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Research Article
Enabling Valuation of Nutrition Integration into
MBBS Program
Niikee Schoendorfer and Jennifer Schafer
DisciplineofMedicalEducation,SchoolofMedicine,UniversityofQueensland,MayneMedicalBuilding,Herston,QLD4006,Australia
Correspondence should be addressed to Niikee Schoendorfer; n.schoendorfer@uq.edu.au
Received November ; Revised April ; Accepted April
Academic Editor: Rose Ann DiMaria-Ghalili
Copyright © N. Schoendorfer and J. Schafer. is is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Good nutrition is the foundation for good health. While basic nutritional assessment is part of many medical consultations, it
remains underutilized despite becoming increasingly recognized as important for chronic disease prevention and management.
Many studies identify shortfalls in physicians’ knowledge and attitudes toward nutrition as a result of inadequate emphasis in
medical school. Additional teaching about nutrition and nutritional assessment procedureswas integrated within a rst year module
of a MBBS program. Blended learning techniques were employed to facilitate student engagement and sessions were evaluated via
student response system technology (clickers) or minute paper feedback. e initial survey to all medical students (𝑛 = 1037)
documented that less than half (%) felt they could discuss nutrition with patients. e majority (𝑛 = 606) regularly consulted the
internet for nutrition information, while only utilised peer-reviewed journals. With the rst year cohort (𝑛 = 297) “clic k ers”
revealed that % felt nutrition important to health care and % felt it important in general practice. % found using clickers an
interesting enhancement, whilst % notedthe nutrition content informative. Early nutrition teaching was well received by students.
Long-term increases in nutritional informationdiss emination, particularly by inuential health care workers, might benet not only
economies but also the health of society as a whole.
1. Introduction
Nutrition assessment and advice are underutilized in medical
practice despite becoming recognized as increasingly vital [].
e rise of chronic diseases such as type diabetes and car-
diovascular disease may be attributed to long-term poor diet
and lifestyle choices. In more than half of the leading
causes of death in the USA were associated with poor dietary
intake []. General practitioners are the rst point of contact
to address patients’ needs and concerns, including that of
nutrition and dietary advice. A large consumer telephone
survey was conducted in the Netherlands in order to ascertain
public preference and perceived expertise of dierent
sources of nutritional information. Results indicated that pri-
mary care physicians scored the highest (%) with respon-
dents choosing physicians for nutrition information above
both dieticians (%) and the Food and Nutrition Education
Bureau (%); despite only ranking rd in level of perceived
expertise, primary care physicians ranked the highest as
public preference to receive nutritional advice []. Despite
sometimes large dierences in health systems and medical
education methods internationally, the same barriers to
the provision of nutrition services and nutrition education
appear to exist.
In a nationwide survey in the USA was conducted to
assess the extent of physicians providing nutritional informa-
tion, which resulted in a total less than % indicating their
use of nutrition in patient treatment plans []. As a result,
the US Department of Health and Human Services issued
a national objective to increase the number of physicians
providing nutritional screening or education to their patients
[]. In a follow-up survey demonstrated only a slight
increase in numbers to less than % []. Over the years sim-
ilar reports have been presented which have led to increased
calls for emphasis on and reform of nutrition education of
physicians []. e US governments Healthy People
objectives identied this decit and included a target goal
of % of physicians oering nutrition counselling to the
Hindawi Publishing Corporation
Journal of Biomedical Education
Volume 2015, Article ID 760104, 6 pages
http://dx.doi.org/10.1155/2015/760104
Journal of Biomedical Education
majority of their patients []. Today in their Healthy People
Topics and Objectives, physicians providing nutritional
and dietary counselling are still a priority [].
e only national guidelines in Australia on nutritional
topics which should be covered during medical education
werepublishedoveryearsagobytheNationalHealthand
Medical Research Council and there are no current guidelines
in this area. Considering the exponential rate of discovery
through research, particularly in the health sector over the
past decade, the signicance placed on nutritional informa-
tion and its dissemination should be addressed. e Aus-
tralasian Medical Council (AMC) does however encourage
medical schools to provide teaching and learning strategies
which address a number of objectives relating to knowledge
and understanding of nutritional therapies. is AMC docu-
ment also highlights that Medical Board guidelines encour-
age doctors to present all information available to allow
patients to make informed choices relating to their manage-
ment [].
Literature surrounding small group activities has shown
numerous positive outcomes such as higher academic
achievement [] and self-esteem [], increased positive atti-
tudes toward the subject area studied, greater persistence and
acceptance of dierences among peers, and greater retention
across a wide range of educational settings []. While inter-
acting with classmates, students are met with a variety of ideas
from peers and have the responsibility of comparing, con-
trasting, and criticizing these ideas for themselves. Active
learning, such as this, is much more like life-long learning
than the mere recital of lecture content [].
To benet the students, lectures should contain interac-
tive components and should not be entirely passive. Learning
has been shown to be more permanent and meaningful when
students take a more active role in the process []. Schlechty
outlined the criteria for what he terms educational design
qualities, based on the premise that when learning activities
are created using this criterion, the students will be more
likely to engage in their work, persevere, and nd satisfaction
within it. ese qualities include activities which improve
formativefeedback,aswellasthosedesignedtoencourage
cooperative action between students and their peers. In order
to achieve good educational practice, given tasks were varied
and required that students acquire new skills, as well as
dierent approaches, presentation styles, and modes of anal-
ysis [].
is project set out to assess students’ perceptions of the
valueofnutritionandarangeofinteractiveandinnova-
tive teaching practices, including small group learning on
improving student’s knowledge and skills in the area of nutri-
tion. Evaluation tools and other classroom assessment tech-
niques were also utilized to increase student engagement and
knowledge retention, as well as gain feedback []. e lec-
tures also contained interactive components for students to
take a more active role in their learning process []. Blended
learning tools such as a variety of online resources, such as
links to government public health and nutrition program
support websites, health organization, and other credible and
nutritionally relevant materials (Appendix), alongside the
interactive lecture formats, were made accessible to students.
With increasing international support for the develop-
ment of integrated nutrition curricula in medical schools, it is
essential to evaluate the impact and assess its outcomes, while
continuing to improve teaching and learning methods as
action research cycles. e aim of this project was to evaluate
students’ perceptions of nutrition and the use of a variety of
blended learning techniques, to enhance medical student’s
engagement and clinical practice development in relation to
nutrition education in the rst year Bachelor of Medicine and
Bachelor of Surgery (MBBS) students.
2. Materials and Methods
Attheoutsetoftheprojectaschoolwidesurveywasalso
conducted to ascertain attitudes and perceived nutritional
knowledge of all current medical students years – at the
University of Queensland (UQ) (𝑛 = 1037). Relevant faculty
members were also engaged and requested to provide details
forwhereineachoftheircoursesnutritioncontentwas
included.
First year medical students (𝑛 = 297)participatedinan
add-on series of small group interactive nutritionally based
educational sessions, integrating with their existing Gas-
trointestinal/metabolism module which spans weeks and
includes other educational components. e initial session
delivered over weeks and of the module comprised an
overview of nutrition as possessing both nutritive and phar-
macological properties, as well as the current state of evidence
relating to the function and uses of probiotics. e second half
of the rst -hour session included a practical component,
where students completed their own nutrition assessments.
e second session was delivered to small groups at the con-
clusion of the Gastrointestinal/metabolism module. is ses-
sion was composed of both evidence-based research informa-
tion and practical role-playing components, to tie in the the-
ory delivered over both sessions. Learning revolved around
nutritional causes and potential treatments, as well as the
biochemical mechanisms of action in relation to obesity and
type II diabetes, with emphasis placed on utilizing primary
research literature. Students were not required to do any
preparation prior to the sessions.
is preliminary session was blended with the use of
student response systems “clickers” not only to gain feedback
from the students at the session’s conclusion, but also to assist
them in summarizing important points throughout the lec-
ture content.
Nutritional assessments in both sessions were completed
using modied versions of REAP and WAVE tools []. ese
tools have been developed by Brown University, USA, and
wereadaptedwithpermissionintoAustralianstandards.e
REAP or Rapid Eating Assessment for Patients is a food
frequency questionnaire, which can be lled out by patients
whiletheyareinthewaitingroom.eREAPtoolisdesigned
to allow immediate recognition of any nutritional issues at
aglanceandhenceisfeasibleforuseinthegeneralpractice
setting. e WAVE or weight, activity, variety, and excess tool
is a desktop ash type card with key inquiries on one side and
recommendations on the other.
Journal of Biomedical Education
e second session was presented as role-play case studies
utilizing the WAVE and REAP tools, in a -minute consulta-
tion style format. A variety of patient information tools were
also provided to be used as an adjunct during the consul-
tation. In pairs the students took turns at being the patient
and physician with a concluding facilitated whole group
discussion. A proportion of the groups were also video-taped
and reviewed by the students for reection, which may assist
students in gauging their own progress and methods of
enquiry.
Minute papers, by Angelo and Cross, were used on com-
pletion of these sessions asking “What was the most impor-
tant thing learned in the class?,” “What important questions
remain unanswered?,” and “Are there any improvements you
could suggest for this session?” Students were provided with
small pieces of paper outlining the above questions along with
space for their brief responses. is method enables session
evaluation in a very short time period and engenders no
further participant burden. ese authors have designed a
number of classroom assessment techniques (CATs) as a type
of simple evaluation utilized to collect data on student learn-
ing, with the aim of improving it. ey are designed to gain
feedbackandassistteachersinndingoutwhatandhowwell
students are learning [].
3. Results
e initial school wide survey administered to all medical
students (𝑛 = 1037) documented that less than half (%) of
the students felt they knew enough about nutrition to counsel
patients. Interestingly the majority of students (𝑛 = 606)reg-
ularly consulted the internet for information about nutrition,
while only utilised peer-reviewed journals. e remaining
results of this component are currently under analysis.
Participating students (𝑛 = 297) responses with the
“clickers,” utilised during the rst sessions, revealed that %
felt nutrition was important to health care and % felt it is
important in general practice (Figure ). % of the students
found using the clickers to be an interesting enhancement to
the session (Figure ), whilst % noted the nutrition content
to be informative.
When asked about their preferred choice of “junk” food
or vegetables snacks, students responded with % and %,
respectively. When asked about the one which they would be
more likely to choose, responses were % and %. e main
driving force for their consumption was based on taste (%),
availability(%),andprice(%),followed,then,byhealth
(%) and peers (%).
In relation to the multiple choice questions which
appeared periodically throughout the session, the majority of
students were able to answer correctly. When asked “Which
micronutrient assists in both immune function and tissue
synthesis” % of students correctly answered Vitamin C. In
response to the question “Which most accurately describes
factors which determine nutrient needs” % identied
absorption, metabolism, and excretion, as well as food intake
and underlying disease, as had been discussed during the
session.
0
10
20
30
40
50
60
70
Strongly
agree
Agree Neutral Disagree Strongly
disagree
Response (%)
Nutrition is an important part of
general practice
F : Clicker response system result from rst series session.
0
10
20
30
40
50
60
70
Strongly
agree
Agree Neutral Disagree Strongly
disagree
Response (%)
I found using the clickers an interesting
enhancement to this session
F : Clicker response system result from rst series session.
For the second series of sessions % of students felt they
wouldutilisethenutritionalassessmenttoolsiftheywerein
general practice, while % were opposed and % unsure
(Figure ).
Students’ qualitative feedback on the educational sessions
is outlined in Tab l e . Major emerging themes included some
students recommending further lecture time to enhance their
understanding of the underlying biochemical mechanisms of
nutritional interventions, whilst others indicated that more
practice at nutritional consulting would be benecial. e
sessions were overall well received with more students pre-
ferring practical components over theory.
4. Discussion
In phase I of the UQ MBBS program, students receive approx-
imately hours of formal nutrition education not including
theinformallearningwithinPBLgroups,asinformedby
relevant faculty. In phase II, nutrition is thought to be
considered where appropriate; however there is no standard
to ensure this is being completed. In light of this, the introduc-
tion of increased nutrition components is being investigated
to address this shortfall, beginning with phase I of the
program.
Withalmosthalfoftheentirestudentcohortfromyears–
documenting insucient knowledge to mention nutrition
to patients, the limited training provided may be a causal fac-
tor in the lack of nutritional assessment and advice utilized in
Journal of Biomedical Education
T : Students’ feedback when asked, “Are there any improvements you could suggest for the session?”
Session Overall theme Selection of quotes
Part : interactive
lecture
Some students indicated they would have
liked additional lecture time given the broad
scope of nutritional interventions and others
indicated additional practical exercises
would be benecial.
“I enjoyed the power point lecture and wished it could have
been longer”
“More focus on mechanisms of action”
“Considering the vast scope of nutrition and health, session was
a brief overview”
“Exemplar video examples of experts taking cases and providing
advice”
“Maybe less of a focus on research and more practical tips on
approaching weight loss with our patients”
“Best ways to convince people to change their diet”
Part : practical case
studies
More students were in favor of the practical
applications over the research details.
“More interactive activities and shorter lecture”
“Breaking up lecture with more activities to maintain interest”
“Spend more time doing cases”
“Case studies at the end were most useful. Not sure whether
these could be worked in throughout to be even more
interactive?”
Part : practical case
studies: subset who
participated in the
videotaped role plays
ese sessions were generally well received
“Really great, interactive, educational session”
“Very good”; “Interesting”
“I found this session much more interesting and applicable then
the rst. I will try and eat better as a result of what I have
learned. Good session overall”
0
20
40
60
80
Yes No Unsure
Response (%)
Do you think you would use the
practical tools if you were in general
practice?
F : Clicker response system result from second series session.
current medical practice. In order to ascertain the importance
students placed on their own food choices, they were asked
whether they preferred or would likely choose either junk
food or vegetable snack options. More students preferred
junk food and only a small percentage of these indicated
theywouldmorelikelychoosehealthieroptions.Considering
that the majority of students documented that nutrition was
an important part of healthcare, nutrition as such was not
highly considered when selecting food choices. is disasso-
ciation of food consumption and health outcomes might be
explainedbythelackofemphasisofnutritionintheirmedical
schoolcurriculaandalsoincurrenthealthcaremodels.
Another deliberation is the commonly large scale availability
andlowpricepointforunhealthyfoodchoices.isin
reection with the sometimes limited budgets of medical
students need also be considered.
It is well established that many blended learning tech-
niques and activities might be useful in assisting students with
the integration of knowledge and the development of deeper
thought processes such as critical thinking and problem solv-
ing. Bloom’s Taxonomy of Educational Objectives identies
these types of objectives as higher level intellectual processes
such as analysis, synthesis, and evaluation []. is cohort
found the practical application of the theoretical components
to be benecial to their learning and also conducive to their
willingness to participate in the blended learning sessions.
Another important component is feedback, which is
more than it is merely happening or not happening. Tech-
nologies such as “clickers” provide immediate responses to
students as to the state of their current understanding of
topics being discussed. Good practice gives prompt feedback
which should happen reasonably soon aer the learning
activity []. What is needed for a lecture to be eective is for
evidenceonperformancetobeavailableatthetimesocorrec-
tionscanbeprogressivelymadewhennecessary.eclicker
technology is a useful method to provide this immediate
feedback and also enhance student engagement.
Regular intervals which allow students to discuss previ-
ous material can help them to summarize and clarify related
information before moving on []. As opposed to asking
questions at the end of a lecture period, utilizing a step-by-
step lecture method whereby the content is arranged into any
number of short periods of exposition, followed by a class
discussion has been shown to be more eective []. In this
way students can also receive their own immediate feedback
and gauge their understanding and progress through the sub-
ject material while keeping them motivated. If things are not
clear at any stage in a learning process, it is better to resolve
these issues before the problem becomes any more extensive.
Most of the students in the cohort were able to answer
multiple choice questions correctly when they were posi-
tioned periodically throughout the lecture, which demon-
strated their engagement with the theoretical lecture style
Journal of Biomedical Education
content. is type of arrangement has been documented to
lend its success to a number of additional variables along with
the benets of immediate feedback. ese include the oppor-
tunity for rehearsal and the reduction of retroactive interfer-
ence, along with the eect of a change of activity and stim-
ulation on the potential decline of students’ attention [].
e students seemed overall in favor of the interactive nature
of the sessions, some making comments about further inte-
gration of the practical component discussions throughout
the initial background research lecture, to maintain their
concentration and interest. Many suggested a greater interest
in the “case studies” rather than the research and background
theories. ose who participated in the video-taped role plays
found the sessions to be most useful.
Limitations to this study included the inability to formally
assess students on their actual content knowledge before and
aer the additional nutrition sessions. Summative evaluation
of students’ ability to perform a clinical nutritional assess-
mentwouldhavealsobeenbenecial.
5. Conclusions
Favorable feedback was highlighted with the provision of
nutrition education and also the utility of blended learning
techniques to enhance student engagement. Importantly
nutritionasthetopicfocuswasdeemed,bystudents,as
essential to their education and also to healthcare practices.
Integration of nutrition in medical education should enhance
future primary care physicians’ ability to recommend nutri-
tion. e underlying processes should recognise nutrition
as both being the cornerstone of preventative health and
being vital to lowering the risk of chronic disease pathologies.
Increasing this awareness, in both physicians and their
patients, may assist in modifying treatment plans and allow
for further health recommendations as opposed to being lim-
ited to drug types of therapy. e burden of rising health care
costs as morbidity, prospective drug prescriptions, and their
potentialsideeects,mayalsosubsequentlybereduced.
Appendix
Online Nutrition Support Resources
Australian Government Health Promotion websites are
(i) Australian Dietary Guidelines and support resources:
http://ww w.eatforhealth.gov.au/,
(ii) Go for & fruit and veggie ideas: http://ww w
.goforand.com.au/,
(iii) Happier Healthier nutrition and tness: http://health-
ier.qld.gov.au/tness/,
(iv) Better Health Channel: http://www.betterhealth
.vic.gov.au/bhcv/bhcarticles.nsf/pages/healthy living
?open,
(v) Public Health Nutrition programs: http://ww w.pub-
lic.health.wa.gov.au////nutrition and healthy
weight.pm.
Other healthy recipe sites to assist in ideas and menu
planning are
(i) http://www.healthyfoodguide.com.au/,
(ii) http://www.betterhealth.vic.gov.au/bhcv/bhcsite.nsf/
pages/bhc recipes,
(iii) http://daa.asn.au/for-the-public/smart-eating-for-you/
recipes/browse/.
For kids sites are
(i) http://www.healthykids.nsw.gov.au/recipes.aspx,
(ii) http://healthy-kids.com.au/parents/recipes/,
(iii) http://kidshealth.org/kid/recipes/index.html.
Activity calorie counter site is
(i) http://www..com.au/balance-and-burn/kj-activ-
ity-comparison/.
Consumer information site is
(i) http://www.foodstandards.gov.au/consumer/Pages/
default.aspx.
Nutrient reference values site is
(i) http://www.nrv.gov.au/.
Drug and supplement information site is
(i) http://www.nlm.nih.gov/medlineplus/druginforma-
tion.html.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
Acknowledgments
Teaching, Education, and Scholarship of Learning (TESOL),
e University of Queensland, provided start-up funding
for this pilot project. Centre for the Discipline of Medical
Education Research and Scholarship (CDMERS) provided
follow-up funding for the project. Brown University allowed
the adaptation and use of a standardized Australian version
of their WAVE and REAP tools. Educational Innovation and
Technology, UQ, provided support with “clicker” technology.
University of Queensland Assessment Network (UQAN)
provided mentoring support. Tracey Seipel and Nita Sharp
are acknowledged for their teaching support.
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