Low priority of obesity education leads to lack of medical students' preparedness to effectively treat patients with obesity: Results from the U.S. medical school obesity education curriculum benchmark study

Abstract

Background:
Physicians are currently unprepared to treat patients with obesity, which is of great concern given the obesity epidemic in the United States. This study sought to evaluate the current status of obesity education among U.S. medical schools, benchmarking the degree to which medical school curricula address competencies proposed by the Obesity Medicine Education Collaborative (OMEC).

Methods:
Invitations to complete an online survey were sent via postal mail to 141 U.S. medical schools compiled from Association of American Medical Colleges. Medical school deans and curriculum staff knowledgeable about their medical school curriculum completed online surveys in the summer of 2018. Descriptive analyses were performed.

Results:
Forty of 141 medical schools responded (28.4%) and completed the survey. Only 10.0% of respondents believe their students were "very prepared" to manage patients with obesity and one-third reported that their medical school had no obesity education program in place and no plans to develop one. Half of the medical schools surveyed reported that expanding obesity education was a low priority or not a priority. An average of 10 h was reported as dedicated to obesity education, but less than 40% of schools reported that any obesity-related topic was well covered (i.e., to a "great extent"). Medical students received an adequate education (defined as covered to at least "some extent") on the topics of biology, physiology, epidemiology of obesity, obesity-related comorbidities, and evidence-based behavior change models to assess patient readiness for counseling (range: 79.5 to 94.9%). However, in approximately 30% of the schools surveyed, there was little or no education in nutrition and behavioral obesity interventions, on appropriate communication with patients with obesity, or pharmacotherapy. Lack of room in the curriculum was reported as the greatest barrier to incorporating obesity education.

Conclusions:
Currently, U.S. medical schools are not adequately preparing their students to manage patients with obesity. Despite the obesity epidemic and high cost burden, medical schools are not prioritizing obesity in their curricula.

Full text

R E S E A R C H A R T I C L E Open Access
Low priority of obesity education leads to
lack of medical students’preparedness to
effectively treat patients with obesity:
results from the U.S. medical school obesity
education curriculum benchmark study
W. Scott Butsch
1
, Robert F. Kushner
2
, Susan Alford
3
and B. Gabriel Smolarz
3*
Abstract
Background: Physicians are currently unprepared to treat patients with obesity, which is of great concern given
the obesity epidemic in the United States. This study sought to evaluate the current status of obesity education
among U.S. medical schools, benchmarking the degree to which medical school curricula address competencies
proposed by the Obesity Medicine Education Collaborative (OMEC).
Methods: Invitations to complete an online survey were sent via postal mail to 141 U.S. medical schools compiled
from Association of American Medical Colleges. Medical school deans and curriculum staff knowledgeable about
their medical school curriculum completed online surveys in the summer of 2018. Descriptive analyses were
performed.
Results: Forty of 141 medical schools responded (28.4%) and completed the survey. Only 10.0% of respondents
believe their students were “very prepared”to manage patients with obesity and one-third reported that their
medical school had no obesity education program in place and no plans to develop one. Half of the medical
schools surveyed reported that expanding obesity education was a low priority or not a priority. An average of 10 h
was reported as dedicated to obesity education, but less than 40% of schools reported that any obesity-related
topic was well covered (i.e., to a “great extent”). Medical students received an adequate education (defined as
covered to at least “some extent”) on the topics of biology, physiology, epidemiology of obesity, obesity-related
comorbidities, and evidence-based behavior change models to assess patient readiness for counseling (range: 79.5
to 94.9%). However, in approximately 30% of the schools surveyed, there was little or no education in nutrition and
behavioral obesity interventions, on appropriate communication with patients with obesity, or pharmacotherapy.
Lack of room in the curriculum was reported as the greatest barrier to incorporating obesity education.
Conclusions: Currently, U.S. medical schools are not adequately preparing their students to manage patients with
obesity. Despite the obesity epidemic and high cost burden, medical schools are not prioritizing obesity in their
curricula.
Keywords: Obesity, Medical school curricula, Obesity education, Medical student, Medical school education
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: drsmolarz@gmail.com
3
Novo Nordisk Inc, 800 Scudders Mill Rd, Plainsboro Township, NJ 08536,
USA
Full list of author information is available at the end of the article
Butsch et al. BMC Medical Education (2020) 20:23
https://doi.org/10.1186/s12909-020-1925-z
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Background
Obesity is a major public health threat and leading cause
of morbidity and mortality in the United States today
[1]. The prevalence of obesity is nearly 40% in U.S.
adults, with higher rates among certain minority groups
[2]. Despite the health and economic impact of obesity
on individuals and society [3,4], medical students re-
main inadequately trained in obesity and obesity man-
agement. A recent survey of medical students found that
understanding genetic and biological factors related to
obesity correlated with better counseling skills for pa-
tients with obesity [5]. This underscores the need to
educate medical students on the disease of obesity to re-
duce bias and improve patient care.
Little progress has been made to incorporate obesity
education into undergraduate medical curricula despite
studies describing insufficient medical student training in
obesity counseling and medical management of obesity [6–
8]. In addition, the 2007 Association of American Medical
Colleges (AAMC) call to action report, which con-
cluded that “medical education must assure that future
physicians will be better prepared to provide respectful, ef-
fective care of overweight and obese patients”and that
education on preventing and treating obesity should be in-
cluded in medical school curricula, has not led to any
meaningful change in medical education and training [9].
Several studies have uncovered the paucity of nutrition
education, an essential component of comprehensive obes-
ity education, in U.S. medical schools [10,11]. A recent
survey on nutrition education reported students receive an
average of 19 h of nutrition education over the course of
medical school, most within the pre-clinical years, falling
short of the recommended 25-h minimum [11]. In
addition, a recent study found a limited number of refer-
ences to obesity in the United States Medical Licensing Ex-
aminations (USMLE). The USMLE focuses on weight-
related complications of obesity such as type 2 diabetes ra-
ther than the disease of obesity itself [12].
To date, there is no literature describing the state of
obesity education in undergraduate medical education.
The aim of this study is to report how obesity is cur-
rently addressed in the curricula of U.S. allopathic med-
ical schools and provide a benchmark from which we
can assess progress toward as well as understand barriers
to implementing core competencies in obesity.
Method
Between July and September 2018, we sent invitations to
medical school curriculum deans and administrators at
141 accredited allopathic U.S. medical schools identified
from the AAMC membership list to request their volun-
tary participation in this cross-sectional study consisting
of an online survey [13].
Survey participation was limited to allopathic medical
schools in the U.S., excluding Puerto Rico. Responses were
restricted to one representative per medical school to en-
sure consistent data and equal representation of each insti-
tution. Online searches identified a total of 552 potential
respondents within the qualifying medical schools using
their title as an indicator of curriculum knowledge, e.g.,
Dean of Medical Education. Potential respondents received
a postal mailing with a letter identifying the study sponsor
(Novo Nordisk) and key collaborators (Drs. Scott Butsch
and Robert Kushner), study objectives, participation re-
quirements, and a modest prepaid incentive of $50 in the
form of a check. At least one follow-up telephone call, fax
or email was used to remind non-responders to participate.
To participate, respondents had to confirm a current role
in undergraduate medical education and knowledge of
their four-year curriculum.
The survey instrument was comprised of 33 questions
addressing the structure, format, content, and method of
education; it included multiple choice, scalar, and nu-
meric text questions. Using a 4-point Likert scale (“great
extent”,“some extent”,“very little”,“not at all”), respon-
dents were asked about coverage of topics related to the
core obesity competencies established by the Obesity
Medicine Education Collaborative (OMEC) [14]. We
also asked respondents about their expectations regard-
ing future incorporation of obesity into the curriculum
and perceived importance of obesity education. The
complete survey is available [see Additional file 1].
Statistical analysis
We performed descriptive statistical analysis (means, fre-
quencies) using SPSS Statistics for Windows 15.0.1
(SPSS, Chicago, Illinois) and Stata/IC 14/1. Data are pre-
sented as number and percentage for categorical vari-
ables, and continuous data expressed as the mean ±
standard deviation (SD) unless otherwise specified.
Results
Characteristics of respondents
Forty medical schools (28.4% of U.S. medical schools)
responded and completed the survey. These schools
(Table 1) are representative of the universe of medical
schools in the U.S. [15] in terms of geographic regions
(current distribution: Northeast-28.4%, Midwest-24.1%,
South-34.8% and West-12.8%) and public and private
(60 and 40%, respectively) funding source. Median time
to complete the survey was 9 min. Respondents had nearly
20 years of experience in undergraduate medical education
and 75.0% of them were medical school deans of educa-
tion. More than three-quarters of the respondents were
“very familiar”with the four-year curriculum and all ex-
cept two reported teaching medical students. See Table 1
for sample characteristics.
Butsch et al. BMC Medical Education (2020) 20:23 Page 2 of 6
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Structure of curriculum
Only 7.5% of medical schools reported offering obesity as a
standalone course while 60.0% integrated a few elements of
obesity education into a broader clinical nutrition or pre-
ventative medicine course. Some medical schools (20.0%)
used virtual learning systems, e.g., Nutrition in Medicine™
modules, to provide obesity education. Although only 17.5%
of medical schools reported teaching obesity in an outpatient
clinical medicine rotation, nearly half (47.5%) reported offer-
ing elective shadowing opportunities with non-medical pro-
viders such as dietitians and psychologists who treat obesity.
Content of curriculum
A mean of ten hours of specific obesity education was
taught across the four-year curriculum, however less than
40% of schools reported covering any topic related to core
obesity competencies to a “great extent”. Core competen-
cies on basic obesity pathophysiology and the physical
examination of a patient with obesity were each covered to
a“very little”extent or “not at all”in 15.0% of medical
schools. Coverage of non-judgmental communication and
use of respectful language with patients who have obesity
was covered to a “very little”extent or “notatall”in more
than one-quarter of the medical schools. Very few schools
thoroughly covered core strategies to develop a comprehen-
sive obesity management care plan such as nutrition inter-
ventions, physical activity, behavioral interventions, and
pharmacological treatments. Policies and public health ini-
tiatives pertaining to obesity were the least covered, with
64.9% of respondents reporting little to no coverage at all
(Fig. 1). Schools which reported having an obesity education
program currently in place were more likely than those
without a program to report most of the core obesity com-
petencies were covered to “some extent”or a “great extent”.
Preparation of medical students to manage obesity
On a 4-point scale ranging from “not at all prepared”to
“very prepared”, only 10.0% of respondents reported that
their graduating medical students are “very prepared”to
manage patients with obesity; a majority (62.5%) re-
ported that their students are only “somewhat prepared”.
Priority to incorporate obesity education in curriculum
Expanding obesity education was a low priority or not a
priority for 50.0% of those surveyed and nearly half of
these schools reported having no obesity education pro-
gram in place and no plans to develop one. Just over one-
third of medical schools reported having an obesity educa-
tion program in place; of those without a program, only
half reported having active discussions on how to incorp-
orate obesity or develop an obesity education program. Of
the one-third of medical schools considering incorporat-
ing or expanding obesity education, most (76.9%) ex-
pected to implement their plans within the next 2 years.
Respondents who stated that expanding obesity education
is not a priority or is a low priority for their school were
less likely to have a program in place or plans to develop
one compared to schools in which obesity education is a
higher priority (Fig. 2).
Lack of room in the curriculum was the most com-
monly reported barrier to integrating obesity education
into the curriculum –half of respondents (50.0%) re-
ported it as a “large barrier”and one-third reported it as a
“moderate barrier”.Lack of faculty expertise was reported
to be a “large”or “moderate”barrier for 27.5% of surveyed
medical schools. Lack of student interest was least likely to
be cited as a barrier. See Fig. 3.
Table 1 Characteristics of 2018 Medical School Curriculum
Benchmark Online Survey Respondents (n= 40)
Respondents
Title/Role n(%)
a
Dean of medical education/curriculum 30 (75.0)
Administrator 4 (10.0)
Course/Curriculum coordinator 2 (5.0)
Curriculum director 2 (5.0)
Other 2 (5.0)
Academic Experience (years) mean ± SD
Time at current institution 15.3 ± 11.0
Time in current role 6.6 ± 4.4
Time involved in undergraduate medical
education
19.7 ± 10.3
Role in Undergraduate Education
b
n(%)
Actively teach medical students 38 (95.0)
Teach a course to medical students 25 (62.5)
Give lectures to medical students 33 (82.5)
Participate as a tutor to medical students 9 (22.5)
Participate as a preceptor in clinic to medical
students
16 (40.0)
Other 12 (30.0)
Institutions
Funding Source n(%)
Public 25 (62.5)
Private 15 (37.5)
Region n(%)
Northeast 9 (22.5)
Midwest 12 (30.0)
South 14 (35.0)
West 5 (12.5)
SD Standard deviation
a
Percentages may not sum to 100% due to rounding
b
Multi-select response options
Butsch et al. BMC Medical Education (2020) 20:23 Page 3 of 6
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Discussion
This is the first study to comprehensively assess the state
of obesity education in undergraduate medical education
in the United States. This Medical School Curriculum
Benchmark Study survey revealed inconsistent and inad-
equate obesity education in U.S. allopathic medical
schools resulting in medical students being ill-prepared to
manage patients with obesity. Despite the recognition of
obesity as a disease by the American Medical Association
(AMA) in 2013 and rising prevalence rates of the disease
[16,17], none of the core obesity competencies were well-
covered by more than four in ten medical schools
surveyed. The survey revealed that in approximately one-
quarter to one-third of the medical schools surveyed, there
was little to no coverage of rudimentary treatments for
obesity, i.e., nutrition, behavioral, and physical activity
interventions.
These data underline not only the limited coverage of
obesity education, but also the lack of prioritization to de-
velop future curricula in obesity. An overcrowded curricu-
lum was reported as the major barrier to implementing
obesity education in this study; however, external barriers,
e.g., poor faculty knowledge about obesity, lack of stan-
dardized testing on obesity, and overall negative attitudes
about the disease of obesity, are possible reasons why
obesity education is not prioritized. Nutrition education,
Fig. 1 Coverage of Obesity Core Competencies. 2018 Medical School Curriculum Benchmark Online Survey Respondents (n= 40). Note: Some
competencies have been shortened for presentation. Responses of “Some extent”and “I don’t know”not shown
Fig. 2 Development of Obesity Curriculum by Stated Priority Level. 2018 Medical School Curriculum Benchmark Online Survey
Respondents (n= 40)
Butsch et al. BMC Medical Education (2020) 20:23 Page 4 of 6
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one facet of obesity education, is similarly underprioritized
in undergraduate medical education. In a recent study of
medical student perspectives on why nutrition education
is inadequate in medical school, the perception that nutri-
tional care is not the responsibility of doctors was sug-
gested as a barrier [18]. Although our study did not obtain
this information, the role of weight bias and the belief that
obesity is the result of a voluntary lifestyle choice, and not
a biologic disease, may influence decisions and opportun-
ities of inclusion in medical school curricula.
To address the paucity of obesity education in U.S. med-
ical schools, two recent educational initiatives included the
development of core competencies in obesity in health care
professional schools. First, the Provider Training and Edu-
cation Workgroup, part of an activity associated with the
Roundtable on Obesity Solutions at the National Acad-
emies, developed ten high-level provider competencies for
the prevention and management of obesity for health care
professional schools [19]. Secondly, OMEC, which is spear-
headed by the Obesity Medicine Association, The Obesity
Society, and the American Society of Metabolic and Bariat-
ric Surgery, developed 32 obesity-related competencies and
associated benchmarks across the six core domains of the
Accreditation Council for Graduate Medical Education
(ACGME). These obesity-related competencies were devel-
oped for medical undergraduate and postgraduate training
programs to assess learners within a training program [14].
Competencies from both initiatives are the first step to
evaluating obesity knowledge of health care professionals
and developing a structure for standards of care.
Limitations
There are several limitations to our study including a
response rate of approximately 30%; however, this is
not unexpected given the target audience of medical
school program leaders who have great demands on
their time. To minimize response bias (i.e., inaccurate
responses) in our survey, the instrument was designed
in collaboration with a survey expert to design opti-
mal questions; however, the survey was not validated,
and response bias is possible. Non-responder bias, in
which certain types of respondents are less likely to
respond (for example, schools without a strong obes-
ity program in place), is also a possibility, and could
have skewed the results toward a more favorable out-
look of obesity education in U.S. medical schools. We
believe that positive skewing is unlikely given the
findings of low prioritization of obesity education re-
ported by the respondents. Some of the reported data
are subjective, including extent that the obesity com-
petencies are covered, student preparedness, and the
prioritization of obesity education.
The design of this research places a greater import-
ance on the number of institutions represented rather
than the homogeneity of respondents. It is important
to have homogeneity of the respondents, and we be-
lieve the deans of education and curriculum leaders
were the most appropriate respondents. In our study,
nearly all respondents taught medical students and
more than 75% were very knowledgeable of their curricu-
lum; however, we were unable to control for the influence
of respondents’varied roles and professional experience on
their responses. Additionally, due to the difficulty of true
random sampling, this research is limited by the extent to
which our sample of 40 schools represents the true popula-
tion of U.S. allopathic medical schools. Development of the
list of contacts was dependent on publicly available infor-
mation, and therefore, the number of contacts identified at
each institution varied. However, our survey sample closely
aligned to the composition of the current medical schools
in the U.S. with regards to regional distribution and source
of funding (public/private). Thus, we believe the sample we
obtained represents the population in question (U.S. allo-
pathic medical schools).
Fig. 3 Barriers to Implementing/Expanding Obesity Education in Medical School. 2018 Medical School Curriculum Benchmark Online Survey
Respondents (n= 40)
Butsch et al. BMC Medical Education (2020) 20:23 Page 5 of 6
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Conclusions
Obesity is a major public health crisis which is clearly
not being prioritized within the context of medical
school education. Our study highlights the need for U.S.
medical school administrators to change their priorities
and recognize the urgency to develop curricula that com-
prehensively address the disease of obesity. Administrators
should take advantage of resources provided by organiza-
tions such as OMEC and incorporate obesity education
into their curricula so that graduating medical students
will be more knowledgeable and prepared to address the
challenges of caring for and managing the nearly 100 mil-
lion people with obesity in the U.S. today.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12909-020-1925-z.
Additional file 1. Medical School Curriculum Benchmark Survey;
Description of data: Survey conducted among medical school directors.
Abbreviations
AAMC: Association of American Medical Colleges; ACGME: Accreditation
Council for Graduate Medical Education; AMA: American Medical Association;
OMEC: Obesity Medicine Education Collaborative; U.S.: United States;
USMLE: United States Medical Licensing Examinations
Acknowledgements
The authors would like to thank Megan Winters for her early efforts in this
survey and Rebecca Hahn of KJT Group, Inc. for medical writing assistance
and support. The authors also would like to thank Eric Campbell, PhD for his
assistance with the survey instrument.
Authors’contributions
WSB, SA, BGS designed the study and developed the study materials. All
authors provided input into the data analyses, contributed to writing the
manuscript, and read and approved the final manuscript.
Funding
Novo Nordisk Inc. financed the development of the study design, third-party
blinded data collection, analysis, and interpretation of data as well as writing
support of the manuscript. Both Dr. Smolarz and Dr. Alford, employees of
Novo Nordisk, co-designed the study, interpreted the data, and generated re-
ported conclusions.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
Ethical approval has been waived (exempted) by Western Institutional
Review Board, July 18, 2018, reference number 1–1095554-1. Prior to
completing surveys, respondents provided informed consent electronically.
Consent for publication
Not applicable.
Competing interests
Dr. Butsch is a health consultant for Novo Nordisk Inc. and on an advisory
board for Rhythm Pharmaceuticals, Inc.; Dr. Kushner is on the advisory board
for Novo Nordisk and WW, and is a clinical researcher for Novo Nordisk; Dr.
Alford is an employee of Novo Nordisk and owns stock in Novo Nordisk.; Dr.
Smolarz is an employee of Novo Nordisk and owns stock in Novo Nordisk.
Author details
1
Bariatric and Metabolic Institute at Cleveland Clinic, Cleveland, OH, USA.
2
Northwestern University, Chicago, IL, USA.
3
Novo Nordisk Inc, 800 Scudders
Mill Rd, Plainsboro Township, NJ 08536, USA.
Received: 21 October 2019 Accepted: 3 January 2020
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