Lifestyle Medicine Electives: Options for Creating Curricula Within Medical School Training

Abstract

Lifestyle medicine (LM) offers future generations of clinicians practical tools to effectively prevent, manage and reverse chronic disease. Due to a variety of factors, introduction of such curricula in medical training has been slow. Until LM becomes more standard in medical schools, electives and tracks are an innovative way to introduce curricula in a time-efficient manner so students can have access to this valuable information during their formative training years. Creating a culture for the acceptance of LM is a critical first step and can be accomplished by collaborating with like-minded faculty as well as developing student interest groups. The latter can also be a strong driver for curricular change. This article provides an overview of several structures that can be implemented within existing curricula to offer students a foundation in LM. Included are offerings during the pre-clinical years, third/fourth year electives, culinary medicine rotations, online opportunities, and the development of a full track. Specific components of each structure are shared as well as examples of successful use of community partnerships, use of pre-existing educational resources, and activities implemented. The authors conclude that implementing electives is a promising avenue for educators to expose medical students to LM and can be molded to work within a variety of current educational structures.

“Choosing the best avenue for an elective will depend on one’s existing curricular design, resources available, and cultural readiness on campus.”

Introduction and Background

Lifestyle medicine (LM) is an emerging field with the potential to help trainees effectively reverse the overwhelming chronic disease burden found in much of the world. Research also clearly demonstrates that students do not receive enough training in LM, particularly in nutrition. However, implementing a LM curriculum into medical schools can sometimes be challenging. Programs often struggle with how to fully cover “board relevant” materials within their curricula. This leaves many important topics that are not adequately represented on board exams to be deprioritized. In response, work is being done to cover critical LM information more effectively on board exams. Once medical schools see the immediate relevance of LM, incorporating these topics into curriculum will follow a natural progression.

Electives are an innovative way to introduce LM into the medical school curriculum. Prior to creating an elective, it is important to build support from students as well as faculty to develop momentum for LM. The authors note here that initially starting a lifestyle medicine interest group can generate the excitement needed to pave the way to its curricular implementation. Additionally, engaging faculty in LM activities can be instrumental in building institutional support.

Most of the electives presented in this article have been created for third or fourth year students as the rotation schedule lends itself well to that format. However, some institutions have a dedicated selective opportunity in the pre-clinical years. Tracks have been included in this article as they represent a robust opportunity for students to gain in-depth knowledge in LM over the course of their time at the medical school.

Currently, most LM electives provide training on all 6 pillars but others, such as culinary medicine, are more specific and target nutrition and cooking skills. Culinary medicine has comprehensive national level curricula already developed, is flexible in terms of how many hours can be presented and has been overwhelmingly popular with students around the country. For those starting out in LM, a culinary offering can be a tangible first step to introduce LM to one’s institution.

Electives and tracks provide a framework to successfully implement LM into medical school curricula. Several of the programs the authors represent have found that interest amongst medical students is high and that a significant percentage will opt for a LM offering when provided the opportunity. This article aims to share the different elective structures that have been successfully developed within medical schools.

Elective and Track Structures

Table 1 summarizes the elective and track offerings that have been developed at several institutions and includes some of the available resources used as a part of their curricula.

Table 1.

LM Elective and Track Structures.

Format	Organization	Structure/Details	Available Resources a
First/second year	LLU b	2-week lifestyle medicine selective  MS1 - 30/h per week  MS2 - 20/h per week Activities  Journal club  Group presentation  Track personal lifestyle behaviors  Hands-on culinary medicine led by local RD Clinical shadowing 2–4 hours Peer and faculty evaluation	Lifestyle Medicine Residency Curriculum (LMRC) through ACLM Community Resiliency Model (CRM)
Third/fourth year	Brown c LLU UCF d	2 or 4 week elective  Clinical time including shared medical appointments (SMAs)  Didactic: Webcourses/zoom lectures and/or readings  Activities: Personal improvement project, evidence-based focus paper 2 or 4 week elective  LM basic science experience (non-clinical) to develop curriculum to incorporate into basic sciences	Lifestyle Medicine 101 (ACLM free resource) The Benefits of Plant-Based Nutrition (ACLM free resource) ACSM Exercise is Medicine The Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits
Culinary medicine	Brown UCF UCI e	4 week elective, MS1-2  Facilitated by chef, RD, and physicians  Partnership with local culinary school for culinary skills 4 week elective, MS2  Partner with Chef at Culinary school/Integrative Health Institute  Didactic: Nutrition by MD/PhD, RD, and health coach to supplement culinary skills	Health Meets Food Culinary medicine (ACLM free resource)
Online	Open resource projected to be available early 2023	2–4 week elective Format  Adaptable to online or in person Activities  Track personal habits  Culinary medicine  Online patient resources 2-week didactic experience or 4-week combined clinical/didactic	Foundations of Lifestyle Medicine for Medical Students: An Introductory Curriculum
Track	LLU	Spans all 4 years  2 week LM selective during MS1 or MS2  4 week summer LM elective  2–4 LM focused workshops during MS3  4 week LM elective in MS4  Quarterly LM track meetings in MS2–MS4  LM capstone project that leads to a presentation in an academic venue

Abbreviation: LM, Lifestyle medicine.

^aListed resources are used at some of the programs but not necessarily all.

^bLoma Linda University School of Medicine.

^cWarren Alpert Medical School, Brown University.

^dUniversity of Central Florida School of Medicine.

^eUniversity of California, Irvine School of Medicine.

First/Second Year

As a part of the first and second year curriculum, Loma Linda University School of Medicine (LLU) offers a variety of 2 week selective options, with LM being one of these. The course covers the six lifestyle medicine pillars, includes three hands-on plant-based culinary medicine experiences, and a catered plant-based lunch. Students also engage in a journal club, clinical shadowing, and personal wellness tracking to enhance personal lifestyle practices during their selective. Students are required to give a small group presentation on one of the LM pillars at the end of the experience. The 75-minute presentation includes interactive activities as well as an introduction to the pillar, and is evaluated by peers and faculty.

Third/Fourth Year

Warren Alpert Medical School, Brown University (Brown) offers a 2 week clinical elective for third and fourth year students in LM. The course uses the Lifestyle 101 ACLM content as a core scaffolding and then builds upon this content with three additional modules in Nutrition: (1) Nutrients, (2) Food and Weight, and (3) Food insecurity and the physician’s role. Students are assessed with pre- and post-tests. Students also have the opportunity to rotate in the hospital affiliated Lifestyle Medicine Center and shadow practitioners who provide integrative health and lifestyle medicine services. Students are exposed to shared medical visits, health coaching and nutritionists and have the opportunity to experience movement therapy, yoga and take part in mindfulness activities. When available, they also have the option to experience the basics of culinary medicine and either observation of or participation in group cooking classes.

University of Central Florida School of Medicine (UCF) offers a fourth year 2 or 4 week clinical elective. The students work alongside a lifestyle medicine boarded physician seeing patients and practice obtaining lifestyle histories and formulating lifestyle prescriptions. They have the opportunity to see patients who follow up after implementing lifestyle changes and witness firsthand the benefits of lifestyle modifications. Other opportunities have included student involvement in providing nutrition education during group obesity/overweight programs at a community wellness site and partnering with a veteran in a power breath workshop for veterans with PTSD as part of the Whole Health program at the Orlando VA. The didactic portion is one day a week and utilizes the LM101 curriculum. The LM elective was also used as a way to engage UCF faculty and build LM culture by providing CME credit for attending the final summative session that included the topic of educational reform around LM.

LLU offers a 2 week clinical elective for third and fourth year students in LM. Requirements for the LM Elective include a (1) minimum of 70% direct observation of LM clinical visits, LM patient education classes, and LM patient support groups, (2) submission of a learning log from the direct observation experiences, (3) personal improvement project based on a 3-day diet history using Cronometer, (4) required readings from ACLM’s The Benefits of Plant-Based Nutrition (2021), and (5) an evidence-based medicine brief report in response to a lifestyle medicine clinical question. Additionally, LLU offers a 2 or 4 week basic science elective for third or fourth year students. Requirements for this elective include developing curriculum, cases, and/or LM thread content that can be implemented into the various system blocks. The LM basic science focus for this elective is chosen based on student interest and faculty needs.

Culinary Medicine

Food is Health at Brown is a pre-clinical elective consisting of four 2-hour sessions of cooking time with a chef at a local culinary school. Students are exposed to the basics of working in the kitchen, meal preparation, and ingredient pairing. The characteristics of different diets as they relate to chronic disease are presented including Mediterranean, Whole Food Plant Based, and DASH diet. After three of the four sessions, students have a follow up lecture to discuss the medical applications of culinary medicine for the prevention of chronic disease. These lectures are taught by faculty at the medical school certified in either LM or with a special interest or focus in the field of Nutrition.

University of California Irvine School of Medicine (UCI) runs a similar program as Brown for pre-clinical students but has partnered with the local Integrative Health Institute which provides funding for a chef. In addition to cooking, students work through a patient case each session with the dietitian and learn about mindfulness topics with a health coach. Students have assigned material before each session that they present on.

UCF has a 4 week culinary medicine elective for fourth year medical students. The goal is to teach medical students how to better communicate and counsel on healthy cooking and healthy eating at home. The students spend the first day of every week at a teaching kitchen at UCF Rosen School of Hospitality Management learning how to cook healthy recipes alongside a chef, dietician, and a physician while discussing various topics such as reading nutrition labels, healthy food shopping, and the benefits of the Mediterranean diet. There are lectures by the physicians utilizing patient cases from the “Health Meets Food” curriculum to highlight the importance of nutrition across many disciplines. For the remainder of the rotation, the students share what they have learned with patients in various community and health settings. Examples include free cooking classes to the public at the YMCA of Central Florida and food demonstrations of quick and easy meals to patients at the Orlando VA and at the diabetes institute at Advent Health.

Online

Foundations of Lifestyle Medicine for Medical Students is an open source curriculum designed for faculty to use either online or in person. Created by Dr. Shipra Bansal and a team of trainees, the curriculum is designed to assist current faculty with developing their own 2–4 week electives or student leaders with incorporating LM materials within extracurricular activities. The modular format allows the material to be used flexibly in a way that may or may not include a clinical component, depending on availability of experiences at one’s current site.

The sections introduce each of the six pillars, lay the foundation for successfully facilitating behavior change and focus on three major disease categories: cardiovascular health, diabetes, and cancer. Articles and videos from the foundation of material provided allow education to be asynchronous and flexible. These are strongly complemented by activities and experiential learning opportunities to help bring the material together. Examples include a label-reading scavenger hunt at a local grocery store, an interactive motivational interviewing app scenario, self-tracking for sleep and other lifestyle habits, and interactive group activities that highlight the research foundation underlying LM principles.

Students are also asked to engage with a variety of patient resources in order to help them build skills as well as become familiar with practical tools they can use in their own patient care. Specific focus is given to the process of behavior change, where students are asked to create a personal goal and are walked through the steps, using worksheets and peer interviewing. In order to keep the elective interactive while also allowing it to be asynchronous, a variety of media are used including apps, targeted group or partner activities, use of pertinent screening tools and online teaching videos with reflection questions.

Track

The Lifestyle Medicine Track at LLU is designed for students who desire advanced knowledge and skills in the use of LM as a primary therapeutic modality for prevention, treatment, and reversal of chronic disease. The goal is for each LM track student to demonstrate advanced levels of competency in personal and clinical application of Lifestyle Medicine across the chronic disease spectrum. This includes (1) demonstrating knowledge of how each of the LM pillars fit into a comprehensive treatment framework, (2) applying evidence-based LM assessments and interventions for all patient populations across multiple specialties, and (3) integrating appropriate dosing of LM to achieve desired treatment outcomes. Students typically apply for the LM Track during the winter of their MS1 year. The LM track selection committee evaluates applications and oversees the selection process. See Table 1 for specific LM Track requirements.

Each student is assessed in the following areas: (1) Faculty evaluations of student clinical skills, individual projects, group work and presentations during the LM selectives, LM workshops, and LM electives, (2) preceptor evaluations during the summer LM Project, and (3) Assessment by LM Track faculty leaders of the capstone project.

Conclusion

The medical school training years are a critical time to introduce students to lifestyle medicine. This is the stage where trainees are developing their foundational understanding of medicine and are often most open to incorporating LM into both their personal lives as well as patient care. Students consistently find these topics highly relevant and are strong ambassadors for promoting more LM offerings within the curriculum.

Electives offer a practical opportunity to introduce LM topics within a curriculum. This article has showcased different formats applied through each of the 4 years of training. Choosing the best avenue for an elective will depend on one’s existing curricular design, resources available, and cultural readiness on campus.