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Predictors of nutrition counseling behaviors and attitudes in US
medical students
1– 4
Elsa H Spencer, Erica Frank, Lisa K Elon, Vicki S Hertzberg, Mary K Serdula, and Deborah A Galuska
ABSTRACT
Background: Nutrition counseling by physicians can improve pa-
tients’ dietary behaviors and is affected by physicians’ nutrition
practices and attitudes, such as the perceived relevance of nutrition
counseling.
Objective: The objective was to provide data on medical students’
perceived relevance of nutrition counseling, reported frequency of
nutrition counseling, and frequency of fruit and vegetable intakes.
Design: Students (n҃2316) at 16 US medical schools were sur-
veyed and tracked at freshmen orientation, at the time of orientation
to wards, and in their senior year.
Results: Freshmen students were more likely (72%) to find nutrition
counseling highly relevant than were students at the time of ward
orientation (61%) or during their senior year (46%; Pfor trend ҃
0.0003). Those intending to subspecialize had lower and declining
perceptions of counseling relevance (Pfor trend ҃0.0009), whereas
the perceived relevance of counseling by primary care specialists
remained high (Pfor trend ⫽0.5). Students were significantly more
likely to find nutrition counseling highly relevant if they were fe-
male, consumed more fruit and vegetables, believed in primary pre-
vention, had personal physicians who encouraged disease preven-
tion, or intended to specialize in primary care. Only 19% of students
believed that they had been extensively trained in nutrition counsel-
ing, and 17% of seniors reported that they frequently counseled their
patients about nutrition. Students who consumed more fruit and
vegetables, believed that they would be more credible if they ate a
healthy diet, were not Asian or white, or intended to specialize in
primary care counseled patients about nutrition more frequently.
Medical students consumed an average of 3.0 fruit and vegetable
servings/d, which declined over time.
Conclusions: The perceived relevance of nutrition counseling by
US medical students declined throughout medical school, and stu-
dents infrequently counseled their patients about nutrition. Interven-
tions may be warranted to improve the professional nutritional prac-
tices of medical students. Am J Clin Nutr 2006;84:655– 62.
KEY WORDS Medical students, diet, fruit and vegetable in-
takes, nutrition counseling, counseling correlates
INTRODUCTION
Although Americans suffer from increased rates of obesity,
hyperlipidemia, and diabetes (1–3), some studies have shown
that if physicians advise their patients about nutrition, the inci-
dence of these diseases will decline (4, 5). Despite the potential
for counseling to improve dietary practices, 쏝50% of primary
care physicians include nutrition or dietary counseling in their
patient visits (6 –11).
Although many factors affect counseling rates, one of the least
explored factors is the observation that physicians’ healthy per-
sonal practices are positively associated with their clinical
prevention-related practices (9, 12–15). Specifically, physi-
cians’ healthy dietary practices positively correlate with their
clinical nutrition counseling attitudes (16) and practices (5, 10,
14, 17). Some small studies have shown that training interven-
tions may improve both medical students’ personal dietary be-
haviors (18) and their prevention counseling attitudes (18 –20).
Building on this preliminary association, we implemented the
“Healthy Doc-Healthy Patient” (HD-HP) study to describe not
only medical students’ attitudes and behaviors regarding per-
sonal and clinical prevention but also the relation between their
personal and clinical practices (21).
Our primary objective was to describe the characteristics of
medical students associated with more frequent nutrition coun-
seling and a higher perceived relevance of such counseling. The
secondary objective was to describe temporal trends in medical
students’ perceived relevance of, reported confidence in, and
reported training in nutrition counseling. To achieve our primary
objective, we assessed the relation between counseling fre-
quency and its predictors in the students’ senior year and exam-
ined how the relations between the perceived relevance of nutri-
tion counseling and its predictors change during the students’
training. Novel predictors of interest include whether the health-
promotion efforts (health-promotion score) of medical schools
and the fruit and vegetable intakes of medical students are asso-
ciated with the nutrition counseling attitudes and behaviors of the
students. Fruit and vegetable servings per day are the principal
dietary component of interest because of their importance in
public health recommendations (22, 23).
1
From the School of Medicine (EHS and EF) and the School of Public
Health, Biostatistics (LKE and VSH), Emory University, Atlanta, GA, and
the Centers for Disease Control and Prevention, Division of Nutrition and
Physical Activity, Atlanta, GA (DAG and MKS).
2
The findings and conclusions in this report are those of the authors and do
not necessarily represent the views of the CDC.
3
Supported by the American Cancer Society.
4
Address reprint requests to E Frank, Department of Health and Epide-
miology, University of British Columbia, 5804 Fairview Avenue, Vancou-
ver, BC, Canada V6T 1Z4. E-mail: efrank@emory.edu.
Received October 29, 2005.
Accepted for publication May 2, 2006.
655Am J Clin Nutr 2006;84:655– 62. Printed in USA. © 2006 American Society for Nutrition
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METHODS
Study design
All medical students in the class of 2003 at 17 participating
schools were eligible for participation at each of 3 HD-HP ques-
tionnaire sessions: at freshman orientation, at the time of orien-
tation to wards, and in the senior year. Our sample was designed
to be similar to all US medical schools in terms of age, region,
school size, National Institutes of Health research ranking, pri-
vate–public school balance, underrepresented minorities, and
sex (24 –27). Our study received approval from the Institutional
Review Board at Emory University.
The HD-HP questionnaires were usually administered after
semimandatory activities to encourage participation, but they
were anonymous and participation was voluntary. One school
was excluded because of protocol nonadherence and a response
rate of 쏝55% on the first 2 questionnaires. The final sample
comprised 16 schools (Appendix A). Our total response rate,
including all respondents from any of the 3 survey administra-
tions and any of the 16 schools, was 80.3%.
Students were tracked across 3 time points throughout4yof
medical school by using an anonymous unique identifier that
used a student’s mother’s initials at her birth and father’s first 2
initials. Of the 2316 students who provided responses at some
time point, 72% (n҃1658) did so at more than one time point,
and 42% (n҃970) were tracked across all 3 survey time points.
Variables
Within the HD-HP questionnaire, queries on outcomes of self-
reported relevance and frequency of talking to patients about
nutrition were asked along with 11 other counseling and 9 screen-
ing practices. The questionnaire administered while the students
were freshmen contained only one nutrition counseling question:
“How relevant do you think talking to patients about nutrition
will be in your intended practice?” The response options were
“not at all,” “somewhat,” and “highly.” All subsequent ques-
tionnaires also contained questions on confidence and training
in nutrition counseling. The questionnaire administered to
seniors also included the following question: “With a typical
general medicine patient, how often do you actually talk to
your patients about nutrition?” The response options were
“never/rarely,” “sometimes,” or “usually/always.” Because
of the relatively small cell sizes for subjects reporting “not at
all” relevant and “never/rarely” concerning counseling
(쏝17% for all categories), the less than “highly” relevant and
less than “usually/always” counseling responses were col-
lapsed into one category.
Independent predictors were a priori choices based on past
literature concerning medical student or physician nutrition
counseling behaviors. Both perceived relevance and reported
frequency of nutrition counseling were cross-tabulated with the
following medical student variables: dietary practices (servings
per day of fruit and vegetables, change in fruit and vegetable
servings over time, and vegetarianism), demographic character-
istics (sex and race-ethnicity), physical health (body mass index,
attempted weight loss, and perceived general health), and clinical
characteristics (intended specialty and a variable measuring a
student’s assessment of his or her school’s health-promotion
score). Counseling outcomes were also cross-tabulated with the
level of agreement with several attitudinal questions plus one
mentoring question. These questions were as follows: “Primary
prevention is the best way to eradicate premature cardiovascular
disease (CVD),” “Physicians have a responsibility to promote
prevention with their patients,” “Patients will adopt a healthier
lifestyle if counseled to do so,” “I will be able to provide more
credible and effective counseling if I eat a healthy diet,” and
“How much emphasis has your personal physician placed on
preventing disease?”. The counseling relevance model addition-
ally contained a time variable (freshman orientation, ward ori-
entation, or senior year).
Queries on predictors included 8 fruit and vegetable items
(French fries, other potatoes, fruit juice, fruit, vegetable juice,
green salad, and vegetable soup, and other vegetables) from a
43-item food-frequency questionnaire within the HD-HP ques-
tionnaire (28). Agreement with attitudes was measured on a
Likert scale of responses: “strongly agree,” “agree,” “neither
agree nor disagree,” “disagree,” or “strongly disagree.” To eval-
uate a student’s exposure to health promotion and prevention at
his or her school, we asked 16 questions about the school’s
encouragement of a minimization of stress and about both the
school’s and classmates’ encouragement of healthy eating, reg-
ular exercise, responsible alcohol use, and discouragement of
smoking. We weighted each topic equally when summing the 16
responses to create an individual school health-promotion or
“preventive-dose” score, as assessed by one student; this in-
dividual student’s “preventive dose” assessment of a partic-
ular school was the variable of interest. Higher values for this
variable indicate a stronger perception of a more preventive,
health-promoting school environment (29). At each time
point, intended specialties were collapsed into “primary care”
(family medicine, general internal medicine, obstetrics/gyne-
cology, pediatrics, and preventive medicine/public health),
“subspecialists” (anesthesia/pathology/radiology, emer-
gency medicine, medical subspecialist, surgery, psychiatry,
and urology), and “undecided.”
Statistics
All analyses were conducted with the use of SUDAAN
(30)—a program that accounts for nonindependent observations
arising from the clustering of students into schools and the cor-
related responses from each student over time. The counseling
outcomes across time are reported in Table 1, only for the subset
of students responding at all 3 time points. The cross-tabulated
associations of relevance and frequency with categorical predic-
tors were determined (Table 2) by using the chi-square test; we
used a Pvalue 울0.01 to test for statistical significance because of
the large number of bivariate associations being tested. To help
preserve statistical power, we included all observations on the
predictors and outcome at all time points.
Starting with multivariate logistic models that included all the
potential predictors listed above, final models were selected (Ta-
bles 3 and 4) via backward elimination and stepwise regression
methods, leaving only covariates with a significance of P쏝0.05.
Because clustering limited our models to 14 maximal df, multiple
response levels of some variables were collapsed. Meaningful
interaction terms were also evaluated (time ҂intended specialty,
fruit and vegetable consumption ҂time, and fruit and vegetable
consumption ҂preventive dose). At P쏝0.01, only time ҂
intended specialty was bivariately significant and hence offered
into the multivariate relevance model. Models were examined to
confirm modeling assumptions and to assess fit.
656 SPENCER ET AL
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Multiple imputation was used to overcome the large quantity
of information lost as a result of incomplete data on at least one
variable (31). Although the median item nonresponse rate was
3% (range: 0 –15%), the fruit and vegetable variable was missing
for up to 14% of participants, because this summary variable was
computed as missing if any of its 8 constituent components were
missing. The selected multivariate models were then analyzed
with 5 imputed datasets. Variables with missing rates over 4%
were imputed by using a nonnormal Bayesian imputation pro-
cedure (32) or SAS’ PROC MI (33); variance estimates were
adjusted for imputation use by the MIANALYZE procedure of
SAS. Imputed results were found to be consistent with those from
the unimputed models. The results of the imputation procedures
were selected to represent the final results of our multivariate
analyses.
RESULTS
Our response rates were 87%, 78%, and 75% on the 3
questionnaire administrations. The median age at freshman
orientation was 23 y (range: 17– 45 y); age was not associated
with any of our outcomes (data not shown). Most of the stu-
dents reported fruit and vegetable intakes of 울3 servings/d
(median: ҃2.7 servings per day), and these intakes declined
over time (P⫽0.008). The women’s consumption decreased
from 2.8 to 2.4 servings/d, and the men’s consumption de-
creased from 2.6 to 2.2 servings/d; the women reported higher
fruit and vegetable intakes than did the men (P⫽0.03) (data
not shown).
Overall, 60% of all 970 students responding to all 3 surveys
perceived nutrition counseling to be highly relevant in their in-
tended practices (data not shown). Freshman-year students were
more likely (72%) to find nutrition counseling highly relevant
than were students at the time of ward orientation (61%) or in
their senior year (46; overall Pfor trend ҃0.0003) (Table 1).
Over time, all students (P⫽0.0003) as well as those intending
to subspecialize (P⫽0.0009) had declining perceptions of coun-
seling relevance, whereas intended primary care specialists’ per-
ceived relevance remained high and did not decline (P⫽0.5).
Only 22% of the students believed that they had been extensively
trained in nutrition counseling in their senior year. Although the
percentage of students who felt extensively trained increased
over time (P⫽0.02), the percentage who felt highly confident
did not change over time (P⫽0.8). A similar percentage of
seniors reported “usually/always” (17%) and “never/rarely”
(16%) providing nutrition counseling to typical general medicine
patients.
With the exception of intended specialty, predictors of
counseling relevance were consistent across time and, hence,
the bivariate relations are reported overall (Table 2). There
was a dose-response for higher perceived nutrition counseling
relevance by increasing quintile of fruit and vegetable con-
sumption (Pfor trend 쏝0.0001). Students intending to spe-
cialize in primary care were much more likely to find nutrition
TABLE 1
US medical students’ self-reported nutrition counseling behaviors and attitudes throughout medical school: perceived relevance to intended practice,
training, confidence, and frequency
1
Time point
P
(chi-square)
Freshman
orientation
(n҃970)
Orientation to
wards
(n҃970)
Senior year
(n҃970)
%
Relevance of nutrition counseling to intended practice
All students 72 앐2.2 61 앐2.3 46 앐2.1 0.0003
Primary care specialty 0.5
Not at all 0 앐0.2 (425) 0 앐0.4 (263) 0 앐0.0 (290)
Somewhat 19 앐2.7 (425) 21 앐2.1 (263) 23 앐2.7 (290)
Highly 81 앐2.7 (425) 78 앐2.1 (263) 77 앐2.7 (290)
Subspecialist specialty 0.0009
Not at all 1 앐0.4 (349) 6 앐0.8 (465) 21 앐1.9 (589)
Somewhat 37 앐3.3 (349) 44 앐3.2 (465) 50 앐2.5 (589)
Highly 62 앐3.4 (349) 51 앐3.1 (465) 30 앐2.2 (589)
Training in nutrition counseling 0.02
None —
2
8앐1.5 4 앐0.9
Some —
2
77 앐1.8 74 앐1.8
Extensive —
2
15 앐2.3 22 앐2.2
Confidence in performing nutrition counseling 0.8
Not at all —
2
3앐0.6 3 앐0.5
Somewhat —
2
52 앐3.6 53 앐2.2
Highly —
2
45 앐3.4 44 앐2.1
Frequency of nutrition counseling with typical general
medicine patient
Never/rarely —
2
—
2
15 앐1.4
Sometimes —
2
—
2
68 (1.6)
Usually/always —
2
—
2
17 (1.6)
1
Includes predictor and outcome data only for individuals who responded at all 3 time points. nin parentheses.
2
Not queried about at this time point.
MEDICAL STUDENTS’ NUTRITION COUNSELING PREDICTORS 657
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TABLE 2
Characteristics of US medical students associated with their perceived relevance and self-reported frequency of clinical nutrition counseling: bivariate
associations
Relevance across all time points
1
Frequency at senior year
2
n
Response of
“highly” P(chi-square)
3
n
Response of
“usually/always” P(chi-square)
3
%%
Total sample 4651 60 — 17 —
Demographic characteristics
Sex — — 쏝0.0001 — — 울0.01
Female 2153 69 — 652 19 —
Male 2494 53 — 740 15 —
Ethnicity — — NS (0.04) — — NS (0.02)
White 2962 57 — 887 14 —
Asian 896 60 — 258 18 —
Black, Hispanic, or other 782 67 — 245 26 —
Health behaviors and characteristics
Quintile of fruit and vegetable
intakes (servings/d)
—— 쏝0.0001 — — 쏝0.0001
Highest 858 69 — 212 23 —
Second highest 880 65 — 230 19 —
Middle 843 62 — 227 22 —
Second lowest 898 57 — 277 13 —
Lowest 811 49 — 293 12 —
BMI (kg/m
2
)—— 울0.01 — — NS (0.05)
쏝25, Normal-weight or underweight 3462 62 — 979 18 —
울25 to 쏝30, Overweight 923 54 — 313 14 —
욷30, Obese 165 59 — 56 11 —
Self-defined vegetarian — — NS (0.05) — — NS (0.2)
Vegetarian 430 67 — 112 14 —
Omnivore 4210 60 — 1278 17 —
Self-rated general health — — NS (0.2) — — NS (0.3)
Excellent 1596 62 — 534 19 —
Good or very good 2928 60 — 799 16 —
Fair or poor 110 54 — 49 14 —
Preventive and school-based attitudes
Primary prevention is effective against
premature cardiovascular disease
—— 울0.01 — — 울0.01
Agree 2225 70 — 946 18 —
Disagree or neither agree nor disagree 1100 59 — 353 12 —
School health-promotion score — — NS (0.1) — — 울0.01
Highest tertile 981 56 — 533 19 —
Medium tertile 907 50 — 448 16 —
Lowest tertile 865 54 — 356 14 —
Student is more credible if he or she eats
a healthy diet
—— 쏝0.0001 — — 쏝0.001
Agree 3988 64 — 1135 18 —
Disagree or neither agree nor disagree 588 37 — 223 10 —
Physicians have a responsibility to
promote prevention with their
patients
—— 쏝0.0001 — — NS (0.06)
Agree 4206 63 — 1211 18 —
Disagree or neither agree nor disagree 356 36 — 141 8 —
Preventive emphasis by student’s
personal physician
—— 쏝0.001 — — NS (0.2)
Some or a lot 2892 63 — 873 18 —
쏝Some 1698 56 — 494 15 —
Intended specialty — — 쏝0.0001 — — 울0.01
Primary care specialties 1636 79 — 421 25 —
Subspecialties 2310 45 — 935 13 —
Undecided 664 65 — 14 29 —
1
Includes predictor and outcome data from all 3 time points, with most persons responding at 쏜1 time point.
2
Includes predictor and outcome data from senior year only.
3
Nonsignificant Pvalues include 0.01 쏝P쏝0.05 because of adjustment for testing multiple variables.
658 SPENCER ET AL
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counseling highly relevant (79%) than were those intending to
subspecialize (45%; P쏝0.0001) and were more likely to
counsel (P҃0.006). A school’s preventive dose was a sig-
nificant predictor (P⫽0.005) of nutrition counseling fre-
quency only. Both perceived nutrition counseling relevance
and frequency were predicted by sex, ethnicity, fruit and veg-
etable intake, BMI, belief in the efficacy of CVD prevention,
belief in increased credibility if a healthy diet was consumed,
and intended specialty.
Results from the multivariate model showed that students
were more likely to find nutrition counseling highly relevant if
they were female (P⫽0.005), consumed more fruit and vege-
tables (P⫽0.002), believed that primary prevention was effec-
tive against premature CVD (P울0.02), or had personal physi-
cians who had encouraged disease prevention (P⫽0.02) (Table
3). The effect of intended specialty was modified by time. For
intended subspecialists, perceived counseling relevance was
lower than that for intended primary care physicians (regardless
of when queried about) and decreased only for subspecialists
(odds ratio: 0.26) over time.
Students were more likely to report frequent nutrition coun-
seling if they were black, Hispanic, or other (compared with
Asian or white) (P⫽0.001), consumed more fruit and vegetables
(P⫽0.004), believed strongly that they would be more credible
if they ate a healthy diet themselves (P⫽0.003), or intended to
specialize in primary care specialties (P⫽0.0007) (Table 4).
DISCUSSION
By senior year, 46% of the students (compared with 72% of
freshmen) perceived nutrition counseling to be highly rele-
vant in their intended practices. The substantial decline in
perceived nutrition counseling relevance over time was fueled
only by those intending to go into a subspecialty. Moreover,
an intended primary care specialty consistently predicted both
higher perceived nutrition counseling relevance and more
frequent counseling. These findings are similar to the findings
of 2 studies in which primary care practitioners, relative to
subspecialists, counseled their patients more frequently about
nutrition (13, 15). However, another physician study did not
find this specialty-based difference (34). In our study, medical
school training did not maintain or increase the relatively
lower percentage of subspecialists that perceived nutrition
counseling to be highly relevant. We found that a school’s
preventive, health promotive emphasis was a weak predictor
of nutrition counseling frequency in the bivariate analysis, but
not in the multivariate analysis.
In their senior year, 쏝25% of the students believed that they
had been extensively trained in nutrition, 쏝50% were highly
confident about their nutrition counseling, and 쏝20% usually
or always counseled their typical general medicine patients.
Regarding training, a 2003 Association of American Medical
Colleges survey of students from all US medical schools
(n҃13 764) similarly reported that 46% believed that “ap-
propriate time” had been “devoted to nutrition instruction”;
3% believed that the time devoted was “excessive” (35). It is
an interesting conundrum that, despite the improvement in the
medical students’ perception of feeling adequately trained to
provide nutrition counseling (P⫽0.02), the students’ confi-
dence in counseling patients did not improve (P⫽0.8).
A broad review of the literature suggests that the nutrition
training of many medical students is inadequate; our data suggest
that the training the medical students in our study received did not
adequately address the requisite skills for real patient encounters.
TABLE 3
Multivariate predictors for US medical students who perceived the
relevance of nutrition counseling to be “high” throughout medical school
Variable Odds ratio
1
(95% CI)
Sex
Female 1.44
2
(1.14,1.81)
vs Male (referent) 1.00
Food and vegetable intakes (continuous) 1.10
3
(1.04,1.16)
Primary prevention is effective against
premature cardiovascular disease
Strongly agree 3.63
3
(2.11,6.27)
Agree 1.78
2
(1.12,2.82)
vs Strongly disagree, disagree, or
neither agree nor
disagree (referent)
1.00
Preventive emphasis by student’s
physician
Some or a lot 1.29
2
(1.06,1.57)
vs Not much or none (referent) 1.00
Time point and intended specialty
Ward orientation vs freshmen
orientation (referent)
Among primary care specialists 0.90 (0.64,1.26)
Among subspecialists 0.67
2
(0.50,0.89)
Senior year vs freshmen
orientation (referent)
Among primary care specialists 0.84 (0.63,1.13)
Among subspecialists 0.26
4
(0.21,0.32)
1
The odds of perceiving nutrition counseling to be highly relevant vs
somewhat or not at all relevant across all time points surveyed.
2
P울0.05.
3
P울0.001.
4
P쏝0.0001.
TABLE 4
Multivariate predictors of senior US medical students who self-reported
frequent nutrition counseling of typical patients
Variable Odds ratio
1
(95% CI)
Ethnicity
Asian 1.40 (0.96,2.05)
Black, Hispanic, or other 2.12
2
(1.43,3.15)
vs White (referent) 1.00
Food and vegetable intakes (servings/d) 1.11
3
(1.04,1.18)
Student will be more credible if he or
she eats a healthy diet
Strongly agree 2.38
3
(1.46,3.89)
Agree 1.44 (0.97,2.14)
vs Strongly disagree, disagree, or
neither agree nor
disagree (referent)
1.00
Intended specialty
Primary care 2.09
3
(1.47,2.98)
vs Subspecialist (referent) 1.00
1
The odds of answering “usually/always” vs “sometimes” or “never/
rarely” in the medical students’ senior year in response to a question about the
frequency in which they engaged in nutrition counseling.
2
P울0.05.
3
P울0.001.
MEDICAL STUDENTS’ NUTRITION COUNSELING PREDICTORS 659
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This finding was also suggested in 2 previous surveys. Similar to
our findings, a 2002 survey (36) of 290 first-, second-, and third-
year medical students and a 1986 survey (37) of 139 third-year
medical students reported that some students were lacking in
knowledge about dietary recommendations, healthy BMI,
CVD risk factors (36), and the ability to deliver nutrition
counseling and education (37). This lack of confidence may
have important consequences; according to a popular behav-
ioral theory (38), medical students’ feelings of self-efficacy
would be important in achieving higher rates of nutrition
counseling (39). Indeed, the literature suggests that self-
efficacy is associated with medical students’ personal health
successes (40) and with the amount of effort physicians spend
on health-promotion strategies (41).
In models, higher fruit and vegetable intakes, at least one
positive opinion on the importance of disease prevention, sex,
and ethnicity were consistent predictors of both frequent coun-
seling and a high perceived relevance of such counseling. These
findings are supported by the literature on physician nutrition
counseling. Several studies have reported associations between
physicians’ healthier diets and increased nutrition counseling of
patients (5, 10, 14, 17). Our study is only the third study (10, 14)
to report this association between healthier dietary intakes
that correspond to national dietary guidelines and the first
study to report this association in medical students. As in our
study, increased clinical nutrition counseling was previously
shown to be associated with physicians having more positive
prevention attitudes (42, 43), being female (42, 44), or being
black, Hispanic, or other (10). In our study, black physicians
counseled their patients about nutrition more frequently than
did other ethnic groups, regardless of specialty, and a higher
percentage of blacks and Hispanics than of other ethnic groups
intended to specialize in primary care. These 2 phenomena
were responsible for the increased rates of counseling by
blacks and Hispanics.
Although national guidelines at the time of this survey
recommended consuming 욷5 fruit and vegetable servings/d
(23), only 11.4% of medical students reported consuming this
amount. Furthermore, fruit and vegetable consumption de-
creased during medical school, perhaps because of normal
dietary changes during those years (45) or because of a de-
clining interest in or prioritization of personal prevention as
training progressed.
A limitation of this study was that our sample of schools was
not randomly selected. This may have caused our conclusions to
be less generalizable than those derived from a random sample.
Although our self-reported data could have introduced some bias
toward overreporting, we validated the frequency of nutrition
counseling in our study population via extensive standardized
patient (46, 47) testing and found a strong relation (odds ratio:
1.93) between self-report and objective measures (48). Frank et
al (29) also found strong correlations between deans’ and stu-
dents’ perceptions of their schools’ health-promotion environ-
ments. Loss to follow-up is a limitation common to longitudinal
studies of this type. Another limitation was that we were confined
to qualitative descriptions of “talking to patients about nutrition.”
Therefore, we were unable to describe the quantity, quality, or
content of the counseling of the students and could not account
for the counseling of patients not perceived as “typical general
medicine” patients.
One strength of our study was that we collected data on both
personal and professional nutrition behaviors from a sample of
16 medical schools across the United States. Previous studies of
medical students’ dietary intakes have been limited by sample
size (only 1 of 49 was a survey of 쏜300 students) and location
(only 1 of 50 was at more than one school). Regarding pro-
fessional nutrition practices, previous reports have not
assessed how the emphasis of various medical schools on
preventive medicine affects the counseling behaviors of med-
ical students differently; we are aware of only one study that
evaluated the counseling and preventive-nutrition attitudes of
medical students at many schools (49). Our study was unique
in that it examined the effect of the general promotion of
preventive nutrition by numerous medical schools on the
association between students’ personal and clinical nutri-
tional attitudes and behaviors.
The principal strength of our study was that it was the first, to
our knowledge, to provide a natural history of the entire medical
school experience. We examined temporal trends in 3 nutrition
counseling variables and many potential correlates, including
how changes over time in key correlates affected counseling
frequency and a change in perceived relevance of counseling.
Other than for subspecialist-focused students, there were no dif-
ferent effects by time for predicting perceived nutrition counsel-
ing relevance or its observed decrease over time. One conclusion
based on this relative absence of a time effect was that most
students’ nutrition counseling attitudes correlated more strongly
with their endogenous attitudes than with the experience of med-
ical school.
Interventions to improve the professional nutrition practices
of students can be built on this study’s foundation. During med-
ical education training, students were progressively less likely to
find nutrition counseling highly relevant in their intended prac-
tices. Training interventions in nutrition counseling are war-
ranted. These interventions could be targeted at students inter-
ested in subspecialties to enhance their perceptions of the
relevance of nutrition counseling in their practices. Because stu-
dents interested in primary care also expressed modest enthusi-
asm for clinical nutrition counseling, it may be beneficial to
rethink the paradigm of nutrition education, making nutrition
more relevant to all disciplines. All students can benefit from
more practical experiences with standardized patients and with
efforts to bolster their confidence in talking to their patients about
nutrition. Future researchers may attempt to quantify the nutri-
tion counseling behaviors of medical students in an effort to
improve their nutrition training and thereby the quality of their
clinical counseling practices.
EHS conducted the analyses, interpreted the data, and wrote and edited the
manuscript. EF designed the study, helped interpret the data, and edited the
manuscript. LKE and VSH helped with the statistical analyses. DAG and
MKS helped interpret the data and edited the manuscript extensively. None
of the authors had any potential conflicts of interest.
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Appendix A
Characteristics of participating US medical schools
School
Location
(state)
Public or
private
NIH
research
rank
1
No. of
students
1
No. of
freshmen
1
No. of
respondents
Creighton University School of Medicine NE Private 108 450 118 105
Duke University School of Medicine NC Private 11 379 100 96
Georgetown University School of Medicine DC Private 45 678 168 125
Loma Linda University School of Medicine CA Private 106 670 174 163
Medical College of Georgia School of Medicine GA Public 85 712 182 174
Mercer University School of Medicine GA Private 119 208 56 53
Morehouse School of Medicine GA Private 80 148 40 37
Texas Tech University Health Sciences Center School of
Medicine
TX Public 104 488 125 118
Tulane University School of Medicine LA Private 79 611 153 91
UCLA School of Medicine/Charles R Drew University of
Medicine and Science
CA Public 13 668 170 162
University of Colorado School of Medicine CO Public 20 524 133 128
UMDNJ
2
—Robert Wood Johnson Medical School NJ Public 62 632 150 132
University of Pennsylvania School of Medicine PA Private 2 594 150 142
University of Rochester School of Medicine and Dentistry NY Private 31 397 100 99
University of Washington School of Medicine WA Public 6 771 101 60
Wayne State University School of Medicine MI Public 54 1044 256 221
1
For the academic year 1999 –2000.
2
University of Medicine and Dentistry of New Jersey.
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