Where is the nutrition? Content analysis of learning objectives within tertiary medicine and health degree programs at an Australian university

Abstract

Background

Poor diet is a leading cause of mortality and morbidity globally. Given their frequent engagement with the community, medical and healthcare professionals can support improved dietary behaviours, as key brokers of nutritional knowledge. Yet, medical and healthcare professionals report receiving suboptimal nutrition education to support practice.

Objective

This project aimed to identify the nutrition education content provided across tertiary medicine and health degree programmes at an Australian university.

Methods

A list of programmes and core courses was compiled using publicly available information in 2023. Learning objectives of core courses were compared against a Nutrition Competency Framework for Australian Medical Training to identify the nutrition education provided.

Results

A total of 13 programmes and 176 core courses were included. No programme made reference to all competencies from the Nutrition Competency Framework for Medicine. The Master of Dietetics Studies programme made the greatest number of references to nutrition (n=39), followed by the Bachelor of Physiotherapy (Hons) (n=36) and the Bachelor of Nursing and Midwifery (n=31). The Master of Organisational Psychology programme made the least number of references to nutrition (n=2), followed by the Master of Psychology (n=5) and Master of Clinical Psychology (n=8). Programmes most frequently included foundational (knowledge-based) nutrition competencies (n=103, 51%), with limited application to clinical practice.

Conclusions

There is a need for increased skills-based nutrition education in medicine and health degree programmes to support the translation of knowledge to future practice. Interprofessional competencies provide an opportunity for synergy across programmes.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• While poor diet is a leading cause of mortality and morbidity globally, medical and healthcare professionals currently report a suboptimal nutrition education to support population dietary improvements.

WHAT THIS STUDY ADDS

• This study is the first to identify the nutrition education provided across all medicine and health degree programmes at an Australian university. This research identified a lack of skills-based nutrition education in medicine and health degree programmes at the University of Queensland and identifies opportunities for synergy across programmes.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study provides an emerging pathway for other universities to map the nutrition education across medicine and health degree programmes and opportunities to improve the nutrition education provided to medical and healthcare students.

INTRODUCTION

Poor diet is a leading cause of mortality and morbidity globally.^{1 2} While dietitians provide specialist care, other healthcare professionals such as doctors, nurses, dietitians, physiotherapists, speech pathologists and occupational therapists have frequent engagement with the community and are therefore well placed to support population dietary improvements.^{2 3} In addition to this, patients want and expect other healthcare professionals to provide brief nutrition advice and refer them for specialist dietetics care when required.^{2 4 5} For example, doctors are the most trusted source of nutrition information by the public, even when compared with dietitians.⁴

Despite this, nutrition has been historically neglected in health professions education, and this remains a barrier to the provision of nutrition care in practice.⁶ Barriers to nutrition education for healthcare professionals include a perceived lack of time to teach nutrition (crowded curriculum), a low priority for nutrition, a lack of suitable faculty to teach nutrition and inadequate resources.⁴ Recent research has also highlighted the lack of incentive for medical schools to include nutrition education in their programme due to poor representation of nutrition in accreditation standards. Nutrition competency frameworks have been proposed for implementation into health programmes globally.⁷ For example, the Lepre et al. (2023) Nutrition Competency Framework for Medicine was developed using mixed-methods research and provides a blueprint for the nutrition knowledge and skills to be included in Australian medical training.⁷ However, little evidence exists to suggest that any framework has been systematically integrated into health professions education. This may be due in part to the lack of representation of nutrition in accreditation standards for medical and health degree programmes. The inclusion of nutrition in accreditation standards would provide an incentive for the integration of nutrition into training, in order to maintain accreditation status.^{1 7}

As of 2023, the University of Queensland (UQ) offered 75 programmes across Medicine and Health, with undergraduate and postgraduate study pathways available in nursing, midwifery, audiology, physiotherapy, pharmacy, dentistry, occupational therapy, speech pathology and more.⁸ Given the frequent contact that these professions have with the general public, including priority populations, nutrition training should be included in these programmes. For example, nurses see patients more than any other healthcare professionals, and doctors and dentists often provide initial consultations to members of the community.^{2 4} However, the status of nutrition education in medical and health degree programmes at UQ is currently unknown.⁴ Identifying the nutrition education delivered in these programmes will provide insight into current strengths and opportunities for further improvement. As such, this study aimed to identify the nutrition education content provided across UQ health programmes based on an Australian Nutrition Competency Framework for Medicine.⁷

METHODS

Overview

We compared learning objectives for core courses in UQ medical and health degree programs offered in 2023 (table 1) against a Nutrition Competency Framework for Medicine to identify references to nutrition.⁷

Table 1. UQ medical and health degree programmes included in this study⁸.

Programme	Faculty	Length of programme	Number of core courses included*
Bachelor of Midwifery (BMid)	School of Nursing, Midwifery and Social Work	3 years	19
Bachelor of Nursing (BN)	School of Nursing, Midwifery and Social Work	3 years	19
Bachelor of Nursing and Midwifery (BN/BMid)	School of Nursing, Midwifery and Social Work	4 years	25
Bachelor of Dental Science (Honours) (BDentSc (Hons))	School of Dentistry	5 years	26
Bachelor of Occupational Therapy (Honours) (BOccThy)	Health & Rehabilitation Science School	4 years	29
Bachelor of Pharmacy (Honours) (BPharm (Hons))	Pharmacy School	4 years	13
Bachelor of Physiotherapy (Honours) (BPhty (Hons))	Health & Rehabilitation Science School	4 years	33
Bachelor of Speech Pathology (Honours) (BSpPath (Hons))	Health & Rehabilitation Science School	4 years	12
Doctor of Medicine (MD)	School of Medicine	4 years	15
Master of Clinical Psychology (MPsychClin)	School of Psychology	2 years	10
Master of Psychology (MPsych)	School of Psychology	2 years	10
Master of Organisational Psychology (MPsychOrg)	School of Psychology	2 years	8
Master of Dietetics Studies (MDietSt)	School of Human Movement and Nutrition Sciences	1.5 years	9
Total			228 (176 when excluding duplicates)

^*Based on the 2023 core courses as listed on the UQ programme page.

Nutrition Competency Framework for Medicine

We used an existing nutrition competency framework as a benchmark to identify existing nutrition education in UQ medicine and health degree programmes. The Nutrition Competency Framework for Medicine was selected for this study as it provides a consensus-based blueprint for the competencies (nutrition knowledge, skills and attitudes) to be included in Australian medical training (figure 1) and is specific to the Australian context, unlike other existing frameworks. The framework is based on reviews of existing nutrition competencies and accreditation standards for medicine, focus groups and interviews with consumers and doctors, and a Delphi study with consumers, doctors, dietitians and academics.^{2 7} The competency framework includes ten enabling concepts and 16 nutrition competencies (figure 1). Enabling knowledge represents essential concepts which underpin the application of nutrition competency in practice, while application-based competencies might be considered ‘higher order composite behaviours’. We used the competencies in this framework to identify nutrition-related content in learning objectives of core courses across and between included programmes.

Figure 1. Nutrition Competency Framework for Australian medical training.⁷.

Data collection and analysis

We identified a list of current programmes offered at UQ by using the UQ ‘study options’ webpage and collated this information into a Microsoft Excel spreadsheet, including information on the programme duration, aims and core courses for the programme.⁸ Programmes that lead to Australian Health Practitioner Regulation Agency registration were included. Self-regulating health professions including dietetics and speech pathology were also included given their role in nutrition care (for example, the ability to chew and swallow is an important dietary factor which is assessed and managed by speech pathologists in practice). Some core courses were delivered into multiple programmes and in these cases were only included once in the analysis. Examples of these courses include ‘Professions, People and Healthcare (HLTH1000)’ and ‘Mental Health and Therapy (PSYC7805)’. Elective courses were not included in this study as they are not required for programme completion.

We identified the learning objectives of the included courses from publicly available electronic course profiles and collated them in the same Excel spreadsheet for analysis. To reduce the risk of bias, 70 courses (~30%) were mapped in duplicate by two researchers (BL and LB), both accredited practising dietitians with experience conducting research related to medical nutrition education.

We initially reviewed the learning objectives from each course in duplicate for keywords such as ‘nutrition’, ‘food’ and ‘diet’ to identify explicit references to nutrition. We then reviewed the learning outcomes against each competency in the Nutrition Competency Framework for Medicine. If a learning objective aligned with a competency, it was counted as a reference to nutrition. For example, if the course included a learning objective related to macronutrients, this was noted as a reference to the ‘basic scientific principles of human nutrition’, a knowledge-based competency in the framework. We categorised each reference to a nutrition competency as explicit (E) or implicit (I). An implicit reference was a learning objective that may align with the competency but does not include nutrition context. The purpose of this was to identify cross-cutting learning objectives.²

Data synthesis

We synthesised the data to identify the number of references to nutrition in each core course and programme. We then also compared this data between programmes. The varying number of core courses within each programme introduced potential for skewed data in terms of the number of courses that included nutrition. To mitigate this, references to nutrition are presented as a percentage of the total number of core courses within each programme.

RESULTS

Thirteen programmes and 176 courses were reviewed against a Nutrition Competency Framework for Medicine to identify references to nutrition. A list of the programmes and details is provided in table 1, including the number of core courses included for each programme.

The Master of Dietetics Studies programme made the greatest number of references to nutrition across learning objectives for core courses (n=39), followed by the Bachelor of Physiotherapy (n=36) and the Bachelor of Midwifery (n=24) (online supplemental material and table 2). The Master of Psychology and the Master of Organisational Psychology programmes made the least number of references to nutrition (n=5 and n=2, respectively) (online supplemental material and table 2).

Table 2. Amount and type of references to nutrition across programmes.

Programme	# of references to nutrition	References to enabling competencies	References to critical competencies	References to application to practice competencies
Bachelor of Midwifery	24	10	2	12
Bachelor of Nursing	20	9	1	10
Bachelor of Nursing and Midwifery	31	13	2	16
Bachelor of Dental Science (Honours)	15	8	2	5
Bachelor of Occupational Therapy (Honours)	16	8	2	6
Bachelor of Pharmacy (Honours)	12	4	1	8
Bachelor of Physiotherapy (Honours)	36	18	4	13
Bachelor of Speech Pathology (Honours)	16	6	2	8
Doctor of Medicine	15	8	1	6
Master of Clinical Psychology	8	4	0	4
Master of Psychology	5	2	0	3
Master of Organisational Psychology	2	2	0	0
Master of Dietetics Studies	39	6	5	28
Total	208	85	20	103

None of the included programmes referenced all of the nutrition competencies (online supplemental material), however it is important to note that the framework was designed for medical training and therefore not all competencies may be relevant to each programme. Knowledge-based competencies that were commonly represented in curricula across programmes included knowledge of the ‘basic scientific principles of human nutrition’ and ‘the role and scope of practice of other health professionals in nutrition care (eg, dietitian, practice nurse)’. Competencies related to multidisciplinary and team-based care were represented well in the included programmes. For example, the ability to ‘identify when it is appropriate to refer to a specialist (eg, a dietitian)’ was referenced nine times across core courses, and the ability to ‘work effectively in a multidisciplinary team to deliver nutrition care (eg, end of life feeding decisions)’ was referenced 21 times. However, these were often implicit references, that is, the learning objectives did not include nutrition context. For example, learning outcomes for ‘HLTH1000—Professions, People and Healthcare’ included the ability to ‘describe the range of roles in health and health-related settings’ and ‘identify the key factors to communicate effectively and work collaboratively in healthcare contexts’. While these learning objectives are key to the ability to work in a multidisciplinary team to provide nutrition care, they do not include specific nutrition context.

Sixty-three of the 176 (~36%) core courses made reference to nutrition. Less than half of the included core courses (n=85, 41%) included higher-order or skills-based nutrition competencies (knows how and shows how/does) (table 2). For example, competencies related to the ability to provide ‘dietary strategies for the promotion of health and prevention of disease’ and the ability to ‘coordinate care when someone might benefit from specialist dietetics care, including support of advice’, were not represented in any programmes (online supplemental material). Attitude-based nutrition competencies, such as ‘awareness of weight-based stigma’ and the ability to ‘demonstrate empathy and understanding in the context of nutrition care’ were only represented in the Master of Dietetics Studies programme.

DISCUSSION

This is the first study to identify the nutrition education provided across medical and health degree programmes at an Australian university. This research provides insight into opportunities for synergy across programmes, to improve the nutrition education provided.

Nutrition education for healthcare professionals remains inadequate globally, and the findings from this study highlight this ongoing challenge. In this study, psychology programmes included the least number of references to nutrition. This is a critical gap—nutrition plays an important role in the prevention and management of mental ill health.⁹ Furthermore, psychologists are likely to be exposed to disordered eating in practice and therefore need baseline nutrition knowledge and skills to support evidence-based care in this context, including support of advice.^{2 4 10} Practising psychologists have previously reported a lack of nutrition competency, and this remains a barrier to the delivery of dietary advice to patients in this context.^{11 12}

The implicit references to nutrition in this research highlight cross-cutting learning objectives that exist across medical and health degree programmes. For example, courses included learning objectives related to team-based care, communication, clinical practice and health promotion. These cross-cutting learning objectives are in line with a review of key themes in existing nutrition competency frameworks for medicine internationally. These themes are not specific to nutrition but provide an opportunity for the inclusion of nutrition context, to improve the nutrition education provided. For example, content on the biochemical demand for energy could be linked to concepts related to energy balance and weight maintenance. Similarly, content related to multidisciplinary care could include a nutrition-related case study or content on the role and scope of practice of a dietitian. This negates the need to add additional content to the programme and is in line with an integrated approach to nutrition education, which is considered best practice.^{2 4 10} In addition, this integrated approach to nutrition education highlights the role of nutrition as part of total patient care, rather than a distinct area of knowledge or practice.

The findings from this study highlight the need for increased skills-based nutrition education in medical and health degree programmes. The majority of references to nutrition were knowledge-based, with limited application of nutrition to a clinical context. For example, there were few learning objectives related to dietary strategies for the prevention and management of disease. While it is important to understand the concepts that underpin nutrition, it is of less relevance in a patient care context. A lack of applied training and the need for increased skills-based nutrition education in medical and health degree programmes has been previously reported.⁶ These themes are not specific to nutrition but provide an opportunity for the inclusion of nutrition context, to improve the nutrition education provided. Nutrition-related Objective Structured Clinical Examinations stations could be used to support skills-based nutrition training for healthcare professionals. Again, this would negate the need to add additional content to curricula and provides an opportunity for students to apply nutrition knowledge to a clinical context. Interprofessional nutrition education is also a key opportunity to provide skill-based nutrition education and increase both the nutrition and interprofessional competence of medical and healthcare students.^{11 12} Furthermore, knowledge sharing and collaboration among peers (such as in interprofessional education) has been shown to cultivate a deeper understanding of topics taught.^{11 12} Interprofessional, skills-based nutrition education could be delivered through case study-based workshops or culinary education, which have been shown to increase nutrition competence.^{9 13 14}

While this is the first study to explore the nutrition education provided across multiple medical and health degree programmes at a tertiary institution, there are limitations. Only core courses were included due to the variability in elective courses, and therefore, some nutrition education may have been missed. Undergraduate studies completed prior to entering the post-graduate programmes (including the Master of Psychology, Master of Clinical Psychology, Master of Organisational Psychology, Master of Dietetics Studies and Doctor of Medicine) were also not included in this study and may include nutrition training. Furthermore, the Nutrition Competency Framework was developed for medical practice and therefore may not be completely generalisable to the included health professions. In particular, some of the competencies are not relevant to dietetic practice (eg, ability to know when to refer to a dietitian), and therefore, the data related to this programme may be skewed. Finally, this study only looked at the learning objectives for core courses, and therefore, it is possible that there is nutrition education in course activities and assessment that was not captured. Future studies could explore the curricula (learning content and assessment) in more depth to identify further opportunities to enhance the nutrition education provided.

CONCLUSION

This study highlights the need for increased skills-based nutrition training for medical and healthcare students, to better equip future professionals to provide effective nutrition care. Nutrition context could be added to programmes where relevant, and interprofessional education may support the development of nutrition and interdisciplinary competence.

Data availability statement

Data are available in a public, open access repository. Data are available upon reasonable request.