrition training. The implementation and outcomes among the inaugural cohort of medical students who received culinary medicine training as a required component of medical school curriculum at the University of Maryland School of Medicine are described. Methods: Following a series of elective pilot sessions, culinary medicine training was provided to all first-year medical students in the 2019-2020 academic year. The 3-hour training included evidence-based nutrition lecture, cooking simple recipes, and group discussion of the application to personal and patient care. Pre-/postsession questionnaires assessed nutrition knowledge, skills, and attitudes as well as nutritional counseling confidence. Paired t-tests estimated mean differences in outcomes pre- and posttraining. Qualitative data were subjected to thematic analysis. Results: Overall, 119 of 125 (95.2%) students provided pre- and posttraining outcomes data. All nutritional and patient counseling outcomes improved (P < .05). Themes of being better prepared to address healthy eating barriers in patient care and personal ability to make healthy dietary changes were noted in qualitative analysis. Conclusion: One session of culinary medicine training in core medical student curriculum was feasible and improved medical student nutrition knowledge, skills, and attitudes and confidence in patient nutrition counseling.

Nutrition Guidelines for Improved Clinical Care

Given the importance of poor nutrition as a cause for human chronic disease, it is surprising that nutrition receives so little attention during medical school training and in clinical practice. Specific vitamins, minerals, fatty acids, amino acids and water in the diet are essential for health, and deficiencies lead or contribute to many diseases. Proper use of the dietary guidelines and nutrition facts labeling can improve nutritional status and lead to the consumption of a healthy diet. COVID-19 has altered access to nutritious foods for millions and increased awareness of the importance of diet and immune function. An improved appreciation for nutrition will improve the outcomes of clinical care.

A Place for Plant-Based Nutrition in US Medical School Curriculum: A Survey-Based Study

Purpose. To evaluate medical students' and family medicine residents' perceptions of their current degree of nutrition training in general and regarding a whole-foods, plant-based (WFPB) diet. Methods. An original survey instrument was administered to medical students and family medicine residents. Quantitative and qualitative data were collected to evaluate perceptions of nutrition education in medical training, a WFPB diet, and ideas for nutrition-focused curricular reform. Results. Of the 668 trainees surveyed, 200 responded (response rate = 30%). Of these, 22% agreed that they received sufficient nutrition education in medical school and 41% agreed that a WFPB diet should be a focus. Respondents with personal experiences with a plant-based diet were more willing to recommend it to future patients. Common ideas for curricular reform were instruction on a WFPB diet along with other healthy dietary patterns, patient counseling, a dedicated nutrition course, and electives. Conclusions. Nutrition education in US medical training needs improvement to address the growing burden of obesity-related chronic disease. Proper nutrition and lifestyle modification should therefore play a larger role in the education of future physicians. A focus on plant-predominant diets, such as the WFPB diet, may be an acceptable and effective addition to current medical school curriculum, and deserves further study.

Medicine, structural racism, and systems

Medicine is having a reckoning with systemic racism. While some continue to believe medicine is apolitical and grounded purely in science, history and research reveal that medicine is inseparable from underlying systems, laws, and policies. Obesity is a useful case study. Weight loss trials have shown the immense difficulty in achieving and sustaining weight loss without addressing overlying systems. Barriers are double for Black, Indigenous, and People of Color (BIPOC) with obesity, who must contend with multiple layers of oppressive systems. Increasingly, illness is not a matter of bad luck, but is a function of oppressive structures. COVID-19 likely originates in a deteriorating environment, we have an increasing global burden of disease from oppressive sales of food, sugar, alcohol, guns, nicotine, and other harmful products, and social inequality and resource hoarding are at a peak. Medicine can and must participate in redefining these systems. In doing so, it must center the experiences of BIPOC and push change that alleviates power disparities.

An Assessment of Nutrition Education in Endocrinology Fellowship Programs in the United States

OBJECTIVE

Counseling patients about nutrition significantly improves chronic disease outcomes. Endocrinologists are uniquely positioned to educate patients regarding nutrition. The purpose of this study was to define the current state of nutrition education in endocrinology fellowship programs in the United States and assess the needs for future nutrition training.

METHODS

Endocrinology program directors were surveyed via an online questionnaire between February-April 2021.

RESULTS

Thirty-eight program directors responded (25% response rate) to the survey. Twenty-two (58%) programs offered nutrition education. Existing nutrition education offerings were 1-5 total hours (13, 34%), primarily didactic (20, 53%), and often led by registered dietitian nutritionists (RDNs) (15, 39%). Only three (8%) programs rated their current nutrition education as extremely effective; 95% of respondents believed further nutrition education was needed. According to respondents, the ideal nutrition education for endocrine trainees should be 1-5 total hours (19, 50%) over multiple sessions (25, 66%), be interactive (24, 63%), and be led by RDNs (26, 68%). The most important topics for independent practice included diet-related behavior modification (21, 55%), components of a healthful diet (19, 50%), and energy expenditure/intake (18, 47%).

CONCLUSION

Although the majority of the program directors believe that further nutrition education is needed, almost half of the surveyed programs do not offer such training. Programs that do offer nutrition education primarily rely on a didactic format. There is an unmet need for interactive, multidisciplinary nutrition education in these programs.

Implementation of a Plant-Based, Nutrition Program in a Large Integrated Health Care System: Results of a Pilot Program

Introduction:

Despite the proven efficacy of plant-based diets in the management of cardiometabolic diseases, most healthcare providers do not incorporate them into treatment plans.

Objective:

Conduct a post-hoc evaluation of a novel plant-based nutrition program in a large integrated health care system, including the impact on health care outcomes.

Methods:

A large integrated health care system launched an innovative 12-week plant-based nutrition program that included weekly nutrition education, peer mentoring, and support. Plasma cholesterol levels, hemoglobin A1C, blood pressure, body weight, and healthcare utilization parameters were measured before and after the program. The current study is a pre- and post-descriptive analysis of the health metrics of individuals who participated in the program and a matched comparison group.

Results:

A total of 408 patients, across a wide range of weight categories, demographics, and co-morbidities, participated in a plant-based nutrition program, and program completers experienced mean reductions in total and LDL plasma cholesterol levels of 11.0 and 8.1 mg/dL, respectively, as well as reductions in medication usage, office visits, and body weight.

Conclusion:

Implementation of a novel plant-based, nutrition program in a large integrated health care system was associated with improvements in health outcomes.

Community-Based Participatory Research partnership with faith-based organizations to address obesity and glucose control

OBJECTIVES

To explore the lived (narrative) experience of obesity and/or diabetes mellitus within focus groups consisting of individuals and community support persons residing in Genesee County, Michigan.

DESIGN

Qualitative study, using Community-Based Participatory Research (CBPR) methodology to design and conduct focus group interviews.

SAMPLE

Nineteen participants from faith-based organizations (FBOs) in Genesee County (74.5% Caucasian, 3.0% Hispanic American).

MEASUREMENTS

Semi-structured narrative focus group interviews, using thematic coding and qualitative analysis software (Otter.com).

RESULTS

Participants from diverse FBOs revealed barriers that prevent them from reaching their weight goals and preventing or controlling diabetes. A shared theme included the concern that providers do not actively inquire about patient concerns at appointments, and they fail to offer practical strategies beyond pharmaceutical interventions.

CONCLUSION

Focus group interviews with community residents revealed issues and barriers patients and their support persons face in health care experiences. Utilizing CBPR (methodology) is an opportunity for advanced practice nurses (health care professionals) to co-create strategies and interventions with the community that can assist them in successfully reaching their weight loss and diabetes prevention goals.

Strategies for Incorporating Lifestyle Medicine in Everyday Hospital Practice

Cardiovascular disease and its associated risk factors such as hypertension, obesity, and diabetes are contributing to a large portion of morbidity, mortality, and health care costs in the United States. Diet and lifestyle education have been shown to be beneficial in reducing cost, mortality, and morbidity associated with these diseases. However, the lack of implementation of diet and lifestyle tools into clinical practices and into hospital systems leaves much room for improvement. Obstacles such as poor physician education, financial concerns, patient preference, and social resistance to change have made it difficult to promote healthy lifestyle and nutrition practices throughout all aspects of health systems. Some hospital systems and hospital-based clinical practices have had important successes in creating prevention clinic models, implementing plant-based menus in their hospital systems, and incorporating intensive rehabilitation programs that will pave the way for more future change. This review describes the current deficits, obstacles, and innovative strategies for implementing lifestyle medicine into hospital systems.

Nutrition education on obesity and diabetes to medical students

It is important for medical students to understand the relationship between nutrition, obesity, and diabetes to educate their patients in the future. However, medical training does not always include nutritional education. An experiential learning project was incorporated into the medical school curriculum as an effort to implement nutrition in the physiology course. First-year medical students (n = 140) received lectures on the regulation of blood glucose levels and their relationship to carbohydrates with different glycemic indexes (GI), obesity, and diabetes. Lectures were followed by a laboratory exercise where students calculated their body mass index (BMI), percentage body fat, and percentage muscle using a Bioelectrical Impedance Commercial Scale. While 63% of students had normal BMI, 31% were overweight or obese and 5% were underweight. A subgroup of 54 students tested different types of breakfasts with varying GI and provided blood samples at 0, 30, 60, 90, and 120 min. Their glucose responses were plotted based on the breakfast GI. Pre- and posttests were conducted to assess the teaching intervention where the Wilcoxon signed ranks test indicated that posttest ranks were significantly higher than pretest ranks (Z = -6.6, P < 0.001), suggesting the intervention was beneficial to students.

Culinary Medicine for Family Medicine Residents

BACKGROUND

Physicians are inadequately trained to effectively provide lifestyle counseling to manage the obesity epidemic.

ACTIVITY

Family and community medicine residents participated in a culinary medicine course taught by two Registered Dietitian Nutritionists (RDNs) in University Park, PA, in March 2020.

RESULTS

All residents (n = 13) reported increased knowledge, 92% (n = 12) reported increased confidence, and 84.6% (n = 11) reported they intended to make changes to their practice based on the class. Most participating residents (85%, n = 11) would attend follow-up classes.

DISCUSSION

Residents recognized the importance of nutrition in clinical care and found the information to be applicable to practice.

Identifying patients with malnutrition and improving use of nutrition interventions: A quality study in four US hospitals

OBJECTIVE

This study investigated how specific nutrition interventions were implemented at four US hospitals, compared rates of malnutrition diagnosis and assessment between physicians and registered dietitian nutritionists (RDNs), and examined how these differences affected the nutrition intervention received during patients' hospital stay.

METHODS

Data on patients' nutrition status and nutrition interventions were collected from 16 669 hospital inpatient records. Data on intervention utilization for patients with differing nutrition assessments and diagnoses from different health care practitioners were compared using descriptive statistics and χ² tests.

RESULTS

The study found high levels of agreement between physician diagnosis and RDN assessment of malnutrition (88%). Much of this agreement related to patients identified as not malnourished. Of patients identified as malnourished by either physician diagnosis or RDN assessment, agreement was reached in 55.5% of patients. Less than half (46.3%) of patients identified as malnourished had a documented nutrition intervention. Oral nutritional supplements (ONS) were the most commonly used intervention, with 5.1% of patients receiving them. Patients identified as malnourished by physician diagnosis, but not by RDN assessment, were more likely to receive enteral and parenteral nutrition. Patients identified as malnourished by RDN assessment, but not by physician diagnosis, were more likely to have received ONS, meals and snacks, counseling, and food/nutrition-related medication management.

CONCLUSION

The high level of agreement on assessment and malnutrition diagnosis suggests positive levels of malnutrition care coordination at the study hospitals. However, significant room for improvement exists in providing interventions to inpatients diagnosed with malnourishment. Differences in interventions may reflect dissimilar approaches commonly used by different practitioners and should be a topic of future study.

Family medicine physicians' report strong support, barriers and preferences for Registered Dietitian Nutritionist care in the primary care setting

BACKGROUND

Previous studies have examined barriers (e.g. time) for Family Medicine Providers (FMPs) to provide nutrition and lifestyle counseling, however, to date no studies have examined access or interest to Registered Dietitian Nutritionist (RDN) care for patients.

OBJECTIVE

The objective of this study was to explore FMP access, referral practices, barriers and preferences for RDN care.

METHODS

A cross-sectional online survey, with content and face validation was conducted with Family Medicine Departments within large academic health care systems in the Southeastern United States. The main variables of interest included: FMP access, interest, current referrals and referral preferences for RDN care, barriers to referrals and overall perceptions regarding RDN care. Descriptive analysis of close-ended responses was performed with SPSS 26.0. Open-ended responses were analysed using inductive content analysis.

RESULTS

Over half of the respondents (n = 151) did not have an RDN on-site (64%) yet were highly interested in integrating an RDN (94.9%), with reported preferences for full-time on-site, part-time on-site or off-site RDN care (49.1%, 39.5% and 11.4% respectively). The greatest reported barriers to RDN referrals were perceived cost for the patient (64.47%) and uncertainty how to find a local RDN (48.6%). The most consistent theme reported in the open-ended responses were concerns regarding reimbursement, e.g. 'Insurance does not cover all of the ways I would like to use an RDN'.

CONCLUSIONS

FMPs report interest and value in RDN services despite multiple perceived barriers accessing RDNs care. Opportunities exist for interprofessional collaboration between dietetic and FMP professional groups to address barriers.

[Pillars for excellence in nutrition support units. Training]

Introduction

Few areas of current medicine have undergone change and evolution in recent years such as those of clinical nutrition. Currently, 98 % of endocrinology and nutrition departments in hospitals with 500 or more beds incorporate a clinical nutrition and dietetics Unit. The training of the professionals that integrate these units has been and will be a key point in their ongoing development towards excellence. In medicine degree studies, despite its relevance, nutrition training is currently scarce and heterogeneous, and needs improvement, which may come hand in hand with the recently published ESPEN proposals. In the case of doctors specializing in endocrinology and nutrition, the adaptations in the teaching program established by the National Commission for this specialty, and the training efforts led by the SEEN have allowed significant improvement. In hospital pharmacy studies there is a nutrition training curriculum that could be updated. University training in nutrition within the nursing degree is also heterogeneous. The most related studies such as the Degree of Human Nutrition and Dietetics, Technician in Dietetics, Food Science and Technology or Bromatology fundamentally address issues related to dietetics. There is a lack of coordinated effort to define the role of the members of these multidisciplinary UNCyDs, also in regard to their training.

Impact of an Online Nutrition Course to Address a Gap in Medical Education: A Feasibility Study

BACKGROUND AND OBJECTIVES

Nutrition is a foundation of health, yet there is a deficiency of nutrition training in graduate medical education. The purpose of this feasibility study was to assess the impact of a brief online clinical nutrition course on medical residents' knowledge and attitudes related to the role of nutrition in clinical practice.

METHODS

Medical residents from two institutions took a 3-hour, online, self-paced and interactive clinical nutrition course that reviewed macronutrients, evidence-based dietary patterns, a rapid nutrition assessment, and motivational interviewing. We administered surveys of nutrition knowledge and attitudes at three time points: (1) just prior to taking the online course, (2) immediately following, and (3) 3 months after course completion.

RESULTS

Seventy-six residents enrolled in the study and 47 (62%) completed the online course and postcourse surveys. For residents who completed the study, the summated nutrition knowledge scores assessed both immediately after taking the course and 3 months later showed significant improvement (P<.001). Three months after completing the course, residents were more likely to believe it was their role to personally provide detailed nutrition information to patients (P=.045) and to endorse the view that a healthy diet is important for self-care (P<.001). The estimated time residents spent counseling patients on nutrition did not change after the intervention.

CONCLUSION

This feasibility study demonstrated the potential of a 3-hour, online, self-paced nutrition course administered to medical residents to result in a significant and sustained increase in nutrition knowledge and positive attitudes about the role of nutrition in clinical practice.

Time for nutrition in medical education

Aim

To synthesise a selection of UK medical students' and doctors' views surrounding nutrition in medical education and practice.

Methods

Information was gathered from surveys of medical students and doctors identified between 2015 and 2018 and an evaluation of nutrition teaching in a single UK medical school. Comparative analysis of the findings was undertaken to answer three questions: the perceived importance of nutrition in medical education and practice, adequacy of nutrition training, and confidence in current nutrition knowledge and skills.

Results

We pooled five heterogeneous sources of information, representing 853 participants. Most agreed on the importance of nutrition in health (>90%) and in a doctor's role in nutritional care (>95%). However, there was less desire for more nutrition education in doctors (85%) and in medical students (68%). Most felt their nutrition training was inadequate, with >70% reporting less than 2 hours. There was a preference for face-to-face rather than online training. At one medical school, nutrition was included in only one module, but this increased to eight modules following an increased nutrition focus. When medical students were asked about confidence in their nutrition knowledge and on advising patients, there was an even split between agree and disagree (p=0.869 and p=0.167, respectively), yet few were confident in the UK dietary guidelines. Only 26% of doctors were confident in their nutrition knowledge and 74% gave nutritional advice less than once a month, citing lack of knowledge (75%), time (64%) and confidence (62%) as the main barriers. There was some recognition of the importance of a collaborative approach, yet 28% of doctors preferred to get specialist advice rather than address nutrition themselves.

Conclusion

There is a desire and a need for more nutrition within medical education, as well as a need for greater clarity of a doctor's role in nutritional care and when to refer for specialist advice. Despite potential selection bias and limitations in the sampling frame, this synthesis provides a multifaceted snapshot via a large number of insights from different levels of training through medical students to doctors from which further research can be developed.

Impact of nutrition education on nutritional knowledge and intentions towards nutritional counselling in Dutch medical students: an intervention study

OBJECTIVE

Management of diet-related chronic diseases may benefit from improved nutrition education of medical students. This study aims to investigate the effects of a nutrition education course on nutritional knowledge and intentions towards nutritional counselling in Dutch medical students.

DESIGN

This is a pre-post intervention study with a comparison group. Participants completed self-reported questionnaires on nutritional knowledge and intentions towards nutritional counselling.

PARTICIPANTS

In total, 118 medical students (64.4% undergraduate, 73.2% women) were recruited from two medical schools in the Netherlands (n=66 intervention group, n=52 comparison group).

INTERVENTION

The intervention group completed a 25-hour course in nutritional counselling (the Students Experienced in Lifestyle and Food (SELF) course) in addition to the standard medical curriculum. The comparison group followed the standard medical curriculum.

OUTCOME MEASURES

Self-reported nutritional knowledge and intentions towards nutritional counselling, including attitude, self-efficacy and social support.

RESULTS

Nutritional knowledge (B: 2.42, 95% CI 1.81 to 3.02), attitude in men (B: 0.50, 95% CI 0.13 to 0.87) and self-efficacy (B: 0.78, 95% CI 0.62 to 0.95) significantly increased in the intervention group compared with the comparison group. No significant differences were found for social support (B: 0.20, 95% CI -0.02 to 0.43) and attitude in women (B: 0.08, 95% CI -0.24 to 0.31) between the two groups.

CONCLUSIONS

The SELF course increased medical students' nutritional knowledge and stimulated their intentions towards nutritional counselling. Future research is needed to evaluate the long-term impact of nutrition education interventions on physician practice patterns and patient outcomes.

Hidden curriculum within nutrition education in medical schools

INTRODUCTION

Previous attempts to enhance medical nutrition education have typically focussed on students' acquiring nutrition knowledge or skills. Given that medical training uses an apprenticeship model of training, surprisingly few studies have explored the 'hidden curriculum' that students experience regarding expectations of behaviour, roles and responsibilities regarding nutrition. This study explored medical students' perceptions and experiences regarding medical nutrition education, focussing on the context in which nutrition teaching has been provided, the presented place of nutrition within medicine and their subsequent views on their role in providing nutrition care.

METHODS

Individual semi-structured qualitative interviews were conducted with 14 postgraduate medical students at different stages of their medical degree in Australia. The interviews were conducted using case studies followed by interview questions. Data were audio recorded, transcribed, coded and then underwent inductive thematic analysis.

RESULTS

Three themes were discovered (i) Valuing nutrition in the medical management of patients whereby students perceived nutrition to be a foundational and central component of ideal medical management for patients, particularly those with chronic disease; (ii) Fluctuating emphasis on nutrition which showed that students experienced diversity in the importance placed on nutrition by others and (iii) Working with others whereby students expressed their understanding of their role in nutrition and the roles of team members such as dietitians.

CONCLUSION

To enhance medical nutrition education, consideration needs to extend beyond counting dedicated teaching hours and mapping nutrition content, to a more contextual understanding of the situated learning that occurs for medical students.

The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients

Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.

Breast Cancer: Lifestyle, the Human Gut Microbiota/Microbiome, and Survivorship

Patients with a current diagnosis of breast cancer are enjoying dramatic cure rates and survivorship secondary to an increase in awareness, earlier detection, and more effective therapies. Although strategies such as Breast Cancer Awareness Month in October focus on early detection, lifestyle changes are seldom discussed other than dietary concerns and physical activity. Lifestyle modifications centered on diet and exercise have been demonstrated to affect overall disease-free survival in breast cancer. Since the early 2000s, the role of the human gut microbiota and its relation to breast cancer has become a major area of interest in the scientific and medical community. We live and survive owing to the symbiotic relationship with the microorganisms within us: the human microbiota. Scientific advances have identified a subset of the gut microbiota: the estrobolome, those bacteria that have the genetic capability to metabolize estrogen, which plays a key role in most breast cancers. Recent research provides evidence that the gut microbiome plays a substantial role in estrogen regulation. Gut microbiota diversity appears to be an essential component of overall health, including breast health. Future research attention should include a more extensive focus on the role of the human gut microbiota in breast cancer.

Nutrition care by primary-care physicians: advancing our understanding using the COM-B framework

OBJECTIVE

To investigate the nutrition education provided by primary-care physicians (PCP).

DESIGN

An integrative review was used to examine literature on nutrition care provided by PCP from 2012 to 2018. A literature search was conducted in MEDLINE, PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Scopus using key search terms.

SETTING

USA, Netherlands, Germany, Denmark, UK, Lebanon, Australia and New Zealand.

PARTICIPANTS

Primary-care physicians.

RESULTS

Sixteen qualitative and quantitative studies were analysed thematically using meta-synthesis informed by the COM-B model of behaviour (capability, motivation and opportunity), to understand the influences on PCP behaviours to provide nutrition care. PCP perceive that they lack nutrition capability. While PCP motivation to provide nutrition care differs based on patient characteristics and those of their own, opportunity is influenced by medical educators, mentors and policy generated by professional and governmental organisations.

CONCLUSIONS

The development of PCP capability, motivation and opportunity to provide nutrition care should begin in undergraduate medical training, and continue into PCP training, to create synergy between these behaviours for PCP to become confident providing nutrition care as an integral component of disease prevention and management in contemporary medical practice.

Advances in Nutrition Science and Integrative Physiology: Insights From Controlled Feeding Studies

Nutrition science is a highly impactful but contentious area of biomedical science. Establishing cause and effect relationships between the nutrients and/or diets we consume and the avoidance of or risk of disease is extremely challenging. As such, evidence-based nutrition is best served by considering the totality of evidence across multiple study types including nutritional epidemiological studies, randomized controlled trials of behavioral interventions, and controlled feeding studies. The purpose of the present review is to provide an overview for those conducting research outside of clinical nutrition on how controlled feeding studies can be used to gain insight into integrative physiology/metabolism as well as to inform dietary guidelines. We discuss the rationale, basic elements, and complexities of conducting controlled feeding studies and provide examples of contributions of controlled feeding studies to advances in nutrition science and integrative physiology. Our goal is to provide a resource for those wishing to leverage the experimental advantage provided by controlled feeding studies in their own research programs.

Time to Revamp Nutrition Education for Physicians

Obesity is a national and global epidemic and is usually the result of a poor diet and lifestyle. Obesity is a strong risk factor for type 2 diabetes and cardiovascular disease, which are leading causes of morbidity and mortality. Ample scientific evidence supports that nutritional interventions involving plant-based diets can be effective in the prevention and treatment of obesity, diabetes, and cardiovascular disease. Many patients are interested in improving their eating habits and frequently look to physicians for dietary advice. However, most physicians are unable to provide meaningful guidance because of a lack of nutrition education. We launched programs to educate our physicians and patients about the benefits of plant-based diets, with an overwhelmingly positive response. Because physicians are at the forefront of fighting the obesity epidemic, it is imperative to emphasize nutrition education for current and future physicians.