Kathleen Wong, OMS-IV
2023 Namey/Burnett Preventive Medicine Writing Award Submission
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
Obesity, defined by the Centers for Disease Control and Prevention, includes adults with BMI of 30 and over. According to the National Health and Nutrition Examination Survey, there has been a gradual growth in the percentage of obese adults over the last 20 years with non-Hispanic Black adults being the most affected group1. More recently, a comprehensive national study of weight change during the first year of the COVID-19 pandemic revealed that 48% of respondents gained some weight (11% gained over 10lbs, while 37% gained less than 10lbs)2. It is known that obesity can be associated with more detrimental conditions, including hypertension, coronary artery disease, metabolic syndrome, chronic inflammation, osteoarthritis and complicated pregnancies3. Obesity can also lead to functional impairment, causing cyclic perpetuation and an impasse. While there are a multitude of factors that can affect a person’s weight, including genetics, environment, dietary habits, physical activity, and psychosocial factors, it is obvious that physicians play a pivotal role by emphasizing prevention and disseminating lifestyle education.
Furthermore, the Global Burden of Disease study in 2017 estimated that 11 million deaths were attributed to dietary risk factors4. Current medical education often covers nutrition in terms of vitamin deficiencies. However, education is lacking when it comes to counseling patients on how to manage the overabundance of high caloric and over-processed foods in an obesogenic environment. Merely encouraging patients to “eat healthier” often yields frustratingly, although understandably, limited results. A systematic review of medical students’ nutrition education showed that graduating medical students consistently report concerns with their nutrition knowledge and skills. Most do not feel confident in counseling patients to bring about effective behavior changes when it comes to diet5. This has been attributed to meager coverage of nutrition in the conventional teaching curriculum, inadequate observation of nutrition counseling during clinical experiences, and absent collaboration with nutrition faculty experts6, 7, 8. When students do not see nutrition as being a valuable educational topic utilized by current healthcare providers, they proceed to practice medicine without incorporating nutrition. A look at family medicine residency programs showed that nutrition education was also highly variable, but having part time faculty dedicated to nutrition was an effective solution9.
Understanding this, what are some ways that we can combat this evident knowledge gap?
- Dietary Guidelines for Americans (dietaryguidelines.gov)
- MyPlate Plan (myplate.gov/myplate-plan) shows food targets and develops a personalized food plan based off of age, sex, height, weight, and physical activity level. Availabe in Spanish.
- The Nutrition in Medicine project (nutritioninmedicine.org) is an evidence based collection of clinical nutrition education online modules for medical students, fellows, and other physicians. This curriculum covers preventative and therapeutic aspects of medical nutrition care.
- The Nutrition Guide for Clinicians (nutritionguide.pcrm.org) is a mobile app that provides evidence based support for disease prevention and treatment for more than 90 conditions. Importantly, it also includes best practices for discussing dietary changes with patients.
In addition, culinary medicine is gaining popularity as a potential nutrition learning tool for both students and residents alike. Culinary medicine includes hands-on cooking experiences for meal preparation and practice in counseling patients. It aims to help participants make educated decisions about what they eat with consideration towards their own personal health condition10. Programs may be taught by chefs or registered dieticians. Despite the inconsistency and lack of standardization in its employment, initial studies from pilot culinary medicine programs have made a positive impact on type 2 diabetic patients’ biometrics11and medical students’ confidence regarding nutritional knowledge and ability to counsel their patients in implementing dietary changes12. Additional larger studies are required to assess the plausible intervention of culinary medicine in medical education, but in the meantime, there are efforts developing to standardize the process13. Financial costs and shortage of equipment could be an added hurdle, but online course modules is an option to provide this education globally through collaboration with the American College of Lifestyle Medicine14.
Another online option that has showed promise in incorporating nutrition education is the Integrative Medicine in Residency 200-hour program launched by the University of Arizona Center for Integrative Medicine. The goal of the program was to address weaknesses in the traditional curriculum by providing a course that encompasses complementary, alternative, and lifestyle medicine. Approximately 186 hours of the program is web-based with the remaining hours dedicated to in-person activities such as cooking and movement therapy. There are multiple studies that back the utilization of web-based education when compared to traditional formats15, 16, 17. A review of the five year pilot phase revealed improvement on formal assessment of medical knowledge of the residents who completed the program compared to the control group. The assessment was based on curriculum objectives and comprised of both primary care and integrative medicine knowledge. It has since been adopted by numerous residency programs across the United States and Canada, but a limiting factor is its yearly tuition costs18.
Moreover, there is limited data that having medical students examine and improve upon their own lifestyle behaviors translate to more confidence in their nutrition counseling skills19. This is not surprising as personal experience often strengthens knowledge. In this case, it could also increase sensitivity and elicit sympathy towards the slow and ongoing plight of pursuing healthy habits. After all, we understand that it’s not so easy to simply tell a patient to stop smoking. The journey of smoking cessation involves goal setting, recurrent relapses, and ongoing social support to make the significant behavioral change. Similarly, pursuing healthy lifestyle choices involves a corresponding long term journey with recurrent relapses and requirement of social support.
Multiple medical schools have acknowledged this experience and have incorporated personal lifestyle improvement projects into their curriculum so that students may “practice what they preach”. Associated studies showed that students described these interventions as an overall positive and impactful educational experience. One school implemented a behavioral change plan for 343 students to implement a change in their exercise, nutrition, sleep, personal habits/hygiene, study/work habits, or mental/emotional health behavior over the course of six to nine weeks. The project incorporated journaling to record any negative thoughts that may be preventing students from reaching their healthy goals. The study found that 49.6% of participants self reported not reaching their goal, illuminating the obstacles to behavioral change. Barriers included being too busy, being sick or injured, setting unrealistic goals, and being too stressed, which are all relatable difficulties to any patient population20.
Therefore, as a general guideline:
- Take a comprehensive nutritional assessment, consider utilizing food journals to assess patient habits
- Address the need to change while recognizing the influence of culture, socioeconomics, and psychosocial factors
- Assess patient’s motivation for change without shaming the patient (ask open ended questions such as “how was your experience with your past weight loss attempt?)
- Set a reasonable, obtainable goal (make one change at a time, discourage non-sustainable fad diets and extreme dietary restriction)
- Educate on alternative healthy choices and encourage mindfulness/balance (may consider use of free mobile apps for patient to track nutrition and food intake)
- Continue to make gradual changes and incorporate physical activity and improve sleep hygiene
- Schedule follow up, provide support
- Consider prescribing pharmacotherapy, enlisting dietician or nutrition consultants if available, or referring to bariatric surgery when appropriate through shared decision making
Discussion should also include recommending small, frequent meals, increasing fresh fruit and vegetable intake, and maintaining proper water intake. Patients should also reflect on general eating habits such as frequency of snacking, eating out, and emotional cravings. There are existing guides on how to write a dietary prescription to gradually initiate a caloric deficit21.
In summary, it is important to realize that there are strong societal factors that make unhealthy lifestyle choices easier than making healthy lifestyle choices. Primary care physicians can make a positive impact in obesity management with the opportunity to collaborate in interprofessional teams to assist with patient goals. A patient-centered approach is more likely to ensure success. We must keep in mind that the journey of “good nutrition” is an imperfect one and afford patients the same respect and kindness that we afford ourselves. In the meantime, nutrition education continues to develop to address the significant knowledge gap across medical curriculums. Keep in mind that this is one critical angle of nutrition, but nutrition education remains noteworthy for discussion due to its importance in geriatric health, nephrology health, pregnancy, and childhood health.
- Division of Health and Nutrition Examination Surveys. NHANES Interactive Data Visualizations. National Center for Health Statistics. 2021.
- Khubchandani J, Price JH, Sharma S, Wiblishauser MJ, Webb FJ. COVID-19 pandemic and weight gain in American adults: A nationwide population-based study. Diabetes Metab Syndr. 2022;16(1):102392. doi:10.1016/j.dsx.2022.102392
- Meldrum DR, Morris MA, Gambone JC. Obesity pandemic: causes, consequences, and solutions-but do we have the will?. Fertil Steril. 2017;107(4):833-839. doi:10.1016/j.fertnstert.2017.02.104
- GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 [published correction appears in Lancet. 2021 Jun 26;397(10293):2466]. Lancet. 2019;393(10184):1958-1972. doi:10.1016/S0140-6736(19)30041-8
- Sierpina VS, Welch K, Devries S, et al. What Competencies Should Medical Students Attain in Nutritional Medicine?. Explore (NY). 2016;12(2):146-147. doi:10.1016/j.explore.2015.12.012
- Mogre V, Stevens FCJ, Aryee PA, Amalba A, Scherpbier AJJA. Why nutrition education is inadequate in the medical curriculum: a qualitative study of students’ perspectives on barriers and strategies. BMC Med Educ. 2018;18(1):26. Published 2018 Feb 12. doi:10.1186/s12909-018-1130-5
- Cooke NK, Ash SL, Goodell LS. Medical students’ perceived educational needs to prevent and treat childhood obesity. Educ Health (Abingdon). 2017;30(2):156-162. doi:10.4103/efh.EfH_57_16
- Danek RL, Berlin KL, Waite GN, Geib RW. Perceptions of Nutrition Education in the Current Medical School Curriculum. Fam Med. 2017;49(10):803-806.
- Deen D, Spencer E, Kolasa K. Nutrition education in family practice residency programs. Fam Med. 2003;35(2):105-111.
- La Puma J. What Is Culinary Medicine and What Does It Do?. Popul Health Manag. 2016;19(1):1-3. doi:10.1089/pop.2015.0003
- Monlezun DJ, Kasprowicz E, Tosh KW, et al. Medical school-based teaching kitchen improves HbA1c, blood pressure, and cholesterol for patients with type 2 diabetes: Results from a novel randomized controlled trial. Diabetes Res Clin Pract. 2015;109(2):420-426. doi:10.1016/j.diabres.2015.05.007
- Rothman JM, Bilici N, Mergler B, et al. A Culinary Medicine Elective for Clinically Experienced Medical Students: A Pilot Study. J Altern Complement Med. 2020;26(7):636-644. doi:10.1089/acm.2020.0063
- Sicker K, Habash D, Hamilton L, Nelson NG, Robertson-Boyd L, Shaikhkhalil AK. Implementing Culinary Medicine Training: Collaboratively Learning the Way Forward. J Nutr Educ Behav. 2020;52(7):742-746. doi:10.1016/j.jneb.2019.12.009
- Hauser ME, Nordgren JR, Adam M, et al. The First, Comprehensive, Open-Source Culinary Medicine Curriculum for Health Professional Training Programs: A Global Reach. Am J Lifestyle Med. 2020;14(4):369-373. Published 2020 Jul 14. doi:10.1177/1559827620916699
- Criley JM, Keiner J, Boker JR, Criley SR, Warde CM. Innovative web-based multimedia curriculum improves cardiac examination competency of residents. J Hosp Med. 2008;3(2):124-133. doi:10.1002/jhm.287
- Lanken PN, Novack DH, Daetwyler C, et al. Efficacy of an internet-based learning module and small-group debriefing on trainees’ attitudes and communication skills toward patients with substance use disorders: results of a cluster randomized controlled trial. Acad Med. 2015;90(3):345-354.
- Sperl-Hillen J, O’Connor PJ, Ekstrom HL, et al. Educating resident physicians using virtual case-based simulation improves diabetes management: a randomized controlled trial. Acad Med. 2014;89(12):1664-1673. doi:10.1097/ACM.0000000000000406
- Lebensohn P, Kligler B, Brooks AJ, Teets R, Birch M, Cook P, Maizes V. Integrative Medicine in Residency: Feasibility and Effectiveness of an Online Program . Fam Med 2017;49(7):514-521.
- Frank E, Elon L, Hertzberg V. A Quantitative assessment of a 4-year intervention that improved patient counseling through improving medical student health. MedGenMed. 2007;9(2):58. Published 2007 Jun 14.
- Kushner RF, Kessler S, McGaghie WC. Using behavior change plans to improve medical student self-care. Acad Med. 2011;86(7):901-906. doi:10.1097/ACM.0b013e31821da193
- Chopra S, Malhotra A, Ranjan P, Vikram NK, Singh N. Lifestyle-related advice in the management of obesity: A step-wise approach. J Educ Health Promot. 2020;9:239. Published 2020 Sep 28. doi:10.4103/jehp.jehp_216_20