Integrating nutrition and culinary medicine into preclinical medical training | BMC Medical Education

This study evaluated the nutrition and culinary medicine curriculum at a new college of osteopathic medicine. The culinary medicine curriculum was licensed from an established program (HmF), however the integration with nutrition coursework and the assessment strategies were novel. There was a small but significant change in overall diet quality between baseline and the end of the year among participants who completed food frequency questionnaires at two time points. While students learned about nutrition, they were also adjusting to a new routine, new budget, new environment and new stressors, all of which may have contributed to their dietary choices. Students did not report a decline in diet quality and there was also no increase in intake of alcohol or caffeine reported over the first year of medical school in our sample.

Our results show that overall diet quality among 195 participating medical students was above the national average of 58 [20], but still below desirable levels. Participant reported average intake of fiber of is below the recommended 25–38 g/day [21]. Fiber is a shortfall nutrient in the US [19], and medical students are also not getting the recommended minimal daily amount. Average sodium intake was well above recommendations [19], while potassium intake was below recommended levels [19]. These findings are important for two main reasons: first, diet quality is less than desirable among medical students, coupled with the high stress and limited sleep typical of medical school puts students at risk for preventable chronic disease. Healthy habits tend to decline in the first year of medical school due to the pressures and time limitations of engaging in a rigorous curriculum [22]. Our finding that diet did not significantly decline during the first year of medical school suggests that a culinary medicine and nutrition curriculum could help prevent these declines. Secondly, evidence from studies among medical students [18, 23] and physicians [24, 25] suggest that personal lifestyle habits of health professionals influence provider counseling for patients on a healthy lifestyle [26]. Therefore, educating future physicians not just on nutritional biochemistry and evidence-based lifestyle interventions, but also providing education on food purchasing, preparation and practical information for improving personal diets are integral to training physicians likely to counsel on these topics.

Attendance at all culinary medicine sessions was approximately 92% for the first cohort and 88% for the second cohort. Attendance was excellent for most of the year and declined in April and May as students began studying for their COMLEX and STEP exams. Students were aware most of the topics would not be tested on board exams and the content from CMW held a low weight on their course examinations. There was no penalty for missing CMW sessions, yet students rarely missed sessions until the late spring. Students were able to eat together at the end of each session and shared that the class reduced their stress levels. They received feedback and reinforcement of their knowledge through the TBL readiness assurance process and applied what they learned in the teaching kitchen.

Nutrition and culinary medicine sessions were facilitated by a nutrition faculty member and a Registered Dietitian Nutritionist. This gave students the opportunity to learn from healthcare providers who would be part of a future interdisciplinary healthcare team. Dietetic interns training at a local university attended sessions and functioned as Teaching Assistants. They also shared cases from their own clinical training and answered questions for the medical students on nutrition topics important to them personally and of professional interest. Other faculty members often stopped by the sessions to sample recipes, talk to students, or just observe the culinary medicine sessions. One faculty member reported that she learned more about a student in observing one session than she did in the whole course she taught that the student attended. This attests to the way students are able to be themselves and interact with faculty in a lower stress environment in the CMW. These types of close interactions between faculty and students may help to promote professional identity formation.

Just 26% of respondents took a nutrition class prior to entering medical school and while more than half of survey respondents (n = 38) reporting doing their own reading or research related to nutrition, less than half of those have read peer-reviewed nutrition journals or nutrition articles geared toward physicians; instead most respondents reported reading nutrition information in the popular media and in diet books. This suggests that the nutrition information being consumed by future physicians could be fraught with misinformation, without guidance from a nutrition course and nutrition professionals.

Nutrition and culinary medicine curricula are well-suited to team-based learning models and some programs have been redesigned to utilize TBL approaches in the undergraduate setting [27, 28] and in selected medical schools [29, 30]. Hands-on cooking classes are increasingly being taught in medical schools across the country [13, 31, 32], but it does not appear that these programs have implemented team-based learning approaches. A college of pharmacy created a lifestyle modification elective course using TBL and taught it with two different cohorts of second year pharmacy students [33] . Investigators evaluated the impact using pre and post-course surveys and a voluntary course evaluation. Examinations showed improved knowledge of nutrition and lifestyle topics and surveys showed high levels of satisfaction (85%); this was done in a curriculum that was primarily lecture-based.

Colleges of medicine provide inadequate nutrition education to allow future providers to be proficient in having discussions of nutrition and lifestyle with patients. A lack of evidence-based guidance to prepare future doctors has limited progress thus far, but we have agreed upon goals. Future physicians should be prepared to assess nutrition-related problems at the individual and community level, provide basic dietary recommendations to patients, identify patients with or at risk for malnutrition and recognize when to refer to a specialist [10]. Medical schools with lasting/sustainable nutrition programs “thread” it throughout the curriculum from pre-clinical to clinical years aiming for a total of at least 30 h [10] . The medical school curriculum is overloaded, but this program did not take away meaningfully from other coursework and integrated skills and topics that students would see in classes and on national board exams. A review of USMLE step exam questions from 1989 to 1993 found a reasonable amount (11%) of questions dedicated to testing nutrition knowledge, but a dearth of questions related to prevention, nutrition support and malnutrition, with an overemphasis on vitamin deficiencies [34]. A review published in 2015 found that the STEP exam preparatory materials contained many references to vitamin and minerals deficiencies, with few references to prevention or diet-related disease management [35]. An analysis of board examinations in Germany found that < 1% of questions were devoted solely to testing nutrition knowledge and 2% included some nutrition-related topic [36]. This is clearly an area of needed improvement to move nutrition in medical education forward.

A recent report from three institutions utilizing culinary medicine training (at the undergraduate and graduate medical education levels) [37] called for additional research into class format and outcome measures in order to create best practices for implementation of culinary medicine. We contribute this work to the evidence-base, however, this study had several limitations. We did not utilize incentives for completion of surveys as they were administered during class time and there was a low response rate on optional and follow up surveys. Poor responses are common among surveys of medical students, and this study was complicated by rapidly changing restrictions due to a global pandemic. Comparisons between baseline and end of year 1 data should be interpreted with caution due to the smaller sample size that completed both diet assessments and surveys. Diet assessment tools are prone to bias due to poor recall or social desirability and limited ability of respondents to estimate portion sizes. The FFQ used in this study uses images to assist with portion size estimation, which helps to mitigate some error [38]. Students received a study ID and were made aware that their data would be anonymized. The strengths of this study were use of a tested curriculum (HmF), use of a validated tool for data collection (FFQ), and data collection at two time points.

In conclusion, nutrition and diet are important components of preventive care and should be integrated into medical education. Including dietetic interns in training is free of cost and of benefit to all learners. Teaching nutrition in a student friendly, interactive way, was effective, beneficial, and this strategy could be used for teaching other topics, particularly those important for the training of future healthcare providers that may not be tested extensively on board examinations.