Student Perceptions of Nutrition Education at Marshall University

Nutrition education is an essential component of medical education if new physicians are to be equipped to address common chronic diseases, including obesity and the associated diabetes, cardiovascular disease, and cancer. Most medical students recognize this need and desire nutrition education; however, finding time in a medical school curriculum and funding are challenging. Available, free online resources and small group exercises can be utilized to provide basic, up-to-date nutrition information to medical students.


Introduction
Many of the health care challenges in the United States could be modified by nutrition changes [1].Poor nutrition and lifestyle choices leading to obesity are a component of risk for many diseases including diabetes, some cancers, osteoporosis, and cardiovascular disease [1].Improving nutrition and lifestyle choices could lower the morbidity and costs associated with disease.West Virginia is an example of a state with multiple health care challenges that might be modified by nutrition change.West Virginia is one of only two states in the US with an adult obesity rate of greater than 35% [2].Additionally, the state records high rates of diabetes and heart disease.In 2012, West Virginia had an age adjusted rate of diabetes of 11.1/100 compared to 9.0/100 in the US [3].Also, diabetesassociated end stage renal disease was 185/100,000 compared to 164/100,000 in the US in 2011 [3].West Virginia was 7th in the US for mortality from heart disease at 208.1/100,000 compared to 170.5/100,000 in the US overall [4].Some of the risk for the statistically high instance of obesity, diabetes, and heart disease in West Virginia could be reduced by preventive care associated with improving the nutritional status of the population.
West Virginia has a high rate of poverty (17.9% of persons live in poverty compared to 15.4% in the US as a whole [5]) and almost 54% of the population lives in rural areas [6].The additional stress of poverty and the rural character of the state make preventive care both difficult (people tend to not go to the doctor until feeling sick) and critical to the health of West Virginians.Improving the nutritional status could be an effective way to lower the rates of obesity, heart disease, and diabetes in the state and to decrease the resulting medical care costs [7].
Marshall University Joan C. Edwards School of Medicine (JCESOM) is one of 3 medical schools in West Virginia.The mission statement declares that JCESOM seeks to "create a center of excellence in primary care in rural underserved areas" to serve the needs of West Virginians.JCESOM admits approximately 75 students to medical school each year; on average 60% of these students are residents of West Virginia.The 2010-2014 graduation questionnaires showed that almost 30% of the 2010-2014 graduating classes stated a desire to remain in the state to deliver healthcare to the people of West Virginia.
Family physicians are a logical source for nutritional information and most (72% or more) [8] physicians feel that it is their responsibility to provide nutritional information as they treat their patients with chronic diseases.However, there are barriers to providing nutritional education.These include the limited time of office visits, the lack of reimbursement for nutritional counseling [9], and perceived noninterest or noncompliance of the patient [10].One survey reported that only about 10% of physicians provided dietary advice to 80% or more of their patients [10].Another study reported that when knowledgeable physicians counseled their patients about dietary change, there were significant weight losses and reductions of body mass index [11] to reduce the patients' risk for cardiovascular disease.However, many physicians feel inadequate to discuss obesity and related health problems with their patients [12].Thus, if students are being trained to serve the health care needs of rural populations, then it is important that physicians receive the nutrition training to be able to deliver nutrition education to patients for prevention of prevalent chronic diseases.
In 1998, the NIH funded the first 10 Nutrition Academic Awards (NAA) with the goal of developing and enhancing nutrition curricula for medical students, residents, and practicing physicians [13].Eleven additional institutions received NAA funding in 2000, with all funding concluded in 2005 [14].The NAA was successful in the NAA funded schools as all of these schools integrated nutrition education into the curriculum; local and national websites were developed and about 50% of medical students had the perception that nutrition education was adequate [14].However, in 2004, in the non-NAA institutions, less than 30% of students felt that their nutrition education was adequate [14].
To address the need for nutrition education, the NIH funded Nutrition in Medicine (NIM) Project was developed to provide access to up-to-date nutrition education for medical students [15].The materials were initially developed as CD ROMs that were distributed free to medical schools.It was found that faculty commitment and training were needed for these modules to be successfully used as a resource [15].In a further evolution, the modules were adapted to a free website, accessible to all registered medical students [16].The case based educational modules are complete and do not require specialized faculty members for nutrition education of students, eliminating many of the cost associated barriers to nutrition education.
At JCESOM, we use a combination of nutrition specific lectures and learning exercises, nutrition information integrated into organ system education, and the NIM modules to provide nutrition information in a cost-effective manner.The aim of this research was to identify the nutrition education sessions and the nutrition related competencies that were addressed during medical school and to report the students' perceptions of the adequacy of nutrition education during their medical school career.

Methods
The JCESOM curriculum map (which describes the content of all education sessions) was queried and relevant faculty members were interviewed, as needed, to identify nutrition related sessions during medical school years 1 through 4. Additionally, the syllabi of the required basic science and clinical educational activities were reviewed for pertinent nutrition content and the course directors were interviewed to confirm content identified in the syllabi.
The JCESOM Core Competencies were reviewed to identify nutrition related competencies and the expected progression of knowledge during medical school.
A nutrition education survey was designed to identify nutrition attitudes, perceived adequacy of education, and basic nutrition knowledge of current JCESOM medical students.This survey used many of the questions in the survey developed by Walsh et al. [17]; permission from the authors was obtained.The Nutrition Survey was available on SurveyMonkey from 1 December to 18 December, 2014.Requests to participate in the Nutrition Survey were sent by email to all year 1 to year 4 medical students, about 300 in total.Respondents were able to rate their agreement with both positive and negative statements related to their nutrition education on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree).
This study was reviewed and approved as an exempt study by the Marshall University Institutional Review Board.No personal identifying data were collected.

Nutrition Education Sessions during Medical School.
Table 1 summarizes the nutrition education sessions, the total hours in each academic year specifically associated with nutrition education, the pedagogy used, and the assessment method of each session. 2 lists the nutrition related competencies expected of medical students and the increasingly proficient outcomes expected of students at the end of each year of their education.

The Nutrition Education Survey.
A total of 69 students (about 23% of the student population) responded to the survey.Of the respondents, 32.1% were year 1, 22.6% were year 2, 13.2% were year 3, and 32.1% were year 4 medical students.Of students who responded, 18 students (26%) did not respond to the questions related to nutrition knowledge; all 69 students answered the nutrition attitude questions.53% of the respondents were male while 47% were female.

Student Perceptions about Nutritional Education (from Survey).
The complete results of the attitude questions are Describe the impact on health of life experiences, poverty, education, race, gender, culture, crime, and the health care system.
Recognize the contribution of social conditions and problems to the health and disease outcomes of patients.Create discharge/management plans that address the impact of social conditions and problems on patients.Describe strategies to ameliorate the impact of social conditions and problems on the health and disease outcomes of patients.
shown in Table 3.Some specific results will be highlighted below.

Attitudes about Presentation of Nutrition Advice to
Patient.Questions 1 to 5 show that most (70 to 80%) of students thought that preventive health and nutrition education was an important part of the physicians job and worth the time and effort.

Perceived Competence to Advise
Patients.More than half of students did not think they were competent to advise patients about nutrition (question 6).This belief is also reflected in question 9, in that 80% were neutral or thought that physicians were not adequately trained to advise patients in nutritional choices and in the overall score of 65% on the nutrition knowledge questions.

Perceived Influence of Nutrition Attitudes of Patient.
Questions 7, 8, and 10-15 address the importance of both physician and patient attitudes toward making nutrition changes.Most students thought that physicians could have a positive influence on adapting healthy lifestyles in their patient.

Adequacy of Nutrition Education (Quantity and Quality).
In questions 16 and 17, almost 50% of students indicated dissatisfaction with both the quality and quantity of their nutrition education.JCESOM uses an organ system organization of the curriculum which could make it difficult to recognize nutrition specific material.Students suggested that more nutrition information be integrated into organ system based instruction as well as separate, specific nutrition classes (questions 18 and 19).The amount of online material seems adequate (question 20) but students would have liked more personally relevant material (question 21).Individual analyses of question 25 (nutrition education after the first year) show that 14 of 28 students who responded with a neutral answer were first year students and would not have had knowledge of curriculum in later years.

Nutrition Knowledge.
Ten general questions were used to assess basic nutrition knowledge.There was an overall score of 65.6% among the 51 students who attempted the knowledge questions.It seems likely that the 18 students who skipped the knowledge questions did not think they knew the answers.Had they attempted the questions it is likely that the overall average would have further decreased.

Specific Suggestions for Improving Nutrition Education.
There were only 5 different suggestions for improving nutrition education.These were (1) clinically relevant nutrition education for weight management and disease process modification which would be beneficial; (2) addressing cultural issues in nutrition.For example, a module comparing "diet fads" and popular trends about which our patients might ask (Atkins, disease specific diets, avoidance of certain food groups in autoimmune conditions, etc.) would be useful information; (3)

Discussion
Many of the health challenges for the US could be modified by changing the diet and exercise practices of the population [7].Since physicians can be instrumental in changing diet behaviors [11,19], nutritional information is an important component of medical student training [20,21] As can be seen in Table 1, most of the focused nutrition information is taught during the first year of medical school.Table 1 also highlights the variety of pedagogy used to present nutrition content.The varied pedagogy is intentional and is meant to enhance learning.Results of other researches indicate that a mix of pedagogical styles better meets the needs of various learning styles of students [22].Typically, lectures are used to introduce material and provide background for clinical relevance.The use of the Nutrition in Medicine materials enables us to present high quality, up-to-date nutrition education without the presence of nutrition experts on School of Medicine faculty [23].The Nutrition in Medicine web-based materials also contribute to the development of "life-long learning" skills.By assigning modules especially applicable to specific health topics (diabetes, cardiovascular disease, nutrition in pregnancy, or aging) and allowing selection of a module of interest, all students get both basic and individually tailored nutrition education.Students learn better if they are motivated, actively engaged, and personally invested.The use of independent learning pedagogy is based on three core elements: presenting the information in small bites, making learning self-paced by the learner, and providing immediate feedback to the learner using the built in selfassessment.The independent learning method of teaching, reinforced with immediate question/answer feedback, helps build a knowledge base and critical thinking skills [21].
Clinical correlate lectures by physicians allow students to ask questions, obtain response from clinicians, and provide reinforcement of the NIM material.The use of small group and role playing exercises enhances learning using peer teaching, a technique beneficial to both "teacher" and "learner" [24].
Almost 50% of students were dissatisfied with both the quantity and quality of their nutrition education during medical school.While somewhat alarming, this also means that 50% of the students were neutral or thought that the quantity and quality of their nutrition education were adequate, a fraction similar to that after completion of the NAA in schools that received that award and much better than the 30% of satisfied students in schools that did not receive the award [13].
Our students largely agreed with previous studies of practicing physicians in that they felt that a physician could influence a patient's nutrition choices [11] but that they felt inadequate to present nutrition and obesity information to patients [8,12].The students also desired more nutrition information during their undergraduate education.As faculty members and curriculum planners, the challenge remains of finding the time to include nutrition education in an already packed medical school curriculum and to help the students recognize the nutrition education that they receive.

Conclusions
Limitations of this study are that the conclusions of this study are limited by the restriction to one medical school with a smaller population than many medical schools, the rural environment, and by the limited response of the students.However this study does demonstrate that the nutrition education can occur without incurring large additional costs though time for the sessions must be found within the curriculum.
Medical students realized the need for nutrition education in their medical school curriculum and the need for physicians to provide this information to their patients.Using online resources and small group exercises, basic nutrition education can be addressed by faculty members who are not nutrition experts.Most medical students desire additional nutrition education; however a challenge remains for finding the time to include this information in the medical school curriculum.

Table 1 :
Summary of nutrition learning activities during medical school years 1-4 at Marshall University Joan C. Edwards School of Medicine.

Table 2 :
Medical knowledge nutrition related competencies and progression during years 1-4 of medical school 1 .

Table 3 :
Results of the Nutrition Survey.
. The resources of JCESOM, as of many medical schools, are, however, limited.Marshall University does have a Dietetics Department within the College of Health Professions.This program offers both Bachelor's and Master's degrees in Dietetics.Still, this school is not part of the medical school; thus access to these nutrition experts for our medical students is limited.As a courtesy, the Chair of the Dietetics Department does present an obesity lecture to our first year medical students.The remainder of the nutrition related material during the first block of the first year is presented by Biochemistry Faculty.