Abstract
Background. Many diseases are linked to lifestyle in the United States, yet physicians receive little training in nutrition. Medical students’ prior knowledge of nutrition and cooking is unknown. Objective. To determine incoming medical students’ prior nutrition knowledge, culinary skills, and nutrition habits. Methods. A dual-methods study of first-year medical students. Cross-sectional survey assessing prior knowledge, self-efficacy, and previous education of cooking and nutrition. Interviews of second-year medical students explored cooking and nutrition in greater depth. Results. A total of 142 first-year medical students participated; 16% had taken a nutrition course, with majority (66%) learning outside classroom settings. Students had a mean score of 87% on the Nutritional Knowledge Questionnaire versus comparison group (64.9%). Mean cooking and food skills score were lower than comparison scores. Overall, students did not meet guidelines for fiber, fruit, vegetables, and whole grains. Interviews with second-year students revealed most learned to cook from their families; all believed it important for physicians to have this knowledge. Conclusions. Medical students were knowledgeable about nutrition, but typically self-taught. They were not as confident or skilled in cooking, and mostly learned from their family. They expressed interest in learning more about nutrition and cooking.
It is crucial that physicians be equipped with the right tools and knowledge to provide the highest level of care, . . .
The United States continues to struggle with preventable cardiometabolic diseases linked to lifestyle. The prevalence of obesity in adults is up to 39.8%, and 18.5% in children aged 2 to 19 years. 1 Furthermore, 30.3 million Americans or 9.4% of the US population are diabetic 2 ; and 47% of adults in the United States are at risk for cardiovascular disease (CVD), 3 which kills 1 out of 4 Americans 4 and is one of the leading causes of death for both men and women. 4 Not only are these diseases devastating to those affected by them, but managing these conditions is exorbitantly expensive. Every year the United States spends $3.2 trillion on health care, averaging roughly $10 000 per person, with much of this cost directly going to the management and treatment of CVD, diabetes, and cancer. 5 The average medical spending among patients diagnosed with diabetes is 2.3 times higher than those without diabetes. 6
It is crucial that physicians be equipped with the right tools and knowledge to provide the highest level of care, which includes preventive counseling on lifestyle behaviors. Obesity, CVD, and diabetes are all conditions which require a balance of appropriate medical interventions and lifestyle modifications to provide the best outcome for the patient. Unfortunately, medical education is inadequate in training physicians to address the necessary lifestyle modifications needed for patient success,7-9 especially in clinical nutrition. 10 Currently, only 25% of medical schools require a dedicated course on nutrition 8 ; less than one-third of medical interns report feeling they received adequate education on clinical nutrition 11 and only half of graduating resident physicians feel adequately trained to counsel patients on preventative health behaviors. 12 One medical school interviewed students, residents, and physicians, all noting that nutrition education currently in their programs were inadequate. 13 It is not known, however, how much nutrition education incoming medical students possess.
Traditional medical school curricula are not training doctors how to counsel patients about nutrition and lifestyle modification. Recently, a small number of medical schools have developed culinary medicine curricula to help teach these skills. In 2003, SUNY-Upstate Medical School taught the first cooking and nutrition elective, and in 2013, Tulane was the first medical program to open a culinary medicine center. 14 Since these milestones, there are reports of medical schools attempting to supplement traditional medical education to improve medical trainee’s nutrition knowledge.14-16 Culinary medicine is a new evidence-based field that integrates the art of cooking with the science of medicine. 17 Its focus is to help people make informed personal medical decisions about accessing and eating high-quality foods that not only prevent and treat disease but also restore well-being.14,17 Despite these positive developments, the majority of medical students are not receiving comprehensive nutrition or cooking education, and they must rely on preexisting knowledge in these areas.
A clinician’s own health habits predict their ability to counsel patients about food and diet.18,19 For this reason, it is important for health care providers to have a hands-on appreciation, skill set, and knowledge of cooking and nutrition to advocate for their patients to prepare their own food at home, which has been proven to reduce the risk of developing type 2 diabetes 20 and obesity. 21 Obtaining nutrition and cooking information directly from the clinical provider reinforces the importance and relevance of sound nutrition practices from specialist providers.22-24
As future physicians get minimal education in nutrition during their medical school experience, they are likely to rely on nutrition knowledge obtained prior to matriculation or on learning outside of standard medical curricula. The level of incoming medical students’ nutrition knowledge and competency in cooking is not known. The overall objective of this project is to determine incoming medical students’ prior nutrition knowledge, culinary skills, and nutrition habits. This will enable nutrition knowledge and cooking skill deficits to be identified for medical educators to design and implement lifestyle and wellness activities for future physicians.
Methods
Participants
All incoming first-year medical students (class of 2023) of a private medical school in the Southeastern United States were invited to participate in the survey portion of the study. Though located in the southeast, the school admits students from across the country. Participation was voluntary, and no incentives were provided. For the interview portion of the study, a convenience sample of second year medical students were invited to participate, as they were also in the classroom instruction period of their medical education. Second-year students were chosen to participate in interviews as they could provide insight into medical and nutrition curricula.
Recruitment
The study was verbally introduced to students before a class presentation during their orientation week. Then, an email containing a link to an online survey was sent to the entire first year class of medical students, who were asked to complete it before the end of the day; faculty in charge of the orientation provided time during that day to complete the online survey, though participation was voluntary, and students were allowed to not complete it. For the interviews, the study was introduced by email to the entire second year class, and volunteers were then contacted to schedule a time to complete the interview.
Procedures and Measures
Questionnaires were securely and confidentially administered via Research Electronic Data Capture (REDCap). The survey included general sociodemographic data (age range, gender, race/ethnicity) formulated to prevent identification of the participants, with additional questions about their educational background and experience in nutrition and cooking. Students self-reported height and weight, with body mass index (BMI) calculated and classified per Centers for Disease Control and Prevention’s guidelines, 25 and compared with their own weight status perception. This was done to briefly assess students’ awareness of weight status and provide further details on the study sample. For the incoming students, measures and questionnaires were chosen to capture prior knowledge and experience pertaining to nutrition and food preparation (cooking), representing practical, applied aspects of nutrition that could be encountered clinically in medical school, training, and physician practice. Little research has been conducted in the field of medical nutrition knowledge, and few standardized measures were available. The following measures were chosen based on known reliability and validity, use in similar age groups (children vs adults), and applicability to the overall objective of the study. Comparison scores from referenced populations were used for general comparison and illustration:
Nutrition knowledge: The Nutrition Knowledge Questionnaire 26 is a short, 20-item measure used to assess individuals’ knowledge on nutrition topics, using common language pertinent to the health qualities of food. It has established reliability and validity and is comparable to the more in-depth General Nutrition Knowledge Questionnaire. 27
Nutritional habits: The National Cancer Institute’s Dietary Screener Questionnaire (DSQ) was utilized. 28 The DSQ is a 26-item measure that asks the consumption of fruits and vegetables, dairy/calcium, added sugars, whole grains/fiber, red meat, and processed meat during the previous month. The DSQ can be interviewer-administered on paper or the web. It has been used in research in similar age groups. 29
Cooking and food preparation: Given the importance of preparing meals for improved nutrition, measures were selected to assess cooking knowledge, confidence, and self-efficacy. The Cooking Skills and Food Skills Measure30,31 is a 33-item was used to capture culinary abilities and has been determined to be valid and reliable. 31 To capture cooking self-efficacy, eight items were selected from the Culinary Attitude and Self-Efficacy Scales, 32 a valid 22-item measure. Two items were taken from the domain of “cooking techniques and meal prep self-efficacy” pertaining to basic cooking techniques and knife skills, and all items from the “negative cooking attitudes” and “self-efficacy for eating/cooking fruit and vegetables” domains.
These surveys were selected based on current literature to broadly capture participants’ information, using validated or extensively utilized measures. Furthermore, measures were chosen to not be overly burdensome to participants; for example, using the DSQ instead of a longer food frequency questionnaire or 24-hour dietary recall.
Given the lack of previous studies in this area, key-informant interviews were also conducted. The interview guide was developed to explore students’ cooking and nutritional background, sources of knowledge, and pertinence to their education and career (Table 1). Question stems were written by the senior investigator, then iteratively developed and expanded with the rest of the research team; questions were then pilot tested with medical student volunteers not participating in the study to ensure clarity and face validity. To protect confidentiality and minimize participant burden, the interviews were not audio-recorded. Interviews were recorded by hand by an assistant to enable the interviewer being engaged with the participant, though the interviewer made notes on the responses. The responses recorded by the assistant were then compared with that of the interviewer, with a composite transcript jointly developed.
Complete Interview Questions.
Data Analysis
Questionnaires were analyzed and scored according to published guidelines or previous research. Unless otherwise noted, descriptive statistics were used to report results. Sample size and study design prevented association and comparison analysis. The Nutrition Knowledge Questionnaire was scored by recording the frequency of correct and incorrect responses for each prompt. 26 Then the total number of correct responses were tallied and divided by the total number of responses to calculate how the subject group performed as a whole. For general comparison, results were matched against the validation study, originally conducted in a representative European sample of 1043 that had a mean correct score of 64.9%. The mean age of the published comparison group was 52.9 years, 60% of respondents were female, 60% of responders had a self-reported BMI of 18.5 to 24.9 kg/m2, and 75% of respondents’ highest level of education was high school/ vocational school.
The DSQ has a scoring algorithm that is publicly available to use in statistical packages (SAS Institute). 29 The scoring algorithm is based on data from NHANES 2009-2010 and is meant to generate mean intakes that agree with 24-hour dietary recalls 28 ; converting questionnaire responses to estimates of dietary intake for fruits and vegetables (cup equivalents), dairy (cup equivalents), added sugars (teaspoons), whole grains (ounce equivalents), fiber (grams), and calcium (milligrams). The analytic approach for this study followed methods used in previous studies. 29 The output from the questionnaire’s scoring algorithm was then compared to the 2015-2020 US Dietary Guidelines for Americans to assess if the study participants diets met said dietary standards. 33
The Cooking Skills and Food Skills Measure was analyzed as previously reported 31 ; the measure was scored by recording the numeric score recorded for each prompt (1 = very poor through 7 = very good), taking the mean of the recorded responses for each prompt as well as the mean for all the recorded responses, giving a single mean value representing the cohort’s mean cooking and food skills score. Results were compared to a national sample of 1049 European (Irish) adults between the ages of 20 and 60 years, 56% female, and 75% high school/vocational school education level. Comparison mean scores were 5.8 ± 0.12 and 5.9 ± 0.09, respectively. 30 The comparison was made to assess how medical student’s food and cooking skills compared with the population average, though populations differed.
The Culinary Attitude and Self-Efficacy Scales was scored by recording the numeric answer for each prompt: 1 = not at all confident/strongly disagree/not at all to 5 = very confident/strongly agree/about every day. Afterward, each section of questions was analyzed by looking at the frequency of the responses (1-5) and taking the mean of each prompt.
Interviews were analyzed using a content analysis approach, 34 a systematic method for coding and analyzing qualitative data. This method is typically used to explore explicit and covert meanings in qualitative text; for the present study, content analysis was used as a means to systematically classify and summarize responses to free response questions. The investigators each developed a coding library by repeatedly reading and reviewing interview transcripts, then combined into a common coding library, reviewed and refined by the senior investigator. The interview transcripts were then analyzed and coded by the study team systematically, with discrepancies resolved through general discussion. Finally, responses and codes were summarized by interview guide question for general interpretation, and when appropriate, summarized response frequencies were calculated.
The institutional review board at the medical school approved the study design and protocol (IRB00057615). Subject participation in the study was voluntary, and confidentiality was maintained.
Results
A total of 142 questionnaires were completed, a response rate of 96.6% (147 in first-year class) (Table 2). There was an almost even split between females and males, 52% and 48%, respectively; two-thirds (66%) identified as White, 21% Asian, 6% Black/African American, and 6% as biracial. The majority of participants fell into the 21- to 24-year age range, and most of them believed their own weight to be “about the right weight.” Using BMIs calculated from the survey (self-report), concordance between the subjects BMI and perceived weight was 79% (21% inaccurately perceived weight status).
Demographics.
Nutrition Knowledge
First-year medical students had a mean score of 87% ± 14% (n = 138) correct out of 20 questions on the Nutrition Knowledge Questionnaire, scoring higher than the published comparison group, which had a mean score of 64.9% ± 12.4%. 26
Dietary Habits
DSQ analysis showed on average male medical students did not meet the US dietary recommendations for daily intake of fruit, vegetables, or fiber (Table 3). However, on average male medical students did consume more than recommended daily intake of calcium but exceeded the recommended intake of total added sugar. For females, the DSQ showed that on average female medical students did not meet the recommendations for daily intake of fruit, fiber, or calcium. Female medical students on average did not exceed the recommended daily limit of total added sugar.
Dietary Screener Questionnaire (DSQ) Results.
Recommended intake is based on a 2400 calories per day diet using the US Department of Agriculture guidelines
Cooking
The means cooking skills score on the Cooking Knowledge and Efficacy Questionnaire was 4.5 ± 0.77 (n = 134), and a mean food skills score of 4.8 ± 0.49 (n = 134), lower than the published comparison group, which scored 5.8 ± 0.12 and 5.9 ± 0.09 (n = 1049), respectively.30,31
The Cooking Skills and Food Skills measure revealed that most medical students felt confident in their basic cooking abilities (68.6%) and knife skills (56.4%). Most medical students did not feel that cooking is frustrating (69.3%) or that cooking is too much work (51.4%), and almost half of medical students did not feel that cooking took too much time (48.6%). Furthermore, most students reported feeling confident in eating fruits and vegetables at every meal of the day (78.6%), eating fruits and vegetables as a daily snack (62.1%), and eating the recommended 9.5 cups of fruits and vegetables (50.7%) at least several times during an average week, if not every day. Most students also reported feeling confident cooking from basic ingredients (fresh produce, raw meat, etc) at least several times a week if not every day (68.6%).
Cooking and Nutrition Education
The majority (70%, n = 100) of first-year medical students reported that they learned to cook from their families, or learned on their own/self-taught (30%, n = 43). Nutrition knowledge was learned primarily on their own/self-taught (58%, n = 83). Students also reported learning about nutrition through their family (17%, n = 24) and via a classroom learning environment (16%, n = 23). Health care providers and medical education professionals were the least frequently noted for teaching cooking, 1%, and nutrition knowledge, 6%. Students also consistently listed social media as an avenue for learning about both cooking (17%, n = 24), and nutrition (11%, n = 16). Only 2 students had undergraduate or graduate degrees in nutrition.
Interviews
Fifteen interviews were initially conducted and preliminarily analyzed, and it was determined that new information was being obtained (Table 4). Five additional interviews, making 20 total, were conducted, yielding no additional new information, at which point saturation was reached. From content analysis, answers to interview questions were grouped into similar or like responses, and frequencies calculated. Students reportedly ate home-cooked dinners 6 nights a week, with 50% (n = 10) of students reporting they ate out more than 1 time per week. It was reported that 55% (n = 11) of students will do weekly meal preparations to provide multiple meals throughout the week. When asked if they considered themselves good cooks, 45% (n = 9) rated themselves as good cooks, 35% (n = 7) as average cooks, and 20% (n = 4) as poor cooks. When asked about how they learned to cook, 75% (n = 15) learned to cook from their families, with 20% (n = 4) learning from social media. When asked how often they tried cooking a new recipe, 75% (n = 15) reported trying one out on at least a monthly basis. In terms of shopping and purchasing ingredients, 65% (n = 13) reported preparing to shop by creating a shopping list, and 95% (n = 19) did not express any concern for the amount of money they spent shopping for food. All (100%, n = 20) wanted to learn more about nutrition and believed that it was important for physicians to have nutritional knowledge; the majority wanted to learn more about cooking, were interested in changing some aspect of their current diet, and believe that it is important for physicians to have knowledge of cooking skills.
Student Interviews.
Discussion
First-year students at one medical school in Southeastern United States had slightly better nutritional knowledge than a comparison population, but little background or formal education in nutrition or cooking. Comparatively, students were less skilled than published averages in cooking and food preparation. Most of the nutrition and cooking knowledge the medical students possess is self-taught or learned outside the traditional classroom setting (ie, parents or other family members). As with much of the population in the United States, medical students are not consuming the recommended amounts of fruit, vegetables, fiber, and grains, and were eating too much sugar. With the importance of nutrition in disease prevention, and the lack of education provided in the majority of medical schools,7-10 more concerted efforts are needed to prepare future physicians in this area, such as assessing dietary intake, nutrition counseling, and use of evidence-based nutritional resources,35-38
Very little is known on the nutrition and culinary habits of medical students, but this prior knowledge is important given the limited nutrition education provided during their training.7-9 Medical students in this study had a solid nutritional knowledge base but may have difficulty in adapting their knowledge for practical use in food preparation and nutrition management. In particular, few of the participants had formal education in nutrition, which is of concern given that they will be expected to provide counseling to patients as practicing physicians. Medical students at this institution are less skilled and confident when it comes to preparing food. Collectively, it is not surprising their dietary patterns resembled that of others in the United States, such as not meeting daily recommended amounts of fruits, vegetables, and other healthful foods. Classroom education in cooking and nutrition is lacking, which may lead students to research these topics on their own and rely on potentially unverified sources for this information. This is especially problematic in the era of social media where information does not have to be evidence based and/or peer reviewed, setting up students to potentially fall prey to misinformation.39-42
As rates of metabolic disease increase, it is imperative that physicians and other clinicians have the tools necessary to treat these patients in a holistic manner. Particularly with regard to nutrition, physicians can be a resource for their patients, using the trust and relationship between doctor and patient to guide them toward a healthier lifestyle. Unfortunately, these skills are not taught in medical school.7-10 Therefore, most of medical student’s nutrition knowledge comes from pre-medical school education. At the medical school studied, they received minimal formal education in nutrition and food preparation, but instead are relying on self-education, which can leave them with insufficient or inaccurate information and clinical skills. Based on the findings of this study, future doctors are not starting their training equipped to counsel, educate, or guide patients in changing nutritional practices. It is not surprising, then, that most physicians-in-training (residents) do not feel equipped to counsel patients on graduating.11,12,43 To better prepare physicians for lifestyle counseling, medical schools should increase focus on students’ training in nutrition science.
Teaching culinary medicine through hands-on cooking classes and applied nutrition in medical school could impact on how future doctors treat lifestyle disease. First, these skills are important for the personal health and longevity of the provider. In 2007, approximately 23% of physicians were obese, and 40% overweight 44 ; about half of doctors report trying to lose weight. 45 This finding illustrates that even healthcare experts are not immune from poor diet and obesity and would benefit from hands-on practical knowledge about food and nutrition. Second, the weight status of a physician has been shown to affect their nutrition counseling practices. Doctors of normal BMI were not only more likely to engage their patients in weight management but were also more confident in their ability to provide diet and exercise counseling to their patients. 46 It is paramount that physicians learn these skills not only to protect their own health but also to become an effective advocate for their patient’s health.
There are several limitations to this study. It only examined a single medical school in the southeast United States, which limits its ability to determine the knowledge of incoming medical students nationally regarding nutrition and cooking. Only first- and second-year students were interviewed, as it is unknown if some of these findings would change as student’s progress through their medical training, though it is doubtful given the paucity of nutrition curricula in medical schools. Regarding culinary and nutrition knowledge, it could be reasoned that they would acquire the knowledge “osmotically,” but with no formal curriculum in those years, it is unknown. However, their value or desire for more learning in these areas could increase or decrease as they progress through the clinical years. The measures and questionnaires used may not have captured all the domains desired to assess student knowledge and ability, there was no control group in this study, and comparison with other studies or populations was general in nature (comparing student scores in this study to other published results). The referenced comparison groups were not similar to the sample population of this study; unfortunately, there are few standardized measures capturing the information of interest in this study. Therefore, comparison group data was provided for general comparison and illustration only. More research is needed in this area. While the interviews were deemed to have reached saturation by the investigators, it was still a small sample (n = 20) of first- and second-year students from one institution.
Conclusion
Medical students have an above average prior knowledge in nutrition, but they struggle to apply that knowledge to practical applications of food preparation. This nutrition knowledge is mostly self-taught outside of the classroom setting, and cooking skills are mostly learned from family. Medical students recognize the importance of nutritional knowledge and cooking skills and would like to further their knowledge in these topics. Future medical education could embrace the educational model of culinary medicine by using hands-on cooking techniques to teach nutrition and its application to food preparation to enable future doctors to address the health of patients related to lifestyle and chronic disease.
Footnotes
Acknowledgements
The authors would like to thank to Marcia Wofford, MD, Stacy Schmauss, EdD, and Lindy Williams MD for their assistance in conducting the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the NRSA Short-Term Research Training Grant, National Institute of Diabetes and Digestive and Kidney Diseases, 5T35DK007400-4 (PI: Donald McClain).
