Nutrition education: a questionnaire for assessment and teaching

Assessment of Students' Perception of the Nutrition Curriculum in a Canadian Undergraduate Medical Education Program

Background

Nutrition plays an important role in diseases, and physicians need to be proficient in providing nutrition counselling to patients. There is limited information regarding nutrition education in Canadian medical schools.

Objective

The objective of this study was to investigate students’ perspectives about nutrition training provided in the undergraduate medical education program at Dalhousie University.

Methods

All medical students in their second, third, and fourth years of training at Dalhousie University were surveyed online with a 23-item questionnaire that included 10 nutrition competencies.

Results

Of 342 students, 89 (26%) completed the survey. Using a five-point Likert scale, ranging from one, indicating ‘very dissatisfied/strongly disagree’ to five, indicating ‘very satisfied/strongly agree,’ the mean overall satisfaction with nutrition curriculum was 2.9 ± 0.81. Perceived competency in nutrition assessment had the highest mean satisfaction rating (3.98 ± 0.89). There was more variance on perceived competency, with other aspects of training including basic nutrition principles (3.51 ± 0.92), disease prevention (3.14 ± 1.12), disease management (3.48 ± 1.00), role of dietitians (2.97 ± 1.05), credible nutrition sources (3.14 ± 1.09), dietary assessment (2.82 ± 1.11), lifecycle nutrition (2.67 ± 1.09), food security (2.4 ± 0.95) and malnutrition (2.74 ± 0.93). Med-4 students agreed significantly more than Med-2 students regarding confidence about their understanding of the role of dietitians. Students recommended a longitudinal nutrition program, inclusion of dietitians as educators, and provision of evidence-based resources in the curriculum. The majority (79%) agreed that more nutrition instruction is needed. Satisfaction with nutrition education has not improved since 2010, despite curricular changes.

Conclusions

Medical students’ satisfaction with nutrition education remains problematic. They want more nutrition training. Ongoing assessment and student feedback is important to make changes and improvements in the nutrition curriculum.

Learner-Directed Nutrition Content for Medical Schools to Meet LCME Standards

Deficiencies in medical school nutrition education have been noted since the 1960s. Nutrition-related non-communicable diseases, including heart disease, stroke, cancer, diabetes, and obesity, are now the most common, costly, and preventable health problems in the US. Training medical students to assess diet and nutritional status and advise patients about a healthy diet, exercise, body weight, smoking, and alcohol consumption are critical to reducing chronic disease risk. Barriers to improving medical school nutrition content include lack of faculty preparation, limited curricular time, and the absence of funding. Several new LCME standards provide important impetus for incorporating nutrition into existing medical school curriculum as self-directed material. Fortunately, with advances in technology, electronic learning platforms, and web-based modules, nutrition can be integrated and assessed across all four years of medical school at minimal costs to medical schools. Medical educators have access to a self-study nutrition textbook, Medical Nutrition and Disease, Nutrition in Medicine© online modules, and the NHLBI Nutrition Curriculum Guide for Training Physicians. This paper outlines how learner-directed nutrition content can be used to meet several US and Canadian LCME accreditation standards. The health of the nation depends upon future physicians’ ability to help their patients make diet and lifestyle changes.

Nutrition in medicine: nutrition education for medical students and residents

Proper nutrition plays a key role in disease prevention and treatment. Many patients understand this link and look to physicians for guidance diet and physical activity. Actual physician practice, however, is often inadequate in addressing the nutrition aspects of diseases such as cancer, obesity, and diabetes. Physicians do not feel comfortable, confident, or adequately prepared to provide nutrition counseling, which may be related to suboptimal knowledge of basic nutrition science facts and understanding of potential nutrition interventions. Historically, nutrition education has been underrepresented at many medical schools and residency programs. Our surveys over a decade show that most medical schools in the United States are still not ensuring adequate nutrition education, and they are not producing graduates with the nutrition competencies required in medical practice. Physicians, residents, and medical students clearly need more training in nutrition assessment and intervention. The Nutrition in Medicine (NIM) project, established to develop and distribute a core nutrition curriculum for medical students, offers a comprehensive online set of courses free of charge to medical schools. The NIM medical school curriculum is widely used in the United States and abroad. A new initiative, Nutrition Education for Practicing Physicians, offers an innovative online medical nutrition education program for residents and other physicians-in-training, but with targeted, practice-based educational units designed to be completed in 15 minutes or less. The NIM project is strengthening medical nutrition practice by providing a free, comprehensive, online nutrition curriculum with clinically relevant, evidence-based medical education for undergraduate and postgraduate learners.

Assessment of nurses' nutritional knowledge regarding therapeutic diet regimens

Metabolic diseases and cardiovascular disease (CVD), the incidence of which is currently increasing in Korea, can be managed well with dietary education and modification. However, it has yet to be established whether nurses have sufficient knowledge to impart appropriate nutritional counseling to patients with these diseases. Our study involved 506 nurses working at Asan Medical Center, Samsung Medical Center, and Seoul National University Hospital between March and May, 2006. The questionnaire was comprised of 42 diet-related questions pertaining to diabetes, obesity, and CVD. Nurses' correct-response rate for overall nutritional knowledge was worse than reported in Western countries (58.4%), and particularly so with regard to obesity and CVD. Although many nurses were aware of the therapeutic aspects of nutrients in relation to CVD, most of them had limited knowledge about low-cholesterol diets and sources of water-soluble fiber, fatty acids and the specific food items that prevent CVD. Our results suggest that there is an urgent need to update the contents of nutrition education for nurses to reflect the current changes in the Korean diet and the increasing incidence of metabolic diseases and CVD.

Nutrition education in U.S. medical schools: latest update of a national survey

PURPOSE

To quantify the number of required hours of nutrition education at U.S. medical schools and the types of courses in which the instruction was offered, and to compare these results with results from previous surveys.

METHOD

The authors distributed to all 127 accredited U.S. medical schools (that were matriculating students at the time of this study) a two-page online survey devised by the Nutrition in Medicine Project at the University of North Carolina at Chapel Hill. From August 2008 through July 2009, the authors asked their contacts, most of whom were nutrition educators, to report the nutrition contact hours that were required for their medical students and whether those actual hours of nutrition education occurred in a designated nutrition course, within another course, or during clinical rotations.

RESULTS

Respondents from 109 (86%) of the targeted medical schools completed some part of the survey. Most schools (103/109) required some form of nutrition education. Of the 105 schools answering questions about courses and contact hours, only 26 (25%) required a dedicated nutrition course; in 2004, 32 (30%) of 106 schools did. Overall, medical students received 19.6 contact hours of nutrition instruction during their medical school careers (range: 0-70 hours); the average in 2004 was 22.3 hours. Only 28 (27%) of the 105 schools met the minimum 25 required hours set by the National Academy of Sciences; in 2004, 40 (38%) of 104 schools did so.

CONCLUSIONS

The amount of nutrition education that medical students receive continues to be inadequate.

Inhibition of the mechanical activity of mouse ileum by cactus pear (Opuntia Ficus Indica, L, Mill.) fruit extract and its pigment indicaxanthin

We investigated, using an organ bath technique, the effects of a hydrophilic extract from Opuntia ficus indica fruit pulp (cactus fruit extract, CFE) on the motility of mouse ileum, and researched the extract component(s) responsible for the observed responses. CFE (10-320 mg of fresh fruit pulp equivalents/mL of organ bath) reduced dose-dependently the spontaneous contractions. This effect was unaffected by tetrodotoxin, a neuronal blocker, N(omega)-nitro-l-arginine methyl ester, a nitric oxide synthase blocker, tetraethylammonium, a potassium channel blocker, or atropine, a muscarinic receptor antagonist. CFE also reduced the contractions evoked by carbachol, without affecting the contractions evoked by high extracellular potassium. Indicaxanthin, but not ascorbic acid, assayed at concentrations comparable with their content in CFE, mimicked the CFE effects. The data show that CFE is able to exert direct antispasmodic effects on the intestinal motility. The CFE inhibitory effects do not involve potassium channels or voltage-dependent calcium channels but rather pathways of calcium intracellular release. The fruit pigment indicaxanthin appears to be the main component responsible for the CFE-induced effects.

Correlates of fruit and vegetable intakes in US children

The objective of this study was to assess the quality of the current intakes of fruits and vegetables compared to the Dietary Guidelines for Americans in US children and adolescents and identify factors related to low fruit and vegetable intake. This descriptive study examined differences in fruit and vegetable intakes by age, sex, ethnicity, poverty level, body mass index, and food security status utilizing data from the 1999-2002 National Health and Nutrition Examination Survey. Six thousand five hundred thirteen children and adolescents ages 2 to 18 years, who were respondents to the 1999-2002 National Health and Nutrition Examination Survey. Mean fruit and vegetable intakes were computed using 24-hour recalls for individuals and compared using analysis of variance. Leading contributors to fruit and vegetable intake were identified using frequency analysis. Children aged 2 to 5 years had significantly higher total fruit and juice intakes than 6- to 11- and 12- to 18-year-olds. Total vegetable and french fry intake was significantly higher among 12- to 18-year-old adolescents. Regarding sex differences, boys consumed significantly more fruit juice and french fries than girls. In addition, non-Hispanic African-American children and adolescents consumed significantly more dark-green vegetables and fewer mean deep-yellow vegetables than Mexican-American and non-Hispanic white children and adolescents. Total fruit consumption also differed significantly among race/ethnicities and household income. Children and adolescents most at risk for higher intakes of energy-dense fruits and vegetables (fruit juice and french fries) were generally boys, and adolescents, at risk for overweight or overweight and living in households below 350% of the poverty level.

Strengthening public health medicine training for medical students: development and evaluation of a lifestyle curriculum

BACKGROUND

Lifestyle factors are major determinants for health and safety. Although many graduates lack interviewing and observational skills for prevention and student lifestyle often deteriorates during training, few medical schools teach comprehensive assessment of lifestyle, particularly in the context of the home environment.

AIMS

A lifestyle curriculum was developed to teach basic causality and provide practical experience in assessing nutrition, exercise, safety, tobacco addiction, and food hygiene, together with generic skills in history taking, on-site observation, researching and presenting.

METHODS

Lifestyle has been integrated into the first-year curriculum, evaluated, and improved at the United Arab Emirates University since 2001. After an introduction to determinants of health, students conduct a home interview and observational survey for family residential and traffic safety, smoking, and food hygiene. For nutrition and exercise, students assess personal lifestyle. Generic skills are developed in the context of lifestyle. Evaluations were by faculty and students, including assessed impact on knowledge, skills, and personal lifestyle. The lifestyle curriculum was compared with other countries by detailed search.

RESULTS

Detailed evaluation found strong agreement/agreement among students that knowledge had improved on: counselling of patients and families 97%, promoting healthy lifestyles 100%; interviewing 88%; history taking 84%; using research for medical practice 89%; and importance of prevention 96%. Eighty six percent were stimulated to think in new ways about health. Improved personal diet was reported by 60% (p < 0.0004) and exercise by 55% (p < 0.0004), while 36% of non-users started wearing a safety belt in front (p < 0.0004) and 20% in the rear (p = 0.008). Literature review found comprehensive lifestyle curricula to be rare.

CONCLUSIONS

A lifestyle curriculum developed prevention-oriented history-taking and observation skills for health maintenance, addressing health priorities, improving medical student lifestyle, and strengthening generic skills. Since lifestyle is a major determinant of health, medical schools should consider development of an appropriate curriculum to address their local and national health priorities.

The evolution of Nutrition in Medicine, a computer-assisted nutrition curriculum

The primary mission of the Nutrition in Medicine (NIM) project is to provide tools to facilitate the nutrition training of undergraduate medical students. NIM has developed and distributed a CD-ROM-based nutrition curriculum to medical schools since 1995. However, the medical school environment is changing rapidly; there is pressure to do more in less time, and many schools are emphasizing independent and integrated learning. The need for a nutrition curriculum that is more flexible and more accessible has driven the evolution of the NIM curriculum from CD-ROM-based delivery into a more modular curriculum with Web delivery. Such changes facilitate access and eliminate the need for installation of CD-ROMs and the associated technical support issues. In addition, the instructional units are smaller and more modular. Eventually, the authoring system will allow instructors to put together a course to meet their specific instructional needs. Our future plans also include custom-tailoring that will allow students to opt out of learning material on the basis of pretest scores if they are already proficient in the content. In this update, we provide a detailed description of the new system and the rationale for the modifications we made. Furthermore, we describe how each change addresses barriers to nutrition education as identified from our surveys and others and from direct user feedback. These innovative strategies should allow a better fit of NIM within diverse medical school environments and help to promote incorporation of the curriculum into more medical schools.

Carbohydrate restriction improves the features of Metabolic Syndrome. Metabolic Syndrome may be defined by the response to carbohydrate restriction

Metabolic Syndrome (MetS) represents a constellation of markers that indicates a predisposition to diabetes, cardiovascular disease and other pathologic states. The definition and treatment are a matter of current debate and there is not general agreement on a precise definition or, to some extent, whether the designation provides more information than the individual components. We consider here five indicators that are central to most definitions and we provide evidence from the literature that these are precisely the symptoms that respond to reduction in dietary carbohydrate (CHO). Carbohydrate restriction is one of several strategies for reducing body mass but even in the absence of weight loss or in comparison with low fat alternatives, CHO restriction is effective at ameliorating high fasting glucose and insulin, high plasma triglycerides (TAG), low HDL and high blood pressure. In addition, low fat, high CHO diets have long been known to raise TAG, lower HDL and, in the absence of weight loss, may worsen glycemic control. Thus, whereas there are numerous strategies for weight loss, a patient with high BMI and high TAG is likely to benefit most from a regimen that reduces CHO intake. Reviewing the literature, benefits of CHO restriction are seen in normal or overweight individuals, in normal patients who meet the criteria for MetS or in patients with frank diabetes. Moreover, in low fat studies that ameliorate LDL and total cholesterol, controls may do better on the symptoms of MetS. On this basis, we feel that MetS is a meaningful, useful phenomenon and may, in fact, be operationally defined as the set of markers that responds to CHO restriction. Insofar as this is an accurate characterization it is likely the result of the effect of dietary CHO on insulin metabolism. Glucose is the major insulin secretagogue and insulin resistance has been tied to the hyperinsulinemic state or the effect of such a state on lipid metabolism. The conclusion is probably not surprising but has not been explicitly stated before. The known effects of CHO-induced hypertriglyceridemia, the HDL-lowering effect of low fat, high CHO interventions and the obvious improvement in glucose and insulin from CHO restriction should have made this evident. In addition, recent studies suggest that a subset of MetS, the ratio of TAG/HDL, is a good marker for insulin resistance and risk of CVD, and this indicator is reliably reduced by CHO restriction and exacerbated by high CHO intake. Inability to make this connection in the past has probably been due to the fact that individual responses have been studied in isolation as well as to the emphasis of traditional therapeutic approaches on low fat rather than low CHO. We emphasize that MetS is not a disease but a collection of markers. Individual physicians must decide whether high LDL, or other risk factors are more important than the features of MetS in any individual case but if MetS is to be considered it should be recognized that reducing CHO will bring improvement. Response of symptoms to CHO restriction might thus provide a new experimental criterion for MetS in the face of on-going controversy about a useful definition. As a guide to future research, the idea that control of insulin metabolism by CHO intake is, to a first approximation, the underlying mechanism in MetS is a testable hypothesis.