Objectives: The provision of nutrition care by health professionals can facilitate improved patient nutrition behaviors. Some education institutions include nutrition in their medical curriculum; however, doctors and medical students continue to lack competence in providing nutrition care. Dietitians are increasingly teaching nutrition to medical students, yet evidence on the topic remains anecdotal. It is important to understand the experiences of these dietitians to support improvements in undergraduate medical nutrition education. The aim of this study was to explore dietitians' perspectives of teaching nutrition to medical students.
Methods: A qualitative study was conducted in collaboration with the Need for Nutrition Education/Innovation Programme (NNEdPro). Twenty-four dietitians who had provided nutrition education to medical students participated in individual semistructured interviews. Participants were from Australia (n = 5), New Zealand (n = 1), the United States (n = 6), Canada (n = 5), the United Kingdom (n = 5), Germany (n = 1), and Finland (n = 1). Data analysis was conducted using a constant comparative approach to thematic analysis.
Results: The dietitians expressed confidence in their ability to teach medical students and believed that they were the most appropriate professionals to administer the education. However, they were not confident that medical students graduate with sufficient nutrition competence and attributed this to poor curriculum planning for nutrition. Dietitians had access to useful resources and tools to support education, with opportunity to contribute further to integration of nutrition throughout medical curricula.
Conclusion: This study suggests that dietitians are likely appropriate nutrition teachers in medical education. However, optimizing dietitians' role requires their further involvement in curriculum planning and development. Including dietitians as members of medical faculty would facilitate their input on nutrition throughout the curriculum, which could enhance the nutrition education of medical students.
Malnutrition is a serious public health problem Citation. Both over- and undernutrition are linked to poor health outcomes that contribute significantly to the global economic burden Citation[2–7]. Health professionals provide nutrition care in several ways to support individuals to have optimal nutrition behaviors, which can reduce the prevalence of malnutrition Citation[8,9]. Doctors play a critical role in the delivery of nutrition care because they have greater contact over time with patients compared to other health professionals and are perceived by patients to be a trusted source of nutrition information Citation[8,10–12].
The inclusion of nutrition in medical education aims to build students' nutrition competence. It is internationally recognized as essential by many institutions, including; the American Society for Clinical Nutrition, the National Academy of Sciences, and the Society for Teachers of Family Medicine Citation[13,14]. However, many medical students still graduate lacking nutrition competence Citation[15–20]. Practicing doctors also lack nutrition competence, and this negatively impacts upon their provision of nutrition care, generating missed opportunities to decrease the prevalence of malnutrition Citation[21–29]. The recognition of missed opportunities has resulted in a renewed interest in nutrition education within many medical education institutions Citation.
Dietitians are increasingly involved in teaching nutrition to medical students, yet limited literature exists on the topic. There are accounts of dietitians contributing to exemplary nutrition education of medical students, despite challenges of curriculum crowding Citation[31,32]. For example, one survey of 258 family practice residency training programs in the United States reported that 47% had a nutrition curriculum and that dietitians had primary responsibility for the nutrition curricula Citation. In addition, another research article from the University of Nevada School of Medicine's Nutrition Education and Research Program reported that more than 18 nutrition faculty members, all registered dietitians, contributed to the implementation and evaluation of the program Citation. Understanding the perspectives of dietitians involved in teaching medical students will help to identify how they can be best equipped to perform their role, provide evidence to implement interventions that enhance the role's effectiveness, and contribute suggestions to improve nutrition in medical education. Therefore, the aim of this study was to explore dietitians' perspectives of teaching nutrition to medical students.
Materials and methods
This study utilized a qualitative design to explore dietitians' perspectives of teaching nutrition to medical students. The study was conducted in collaboration with the Need for Nutrition Education/Innovation Programme (NNEdPro), which is based in Cambridge in the United Kingdom Citation. The study was approved by the Griffith University Human Research Ethics Committee, Queensland, Australia (reference number 2016/020).
Potential participants were English-speaking dietitians from any country who currently provide or who have previously provided nutrition education to medical students in a tertiary institution or a hospital education rotation. Purposive and snowball sampling was used to recruit participants. Existing networks of contacts were sourced through NNEdPro. An e-mail was sent to NNEdPro contacts requesting their assistance in identifying dietitians associated with teaching nutrition in medical education. Interested individuals were asked to reply via e-mail to the lead researcher and telephone interviews were then arranged. Consent was inferred when participants responded to the e-mail and the interview time was confirmed.
Data collection involved individual semistructured interviews that used open-ended questions to guide discussions. The interview questions were selected to gain insight into dietitians' perspectives of their role, scope of practice, challenges, and future opportunities. The questions were informed by a review of relevant literature and through discussions with the research team regarding what is currently unknown about the topic and what would facilitate future support for dietitians in these roles. outlines each interview question using inquiry logic to confirm the questions aligned with the study aim. Questions were piloted by conducting an interview with one individual from the participant pool. Three members of the research team then examined the pilot data to ensure that questions were appropriate for the study aims.
All interviews were conducted by one investigator and were recorded with a digital dictaphone. The interviewer disclosed herself as a training dietitian at the start of each interview to minimize bias. The interviews lasted approximately 20 minutes. Following each interview, recordings were transcribed verbatim. To ensure anonymity, participant information was not saved or disclosed to third parties and transcripts were stored securely online using password restrictions. Data collection continued until saturation of themes occurred. Data saturation was considered as the point where no new codes or themes were identified from new interviews. Saturation was confirmed through discussions between 3 research team members. After this point, all remaining scheduled interviews were completed but no new participants were recruited.
Data analysis was conducted concurrent to data collection using a constant comparative approach to thematic analysis Citation[34,35]. A constant comparative approach is used to develop ways of understanding human phenomena within the context in which they are experienced Citation. It is an iterative process that involves coding data inductively and then comparing pieces of data against each other to uncover possible relations between them Citation[35,36]. Three research team members read the interview transcripts separately to become familiar with the results and to form their own opinions. One researcher then manually coded sections of each transcript, organized them into themes and subthemes according to their properties and dimensions, and entered them into a Microsoft Excel spreadsheet Citation. Following this, triangulation of findings occurred during postanalysis discussions to ensure that themes reflected the data for transferability and credibility. Research team discussions continued until agreement was reached on the titles of themes and subthemes and the links between them. Indicative quotes from transcripts have been used to illustrate key themes identified from the data.
Twenty-four female dietitians from Australia (n = 5), New Zealand (n = 1), the United States (n = 6), Canada (n = 5), the United Kingdom (n = 5), Germany (n = 1), and Finland (n = 1) participated. At the time of interview, 19 participants currently or previously held lecturing positions at a tertiary institution. One of these positions was within a medical faculty and all others were in nutrition and dietetics, public health, or exercise and nutrition sciences faculties. Five participants were clinical dietitians involved in teaching medical students at a hospital.
Participants reported to have acquired their teaching role by (1) applying for it directly; (2) being approached by a member of a medical school; or (3) approaching a medical school directly. Participants frequently reported teaching first- and second-year medical students. The education was generally delivered by occasional “one-off” lectures. Only 2 participants reported that nutrition was integrated into the medical curriculum at their institution and not taught as a separate component. Topics covered during the education were diverse and generally lacked consistency. Many dietitians were asked by medical faculty to prioritize the content they would discuss based on allocated time. In these situations, the dietitians tended to take a pragmatic approach and gave a broad overview of general nutrition or reviewed nutrition issues they believed students would most frequently be exposed to, such as general healthy eating. Others were given an assigned topic that they had little opportunity to deviate from, such as type 2 diabetes mellitus. Case studies and clinical questions were commonly used to demonstrate the applicability of nutrition to students.
A summary of the themes and subthemes that emerged from the analysis is displayed in .
Theme 1: Educating medical students to be competent in nutrition is fundamental
Dietitians believed that it was important for medical students to be proficient in nutrition, and this facilitated dietitians to perform their role with enthusiasm. Dietitians' professional experience played a role in developing this passion for teaching. The majority of participants had worked as clinical dietitians and were experienced in explaining how nutrition is relevant to doctors' daily practices. Dietitians' experiences also helped them recognize the key role that nutrition plays in disease prevention and management: “Patients will go to see their doctors and ask them for nutrition advice …; therefore, we need to make sure they [medical students] know about nutrition.”
Theme 2: Feeling confident in their teaching role
Dietitians were confident in their role as nutrition educators. They believed that dietitians were the most qualified health profession for educating medical students about nutrition. Many participants held doctor of philosophy (PhD) qualifications, extra teaching qualifications, or second undergraduate degrees. Dietitians believed that they were appropriate educators because they kept abreast with current nutrition practices: “I feel confident as I have been teaching medical students for a number of years and I am a nutrition academic so am up to date.”
Dietitians were confident in their ability to disseminate appropriate nutrition education. Many factors helped build dietitians' confidence, such as their passion for nutrition, which was identifiable through their enthusiastic tone of voice and commitment to improving nutrition education in medical programs.
Dietitians cited support from surrounding networks, including other lecturers, as contributing to their confidence. These individuals were vital in helping to promote the message that nutrition was an important component of the medical curriculum at their institution. Many dietitians reported that individuals in these networks acted as mentors with whom they could discuss ideas and facilitate improvements in their teaching. Past teaching practices and research experience also contributed to dietitians' confidence: “I have worked in a hospital, so I have actual clinical experience with using some tools that I am teaching about.”
Though dietitians were confident with their personal abilities as nutrition educators, several were uncertain that the nutrition education received by students prepared them for later health care practice. This uncertainty was a significant concern for many dietitians who raised the issue during their interview. Dietitians related this issue to the limited contact hours dedicated to nutrition at their institution and to the separation between nutrition and other medical subjects: “I am not confident about the nutrition education producing graduates with the necessary understanding of nutrition that I would like.”
Theme 3: Utilizing plentiful resources and tools
Dietitians were comfortable with selecting appropriate methods, techniques, and materials and reported having access to a range of suitable resources for teaching. Dietitians believed that it was important to expose students to a range of credible resources to use in later practice. National dietary guidelines, government resources, and evidence-based statements were the most frequently used tools to supplement the recommendations provided through teaching experiences. Dietitians also incorporated research into their teaching. Research was seen as a way to demonstrate applicability of topics to students and assist their understanding of dietitians' research roles: “I try to incorporate research snippets wherever possible. … Just to bring them along on the research road and get them engaged in how dietitians look at research.”
Theme 4: Overcoming challenges of the role
Dietitians experienced many ongoing challenges in their teaching role. The majority of dietitians perceived that nutrition education was not supported by medical faculty. This perception was exemplified by the fact that 2 dietitians volunteered their time and were not compensated financially. Additionally, some dietitians had sole responsibility for the nutrition education content and delivery at their institution but were not involved in any program or curriculum development. This meant the dietitians were unable to generate innovation in teaching and often felt unheard: “The frustration lies in me being very motivated to teach and the students being motivated to learn but the people in charge of formal curriculum development not seeing nutrition as an urgent topic that needs to be taught.”
Dietitians also reported difficulty engaging and communicating with medical faculty to ensure that the nutrition education complemented other curriculum components. Further collaboration between dietitians and medical faculty to provide a “team teaching” environment was suggested as a means to overcome this challenge.
The minimal time dedicated to nutrition also presented challenges, with some dietitians only teaching one 1-hour session per year. Many dietitians were given set topics to cover, such as nutrition for type 2 diabetes, whereas others were asked to provide the topic for an allocated time slot. When dietitians were given full responsibility for topic selection, they reported challenges in choosing what to prioritize. This selection process was a challenge because the dietitians had minimal understanding of medical students' background knowledge in related fields and other topics previously taught to students. Dietitians perceived that this aspect of curriculum planning was disconnected and believed that it did not support adequate student learning. Time constraints within the curriculum also made it difficult for dietitians to prioritize nutrition topics: “The biggest challenge is deciding what to teach them [medical students] because there is so much I could teach and think is important, but I only have 90 minutes.”
Dietitians also mentioned challenges when promoting the importance of nutrition because students often perceived nutrition to be less essential than other subjects. This perception was viewed as the result of poor curriculum planning whereby students received intensive nutrition exposure for a limited period that did not continue throughout their medical training. Lack of exposure to nutrition in medicine created problems when discussing the pervasive relevance of nutrition in medicine and promoting its legitimacy. Dietitians also suggested that students would have more incentive to engage with nutrition if it were assessed in examinations or practical tasks.
Theme 5: Promising opportunities for the future
Dietitians recommended several ways to improve the quality of nutrition education provided to medical students and were confident that such changes could be employed. Dietitians acknowledged that the medical curriculum was already crowded and did not deem it feasible to provide independent nutrition lectures within curricula. Instead, they believed nutrition should be included throughout the curriculum in a more integrated manner. This integration would help students recognize the importance of nutrition within existing curriculum components. One way to progress toward integration would be to embed supplementary nutrition information in relevant lectures: “Just having the curriculum more devoted and integrated to nutrition is important. For example, integrating how nutrition is related in the pathophysiology of diabetes when it is already being discussed.”
Dietitians acknowledged that it was unrealistic to expect medical students to be well versed in all nutrition topics. Students already had a demanding curriculum, so dietitians felt it important to educate on how to source evidence-based guidelines and resources. Another recommendation was for medical students to have more interactions with allied health professionals, including dietitians. Dietitians advised that many students had not been exposed to the role of a dietitian and held ill-informed ideas about their roles in hospital and primary care settings. Many dietitians had experienced previous success in teaching nutrition and dietetics students through multidisciplinary teaching activities, including case studies and problem-based learning. The dietitians perceived that incorporating more multidisciplinary teaching activities into programs would expose medical students to situations where nutrition is applicable. Dietitians believed that this type of multidisciplinary learning would also develop students' recognition of when and how to refer patients to other health care professionals.
This study aimed to explore dietitians' perspectives of teaching nutrition to medical students. The results provide insight into ways to achieve future excellence in delivery of medical nutrition education. Overall, dietitians in this study appeared to be passionate, confident, and qualified as nutrition educators and believed that they were the most appropriate health profession to provide the education. However, dietitians were uncertain that the nutrition education provided produces nutritionally competent medical graduates, warranting further attention on this important topic.
Dietitians as nutrition educators
The results from this study suggest that dietitians are appropriate nutrition educators to teach in medical education institutions. All dietitians had extensive clinical and research experience and many held additional higher education qualifications. Literature supports the idea that dietitians are appropriate to teach nutrition in medical education due to their comprehensive knowledge and experience with nutrition Citation[36–40]. Some doctors and medical students also identify dietitians as suitable sources of nutrition information and recommend dietitians be involved in medical education Citation[41,42]. This literature suggests that dietitians are a qualified, valuable, and desired addition for medical programs and that their expertise should be utilized more often.
Dietitians experience many ongoing challenges in their role in providing nutrition education, including challenge in receiving support from and engaging with medical faculty, minimal time dedicated to nutrition, lack of prioritization of nutrition topics, and lack of promotion of the validity and importance of nutrition to students. Many of these challenges have been previously identified, including lack of support from and engagement with medical faculty Citation[43,44]. The minimal support from medical faculty made dietitians in this study feel isolated and subjugated in their pursuit to enhance the nutrition education of medical students. Lack of communication between disciplines also made it difficult for dietitians to identify topics to prioritize for teaching because they did not have an adequate understanding of students' prior knowledge. This lack of understanding suggests a need for dietetic and medical faculties to work together collaboratively for optimal education of students.
Dietitians in the present study were challenged with regard to the limited time dedicated to nutrition at their institution. Issues with time in medical nutrition education have been described previously Citation[14,44–46]. Lack of dedicated time to nutrition meant that students were often exposed to nutrition for a short, one-off period. This short duration created issues for dietitians when trying to validate the importance of nutrition to students who perceived it to be less essential than other subjects. Early literature on the importance of dietitians as medical educators described the need to convince students, residents, and practicing doctors that nutrition can make a difference in the quality of their patients' lives Citation[47,48]. The results from the present study suggest that greater signposting of nutrition in medical curricula could improve medical students' nutrition competence and facilitate them in gaining an understanding and appreciation for the role of nutrition in their future practices as doctors.
The majority of dietitians in this study believed that medical students' lack of nutrition competence could largely be attributed to program and curriculum development issues. The dietitians perceived that it would be more effective to integrate nutrition content into required courses throughout undergraduate medical training, rather than delivering single-topic nutrition education sessions. Evidence exists that suggests that providing an integrated curriculum is the next step for nutrition education in medicine Citation[49–51]. Formal attempts to introduce integrated nutrition curricula have been made with success in some U.S. institutions Citation[50,51]. In the present study, 2 university-based dietitians indicated that their institution had an integrated curriculum. Both of these dietitians had roles that involved assessing the medical school curriculum and identifying where nutrition could be taught within different clinical systems. The experiences of participants in this study and previous literature provide evidence that integration of nutrition in medical curricula is already implemented in some countries with promising results Citation[49–52]. In order to build upon this momentum, dietetic educators around the world should work with their institution to implement similar structures.
There were some notable limitations in the present study. Firstly, a sampling bias may be present because all participants were English speaking. The participant sample may not be representative because dietitians who were passionate about teaching nutrition to medical students could have been more likely to participate. Secondly, all participants were sourced through the same medical nutrition education network, meaning that the views of interviewed participants may not reflect those of other dietitians. It is also necessary to acknowledge that many doctors and nutritionists are qualified to teach nutrition to medical students and it is not only dietitians who could contribute to improving the nutrition competence of medical students.
In conclusion, the current study investigated dietitians' perspectives of teaching nutrition to medical students. The results suggest that dietitians believed that they were the most appropriate health care professionals to teach nutrition to medical students due to their qualifications, passion, and confidence. However, the dietitians lacked confidence that medical students are graduating with a level of nutrition competence that equips them to provide appropriate nutrition care and attributed this to poor curriculum planning for nutrition.
This study contributes new information for a growing area of dietetic practice and strengthens existing literature surrounding the need for further development of nutrition education in medical schools. To provide the most effective nutrition education to medical students, dietitians need support with overcoming a number of barriers. Some of these barriers may include program and curriculum development issues, inadequate communications with medical faculty, and insufficient time allocated to nutrition. Including dietitians in university medical faculty would promote a cohesive environment between nutrition and medicine and allow dietitians to be involved in curriculum development and planning. Dietitians should also be given the opportunity to integrate nutrition throughout the entire medical curriculum to allow more time and exposure to nutrition in existing curriculum components and to promote the relevance of nutrition to students. To support this area of practice, future competency standards for undergraduate dietetic training should include competencies surrounding educating other health professionals, including medical students.
The authors acknowledge the participants for their involvement and the Need for Nutrition Innovation/Education Programme (NNEdPro) for their assistance with participant recruitment.
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