Show Me Your Objectives: Nutrition Education in a US Medical School Curriculum

Abstract

Background

Health authorities around the globe have called for improvement in nutrition education in medical schools. It was deemed necessary to study our current curriculum to document what exists and identify gaps. This project surveyed nutrition education objectives within a US medical school during 1 year followed by informal interviews of faculty aimed toward improvement in the curriculum.

Methods

A survey tool was created using the list of competencies in Table 1 of “Nutrition Competencies for Graduating Medical Students” from the Nutrition in Medicine (NIM) project. Educational objectives for all 26 courses encompassing the first-, second-, and third-year curriculum at the University of New Mexico School of Medicine (UNM SOM) were surveyed in order to identify the current nutrition curriculum content. Faculty course directors were contacted after data collection to verify accuracy and fill in any missing information.

Results

Out of 61 competencies, at least one was covered in 16 of 26 courses (62%) by survey of objectives. Additional content in nutrition education was identified for 4/16 (25%) of these courses through follow-up faculty interviews. Findings were discussed with three key curricular groups.

Discussion

The study results highlighted the importance of accurately publishing objectives to fully reflect course content. This project demonstrates an approach that may be utilized at other medical schools to assess nutrition education curricula and create a structure for dialog within their own institutions.

Background

Nutrition represents a timeless challenge and one of the greatest opportunities to impact health and disease. The US population has become increasingly overweight and obese in recent decades resulting in numerous nutrition-related diseases. To begin to address this health epidemic, the National Academy of Sciences has recommended that medical schools provide a minimum of 25 h of nutrition education during medical school [1]. Medical schools vary tremendously in the number of hours of nutrition curriculum provided [2]. Medical educators have been called upon to improve nutrition competencies in undergraduate medical education as a means toward improving health outcomes [3, 4].

Physicians in the USA continue to practice with a pervasive gap between the epidemic of nutrition-related disease and practitioner skill at addressing the nutritional aspects of preventing and treating chronic conditions such as obesity, diabetes, hypertension, cardiovascular disease, and non-alcoholic fatty liver disease, among others. Thus, medical schools must prepare their graduates to utilize clinical and medical nutrition approaches to try to reduce the burden of chronic disease.

Study Aims

This study set out to determine if the University of New Mexico School of Medicine (UNM SOM) undergraduate medical education curriculum provides adequate coverage of the nutrition topics that have been identified as expected competencies for graduating medical students. To address this question, this study had two goals. The primary goal was to survey the content of the first-, second-, and third-year course objectives to determine to what extent and within which courses our undergraduate medical education curriculum provides foundational material on nutrition. The secondary goal was to use this data to open discussion of the strengths of our curriculum, gaps, and opportunities for improvement in nutrition education with key curricular and faculty groups.

Methods

Interviews were conducted with faculty educators to ascertain whether anyone had ever surveyed the medical school curriculum through the lens of nutrition education. No history of any comprehensive nutrition curriculum evaluation was identified, and all stakeholders interviewed affirmed that such a survey would provide a solid basis for granular discussion of curriculum strengths, deficits, and opportunities for improvement. The gold standard for defining teaching goals and learning outcomes is learner-centered objectives [5], so a study to survey curricular objectives was deemed the best strategy for assessing the existing curriculum.

Literature review did not reveal publication of a detailed survey tool, so it was necessary to create a data collection instrument. The data collection tool was created using the list of competencies in Table 1 of “Nutrition Competencies for Graduating Medical Students” from the Nutrition in Medicine (NIM) project at the University of North Carolina [6]. This article identified five broad categories: Foundation in nutrition science, Nutrition assessment, Prevention, Disease treatment, and Nutrition therapy. A sixth category called “other” was placed on the data collection tool in order to document additional relevant objectives and course content. Each category listed a number of competencies. One competency, “Human microbiome (how it is established, role in health and disease),” was added under Foundation in nutrition science, because there had been an explosion of publications related to the human microbiome in the 5-year interval between publication of the NIM article and creation of this study. Thus, 61competencies were examined within 6 major categories. (Please refer to Appendix I for the data collection tool within which is listed the complete list of categories and competencies.)

Table 1.

Number of competencies covered by course

Course/clerkship	Number
Gastroenterology, nutrition, metabolism and endocrinology	24
Pediatrics	22
Cardiovascular, pulmonary and renal	9
Surgery	4
Foundations of medical science	4
Internal medicine	3
Neuroscience	2
Infectious diseases	2
Family and community medicine	2
Public health	1
Human sexuality and reproduction	1
Hematology	1
Psychiatry	1
Obstetrics and gynecology	1
Transitions	1
Learning communities	1

This observational, mixed methods study was approved by the University of New Mexico Health Sciences Center Human Research Review Committee (IRB# 15-218).

All of the data collection was performed by a single investigator in an effort to optimize consistent data interpretation and use of the data collection tool. Consultation with a biostatistician was undertaken prior to data collection and during the study regarding the study design.

Data Collection

The study period was from July 1, 2015 to June 30, 2016. Curricular calendars for basic sciences (defined in this curriculum as phase I) and clinical clerkships (phase II) were examined in order to identify the temporal sequence of courses. The first year of medical school in this program, also referred to as phase I, consists of two semesters. There were nine basic science phase I 2015 block courses during the first semester: Introduction to Public Health (PH); Foundations of Medical Science (FMS); Doctoring I; Clinical Reasoning I, Gastroenterology, Nutrition, Metabolism and Endocrinology (GINME); Infectious Diseases (ID); Musculoskeletal, Skin and Connective Tissue (MSCT); Human Sexuality and Reproduction (HSR); and Hematology (Heme).

There were five phase I 2016 block courses during the second semester: Doctoring II; Clinical Reasoning II; Neurosciences (Neuro); Cardiovascular, Pulmonary, and Renal (CVPR); and Transitions (Tr).

All 14 block courses in the phase I curriculum, nine of which occurred during 2015 and five offered during 2016, were surveyed. Five additional required longitudinal courses during phase I were identified in One45 (described below). The reason for later identifying these courses was that they were taught longitudinally throughout multiple blocks or overlapped several blocks which provided the main structure to the curriculum. These included the following: perspectives in medicine, one supplemental learning communities (LC) activity, diversity of human experience, evidence-based practice, and epidemiology/biostatistics.

One might therefore characterize phase I as consisting of 19 courses.

Seven phase II 2015–2016 clerkships provided to students in 4- to 8-week blocks were surveyed: Internal Medicine (IM), Pediatrics (Ped), Family and Community Medicine (FM), Surgery (Sur), Obstetrics and Gynecology (OBG), Psychiatry (Psy), and Neurology.

Thus, 26 “courses,” 14 phase I blocks, seven phase II, and five additional longitudinal phase I courses, were examined.

The first phase of data collection consisted of surveying each phase I course upon its completion, so as to avoid missing any change in objectives that may have been made during of the course.

All courses published objectives in a curricular data base called One45. Access to all courses in One45 was provided to the principal investigator. Initially, data collection using key words was attempted; however, it appeared that results were incomplete when only a few objectives were identified. It became evident that it would be necessary to review every individual course, examining each objective. Next, every link to every lecture was opened and reviewed in search of all nutrition objectives and content. In some cases, individual lectures specified additional objectives. In other cases, a PowerPoint lecture presentation may have been available for review. All identifiable nutrition objectives and course content not listed by objective was abstracted manually onto the data collection tool for each course.

Following comprehensive One45 review, course directors were contacted to verify accuracy of or complete data collection as needed. In all but one instance, (25/26 courses), it was possible to communicate by email, phone, and/or personal interview with the course director prior to completion of the study.

A competency was coded as having been covered when it met one of the five criteria: (1) it was addressed in any objective, (2) one or more elements of the competency was mentioned, (3) there was a lecture title synonymous with the competency, (4) there was content identified within a lecture PowerPoint, or (5) content was identified from additional objectives or content provided by the course director during the second step of data collection. For example, Foundational topic 1 on energy was coded as being covered based upon an objective within the GINME block stating, “Explain how energy balance is regulated in the short term and over the long term,….” There was also a lecture entitled, “Metabolism summary and Review within the same block,” so this competency was covered twice.

Results

What Categories and Competencies Were Covered?

Sixteen of the 26 (65%) courses were found to have addressed at least one nutritional competency. More specifically, ten of the 14 (71%) of phase I courses and five of the seven (71%) phase II clerkships included one competency area. One of the five (20%) of the additional courses also included nutrition content.

Table 1 lists the number of competency objectives covered by course.

Tables 2, 3, 4, 5, and 6 itemize which courses specifically covered which competencies. Those competencies identified by review of published objectives are marked with an “x.” Competencies identified by follow-up communication with the course director are marked with an “o.”

Table 2.

Foundational topics

Course >	GINME	FMS	ID	Heme	Neuro	CVPR	IM	Sur	Ped	Tr
Competency V
1 Energy	x	x
2 Protein	x
3 Carbs	x	x
4 Fats	x
6 Micronutrie	x			x	o	x		x
8 Water/elect						x	x	x	x	x
9 Physio						o
10 GI function	x
11 Hormonal	x
13 Microbiom	x	x	x

Table 3.

Nutrition assessment

Course >	Pediatrics	GINME	CVPR
Competency V
17 Diet history	o
18 Nutrition PE	x		o
19 Lab evaluation	o	x
20 Growth	x	x
21 Nutrient intake recs	o

Table 4.

Prevention

Course >	GINME	Ped	FM	FMS	PH	Neuro	CVPR
Competency V
22 Preconc	x	x
23 Growth	x	x		x		x
24 Aging	x
26 Osteop	x
27 Oral hea		o
28 Cancer
29 CV diseas	x						x
30 Obesity		o			o
31 Hyperten		o	x				x
32 Charact		o

Table 5.

Disease treatment

Course >	GINME	PH	CVPR	IM	Sur	FM	Ped	ID
Competency V
35 Chron dz	x	x	x			x	x
36 Nutrition anemia	x						x
37 FTT							x
38 Eating di	x						o
39 Kidney			x
40 Water			x	x	x		x	x
41 Liver	x						o
42 GI d/o	x			x			x
44 Hyperur	x				x
46 Surgery
49 Food all							x
51 HIV/AIDS								x
52 CF							o
54 Depre							o

Table 6.

Nutrition therapy

Course >	GINME
Competency V
55 Nutrition prescriptions and referrals	x
56 Behavior change counseling	x
58 Enteral and parenteral nutrition	x

The Gastrointestinal, Nutrition, Metabolism and Endocrinology (GINME) course addressed 24 of 61 competencies. Not surprisingly, this was the greatest number of competencies evident by review of course objectives. Of the clinical clerkships, Pediatrics addressed the most: 22/61. Eleven of these were identified in One45 review. Similar to the phase I data collection process, an additional 11 objectives were identified only upon interview with the clerkship director to discuss the information provided to students during the clerkship.

The category Foundation in nutrition science included the 12 content areas listed in Adams et al. [2] plus the added competency: human microbiome. Ten courses included content in one or more foundation category competencies. The most frequently included of these competencies were “Water and electrolytes” and “Sources, bioavailability, action, deficiency, excess of micronutrients.” Each of these competencies was addressed in five courses. “Human microbiome” was included in three courses. This data is summarized in Table 2.

The Nutrition assessment category included eight competencies. Only three courses included content in this category. (Please refer to Table 3 for this data.)

Prevention competencies were addressed in seven courses. The GINME block provided the most content in the Prevention category, covering 5 of the 13 competencies. (Please see Table 4.)

Eight courses included one or more objectives pertaining to the 20 Disease treatment competencies. GINME and Pediatrics addressed the greatest number, 6 and 10 respectively. “Chronic disease” and “Diarrhea, water, electrolytes, acid-base balance” were each addressed in five courses. Although this may appear to be a redundant finding, it would make sense that water, electrolytes, and acid-base balance are covered in multiple courses, because this category of physiologic processes dynamically impact life-or-death clinical outcomes.

Lastly, three of the seven competencies within Nutrition therapy were covered within the GINME block.

How Much Time Was Devoted to Nutrition Education?

It was conservatively estimated that 34 h of nutrition education were provided in phase I and 7 h in phase II, yielding an estimated 41 h of education. These results show that the UNM SOM provided more than the minimum 25 h of recommended curriculum in nutrition education. It may be useful to reassess the competencies that are covered in multiple courses to identify whether they represent necessary redundancy.

What Was Missed?

Potential curricular content could have been missed due to lack of representation in One45 and/or a lack of follow-up interview. For example, one course director was not available for an interview. Another example is total parenteral nutrition rounds which are held on some UNM Hospital inpatient units and often include medical students. This educational activity was not captured by the survey of course objectives. Health coaching has been incorporated into Doctoring II, but its application to nutrition education was not captured in course objectives.

Competencies not listed within Tables 2, 3, 4, 5, and 6 were not identified within published objectives or follow-up conversation with the course director; however, many of these topic areas are covered within the curriculum. Adult and childhood obesity and food insecurity were identified as important health issues during community site visits in the public health course. During presentation of this study to the curriculum committee, student members of the curriculum committee commented that many of the competencies that did not appear to have been covered actually were covered within the curriculum.

Discussion

Defining which competencies and topics are most relevant to learners and at what stage is one of the most interesting but complicated questions in undergraduate medical education. It has become customary to delineate learning objectives into the domains of knowledge, skill, and attitude [7]. The Nutrition Academic Award (NAA) Program sponsored by the U.S. Department of Health & Human Services National Heart, Lung and Blood Institute between 1998 and 2003 culminated in publication of the NAA Curriculum Guide for Training Physicians [8]. This document delineates recommended knowledge objectives, practice behavior skills, and attitude objectives by specified learner levels: medical students, residents, specialists, and all levels. It was too detailed to translate into a survey tool for the purpose of this study, thus leading to selection of the Nutrition in Medicine list “Nutrition Competencies for Graduating Medical Students” as a useful comprehensive content list.

Work in this area has continued to be published periodically. Sierpina et al. proposed a list of core competencies in nutrition education in medical school [9]. Lindsley et al. recently published results of a survey of US medical educators, reducing the number of learning objectives from 473 in the NAA document to 83 nutrition objectives within 11 competency domains [10].

Content gaps have been identified in our program, despite the fact that our undergraduate medical curriculum provides more than the minimum 25 h of nutrition education recommended by the NAS. In light of these findings, it may be that all US medical schools need to devote many more hours than 25 in order to provide adequate nutrition education.

Study Strengths

The survey tool utilized for this study was thorough and comprehensive, creating a credible basis for conversation with faculty and other stakeholders in our institution. Ironically, this strength also constitutes one of the weaknesses of the study in that it made data collection extremely time-consuming.

Results of this study have been shared with this medical school’s curriculum committee, block chairs, and clerkship directors committees. Several themes emerged from these conversations:

• universal agreement that nutrition education may be more fully addressed throughout the curriculum

• it continues to be a challenge to prioritize nutrition education, because courses are simultaneously addressing multiple knowledge and skill competencies, and

• all courses work toward a common overarching goal to create effective and competent physicians.

Course directors appeared invigorated to consider their own curricular objectives and to consider revising or adding nutrition content where relevant. Several directors also articulated changes in nutrition curriculum that had already occurred since the study was completed. Others articulated a commitment to be more complete with publication of objectives in an attempt to precisely define and reflect course content.

Faculty and students expressed interest in and enthusiasm for the topic improving nutrition education.

Study Limitations

The research question lacked clarity in that it asks whether the UNM SOM curriculum provides “adequate coverage of all topics that have been identified as competencies for graduating medical students.” The phrase “adequate coverage” was deliberately vague. Medical literature has included numerous articles describing the importance of nutrition education without clear consensus as to what “adequate” specifically means [11]. This question, however, was useful in providing specific data for conversation with course directors.

The sixty-one competencies examined demonstrated variability in complexity and relevance. Each was covered at least once in 41/61 (67%) of courses. For example, competency 6 under Foundational topics was “Sources, bioavailability, action, deficiency, excess of micronutrients (vitamins A, C, E, K, B12, thiamine, riboflavin, niacin, folate, calcium, phosphate, magnesium, iron, zinc, iodide, copper, chromium, manganese, molybdenum, selenium)”. This material is captured in multiple objectives due to the variety of components. In contrast, competency 12, “Nutrition and immunity,” also under Foundational topics, was not identified as an objective in any course, nor would one expect this narrow topic to be covered often. It would have been more accurate from a quantitative perspective to separate each element of each competency into a single yes/no question so as to give equal weight to every topic or concept.

This was a time-consuming project due to the level of detail of the survey tool. It may be more realistic for other institutions to identify a shorter list of competencies for survey of their own curriculum. Kushner et al. list six proposed core nutrition competencies for preclinical medical students and five for clinical students [3]; thus, it may be possible to employ key words to survey a school’s curriculum with a shorter list of search terms.

Terminology may have been confusing. For the purpose of this study, the terms “competencies,” “content,” and “topics” were interchangeable, all referring to informational aspects of curricula. It would be more precise to distinguish learning outcomes by knowledge, skill, behavior, and attitude domains and to delineate content and topic areas.

Course objectives did not fully reflect course content. This important finding of this study has been emphasized in every follow-up conversation. In the USA, the American Association of Medical Colleges (AAMC) maintains a curriculum inventory to which all participating accredited medical schools upload curricular objectives [12]. It is important for medical school courses to define objectives as clearly and completely as possible in order to provide accurate information to this data set. This will enable schools to participate in national conversations as to what is taught in our programs and creates an invaluable resource for curriculum research.

The second step of the project was also more time-consuming than anticipated, because academic faculty work in many roles with complicated schedules. In a few instances, it took several weeks to reach a course director.

Despite the fact that it was estimated that the curriculum provided more than the recommended minimum of 25 h of curriculum in nutrition education, some of the subtopic areas surveyed were not identified as having been covered. This partially is an artifact of the study design. The survey tool was extremely broad. Furthermore, unnecessary redundancies may reduce the time that unique content. Detailed curriculum mapping and articulation of educational objectives is now the norm and will prevent the confusion that might arise from such variables in the future.

This study did not attempt to ascertain how effectively students actually achieved the competencies or how well-stated objectives were covered. Efforts to delineate and assess milestone achievements are part of the present and future educational climate.

Next Steps

It has been several years since the completion of this study, so it may be valuable to map the curriculum again in light of the “Medical student learning objectives organized by competency domains,” Table 1 of Lindsley et al. 2017. A gaps and redundancies tool has been added to One45, as has a key word search, both of which would make this review smoother, faster, and more comprehensive. A Learning Management System has also been added to house course content, making review of course materials easier as well. Alternatively, programs could utilize a tool aimed at student assessment based upon the overarching goal articulated in the same article: “All graduating medical students will assess nutritional status and manage the clinical encounter to facilitate a personalized nutritional approach for optimal health.” [10, p. 583]

Our phase I curriculum is undergoing a quality improvement initiative aimed at integrating competencies among all basic science, clinical reasoning, and doctoring courses. Our standards now require mapping of lecture, course, school of medicine, and USMLE objectives. This level of detail did not exist at the time that this study was originally conducted. Course directors will continue to collaborate to strategically address curricular objectives in recognition of developmentally appropriate milestone goals. Nutrition integration will be included in this endeavor.

Conclusions

This study comprehensively examined nutrition competencies in a US medical school by surveying the entire basic and clinical science curriculum during a 1-year period. Nearly two out of three of all basic science blocks and clinical clerkships provided content in one or more nutrition competencies. There was more variability than anticipated in utilizing course objectives to survey the curriculum. Course directors and curriculum leaders were presented with findings of this study and continue to consider opportunities for improvement in nutrition education within their respective disciplines. This approach to the survey of nutrition education followed by conversations about the findings may be useful at other medical schools as a process to enhance nutrition education within their programs.

Appendix. Data Collection Tool

The subtopics in each numbered line comes verbatim from Table 1 of Adams (2010, Nutrition in Medicine) with the addition of subtopic 13. Permission to reprint Table 1 (which appears in Appendix I) from the Adams [2] article was granted by SAGE publishing.

Nutrition Education Curriculum Survey UNM SOM 2015–2016

Compliance with Ethical Standards

Conflict of Interest

The author declares that she has no conflict of interest.

Permissions

Permission to reprint Table 1 (which appears in Appendix I) from the Adams [2] article was granted by SAGE publishing.