Nutrition as Medicine, Food Sensitivities, and Chronic Disease: a Mini Curriculum Shaped by Transformative Learning Theory

Abstract

Nutrition-related diseases are preventable twenty-first-century health problems. Students report being underprepared for nutritional therapeutics. We developed a mini, spiral curriculum shaped by transformative learning theory and centered on nutrition as medicine, food sensitivities, and chronic disease to kick-start a shift in cognition, attitudes, and skills. Seven demographically representative students participated in the 3-week curriculum. Visual, textual, and verbal data were captured and analyzed qualitatively. We found the curriculum evoked paradigm transformation that persisted 6 months later and facilitated opportunities for our cohort to self-identify learning gaps and consider how they related to their current and future goals for patient care.

Background

Nutrition-related non-communicable diseases are common, costly, and preventable health problems in the United States (US) [1, 2], yet physicians lack skills to provide effective dietary counseling [3–7]. In 2001, most US medical schools did not have an identifiable nutrition curriculum [8]. In 2010, Adams et al. found the amount of nutrition education in US medical schools remained inadequate; they noted, “the Association of American Medical Colleges (AAMC) last included a nutrition question in its graduation questionnaire in 2005. At that time, 51.1% of all students reported that nutrition in the curriculum was inadequate” [9, 10]. Since then, the quantity of health professions’ formalized nutrition education has continued to shrink [11]. The expanding fields of metabolomics, proteomics, and nutrigenomics are ushering in an era of nutrition therapeutics [12–15] that require a paradigm shift in cognition, attitudes, and skills to adequately prepare physicians-in-training for the opportunities and challenges they will face heading into the mid-twenty-first century. Medical students’ learning needs to be increasingly self-directed and amenable to addressing their own education gaps. We used transformative learning theory (TLT) as a conceptual framework to guide the development of a mini, spiral curriculum [16] to kick-start student interest and attention to nutrition as medicine. TLT states that perspective transformation may be evoked by five conditions [17]: (1) activating event, (2) identifying underlying assumptions, (3) critical self-reflection, (4), critical discourse with others, and (5) opportunity to apply new perspectives. By deploying TLT in a spiral structure, the elements can be repeated in progressively more challenging ways to highlight important topics and themes.

Our research objective was to pilot the impact on cognition, attitudes, and skills of a 3-week mini, spiral “nutrition as medicine” curriculum shaped by TLT on first-year medical students.

Activity

• Week 1: Problem-based learning case: patient with increased intestinal permeability

• Week 2: Lecture on physiology and pathophysiology of increased intestinal permeability

• Week 3: Nutritional history-taking regarding increased intestinal permeability

This qualitative, feasibility study used a demographically representative sample of n = 7 M1 students (female, 4; Male, 3; African-American, 1; Asian, 2; Caucasian, 3; South Asian, 1; mean age = 25 years) from the Frank H. Netter MD School of Medicine. This cohort mirrors the small group size that many medical schools use for problem-based learning events. Seventy-five-dollar gift cards were offered as compensation. Table 1 outlines our mini curriculum offered during the gastrointestinal-endocrine-reproduction block of year one. Baseline and 6-month data were collected before and after implementation (Table 2). Participants met in-person with a facilitator for 1 h on Mondays and Wednesdays. They created single 8.5 × 11 page concept maps and completed brief (< 300 words) self-reflective pieces of writing (Table 3). The visual (concept map), textual (reflective writing), and verbal (audio-recorded group discussion) sources of data were subjected to de-identified qualitative analysis and permitted triangulation of how medical students interpret the emerging significance of nutrition, food sensitivities, and chronic disease. Triangulation is an analysis technique in qualitative research that facilitates a comprehensive understanding of phenomena through cross-verification from two or more sources [18].

Table 1.

Week 1 of the mini, spiral curriculum shaped by transformative learning theory

TLT component	Learning event	Day
1. Activating event	Problem-based learning case	Monday (12–1 pm)*
2. Identify beliefs	Concept map	Tuesday–Wednesday†
3. Critical self-reflection	Short writing prompt	Tuesday–Wednesday†
4. Critical discourse	Group discussion	Wednesday (12–1 pm)*
5. Opportunity to apply	Students’ normal day-to-day lives	Thursday–Sunday†

*Synchronous, in-person learning event; †Asynchronous learning event; students free to complete whenever suits them

Table 2.

Qualitative data from n = 7 learners before, during, and 6 months after the mini curriculum organized by codes, themes, and domains. Key: visual (concept maps); textual (reflective writing); verbal (audio-recorded group discussion)

Table 3.

Concept map and short writing prompts used in the mini, spiral curriculum

Concept map prompt

Weeks 1–3: “Make a single page concept map that captures your knowledge, beliefs, and skills regarding nutrition. Aim for 5–10 min to do this.”

Short writing prompts

Write a short (no more than 300 words) reflection on the statement that:

Week 1: “Food is inert.”

Week 2: “The nutrition knowledge I possess is an acceptable blend of evidence-based knowledge and public opinion.”

Week 3: “Think ahead to 1 year, 3 years, and 10 years from now, to what extent do you see yourself:

Performing a nutritional history? Counseling patients beyond encouraging them to “eat healthier” with regard to food and diet? Problem-solving nutrition-related clinical cases?”

AY and DM independently read and coded the data using first-level provisional coding. Iteratively, similar codes were grouped to reduce the number of categories and major concepts identified. These were further defined, developed, and refined into main themes connected to cognition (knowledge), attitudes (beliefs), and skills (performance) domains. The Quinnipiac University Institutional Review Board determined this study to be exempt research (protocol #03218).

Results and Discussion

Learners’ baseline knowledge focused on food items, diet, health impact, and nutrients; beliefs on food sources and diet change; and performance on cooking and food preparation (Table 2). Six main themes emerged from the visual (concept map), textual (reflective writing), and verbal (group discussion) data sources over the course of the TLT-informed curriculum (Table 2). Cross-verification of transformation in attitude and skill was evident in the participants’ writing and audio transcripts, whereas all three data sources pointed to shifts in learners’ cognition. The concept maps, with the exception of one student, were skewed in favor of presenting facts and knowledge-based relationships. We found this bias towards the lower tiers (i.e., knowledge and comprehension) of Bloom’s cognitive domain [19], and lack of emotion- or action-based specifics until the final curricular week, interesting. Most definitions of concept mapping describe it as a knowledge representation tool [20], so our findings are perhaps to be expected. However, as a technique, it also allows learners’ a flexible and intuitive means of externalizing their mental schema of a given subject. From this angle, the delayed emergence of belief and skill details may be evidence of learner consolidation and a more semantically integrated understanding of nutrition, food sensitivities, and chronic disease [21]. The themes remained readily discernible after 6 months, which is encouraging evidence of persistent paradigm transformation (Table 2).

Cognition (Knowledge)

Food Sensitivities and Gut Health

An evident theme was the interaction between food and gut health. Learners knew the gastrointestinal tract is chiefly responsible for digestive and absorptive processes, yet the reality that gut health is impacted reciprocally by food was novel. The difference between food allergy, food intolerance, and food sensitivity was also new; the group commented on how these terms are often falsely used interchangeably and was unaware how impactful food sensitivities can be.

I am appreciating more and more the intricacies of diet and how it can lead us to disease if we are not aware of our own food sensitivities. – Subject 6

Nutrition and Chronic Disease

Nutrition and development or treatment/management of chronic disease was also a theme that surfaced. Learners expressed their nascent pathophysiological understanding of how an individual’s food sensitivities may bring about a vulnerable intestinal wall and subsequent increased intestinal permeability (IIP). IIP is a pathological state where chronic consumption of foods that someone is sensitive to leads to breakdown of their intestinal wall [22]. The students became able to recognize specific food components and anti-nutrients that may trigger this breakdown and interact negatively with gut microbiota. They connected this to the development of symptoms (e.g., bloating, headaches, itchiness, loose bowels). Learners were surprised by peer-reviewed literature referencing IIP as perhaps a necessary precursor to many chronic diseases [23, 24]. They hypothesized how food-prompted increases in local and systemic pro-inflammatory agents relate to underlying mechanisms of nutritional therapeutics. They became eager to learn more about IIP.

IIP is definitely something I should know about…As the bacteria in our colon are essential for our appropriate digestive and immune functions, ingestion of certain foods can result in an abnormal interaction with our gut microbiota, thus causing symptoms like bloating. – Subject 2

The more you really think about it in terms of prevention, nutrition is a reason why we have so many chronic disorders in our country instead of communicable diseases. – Subject 5

Attitude (Belief)

Food Is Not Inert

The belief that food is not inert coalesced and was embraced by all seven learners. This perspective illuminated their conviction that food is not static but modulates host and microbial health, mood, and well-being.

Food cannot be considered as a static or inactive substance… There exists a complex interaction between our digestive process, our microbiota, and the food that we eat. – Subject 2

Self-Awareness of Learning Gaps

As the mini curriculum progressed, students identified their own learning gaps and acknowledged public opinion as their primary source of nutritional guidance prior to medical school rather than evidence-based information. Learners expressed their growing belief in the need to invest personally in learning more about the “underappreciated” science of nutrition and that it should have a greater role in healthcare.

I didn’t realize just how lacking my knowledge of nutrition and its importance is. It’s definitely something that I feel more inspired to actively try and learn more about. – Subject 2

I plan to continue developing my nutritional knowledge… I will need to actively seek out nutrition-related educational experiences. – Subject 4

Nutrition Is Personalized

Although learners maintained the conviction that certain guidelines are broadly applicable (e.g., eat in moderation, balance macronutrients), a view emerged that food sensitivities and appropriate nutrition are personalized. Food that is beneficial and innocuous to one person may harm another, even between family members. Learners conveyed their insight that giving identical nutritional advice to all patients may have unintended consequences. They argued against making overly simple blanket statements such as “eat healthier.”

Nutrition, turns out, is very personal and the consequences of our intake has significantly different results based on our metabolism, genome, and microbiota. – Subject 5

Skill (Performance)

Nutrition History-Taking

Nutritional history-taking was something many learners noted a gain in confidence in (e.g., use of food logs, role of food sensitivity testing). All students were explicit that further training and practice were needed before they would feel comfortable providing advice in a clinical setting.

I now know it is not enough to just ask what kind of foods one is eating purely on a caloric basis, but more so the types of foods that may incite an inflammatory reaction for some individuals. – Subject 1

In terms of feasibility, this mini curriculum would require 6 h (two per week) and a sufficient number of faculty facilitators to implement as-is for a whole class of learners. Faculty need not be content experts as long as facilitator guides and pre-event training is provided. The limitations of this study include that it was conducted once with a small sample of learners at a single institution and only has a single-source baseline and 6-month data (concept map and group discussion, respectively).

As the incidence of nutrition-associated chronic disease continues to rise, the need for physicians-in-training to commit to appropriate life-long self-education in this area is paramount. This mini, spiral curriculum facilitated opportunities for our demographically representative cohort to self-identify learning gaps and consider how they related to their current and future goals for patient care. Further, we believe a TLT-informed pedagogy may kick-start in learners the necessary paradigm shift in cognition, attitudes, and skills aligned with preventative health nutrition and nutritional therapeutics.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.