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Beauchamp T, Devarakonda A, Chiruvella V, Lorenz P,Hilton L. Medical student attitudes towards nutritional and exercise science integration. HPHR. 2022;63. 10.54111/0001/KKK3
Application of the fundamental principles of nutrition and exercise in clinical management can improve the outcomes of highly fatal diseases. The purpose of this study is to assess whether a knowledge gap in preventative measures of nutrition and exercise exists amongst medical students. We aim to see if current medical education provides students with the appropriate background for applying preventative medicine principles to clinical practice.
Study participants were pooled from current 1st, 2nd, and 3rd year medical students. Of the total 614 students contacted, 42 1st year, 49 2nd year, and 45 3rd year students completed the survey. The survey consisted of 20 questions based on a 10-point Likert Scale that asked students to assess their own self-confidence on various aspects of nutrition and exercise education. Survey responses were aggregated and separated by year of medical training. Average response scores for each cohort were compared using a Mann-Whitney U test.
Across the three classes, average self-confidence levels in baseline nutrition and exercise understanding were less than 6.6/10, and average confidence in their ability to educate patients on nutrition and exercise needs were less than 6.61/10. Yet, the average score for student perception of the importance of preventative medicine education was greater than 7.5/10. There were no statistical differences in scores amongst the three cohorts for 19 of 20 questions.
Finding no significant difference between self-confidence in an average 1st year and an average 3rd year medical student suggests an educational deficit in the current curriculum model. The self-confidence scores presented are concerning for poor understanding of exercise and nutritional science principles which could result in poor delegation of preventative advice in the clinical setting. As such, it appears that the current education model is not preparing students for counseling on patients regarding nutrition and exercise.
As appointment times are increasingly cut short in the primary care setting,11 topics that require discussion may include smoking cessation, dietary modification, sleep management, and exercise are deprioritized. Interdisciplinary professions such as dieticians and physical therapists are often glossed over.1 While preventative medicine is a vital aspect of general population health, it is not fully integrated into medical curricula across medical schools within the United States.2,3 While the National Academy of Sciences (NAS) recommended a minimum of 25 hours of nutrition education in 1985, many medical schools do not abide by these mandates. Even those that participate do not provide comprehensive or frequent nutrition education.3-6
Diet and exercise have broad implications for disease prevention.7 Application of the fundamental principles of diet and exercise in clinical management can improve the outcomes of highly fatal diseases, such as heart disease, type II diabetes (T2D), and metabolic syndrome, all of which have increased in prevalence along with rising global obesity rates.3,8 According to the Centers for Disease Control (CDC), the national obesity rate in adults was approximately 42% for 2017-2018, representing an increase from 30.5% in 1999-2000. Not only does obesity predispose individuals to higher morbidity and mortality, but it also increases the cost of medical care, which is statistically higher in individuals with obesity when compared to those who are not obese.9 This not only increases individual spending but also places a large economic burden on the countries with a high proportion of individuals with obesity.12 Education in preventative medicine is thus important for the development of clinical skills to identify, prevent, and treat prevalent diseases.
In 2011, the Association and American Medical Colleges (AAMC) recommended curriculum reform with the incorporation of nutrition and diet behavior into medical education. The purpose of this integrated curriculum was to promote the acquisition of clinical knowledge and skills on the behavioral and social determinants of health, including diet, exercise, smoking status, and socioeconomic status which may be incorporated into clinical practice to benefit patient outcomes.10 Studies such as the Nutrition in Medicine (NIM) project have shown that with sufficient education medical students can competently utilize preventative medicine in clinical practice and increases student perception of nutritional education.2,3 The goal of integrating preventative medicine into the curriculum is to help physicians-in-training better manage chronic diseases associated with poor nutrition, lifestyle habits, and obesity. With time and national adoption of the curriculum, future physicians would be better equipped to address lifestyle goals with patients early to decrease obesity rates and reduce medical and economic burdens to society.
The purpose of this study is to assess whether a knowledge gap in preventative measures of nutrition and exercise is present in a medical student population. We aim to see if the current medical education curriculum sufficiently provides students the appropriate background necessary for application of preventative medicine and evaluate if this progresses over the course of didactic and clinical education. Our goal is to understand medical student attitudes on preventative medicine in a clinical practice setting to determine if students believe nutrition and exercise for prevention of disease is practical for patient care. We would also evaluate student interest level in receiving supportive education on exercise and nutrition for the purpose of determining the benefit of providing supplemental educational tools.
This study was approved by the institutional review board (IRB) at the Medical College of Georgia. Study participants were pooled from current medical students attending The Medical College of Georgia. As a condition of IRB approval, the study was isolated to 1st year through 3rd year medical students over the age of 18. A total of 614 students were contacted (204 1st year students (M1), 197 2nd year students (M2), and 213 3rd year (M3) students collectively) via phone and email to complete a survey stored on Qualtrics. Of this group, 42 M1 students (20.6% response rate), 49 M2 students (24.9% response rate), and 45 M3 students (21.1%) completed the survey. Each student was given an opportunity to read the web-based consent form explaining the purpose of the study and their required role within the study, which was solely to complete the survey lasting approximately 5-10 mins. No identifiable information was recorded or asked of throughout the survey response process nor during data acquisition. If students chose not to consent to the study, their survey was disregarded and not included in the acquired responses. Only upon consenting to the study were students granted access to the full survey.
The survey consisted of 20 questions based on a 10-point Likert Scale that assessed student self-confidence over various levels of nutrition and exercise education (including but not limited to their own opinions on nutrition and exercise education in the field of medicine, how strong they felt their own understanding of these topics were, and how confident they believed they could accurately educate others on nutrition and exercise). By self-confidence, the survey aims to measure how assured student responders felt in their own understanding, in both mastery of educational topics and in their ability to relay said information to others. Each question was scaled with 1 being not-confident-at-all to 10 being extremely confident. Survey responses were aggregated and separated by year of medical training (M1, M2, and M3). Average scores for each response were tallied and compared across years. Scores were compared using a Mann-Whitney U test with an alpha value of 0.05. All statistical analysis was conducted in R version 4.0.3.
Overall, the average scores for being able to provide counseling about nutrition and exercise-related interventions for disease treatment and prevention were 5.93 for 1st years, 6.61 for 2nd years, and 6.42 for 3rd years (p > 0.05).
The average scores across for 1st through 3rd year medical students in their own understanding of nutritional science prior to beginning medical school were 5.05 for 1st years, 5.62 for 2nd years, and 4.60 for 3rd years (p > 0.05). For exercise science, averages were 5.46 for 1st years, 5.49 for 2nd years, and 5.24 for 3rd years (p > 0.05).
The average scores in their own understanding of nutritional science at present-day were 6.33 for 1st years, 6.45 for 2nd years, and 5.98 for 3rd years (p > 0.05). For exercise science, averages were 6.07 for 1st years, 6.52 for 2nd years, and 6.02 for 3rd years (p > 0.05).
Finally, the average scores across 1st through 3rd year medical students on the importance of developing nutritional education in preventative medicine were 8.45 for 1st years, 8.60 for 2nd years, and 8.04 for 3rd years (p > 0.05). For developing exercise education, averages were 8.05 for 1st years, 8.33 for 2nd years, and 7.88 for 3rd years (p > 0.05). For preventative care being a part of a physician’s duty, averages were 8.40 for 1st years, 8.86 for 2nd years, and 8.96 for 3rd years (p > 0.05). For full results, see Table 1.
Table 1. Medical student Nutrition and Exercise confidence survey results.
| Year | N | Mean | Med | STD |
Lowering Metabolic Syndrome Risk
| M1 | 42 | 5.833333 | 7 | 2.21873 |
M2 | 49 | 6.44898 | 6 | 2.227304 | |
M3 | 45 | 6.244444 | 7 | 2.227469 | |
p-values: M1 vs M2 = 0.2612; M1 vs M3 = 0.3762; M2 vs M3 = 0.7097 | |||||
Counseling Dietary Changes for Treatment/Prevention | M1 | 42 | 5.928571 | 7 | 2.267403 |
M2 | 49 | 6.612245 | 7 | 2.298698 | |
M3 | 45 | 6.422222 | 7 | 2.301076 | |
p-values: M1 vs M2 = 0.1728; M1 vs M3 = 0.3738; M2 vs M3 = 0.7107 | |||||
Heart Failure and Sequalae Prevention | M1 | 42 | 5.452381 | 6 | 2.232819 |
M2 | 49 | 6 | 6 | 2.42384 | |
M3 | 45 | 5.711111 | 6 | 2.436673 | |
p-values: M1 vs M2 = 0.3; M1 vs M3 = 0.5534; M2 vs M3 = 0.6356 | |||||
Kidney Failure and Sequalae Prevention | M1 | 42 | 3.761905 | 3 | 2.261119 |
M2 | 49 | 5.081633 | 5 | 2.431021 | |
M3 | 45 | 4.8 | 5 | 2.170044 | |
p-values: M1 vs M2 = 0.01623; M1 vs M3 = 0.04082; M2 vs M3 = 0.6851 | |||||
Liver Failure and Sequalae Prevention | M1 | 42 | 4.170732 | 4 | 2.407306 |
M2 | 49 | 5.326531 | 5 | 2.656656 | |
M3 | 45 | 5.066667 | 5 | 2.319875 | |
p-values: M1 vs M2 = 0.05065; M1 vs M3 = 0.08408; M2 vs M3 = 0.7425 | |||||
Current Exercise Science Education Confidence | M1 | 42 | 6.071429 | 6 | 2.25662 |
M2 | 49 | 6.541667 | 7 | 2.113365 | |
M3 | 45 | 6.022222 | 6 | 2.388313 | |
p-values: M1 vs M2 = 0.3491; M1 vs M3 = 0.9932; M2 vs M3 = 0.3597 | |||||
Exercise Science Education Confidence Prior to Med School | M1 | 42 | 5.463415 | 5 | 2.398933 |
M2 | 49 | 5.489796 | 5 | 2.643127 | |
M3 | 45 | 5.244444 | 5 | 2.487748 | |
p-values: M1 vs M2 = 0.9772; M1 vs M3 = 0.7971; M2 vs M3 = 0.8131 | |||||
Current Nutrition Education Confidence | M1 | 42 | 6.333333 | 6 | 1.734396 |
M2 | 49 | 6.458333 | 7 | 1.956531 | |
M3 | 45 | 5.977778 | 6 | 2.200092 | |
p-values: M1 vs M2 = 0.6967; M1 vs M3 = 0.4513; M2 vs M3 = 0.3252 | |||||
Nutrition Education Confidence Prior to Med School | M1 | 42 | 5.04761905 | 5 | 2.27341347 |
M2 | 49 | 5.26530612 | 5 | 2.2801271 | |
M3 | 45 | 4.6 | 5 | 2.1991734 | |
p-values: M1 vs M2 = 0.5959; M1 vs M3 = 0.5482; M2 vs M3 = 0.1993 | |||||
Confidence in Current Nutrition Curriculum | M1 | 42 | 4.425 | 5 | 2.363043 |
M2 | 49 | 5 | 5 | 1.859659 | |
M3 | 45 | 4.244444 | 4 | 2.297781 | |
p-values: M1 vs M2 = 0.5309; M1 vs M3 = 0.5276; M2 vs M3 = 0.08989 | |||||
Confidence in Current Exercise Curriculum | M1 | 42 | 4.595238 | 5 | 2.660089 |
M2 | 49 | 4.5625 | 5 | 1.69989 | |
M3 | 45 | 4.2 | 4 | 2.312024 | |
p-values: M1 vs M2 = 0.4666; M1 vs M3 = 0.3001; M2 vs M3 = 0.3502 | |||||
Importance of Nutritional Education in Preventative Medicine | M1 | 42 | 8.452381 | 8 | 1.468405 |
M2 | 49 | 8.604167 | 9 | 1.300402 | |
M3 | 45 | 8.044444 | 8 | 1.770408 | |
p-values: M1 vs M2 = 0.6977; M1 vs M3 = 0.2948; M2 vs M3 = 0.1638 | |||||
Importance of Exercise Education in Physician Training | M1 | 42 | 8.047619 | 8 | 1.513394 |
M2 | 49 | 8.333333 | 9 | 1.837359 | |
M3 | 45 | 7.886364 | 8 | 1.832725 | |
p-values: M1 vs M2 = 0.1971; M1 vs M3 = 0.6913; M2 vs M3 = 0.1998 | |||||
Importance of Physician’s Role including Preventative Care | M1 | 42 | 8.404762 | 9 | 2.02496 |
M2 | 49 | 8.857143 | 10 | 1.632993 | |
M3 | 45 | 8.955556 | 10 | 1.609002 | |
p-values: M1 vs M2 = 0.2601; M1 vs M3 = 0.1697; M2 vs M3 = 0.7989 | |||||
In this study, we assessed medical student self-confidence in their ability to provide nutrition and exercise counseling to patients for general health and with various medical conditions. Overall, the average self-confidence levels in baseline nutrition and exercise understanding did not surpass 5.5 out of 10 prior to medical school matriculation in all 3 classes. The highest self-confidence was noted in 2nd year students with 5.49 in nutritional science, and the lowest being 4.60 in nutritional science in 3rd years. At their level of education at the time of this survey, self-confidence averages did not surpass 6.6 out of 10, with the highest self-confidence being 6.52 out of 10 in exercise science in 2nd year students and the lowest being 5.98 in nutritional science in 3rd years. These findings suggest that regardless of years spent in medical education, students did not feel very confident in their own understanding of nutrition and exercise science despite progressing through medical education. With no significant differences present between classes on these assessments (all p values >0.05), it can be surmised that there is likely no difference in self-confidence of these subjects between the three classes assessed. Finding no significant difference between an average 3rd-year medical student and an average incoming medical student suggests a deficit in nutritional and exercise education in the current curriculum model. These findings also support evidence of the Dunning-Kruger effect in medical education; those with limited perspective and ability tend to overestimate their competence, whereas those with a greater perspective more accurately estimate or even under-estimate their ability. First-year medical students objectively have less medical educational training than third-year students, yet they demonstrate no statistical difference in self-confidence in their educational capabilities as compared to students who have been training for two years longer. However, the Dunning-Kruger effect alone does not fully address this stagnation in exercise and nutrition understanding, which leads these authors to believe that the insufficient medical curriculum is to blame.
This is supported by the findings assessing student self-confidence in their ability to educate their patients on nutrition and exercise needs. When students were assessed broadly on their confidence in discussing dietary and exercise changes for disease treatment and prevention, mid-level self-confidence was reported across classes (the lowest average being 5.93 in 1st years and the highest being 6.61 in 2nd year students). For disease-specific counseling, mid to low levels of self-confidence were reported as well (the lowest average being 3.76 for 2nd years on kidney failure and the highest being 6.45 for 2nd years on metabolic syndrome). As noted previously, there was a significant difference in self-confidence found between 1st years’ ability to educate kidney failure patients and their 2nd and 3rd-year counterparts, however, no such difference was found in any other disease state. This implies that potential nutritional and exercise educational gaps in the current curriculum exist ubiquitously rather than tied to specific disease states.
Student perception of the importance of nutritional and exercise education highlights how detrimental these educational gaps are to student performance. Besides the importance of exercise education in physician development (which 3rd years reported an average score of 7.89), all other averages across classes regarding the importance of nutrition and exercise education in physician development as well as the importance of preventative medicine in a physician’s duty did not fall below 8 out of 10 (the lowest being 8.04 for 3rd years on nutritional education importance). As students place such a high priority on nutrition and exercise information for proper patient care yet report dissatisfaction with their own level of understanding, it can be implied that student educational needs are not being met.
Overall, there was a lack of statistical difference in self-confidence averages regardless of the questions asked, which suggests insufficient knowledge acquisition from the medical curriculum. Even more disconcerting were the instances of small declines in self-confidence averages from 1st years to 3rd years, implying deemphasis on these subjects. A remarkable finding is the discrepancy between average confidence scores on education, understanding, and ability to communicate said understanding compared to student opinion on the importance of mastering these skills. This is considerably problematic for developing surgical and medical physicians alike. Improper preventative medicine education for bariatric surgeons could direct patient management towards more invasive therapeutics in lieu of diet and activity self-management. For non-surgical primary care and obesity physicians, not having a well-developed understanding of preventative medicine could lead to a lack of recognition of manageable problems. Regardless of class, students reporting mid to low-level self-confidence in their education while simultaneously reporting high averages on the importance of this education to the field of medicine suggest that students may not feel the current curriculum model is adequately preparing them on preventative care measures necessary for their future patients.
Our study is not without limitations, including sampling from only one medical school. As we are only elucidating the attitudes of students from a singular curriculum, it may not be an accurate representation of nutrition and exercise incorporation into curriculums nationally. Also, the study relied on qualitative measurement in subjective survey responses over more objective measurements such as standardized nutrition and exercise testing for knowledge. While this was done intentionally as the focus was on student attitudes of their curriculum rather than illustrating their true ability of knowledge, this is something we would love to pursue in future studies to help illustrate potential gaps in medical education. Though a sizable proportion of students answered the questionnaire, there may be some selection bias of students who are more interested in incorporating nutrition and exercise topics into their practice, or who have a generalized interest in their own nutrition and exercise education. However, this may work in favor of the study, as these students would have higher baseline knowledge of nutrition and exercise knowledge, which may allude to an even greater dearth in nutrition and exercise topics within the curriculum. Another concern of the study came forth from a lack of relevant recent literature found during the initial review process, leading us to rely on reference sources from the 2000s and 2010s. While this may be viewed as a limitation in having to rely on potentially outdated information, the fact that more recent sources were difficult to find demonstrates even further the need for updated reviews such as this study to be more known. While the sample of students surveyed for this study was from only one medical school, these findings support the need for additional research into medical student attitudes under different curriculum models across many institutions. The team behind this study would be eager to continue exploring these ideas in future research by including a larger number of medical schools as well as objective knowledge-based measures. This may elucidate a more optimal method of education regarding nutrition and exercise science integration or further expose discrepancies that need to be addressed in the current training model. Despite its limitations, this study provides thought-provoking data on the status of nutrition and exercise science within the medical curriculum, and the deemphasis on preventative care in said curriculum.
Streptozocin is toxic to pancreatic islet cells in animals, so there is little mystery as why it should generate a deficit in insulin production.
Surprisingly, this important data on the induction of type 1 diabetes in animals, including primates, has often been ignored in the public health and epidemiology literature.
The extensive animal data raises the possibility that there is a class of compounds present or introduced into the environment which causes type I diabetes in humans by damaging pancreatic islet cells. We can identify many human diseases with such etiology – mesothelioma from asbestos; liver cancer from aflatoxin; neurological damage in Minamata disease from mercury poisoning; bladder cancer from aromatic amines; black lung from coal dust; byssinosis from cotton bract fibers.
Of particular interest are those cases in which the toxin was a product of a micro-organism present in the food chain. Some liver cancers are associated with the contamination of peanuts by aflatoxin due to the growth of the Aspergillus flavus fungus when peanuts are stored without protection from moisture22,23. In the Western Pacific neurological diseases are associated with ingestion or treatment with cycad plant extracts containing cycasin – methylazoxymethanol-B-D-glucoside 24.
Given the extensive animal experiments, it was reasonable to pursue streptozocin, or its cousins, as a potential etiological agent. Its chemistry explains its islet toxicity – a sugar so that compound is taken up by islet receptors, combined with an alkylating agent that is cytotoxic. Given that streptozotocin is toxic to islet cells in mice, rats, guinea, pigs, sheep and baboons, it is certainly reasonable that it is toxic to islet cells in humans.
In the midst of an obesity epidemic, preventative care confers a substantial benefit in reducing associated morbidity and mortality of obesity, which in turn helps improve broader epidemiologic and economic outcomes. As such, students should be equipped with the proper training to counsel patients on proper dietary and nutrition advice to promote better clinical outcomes in patients. Even in acute care settings, having the proper pathophysiologic understanding of nutrition and exercise science can make an effect on patient treatment modalities and outcomes. As such, it is crucial that our future physicians not only be competent but also confident in their ability to communicate basic nutritional and exercise counseling and therapies to any patient they may one day encounter.
The knowledge-to-confidence discrepancy illustrated in this study clearly highlights that once medical students begin practicing, they may not be ready to provide specific interventions related to nutrition and exercise. Additionally concerning is the notion that knowledge of preventative medicine is so highly valued by students for proper future practice, as evidenced by high scores in the importance of nutrition and exercise science in clinical care. As such, it appears that the current medical curriculum model is not adequately preparing students for counseling on beneficial preventative interventions. Considering the rising prevalence of metabolic disorders, it is possible that medical education may benefit from adapting the current curriculum to be more inclusive of adequate preventative health education.
The authors have no relevant financial disclosures or conflicts of interest.
Ethics Approval and consent to participate: This study was approved by the IRB of The Medical College of Georgia at Augusta University. All study participants provided written consent prior to study participation.
Consent for publication: All authors give consent for publication
Availability of data and materials: All data and materials used in study have been provided and are available for publication.
Funding: No grants or funding were used throughout this study.
Authors’ Contributions: Mr. Tyler Beauchamp served as manuscript writer as well as aided in study design and data collection. Mr. Aditya Devarakonda served as the study’s statistician as well as aided in study design. Ms. Varsha Chiruvella served as manuscript editor as well as aided in data collection. Ms. Jessica Hatch served as study designer as well as aided in manuscript editing. Mr. Patrick Lorenz aided in data collection and manuscript editing. Dr. Lisa Renee Hilton served as the study’s Principal Investigator.
Tyler Beauchamp is a fourth-year medical student at the Medical College of Georgia at Augusta University pursuing the field of Pediatrics. His research areas include Pediatrics, nutrition and preventative medicine, and holistic medicine.
Aditya Devarakonda is a fourth-year medical student at the Medical College of Georgia at Augusta University pursuing the field of Otolaryngology. His research areas include Surgery, Statistics, and Genetics.
Varsha Chiruvella is a fourth-year medical student at the Medical College of Georgia at Augusta University pursuing the field of Family Medicine. Her research areas include Family Medicine, nutrition and preventative medicine, and Internal Medicine.
Jessica Hatch is a fourth-year medical student at the Medical College of Georgia at Augusta University pursuing the field of Neurology. Her research areas include Neurology, Surgery, and Nutritional Health.
Patrick Lorenz is a fourth-year medical student at the Medical College of Georgia at Augusta University pursuing the field of Psychiatry. His research areas include Pediatrics, nutrition and preventative medicine, and holistic medicine.
Dr. Lisa Renee Hilton is a practicing Bariatric Surgeon at the Augusta University Medical Center and professor in the Department of Surgery at the Medical College of Georgia at Augusta University. Her research areas include minimally invasive surgery and nutrition.
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