An initiative to improve nutritional education among medical students

Abstract

Background

India faces a double burden of Malnutrition-undernutrition and overnutrition. In the medical institutes of India, there are no practice-based teaching methods to instill a greater understanding of the concepts of nutrition and healthy cooking. Hence, we have focused on an initiative named “Diet Demonstration” (DD) that is being practiced in the Department of Community Medicine at a government medical college in New Delhi.

Methods

Diet Demonstration is conducted in batches of 30–40 students. This specific exercise was conducted in May 2018. A batch of 35 MBBS students was subdivided into five groups, with 7 students/group. Each group was given a scenario/person with certain health conditions. They formulated a 24-h balanced dietary plan for nutrients and devised a food menu according to the scenario provided to them. The groups procured the raw materials from local markets, prepared the food according to their menu in the home/hostel kitchens. The cooked foods, alongside the equivalent raw materials used for cooking the respective foods, were presented and explained by each group in front of the whole batch and the faculty of the department.

Results

majority of the students opined that it had helped them in understanding nutrition in a better way, practice healthy cooking methods, and to learn the associated practical difficulties while planning and cooking a balanced diet.

Conclusion

Diet Demonstration can be an innovative, cost effective way of inculcating nutrition knowledge and healthy cooking practices among the budding doctors, which needs replicability and feasibility studies in other settings.

Introduction

Nutrition is the sustaining element of life. Good nutrition is an important part of leading a healthy lifestyle. The spectrum of diseases caused by macronutrient and micronutrient deficiency is large.¹ The diseases and adverse health conditions of lifestyle such as Hypertension, Cardiovascular diseases, Diabetes mellitus, Obesity, etc, have close association with the food we intake. Nutrition has an inseparable role in communicable diseases as undernutrition increases the risk of Acute Diarrheal Diseases, Tuberculosis, Pneumonia, etc., and decreases the cure rate as well.² India is facing a double burden of Malnutrition-undernutrition and overnutrition. The physical, mental and social well-being of the human become increasingly dependent on the nutritional component, as the world is in the transitional phase where the epidemiology of the disease is shifting from communicable to noncommunicable disease or lifestyle diseases.³ In India the shift is fast and diverse according to states, with the current Epidemiological Transition Level (ETL) being 0.76 showing that mortality due to noncommunicable and injuries have overtaken the infectious and maternal/neonatal mortality rate.⁴ As the importance of diet and nutrition becomes clearer day by day, its integration into the day to day practice by the physician has become a necessity. Since we do not have enough nutritionists or dieticians, as recommended by the erstwhile planning commission of India, to cater to the 1.3 billion people in India,⁵ the burden eventually falls on the doctors who are expected to treat a disease holistically, by including the nutrition counseling along with their pharmacological and surgical therapy. However, studies from across the world reveal that physicians are being inadequately trained to provide nutritional counseling, and a majority of them attributed the inadequacy to the insufficient nutrition education they received in medical schools.^{6, 7, 8} It has also been reported in multiple cross-sectional surveys that medical students’ nutrition training does not adequately provide the skills required for patient encounters.⁹ Lack of knowledge regarding ingredients that go into the local cuisine is also an issue to be noted. It has been reported that physician’s health practices may have effects on patients.¹⁰ Hence, in order to make them competent in nutrition counseling and management, prompt and effective inculcation of nutrition education should start from the medical colleges. Countries and health bodies have started recognizing this issue and are addressing it through varied strategies for medical students, as well as practicing physicians.^11,12

The knowledge of nutrition is complete only when it can be translated to the plates through the means of healthy cooking practices. Innovative Public Health Nutrition strategies in curriculum framing, revisions, research, and practical implementation must be prioritized.⁵ This is where culinary medicine comes in. Culinary medicine is the fusion of the art of cooking and the science of medicine for health promotion.¹³ It is aimed at helping people reach good personal medical decisions about accessing and eating high-quality meals that help prevent and treat disease and restore well-being.¹³ Although nutrition is being covered as a part of the Community Medicine in the undergraduate medical institutes of India, there are no hands-on training methods to instill interest and greater understanding about the concepts of nutrition and how to cook a healthy diet. Whatever is there remains in theory. Hence, we have focused on the description of an initiative named “Diet Demonstration” (DD), within culinary medicine, aimed at improving nutrition knowledge and cooking behavior of the undergraduate medical students, which is being practiced in the Department of Community Medicine at a public-funded medical institute.

Material and methods

Diet Demonstration is conceptualized and practiced at the Department of Community Medicine since 2007. The MBBS students in the 4th semester are divided into four batches during their 20 days of Community Medicine practical postings conducted under the name “Family Health Advisory Services Program” (FHASP). Each batch is supervised by one professor, one senior resident, one postgraduate student, one health educator, and one medical social worker. Each student in the batch has to study a family from the field practice area of the department, assess their health status and needs, nutritional status, make a clinic-social diagnosis, and advise the families accordingly. The students are trained in nutrition practices of healthy cooking and healthy eating by the technique of “Diet Demonstration,” which is incorporated within the FHASP. Under the diet demonstration initiative, the students are sensitized about the basic principles of nutrition and cooking, wherein the concepts of nutrition, its essentiality, balanced diet, methods of nutritional assessment, dietary advice, practices of precooking treatment of raw materials, healthy cooking methods and reading the labels of the packed foods are inculcated ot the students. Then, the practice of diet demonstration for a given scenario is done by the students by cooking the food in home kitchens. This particular diet demonstration exercise was conducted during May 2018, which was done over a period of 9 days (Fig. 1).

Fig. 1.

Diet demonstration capsule-Time Schedule.

The batch consisted of 35 students, who were subdivided into five groups, with 7 students/group, and each group was given a case scenario/person with certain health conditions (Table 1). Each group formulated a 24-h balanced dietary plan for nutrients and devised a food menu according to the scenario provided to them, imbibing the basic principles of diet, calories, and nutrient requirement/restrictions, as recommended by the National Institution of Nutrition (Table 1).¹⁴ The diet should include the foods and seasonal fruits available and consumed by the local community, at a cost affordable to them. The students were asked to use the commonly utilized vessels in the local community for measuring and serving, such as steel bowls and glasses of varying volume. Each group was provided with a small weighing machine. They were taught to weigh the raw materials and cooked food using the weighing machine. The students brought the glasses and cups from their home, which were to be used while preparing and serving the food, and their volumes were calculated using the standard measuring cylinders available in the public health laboratory of the department. Students were sensitized to using a teaspoon and tablespoon. Each group procured the raw materials from local markets, prepared the food according to their menu in their home kitchens. The groups were so made that at least one day-scholar was present in each group, to enable a home-based environment for cooking. The raw materials and cooked items were measured and weighed. The students were asked to photograph and video graph their culinary activities.

Table 1.

Scenarios allotted, and Food items prepared by the groups for the scenario, along with nutrients recommended and achieved.

Scenario	Recommended	Achieved
1. A 26-year-old male bank clerk
Breakfast:	Carbohydrates: 464 g	2312 Kcal
Aloo Paratha (2)- 476 Kcal	Calories: 2320 Kcal	425 g
Tea- 1 glassa- 74 Kcal	Proteins: 60 gm	60.7 gm
Banana(1)- 40 Kcal	Visible fat: 25 gm	41.8 gm
Prelunch:Vegetable Sprouts Salad (1/2 cup)b- 107 kcal
Lunch:Roti (3)- 312 KcalRice(3/4 cup)b- 173 KcalDal (1 cup)b- 234 KcalAloo Patta Gobhi (1 and ¼ cup)b- 225 kcal
Evening snacks:Tea- 1 glassa- 74 KcalBiscuits (4)- 100 Kcal
Dinner:Roti(3)- 312 KcalPalak Paneer (3/4 cup)b- 185 kcal
2. A 55-year-old diabetic female with normal BMI in a budget of 60 Rs. Early Morning:Tea (1/2 glass)c- 28 KcalBiscuits rich in fiber (2)- 45 KcalBreakfast: Dalia (2 cups)d- 466 kcal Snacks:Watermelon (3/4 Cup)d- 24 KcalPapaya (1 Cup)d- 32 kcal Lunch:Phulka (2)- 200 KcalBhindi masala (1 Cup)d- 102 KcalEvening snacks: Sprouts (1/2 Cup)d- 187 kcal Dinner:Phulka (2)- 200 KcalDal (1 cup)d- 130 KcalSoyabean (1/2 cup)d- 158 KcalBed time: Milk (1 glass)c- 112 kcal	Calories: 1670 Kcal Carbohydrates: 271 g Protein: 60 g Visible fat: 25 g Fiber: 35 g Cost: 60 Rs	1664 Kcal 272 g 62 g 33 g 44 g 65 Rs
3. 24-year-old moderately working pregnant women in second trimester, Budget Rs. 60 Early Morning:Tea (1 glass)a- 65 KcalGroundnuts (4 tablespoons)- 113 Kcal Breakfast:Poha (1 and ¼ cup)b- 404Boiled Egg (2)- 242Milk (1 glass)a- 90 KcalSnack: Sprouts (1/2 cup)b- 297 kcal Lunch:Ghee Roti (3)- 276 KcalBindi sabzi (1and1/2 cup)b- 173 KcalCurd (1/2 cup)b - 60 KcalSalad (3/4 cup)b - 45 KcalJaggery (20 gm)- 77 Kcal Evening snackMango (1/2 cup)b - 74 KcalWatermelon (1 cup)b - 32 kcal Dinner:Ghee Roti (3)- 276Aloo palak matar (1 and ¼ cup)b - 350 kcal	Calories: 2580 Kcal Carbohydrates: 495 g Proteins: 82.2 gm Visible fat: 30 gm Calcium: 1200 mg Iron: 35 gm Cost: 60 Rs	2574 Kcal 485g 91.25 gm 30 gm 1232 mg 41.27 gm 66.09 Rs
4. 45-year-old hypertensive male sedentary worker with 60 Kg weight and 170 cm height (DASH diet) Early Morning:Tea made with double toned milk (1 glass)e- 98 kcal Breakfast:Poha (2 cup)d- 287 KcalMorning snack:Banana Shake (1 and ½ glass)e- 220 KcalEgg White (2)- 30 Kcal Lunch:Dal (1 and 2/3 cups)d- 366 KcalRice (2/3 cup)d- 173 KcalRoti (2)- 174 KcalSalad (2 Cup)d- 65 KcalButtermilk (1 glass)e- 18 kcal Evening:Tea (1 glass)e- 98 KcalBiscuits (2)- 60 Kcal Dinner:Aloo Palak Sabji (1 and ¼ cup)d- 142 KcalRoti (4)- 348 KcalSalad (1 Cup)d- 68 kcal	Calories: 2204 Kcal Carbohydrate: Proteins: 60 g Visible fat: 25 g Sodium: <2.3 g	2147 Kcal 376 g 65 g 25.5 g 1.5 g
5. 4-year-old male child, Budget: Rs 50 Breakfast:Paratha (1)- 216 KcalDahi (1/4 Cup)b- 30 kcal Brunch:Banana (1)- 105 KcalMilk (1 glass)f- 88 kcal Lunch:Roti (2)- 139 KcalRice (1/2 cup)b- 104 KcalDal (1/2 cup)b- 74 kcal Evening snackBiscuits (4)- 114 KcalMilk (1 glass)f- 106 kcal Dinner:Ghee Roti (2)- 132 KcalAloo palak (3/4 cup)b- 128 KcalPudhina chutney (5 teaspoons)- 12 Kcal Post Dinner: Milk (1 glass)f- 106 kcal	Calories: 1350 Kcal Carbohydrate: 245 g Proteins: 25 g Visible fat: 30 g Calcium: 600 mg Iron: 13 g Cost: 50 Rs	1355 Kcal 222 g 36 g 36 g 740 mg 13 g 48 Rs.

^a1 glass = 150 ml.

^b1 cup = 200 ml.

^c1 glass = 200 ml.

^d1 Cup = 150 ml.

^e1 glass = 180 ml.

^f1 glass = 100 ml.

The cooked foods, alongside the equivalent raw materials used for cooking the respective foods, were brought to the college and presented by each group in front of the whole batch and the faculty of the department for further fine-tuning and evaluation of their experience and understanding (Table 1). The diet demonstration exercise was strategically placed during the initial part of the FHASP postings, as students can translate their learnings in good practices of nutrition and healthy cooking to the families that were allotted to them for study.

Results

Post diet demonstration exercise, the students were asked to give their feedback on the exercise, the feedback was kept anonymous, and its role in their nutrition knowledge and practices. This is done as a routine after every practical exercise in the department. Among the 35 students, 91.4% (32) of them opined that it had helped them in understanding the nutrition advice in a better way and imbibe healthy cooking practices. 71.4% (25) of the participants said the exercise helped them to understand the practical difficulties associated while preparing a balanced diet. All (100%) of them felt confident about prescribing and counseling the patient/public, a healthy and balanced diet. In Table 2, the verbatim of the student statements are enumerated.

Table 2.

Student perspectives regarding the diet-demonstration exercise.

“It helped me getting an estimate of the amount and quality of food one need to take to complete his/her daily needs, on a practical basis.”

“The diet demo concept during FHASP posting was a great learning experience as it helped me understand the importance of a balanced and nutritious diet depending on a patient’s daily routine and health. Furthermore it taught me about the good cooking and pre-cooking practices.”

‘It made me to realize the hardships and hiccups we face when we try to cook a prudent diet and planned diet …. ….”

“Diet demo is a good thing in long run, I guess, because it does give you an overview of what you can and cannot prescribe as a nutritionist to your patient.”

“Diet Demonstration has helped me to know the calories and nutrients required by different vulnerable groups. This exercise will furthermore help me in determining the precise nutrition requirement for myself & my family. I will be able to counsel my patients and families from the experience I gained from this.”

“It was good enough. It helped us get a basic idea of the quality of food that we are actually receiving and we need to have.”

Discussion

The current diet demonstration exercise increased the interest of students in learning about nutrition and confidence in healthy cooking practices since it provides the opportunity for “Experimental Learning.” Previous studies in the west have demonstrated that similar exercises increased the physician’s personal, as well as professional, nutrition-related behavior.^{7,15, 16, 17, 18} The exercise takes their attention away from books to bowls. Kerrison et al in their quasi-experimental among the freshman in the United States of America, revealed that the culinary training program significantly impacts the Cooking Behavior and current knowledge and abilities with identifying low-cost produce.¹⁷ Khandelwal et al. had shown that better resident dietary habits are associated with a higher frequency of dietary counseling for patients, thus implying the impact of physician’s personal dietary habits on the nutrition of patients.¹⁹ Schoettler et al. in their review on The Student Nutrition Awareness and Action Council’ (SNAAC) strategies implemented in Boston University to increase nutrition practices among medical students, gives a strong note on the inclusion of kitchen based and hands-on nutrition teaching.²⁰ Polak et al and Ring et al in their studies, found out how the culinary health classes improved the attitudes and confidence of the Culinary Coaches (CC) and medical students.^18,21

The current exercise exposed the students to the pragmatic difficulties the general public and patients face while preparing a balanced and prudent diet recommended to them. It helped the students to appreciate the conversion of weight from raw to cooked material. It made the students learn about the market prices of common raw materials for food and aware of the concept of cost-effective meals. Thus the current diet demonstration exercise may have improved the students learning about nutrition and providing counseling, as it provided the opportunity of “Learning by Doing.”

Limitations

The description of the practice was based on cooking practices at an urban city in northern part of India, and thus, rural settings have not been explored. The wide regional culinary preference could not be accounted for, which is an inherent limitation due to the place of location of the institute. The effectiveness of the exercise was not assessed quantitatively. The nonvegetarian portion of the diet has not been explored by the students.

Conclusion

Our teaching method of diet demonstration is innovative in the sense that traditional culinary medicine programs in western countries involve establishing a teaching kitchen at institutes, which requires additional resources of money and space. Whereas our initiative uses home kitchens of the students, hence does not require additional resources at the institutional level. Home kitchens provide an advantage of real time kitchen experience, than the teaching kitchens at institutes. Analytical studies should be planned to assess the effectiveness of the exercise quantitatively. Future diet demonstration must include nonvegetarian items as part of the menu. Although it requires minimal budget, the replicability and feasibility of this teaching method in other settings in India needs to be tested. Overall, the Diet Demonstration can be explored as a cost effective way of inculcating nutrition knowledge and healthy cooking practices among the budding doctors.

Disclosure of competing interest

The authors have none to declare.