Abstract
Background:
Nutrition is often overlooked in everyday health care despite the definitive connection between diet and health. Many practicing physicians and medical students feel unqualified to discuss specific dietary recommendations with patients, which may be attributed to inadequate nutrition education during medical school.
Objective:
To assess the nutrition knowledge of osteopathic medical students and their attitudes regarding the importance of nutrition counseling in their future role as practicing physicians.
Methods:
Using a descriptive, cross-sectional study design, the authors evaluated first- and second-year osteopathic medical students’ nutrition knowledge and attitudes toward nutrition counseling. A questionnaire that assessed attitudes toward nutrition counseling and a quiz that tested nutrition knowledge were used.
Results:
A total of 257 first-year (n=139) and second-year (n=118) medical students (mean [SD] age, 24.8 [3.4] years; 52.8% female and 78.2% white) completed the quiz and survey. The average score of the nutrition knowledge quiz was 69.5%, with 130 participants (50.6%) scoring below the school's passing rate of 72.5%. Second-year students performed better than first-year students on the quiz (mean, 74.2% vs 65.9%; t=−5.17; P<.001). The majority of participants (143 [55.6%]) felt comfortable counseling patients on nutrition recommendations; however, only 30 (11.9%) were aware of the current dietary reference intakes. Qualitatively, most participants acknowledged the importance of providing patient education, promoting overall health and wellness, and preventing and treating disease.
Conclusion:
The majority of participants felt comfortable counseling future patients on nutrition recommendations; however, most participants lacked knowledge of dietary reference intakes and medical nutrition therapy. Because half of osteopathic medical students typically enter primary care, students and their future patients would benefit from the integration of more nutrition education in medical school.
The foundation for a health-promoting lifestyle is a balanced diet with a variety of nutrient-dense foods and beverages consumed in moderation along with ample physical activity.
1,2 Despite the importance of eating a well-balanced diet, most people in the United States are not eating a diet with sufficient or quality proportion of nutrients.
3 Many are overconsuming total kilocalories, added sugars, and saturated fats while underconsuming several vitamins and minerals.
3 Furthermore, the estimated proportion of adults in the United States with a poor-quality diet is 45.6%, and less than 10% of adults are meeting the recommended consumption of fruits and vegetables.
4 These imbalances are a major cause for concern because poor dietary habits can lead to overweight and obesity and, in turn, chronic disease or poor management of existing diseases.
5
Currently, more than one-third of adults in the United States are classified as obese, and obesity-related diseases and conditions (eg, coronary artery disease, stroke, type 2 diabetes mellitus, some cancers) contribute between $147 and $210 billion in health care costs per year.
6,7 These obesity-related diseases and conditions could be reduced and better managed with patient education on proper nutrition, and health care professionals at all levels should be equipped to provide this education. The member of the health care team most proficient in medical nutrition therapy or nutrition education and counseling is the registered dietitian (RD) or registered dietitian nutritionist (RDN).
1 Ideally, physicians would refer patients in need of nutrition counseling to RDs/RDNs. However, most patients are not referred because of countless physician barriers, including time, lack of insurance coverage, finances, and confidence in a patient's willingness to change behaviors.
8 For this reason, primary care physicians (PCPs) are often the sole source of nutrition education or nutrition counseling.
9 A specific goal of Healthy People 2020 is to increase the proportion of patient-physician appointments dedicated to counseling or education related to nutrition or weight.
10 Although physicians are more knowledgeable in the management of disease, several studies suggest that many practicing physicians as well as medical students feel ill-prepared to discuss specific dietary recommendations with patients.
9,11-16
Physicians’ and medical students’ perceived lack of nutrition proficiency may be attributed to inadequate nutrition education during medical school. Previous research on allopathic and osteopathic medical students found that medical schools do not provide the recommended number of hours of nutrition education.
17,18 However, to our knowledge, osteopathic medical students have not been studied extensively with respect to nutrition knowledge and attitudes toward nutrition counseling. Furthermore, the tenets of osteopathic medicine emphasize the body's ability to self-regulate, self-heal, and maintain health.
19 Thus, nutrition education aligns both with osteopathic philosophy and the focus of primary care on prevention and wellness. For these reasons, adequate nutrition knowledge is vital in the osteopathic student population.
The preclinical curriculum at the Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) consists of medical knowledge and clinical skills. The medical knowledge courses are divided into blocks of curricular content (eg, cardiovascular), which are further segmented into weekly modules identified by theme or clinical presentation (eg, hypertension). Nutrition-based lectures are integrated into these blocks throughout the first 2 years of medical education. Students must earn a score of 72.5% or higher to pass each block. The purpose of this study was to assess the nutrition knowledge and the attitudes of preclinical (first- and second-year) osteopathic medical students toward nutrition counseling in their future role as practicing physicians.
Methods
The University Office of Research Compliance at OU-HCOM approved the protocol and all recruitment procedures and materials.
Participants
An e-mail invitation was sent by the study investigator (E.A.B.) via school-maintained listservs to first- and second-year osteopathic medical students currently enrolled at the main campus (Athens) and 2 distance campuses (Dublin and Cleveland). Students were informed that they would receive a $15.00 gift card as compensation for participating in the study, which involved completing a nutrition quiz and a survey. The survey was sent on January 5, 2016, and a reminder email was sent on January 12, 2016. Participation in the study was voluntary.
Measures
Participants completed a short demographic form, a nutrition quiz, and a survey with 6 items that pertained to their beliefs about PCPs’ role in nutrition counseling, awareness of dietary reference intakes (DRIs), comfort level with nutrition counseling and designing nutrition plans, understanding the role of RD/RDNs on the health care team, and perceived importance of nutrition education in medical school.
The Nutrition Knowledge Quiz, a 20-item multiple choice quiz adapted from a 40-item multiple choice quiz created to measure medical interns’ nutrition knowledge.
16 Although the quiz is not validated, it was created using questions from a reliable nutrition textbook and has been used in a previous study that assessed allopathic medical students’ nutrition knowledge. Questions assessed general nutrition knowledge and specific nutrition interventions, including obesity, endocrine nutrition, cardiovascular nutrition, and basic nutrient information. These questions were developed specifically for use in this study and consisted of closed-response and open-ended response options.
Participants completed the survey via the online questionnaire service Qualtrics. To consent, participants clicked a radio button indicating “Yes, I consent to participate in this study. I may withdraw my participation at any time.” To decline, participants clicked a radio button indicating “I decline to participate.” To avoid coercion, the online screen to the survey and the informed consent document both specified the voluntary nature of participation. The informed consent document explicitly informed potential participants that their responses had no bearing on academic performance. Participants with questions about the study were directed to e-mail or telephone the research investigators. Completion of the survey took approximately 30 minutes. Qualtrics permitted the research team to download participants’ survey responses into a spreadsheet without including identifying information (eg, name, e-mail address) to ensure anonymity at the level of data.
Data Analysis
Basic sociodemographic characteristics of participants were assessed using descriptive statistics. Frequencies of individual question responses were also calculated. Nutrition quiz scores were calculated by summing the number of correct responses divided by total questions multiplied by 100 to yield a percentage score. Independent sample t tests were conducted to examine differences in nutrition quiz scores by year in medical school, sex, awareness of DRIs, and comfort level with nutrition counseling and designing nutrition plans. χ2 tests were conducted to examine differences in comfort level with nutrition counseling and designing nutrition plans by sex and year in medical school. For analysis, the variables for comfort level with nutrition counseling and designing nutrition plans were dichotomized, with 1 including “very comfortable” and “somewhat comfortable” responses and 0 consisting of “not too comfortable” and “not at all comfortable” responses. Statistical significance was defined as P<.05. All analyses were conducted with SPSS statistical software version 23.0 (IBM).
The open-ended short-answer responses were analyzed using standard qualitative techniques. Specifically, 2 experienced researchers (E.J.H., E.A.B.) performed content analysis
20 by independently marking and categorizing key words, phrases, and texts to identify codes that described the perceived importance of nutrition education in medical school. All short-answer responses were coded and reviewed to establish intercoder reliability.
21 Qualitative counts were then provided to group the findings.
Results
Of the 424 osteopathic medical students enrolled at OU-HCOM's 3 campuses, 257 (60.6%) completed the survey and quiz. Six participants chose not to disclose their campus, and not all students completed every question. One hundred thirty-nine participants were first-year students, and 118 were second-year students. One hundred thirty-four (52.8%) were women, and 107 (42.5%) planned to pursue a career in primary care. Demographic data are presented in
Table 1.
Table 1.
Assessment of Nutrition Knowledge and Attitudes in Preclinical Osteopathic Medical Students: Participant Demographic Characteristics (N=257)
| Characteristicb | No. (%)a | P Value |
| All Participants | First-Year Students (n=139) | Second-Year Students (n=118) |
| Age, mean (SD) y | 24.8 (3.4) | 24.2 (3.5) | 25.7 (3.1) | .001 |
| Gender | | | | |
| Female | 133 (52.8) | 76 (54.7) | 57 (50.9) | .468 |
| Male | 118 (46.8) | 63 (45.3) | 54 (48.2) | |
| Ethnicity | | | | |
| White | 197 (78.2) | 108 (77.7) | 89 (79.5) | .302 |
| Asian | 27 (10.7) | 19 (13.7) | 8 (7.1) | |
| Black | 13 (5.2) | 4 (2.9) | 9 (8.0) | |
| Mixed | 6 (2.4) | 1 (0.7) | 2 (1.8) | |
| Pacific Islander | 2 (0.8) | 3 (2.2) | 1 (0.9) | |
| Other | 5 (2.0) | … | 2 (1.8) | |
| Community Participant Grew Up in | | | | |
| Major metropolitan area (>1 million) | 15 (6.0) | 7 (5.0) | 8 (7.1) | .900 |
| Metropolitan area (500,001-1 million) | 27 (10.7) | 16 (11.5) | 11 (9.8) | |
| City (100,001-500,000) | 50 (19.8) | 26 (18.7) | 24 (21.4) | |
| Small city (50,001-100,000) | 41 (16.3) | 24 (17.3) | 17 (15.2) | |
| Town (2,500-50,000) | 88 (34.9) | 51 (36.7) | 37 (33.0) | |
| Rural area (fewer than 2,500) | 30 (11.9) | 15 (10.8) | 15 (13.4) | |
| Campus | | | | |
| Main campus | 175 (69.4) | 95 (68.3) | 80 (71.4) | .123 |
| Distant campus 1 (Dublin, n=98) | 55 (21.8) | 23 (16.5) | 32 (28.6) | |
| Distant campus 2 (Cleveland, n=48) | 21 (8.3) | 21 (15.1) | NAc | |
| Planning on a Career in Primary Care | | | | |
| Yes | 107 (42.5) | 60 (43.2) | 47 (42.0) | .898 |
| No | 144 (57.1) | 79 (56.8) | 65 (58.0) | |
| Previous Nutrition Course in Undergraduate or Graduate Education | | | | |
| Yes | 67 (26.6) | 43 (30.9) | 24 (21.4) | .149 |
| No | 176 (69.8) | 94 (67.6) | 82 (73.2) | |
Table 1.
Assessment of Nutrition Knowledge and Attitudes in Preclinical Osteopathic Medical Students: Participant Demographic Characteristics (N=257)
| Characteristicb | No. (%)a | P Value |
| All Participants | First-Year Students (n=139) | Second-Year Students (n=118) |
| Age, mean (SD) y | 24.8 (3.4) | 24.2 (3.5) | 25.7 (3.1) | .001 |
| Gender | | | | |
| Female | 133 (52.8) | 76 (54.7) | 57 (50.9) | .468 |
| Male | 118 (46.8) | 63 (45.3) | 54 (48.2) | |
| Ethnicity | | | | |
| White | 197 (78.2) | 108 (77.7) | 89 (79.5) | .302 |
| Asian | 27 (10.7) | 19 (13.7) | 8 (7.1) | |
| Black | 13 (5.2) | 4 (2.9) | 9 (8.0) | |
| Mixed | 6 (2.4) | 1 (0.7) | 2 (1.8) | |
| Pacific Islander | 2 (0.8) | 3 (2.2) | 1 (0.9) | |
| Other | 5 (2.0) | … | 2 (1.8) | |
| Community Participant Grew Up in | | | | |
| Major metropolitan area (>1 million) | 15 (6.0) | 7 (5.0) | 8 (7.1) | .900 |
| Metropolitan area (500,001-1 million) | 27 (10.7) | 16 (11.5) | 11 (9.8) | |
| City (100,001-500,000) | 50 (19.8) | 26 (18.7) | 24 (21.4) | |
| Small city (50,001-100,000) | 41 (16.3) | 24 (17.3) | 17 (15.2) | |
| Town (2,500-50,000) | 88 (34.9) | 51 (36.7) | 37 (33.0) | |
| Rural area (fewer than 2,500) | 30 (11.9) | 15 (10.8) | 15 (13.4) | |
| Campus | | | | |
| Main campus | 175 (69.4) | 95 (68.3) | 80 (71.4) | .123 |
| Distant campus 1 (Dublin, n=98) | 55 (21.8) | 23 (16.5) | 32 (28.6) | |
| Distant campus 2 (Cleveland, n=48) | 21 (8.3) | 21 (15.1) | NAc | |
| Planning on a Career in Primary Care | | | | |
| Yes | 107 (42.5) | 60 (43.2) | 47 (42.0) | .898 |
| No | 144 (57.1) | 79 (56.8) | 65 (58.0) | |
| Previous Nutrition Course in Undergraduate or Graduate Education | | | | |
| Yes | 67 (26.6) | 43 (30.9) | 24 (21.4) | .149 |
| No | 176 (69.8) | 94 (67.6) | 82 (73.2) | |
×
The average score on the nutrition knowledge quiz was 69.5%, with 130 participants (50.6%) scoring below the school's passing rate of 72.5%. No significant differences were observed between male and female students by average quiz score (mean, 68.7% vs 70.0%;
t=0.769;
P=.442) or individual quiz questions (
Table 2). However, second-year students performed better on the quiz compared with first-year students (mean, 74.2% vs 65.9%;
t=−5.17;
P<.001;
Table 2). Specifically, second-year students were more likely than first-year students to understand energy density (73 [65.2%] vs 57 [41.0%], respectively; χ
2=19.3;
P<.001), energy balance (33 [29.5%] vs 26 [18.7%], respectively; χ
2=4.9;
P=.027), types of fatty acids (87 [77.7%] vs 90 [64.7%], respectively; χ
2=8.7;
P<.001), gastroesophageal reflux (94 [83.9%] vs 95 [68.3%], respectively; χ
2=15.1;
P<.001), risk for insulin resistance (79 [70.5%] vs 82 [59.0%], respectively; χ
2=5.9;
P=.015), and medical nutrition therapy for obstructive sleep apnea (102 [91.1%] vs 118 [84.9%], respectively; χ
2=11.5;
P<.001). First-year students performed better than second-year students on one question about the DASH (Dietary Approaches to Stop Hypertension) diet (110 [79.1%] vs 69 [61.6%]; χ
2=7.9], respectively;
P=.005). Questions in which both first- and second-year students performed below the school passing rate included questions about energy density, energy balance, cholesterol guidelines, medical nutrition therapy to lower serum cholesterol, and insulin resistance.
Table 2.
Correct Responses to a Sample of Nutrition Knowledge Quiz Questions by Year in Osteopathic Medical School and Sex (N=257)a
| Questionbc | No. (%) | P Value | No. (%) | P Value |
| All Participants | First-Year Students (n=139) | Second-Year Students (n=118) | Female(n=134) | Male (n=123) |
| 1. A 50-year-old woman wants to reduce her caloric intake enough to lose 1 lb per week. By how many calories must she reduce her intake each day to achieve her goal? | 159 (63.1) | 87 (62.6) | 72 (64.3) | .41 | 84 (63.2) | 74 (62.7) | .791 |
| a. 500 calories | | | | | | | |
| b. 1000 calories | | | | | | | |
| c. 250 calories | | | | | | | |
| d. 2000 calories |
| 4. Metabolism of 150 g carbohydrate, 20 g fat, and 20 g protein yields approximately how many kilocalories? | 141 (56.0) | 74 (53.2) | 67 (59.8) | .098 | 72 (54.1) | 68 (57.6) | .610 |
| a. 300 kcals | | | | | | | |
| b. 550 kcals | | | | | | | |
| c. 820 kcals | | | | | | | |
| d. 1000 kcals |
| 9. A 50-year-old woman has 1 risk factor for heart disease. At what LDL cholesterol level should dietary therapy be initiated? | 45 (17.9) | 22 (15.8) | 23 (20.5) | .258 | 23 (17.3) | 22 (18.6) | .802 |
| a. 100 mg/dL | | | | | | | |
| b. 130 mg/dL | | | | | | | |
| c. 160 mg/dL | | | | | | | |
| d. 200 mg/dL |
| 10. What dietary factor is most responsible for raising serum cholesterol levels? | 129 (51.2) | 68 (48.9) | 61 (54.5) | .206 | 70 (52.6) | 58 (49.2) | .522 |
| a. dietary cholesterol | | | | | | | |
| b. unsaturated fat | | | | | | | |
| c. saturated fat | | | | | | | |
| d. simple sugars |
| 11. Which of the following medical nutrition therapies are recommended to reduce hypertension? | 179 (71.0) | 110 (79.1) | 69 (61.6) | .005 | 94 (70.7) | 84 (71.2) | .992 |
| a. reduce dietary sodium intake | | | | | | | |
| b. increase dietary potassium and calcium intake | | | | | | | |
| c. moderate alcohol intake | | | | | | | |
| d. all of the above |
| 18. Individuals who are at increased risk for insulin resistance include which of the following? | 161 (63.9) | 82 (59.0) | 79 (70.5) | .015 | 83 (62.4) | 77 (65.3) | .603 |
| a. patients with a history of hypercholesterolemia | | | | | | | |
| b. patients with a “pear-shaped” body | | | | | | | |
| c. patients with a first-degree relative with type 2 diabetes | | | | | | | |
| d. patients with a first-degree relative with hypertension |
| 19. Medical nutrition therapy for patients with obstructive sleep apnea syndrome should focus on which of the following? | 220 (87.3) | 118 (84.9) | 102 (91.1) | <.001 | 116 (87.2) | 103 (83.7) | .829 |
| a. weight reduction | | | | | | | |
| b. protein repletion | | | | | | | |
| c. vitamin and mineral deficiencies | | | | | | | |
| d. fluid repletion |
| Mean (SD) quiz score | 69.5 (12.9) | 65.9 (13.1) | 74.2 (11.1) | <.001 | 70.0 (12.1) | 68.7 (13.8) | .442 |
Table 2.
Correct Responses to a Sample of Nutrition Knowledge Quiz Questions by Year in Osteopathic Medical School and Sex (N=257)a
| Questionbc | No. (%) | P Value | No. (%) | P Value |
| All Participants | First-Year Students (n=139) | Second-Year Students (n=118) | Female(n=134) | Male (n=123) |
| 1. A 50-year-old woman wants to reduce her caloric intake enough to lose 1 lb per week. By how many calories must she reduce her intake each day to achieve her goal? | 159 (63.1) | 87 (62.6) | 72 (64.3) | .41 | 84 (63.2) | 74 (62.7) | .791 |
| a. 500 calories | | | | | | | |
| b. 1000 calories | | | | | | | |
| c. 250 calories | | | | | | | |
| d. 2000 calories |
| 4. Metabolism of 150 g carbohydrate, 20 g fat, and 20 g protein yields approximately how many kilocalories? | 141 (56.0) | 74 (53.2) | 67 (59.8) | .098 | 72 (54.1) | 68 (57.6) | .610 |
| a. 300 kcals | | | | | | | |
| b. 550 kcals | | | | | | | |
| c. 820 kcals | | | | | | | |
| d. 1000 kcals |
| 9. A 50-year-old woman has 1 risk factor for heart disease. At what LDL cholesterol level should dietary therapy be initiated? | 45 (17.9) | 22 (15.8) | 23 (20.5) | .258 | 23 (17.3) | 22 (18.6) | .802 |
| a. 100 mg/dL | | | | | | | |
| b. 130 mg/dL | | | | | | | |
| c. 160 mg/dL | | | | | | | |
| d. 200 mg/dL |
| 10. What dietary factor is most responsible for raising serum cholesterol levels? | 129 (51.2) | 68 (48.9) | 61 (54.5) | .206 | 70 (52.6) | 58 (49.2) | .522 |
| a. dietary cholesterol | | | | | | | |
| b. unsaturated fat | | | | | | | |
| c. saturated fat | | | | | | | |
| d. simple sugars |
| 11. Which of the following medical nutrition therapies are recommended to reduce hypertension? | 179 (71.0) | 110 (79.1) | 69 (61.6) | .005 | 94 (70.7) | 84 (71.2) | .992 |
| a. reduce dietary sodium intake | | | | | | | |
| b. increase dietary potassium and calcium intake | | | | | | | |
| c. moderate alcohol intake | | | | | | | |
| d. all of the above |
| 18. Individuals who are at increased risk for insulin resistance include which of the following? | 161 (63.9) | 82 (59.0) | 79 (70.5) | .015 | 83 (62.4) | 77 (65.3) | .603 |
| a. patients with a history of hypercholesterolemia | | | | | | | |
| b. patients with a “pear-shaped” body | | | | | | | |
| c. patients with a first-degree relative with type 2 diabetes | | | | | | | |
| d. patients with a first-degree relative with hypertension |
| 19. Medical nutrition therapy for patients with obstructive sleep apnea syndrome should focus on which of the following? | 220 (87.3) | 118 (84.9) | 102 (91.1) | <.001 | 116 (87.2) | 103 (83.7) | .829 |
| a. weight reduction | | | | | | | |
| b. protein repletion | | | | | | | |
| c. vitamin and mineral deficiencies | | | | | | | |
| d. fluid repletion |
| Mean (SD) quiz score | 69.5 (12.9) | 65.9 (13.1) | 74.2 (11.1) | <.001 | 70.0 (12.1) | 68.7 (13.8) | .442 |
×
Table 2 (continued).
Students’ Knowledge of and Confidence in Nutrition Education and Counseling by Year in Osteopathic Medical School and Sex (N=257)a
| Questionb | No. (%) | P Value | No. (%) | P Value |
| All Participants | First-Year Students (n=139) | Second-Year Students (n=118) | Female (n=134) | Male (n=123) |
| Are you aware of the current dietary reference intakes (DRIs) nutrition guidelines? | | | | .017 | | | .270 |
| Yes | 30 (11.9) | 23 (16.5) | 7 (6.3) | | 18 (13.5) | 11 (9.3) | |
| No | 213 (84.9) | 114 (82.0) | 99 (88.4) | | 109 (82.0) | 104 (88.1) | |
| If you were in clinical practice today, how comfortable do you feel counseling patients on nutrition recommendations? | | | | .816 | | | .216 |
| Very comfortable | 25 (9.9) | 15 (10.8) | 10 (8.9) | | 18 (13.5) | 7 (5.9) | |
| Somewhat comfortable | 118 (46.8) | 63 (45.3) | 55 (49.1) | | 58 (43.6) | 59 (50.0) | |
| Not too comfortable | 89 (35.3) | 53 (38.1) | 36 (32.1) | | 46 (34.6) | 43 (36.4) | |
| Not at all comfortable | 11 (4.4) | 6 (4.3) | 5 (4.5) | | 5 (3.8) | 6 (5.1) | |
| If you were in clinical practice today, how comfortable do you feel designing a nutrition plan for a patient? | | | | .264 | | | .123 |
| Very comfortable | 14 (5.6) | 8 (5.8) | 6 (5.4) | | 9 (6.8) | 5 (4.2) | |
| Somewhat comfortable | 72 (28.6) | 39 (28.1) | 33 (29.5) | | 37 (27.8) | 35 (29.7) | |
| Not too comfortable | 124 (49.2) | 76 (54.7) | 48 (42.9) | | 68 (51.1) | 55 (46.6) | |
| Not at all comfortable | 33 (13.1) | 14 (10.1) | 19 (17.0) | | 13 (9.8) | 20 (16.9) | |
Table 2 (continued).
Students’ Knowledge of and Confidence in Nutrition Education and Counseling by Year in Osteopathic Medical School and Sex (N=257)a
| Questionb | No. (%) | P Value | No. (%) | P Value |
| All Participants | First-Year Students (n=139) | Second-Year Students (n=118) | Female (n=134) | Male (n=123) |
| Are you aware of the current dietary reference intakes (DRIs) nutrition guidelines? | | | | .017 | | | .270 |
| Yes | 30 (11.9) | 23 (16.5) | 7 (6.3) | | 18 (13.5) | 11 (9.3) | |
| No | 213 (84.9) | 114 (82.0) | 99 (88.4) | | 109 (82.0) | 104 (88.1) | |
| If you were in clinical practice today, how comfortable do you feel counseling patients on nutrition recommendations? | | | | .816 | | | .216 |
| Very comfortable | 25 (9.9) | 15 (10.8) | 10 (8.9) | | 18 (13.5) | 7 (5.9) | |
| Somewhat comfortable | 118 (46.8) | 63 (45.3) | 55 (49.1) | | 58 (43.6) | 59 (50.0) | |
| Not too comfortable | 89 (35.3) | 53 (38.1) | 36 (32.1) | | 46 (34.6) | 43 (36.4) | |
| Not at all comfortable | 11 (4.4) | 6 (4.3) | 5 (4.5) | | 5 (3.8) | 6 (5.1) | |
| If you were in clinical practice today, how comfortable do you feel designing a nutrition plan for a patient? | | | | .264 | | | .123 |
| Very comfortable | 14 (5.6) | 8 (5.8) | 6 (5.4) | | 9 (6.8) | 5 (4.2) | |
| Somewhat comfortable | 72 (28.6) | 39 (28.1) | 33 (29.5) | | 37 (27.8) | 35 (29.7) | |
| Not too comfortable | 124 (49.2) | 76 (54.7) | 48 (42.9) | | 68 (51.1) | 55 (46.6) | |
| Not at all comfortable | 33 (13.1) | 14 (10.1) | 19 (17.0) | | 13 (9.8) | 20 (16.9) | |
×
One hundred seventy-one participants (68%) felt that nutrition counseling and meal planning were the responsibility of the PCP. However, only 30 participants (11.9%) were aware of the current DRIs, which denote the most current scientific knowledge of a healthy person's different nutrient needs. First-year medical students were more likely to be aware of DRIs compared with second-year students (χ2=5.7; P=.017). Awareness of DRIs did not differ by sex (χ2=1.2; P=.270). Furthermore, participants’ awareness of DRIs or lack thereof was not associated with scores on the nutrition knowledge quiz (mean, 70.7% vs 69.3%, respectively; t=0.53; P=.594). Despite the limited awareness about DRIs, 143 students (55.6%) felt at least somewhat comfortable counseling future patients on nutrition recommendations, and 86 (34.2%) felt at least somewhat comfortable designing a nutrition plan for a patient. Independent sample t tests showed that when comparing average nutrition quiz scores, participants who felt at least somewhat comfortable counseling future patients on nutrition recommendations scored higher on the quiz compared with those who did not feel comfortable (mean, 72.2% vs 68.0%, respectively; t=2.43; P=.016). Of importance, participants in all comfort level groups scored below the school's passing grade of 72.5%. Comfort level with nutrition counseling and designing meal plans did not differ by year in medical school (nutrition counseling: χ2=0.9; P=.816; designing meal plans: χ2=3.9; P=.264) or sex (nutrition counseling: χ2=4.5; P=.216; designing meal plans: χ2=3.5; P=.325).
One hundred thirty-two participants (54%) reported knowing the role of an RD/RDN, but qualitatively, they did not fully understand the RD/RDN's role on the health care team. Of these 132 participants, 128 (97.0% response rate of sample) provided written descriptions of this role. The majority of participants (111 [86.7%]) described only 1 aspect of an RD/RDN's role, and 17 participants (13.3%) described more than 1 aspect (patient assessment, n=58; nutrition education, n=55; meal planning, n=33; promoting wellness through community outreach, n=1; and staying up to date with research and guidelines, n=1).
Participants who completed the short answer to the question “Do you know the role of a registered dietitian? If yes, please explain” did not differ by age, sex, race, community, or year in medical school compared with participants who did not complete the question.
One hundred sixty-six participants (68%) rated nutrition education as very important in medical school. Qualitatively, 201 participants (78.2% response rate of sample) noted the importance of nutrition education as a means to provide patient education (n=41), promote overall health and wellness (n=68), prevent disease (n=31), and manage disease (n=61). Comments included the following:
As a physician, you are the person that people will go to for information on nutrition first. The likelihood that a person will see a nutritionist before asking their PCP questions is minimal. It is important that the physician knows what they are talking about and can provide help.
It is the basis of our osteopathic education to get the body in the most prime shape to fix/preserve itself and nutrition is a large part of that.
I think nutrition education needs to be much more valued in medical school because of where our country is in terms of morbidity and mortality, it comes down to chronic disease conditions that can be prevented with lifestyle.
Nutrition is the most basic form of medical therapy. Improper nutrition accounts for many of the preventable diseases we will encounter regularly in our practice.
Participants who completed the short answer to the question “How important is nutrition education in medical school? Please explain.” did not differ by age, sex, race, community, or year in medical school compared with participants who did not complete the question. Five participants also commented that nutrition was not covered on board examinations despite its importance in health and well-being. For example, a participant wrote: “In reality, it is very important. But I am more worried about learning material that will be tested on boards.”
Discussion
This study found that 130 participants did not receive a passing nutrition quiz grade. Second-year students performed better on the quiz compared with first-year students; however, both classes performed below the school's passing rate on questions about energy density, energy balance, cholesterol guidelines, and medical nutrition therapy to lower serum cholesterol level. These findings suggest that topics, including dietary recommendation categories, energy density, energy balance, and dietary fat, may need to be added to the preclinical curriculum. The majority of participants, who were preclinical osteopathic medical students, recognized the importance of nutrition education. Qualitatively, most participants valued nutrition education in medical school, particularly for providing patient education, promoting overall health and wellness, preventing disease, and managing disease. Furthermore, the majority of participants reported feeling “very or somewhat comfortable” counseling patients on nutrition recommendations. Despite the perceived importance of nutrition education and comfort level with counseling patients, the vast majority of participants lacked knowledge about DRIs
In 2012, the National Ambulatory Medical Care Survey reported more than 506 million visits to PCPs in the United States.
22 More than 60 million office visits were to osteopathic physicians.
22 Osteopathic medicine embraces a holistic approach to medicine and recognizes the importance of nutrition in preventive and therapeutic medicine. For this reason, PCPs—in particular, osteopathic PCPs—are well positioned to play a key role in promoting healthy eating.
23 The US Preventive Services Task Force recommends that PCPs provide nutrition counseling as part of routine preventive health care.
24 However, a study published in 2011 found that less than 50% of PCPs surveyed reported always discussing diet with their patients.
25 Another study found that although a majority of PCPs thought that nutrition should be part of every primary care visit, they reported not having adequate nutrition training to counsel patients.
16 For these reasons, adequate nutrition education is especially important in medical school.
The current study builds on previous work and confirms findings from allopathic medical schools showing that nutrition education is lacking. In a 2008 study conducted with incoming and current medical interns, the average score on a nutrition knowledge quiz was a 66%, indicating major gaps in basic nutrition concepts.
16 In the current study, the level of knowledge reflected by students in response to several nutrition quiz questions did not follow the expectations set by the tenets of osteopathic medicine.
19 Specifically, nonmedication methods should be considered first when treating patients with conditions such as hypertension and high cholesterol. However, a large percentage of participants did not know dietary approaches to managing these conditions. Second-year students performed slightly better on the nutrition quiz compared with first-year students. One possible explanation for this finding is that second-year students have an additional year of education and training in medical knowledge, which may have improved their quiz scores.
The findings of the current study are in accord with a study by Smith et al.
26 which surveyed PCP residents on their preparedness to provide obesity and nutrition counseling. The study concluded that PCP residents have room for improvement with regard to assessment and management methods for obesity and nutrition.
26 However, unlike other studies, the current study showed that the majority of participants felt comfortable offering nutrition counseling despite gaps in their nutrition knowledge. Previous research identified insufficient training and lack of counseling skills as barriers to providing nutrition education and counseling to patients.
14,16 In the current study, participants’ confidence to discuss general nutrition guidelines without knowledge of DRIs is concerning. Importantly, research has shown that physicians who are overly confident are less likely to seek additional resources and more likely to misdiagnose their patients’ conditions.
27 Likewise, medical students who are overly confident in their general nutrition knowledge but lack knowledge of important reference values, such as the DRIs, may not attempt to further understand or explore these important recommendations in treating future patients. The DRIs for nutrient and energy intake vary dramatically by age, sex, and circumstance (eg, lactation, pregnancy, disease).
28 Medical students need to acknowledge that a one-size-fits-all recommendation for nutrients is not appropriate, and DRIs are updated routinely as new research is available. Therefore, an understanding of these recommendations is critical to the future physician providing dietary advice. Furthermore, medical students and practicing physicians should be aware of online interactive tools (eg,
https://www.nal.usda.gov/fnic/interactiveDRI/) to quickly calculate the DRIs for patients. These resources may be underused by those overly confident in their nutrition knowledge and counseling skills.
Many studies have examined the amount and quality of nutrition education in medical education programs. A survey conducted in 1985 by the National Academy of Science found that nutrition education was inadequate in allopathic medical schools, prompting the organization to recommend a minimum of 25 hours of nutrition instruction.
29 However, a study conducted in 2006 showed that the average number of nutrition instruction hours in medical schools fell below the recommended 25 hours and was often a part of another course.
17 With regard to osteopathic medical schools, a 2015 study indicated that required nutrition education averaged only 17 hours and that the nutrition instruction was often a part of an integrated course rather than a course dedicated to nutrition education.
18 A 2016 study assessing nutrition training in residency programs showed that only 26.4% of programs have a formal nutrition course, and 13.9% report no form of nutrition training.
30 Moreover, the format of nutrition education was reported to vary significantly from a single 45-minute lecture to multiple 1-hour sessions, which could include lectures, informal rounds, conferences, and web-based learning programs. These findings show multiple shortcomings in nutrition education at medical schools, which, in turn, can have large health ramifications if physicians are not adequately trained to educate and counsel patients on nutrition. The qualitative responses from participants in the current study demonstrate that students understand the importance of having nutrition education in medical school with regard to preventive and therapeutic medicine; thus, more nutrition training and education is necessary.
At least 1 nutrition lecture should be included in each education block because every organ system benefits from proper nutrition, and every disease associated with the organ system has specific dietary needs. To encourage nutrition education in medical schools, the National Heart, Lung, and Blood Institute created a Nutrition Academic Award with a grant to support the growth and enhancement of nutrition education for medical students, residents, and practicing physicians.
31 However, the creation of the award has had little impact on increasing nutrition education in medical schools.
31 Of the 141 accredited allopathic medical schools and 31 accredited osteopathic medical schools, only 21 medical schools have been awarded the Nutrition Academic Award.
32 Another opportunity for improving nutrition education in medical school is to require students to shadow an RD/RDN to better understand their role in the health care team. More than half of the participants in the current study reported knowing the role of RDs/RDNs; however, none of the students accurately described the role in overall patient care.
Limitations
Study limitations include homogeneity of the study sample from 1 osteopathic medical school in a Midwestern state, the cross-sectional study design, and participants’ self-reported data. Therefore, the ability to generalize the findings to all osteopathic medical schools is limited. However, it should be noted that the 3 campuses reside in very different geographical regions across the state—rural, suburban, and urban—which may increase the generalizability of the findings. Furthermore, only students who were enrolled in preclinical education were included in the study; medical students in clinical education were excluded because clinical exposure to nutrition education varies by rotation site and preceptor. Moreover, only 59.6% of the first- and second-year students enrolled at the school completed the survey. The participating students who volunteered may have been more willing or motivated to answer questions about nutrition compared with the students who did not participate. For these reasons, the self-reported findings are susceptible to selection bias. No researchers were present when potential participants decided to participate or decline, and thus they may have felt less pressure than in a face-to-face consent process. Future research with a larger, more heterogeneous sample should include medical students enrolled in preclinical and clinical education as well as students from multiple osteopathic medical schools. Longitudinal assessment by year of medical school is needed to determine whether nutrition knowledge and attitudes toward nutrition counseling change between the preclinical and clinical years.
Conclusion
Although students expressed the importance of nutrition education in medical school, and many felt comfortable counseling future patients on nutrition, most students lacked knowledge of DRIs and other nutrition knowledge. To address the growing rate of obesity and obesity-related chronic diseases in the United States, osteopathic medical students would benefit from the integration of more nutrition education in the curriculum. The NAS recommends a minimum of 25 hours of nutrition education; however, this guideline is not being met at most allopathic and osteopathic medical schools. Incorporating nutrition-related competencies as well as including nutrition questions on board certification examinations may help ensure that schools adhere to the minimum number of hours of nutrition education.
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; Ms Hargrove and Dr Beverly drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and Dr Beverly agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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