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3
Department of Epidemiology,
*
College of Public Health and
Department of Internal Medicine, College of Medicine, University of Iowa, Iowa City, IA 52242
3To whom correspondence should be addressed. E-mail: linda-snetselaar{at}uiowa.edu
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ABSTRACT |
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 TOP ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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KEY WORDS: • medical school • cardiovascular • nutrition education • fitness • diet
Medical students have long indicated that they feel their medical curriculum does not provide enough education about nutrition issues. They have indicated, especially, that they would like to learn more about how to talk about nutrition with their patients. The University of Iowa, with support from the Nutrition Academic Award (NAA) grant of the National Heart, Lung and Blood Institute (NHLBI), is working to increase medical students’ exposure to nutrition education.
Surveys of practicing physicians that identify their attitudes and resulting clinical performance behaviors provide clues to where changes in the medical school curriculum might occur. Clinical practices in nutrition areas reported by 3416 physicians surveyed by Levine et al. (1
) were far below the minimum levels defined by Young et al. (2
) as essential core competencies in clinical nutrition. Those practicing physicians who had studied nutrition had more favorable attitudes toward nutrition but did not use clinical nutrition skills in their practice to any greater degree than those who had not studied nutrition during medical school training. The missing element is the application of the nutrition knowledge to patient care. The authors suggest using strategies to increase application (1
). Specifically, they identify as effective learning experiences that increase the student’s understanding of his/her own diet and lipid levels.
A clinical experience for 3rd-y medical students at the University of Iowa offers the opportunity to do self-assessments of personal risk factors for cardiovascular disease (CVD). Students are invited to the University of Iowa Hospital and Clinic’s General Clinical Research Center (GCRC) to experience the diagnostic testing that is a standard part of cardiovascular assessment procedures. A variety of activities, designed to highlight important nutrition and fitness health factors with immediate feedback, is offered to the students individually and in small groups. This experience allows a hands-on approach to learning as it increases the students’ understanding of their own health issues.
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MATERIALS AND METHODS |
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TOPABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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Third-year medical students at the University of Iowa participated in this experience as a required part of their rotation in Internal Medicine’s Ambulatory Medicine clerkship. Every 3 wk, a new rotation group of 6–10 students spent two afternoons participating in this CVD Risk-Factor Self-Assessment Experience. At the time of this writing, 88 students had completed their participation; a total of 160 students are expected to participate by the end of the academic year.
Facilities
All activities were carried out in the University of Iowa Hospital and Clinics (UIHC). Students divided their time between the GCRC and the Cardiovascular Health, Assessment, Management and Prevention Services (CHAMPS) at UIHC.
Schedule
Each rotation of medical students was divided into two groups. During the 2nd wk of their 3-wk rotation, the first group spent an afternoon in the GCRC, whereas the second group went to CHAMPS; the following afternoon, the two groups traded places. At the end of the second afternoon, the two groups joined at the GCRC for a meal and nutrition discussion roundup.
GCRC stations
In the morning, students went to the GCRC nurse’s station to have their fasting blood drawn for lipid screening and their vital statistics (blood pressure, resting pulse, height, weight) measured. They returned to the GCRC in the afternoon to participate in a series of stations designed to assess CVD risk. The afternoon stations are described in Table 1
.
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Following a 12-h fast, students had blood drawn for a lipid profile. Blood samples were analyzed for total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and triglycerides. Results of the lipid analysis were discussed individually with a dietitian during the individualized counseling session.
Dual-energy X-ray absorptiometry (DEXA)
We gave students the opportunity to have a DEXA scan performed by the GCRC DEXA technician. Full-body and left hip scans provided information about percentage body fat and bone mass density. Students received a copy of the complete DEXA printout. The specific information typically reported to a patient’s physician was emphasized.
Anthropometry
Fully qualified and experienced GCRC staff performed anthropometric analyses on each student individually in a private room. Students received information about their body mass index (BMI), percentage body fat as well as waist, hip and mid-arm circumference. We discussed the relationship of these measurements to risk of heart disease.
Diet self-assessment
Before coming to participate in the GCRC Clinical Experience, students kept records of everything they ate and drank for 1–3 d. They were then responsible for analyzing their own intake of food and beverages using the Healthy Eating Index (HEI), an online dietary assessment tool. The HEI website (http://147.208.9.133/), developed by USDA’s Center for Nutrition Policy and Promotion, asks for complete descriptions of food and beverage intake and then provides HEI scores and daily nutrient intakes for the user, as well as a graphic depiction of their "personal Food Pyramid."
Dietary counseling
Students had the opportunity to discuss the results of their dietary self-assessment with a licensed dietitian in an individual consultation. Their lipid profile results were discussed in context with their dietary behaviors. Through the counseling session, the dietitian modeled a preventive nutritional counseling format that is typically used by dietitians in a clinical setting. Also discussed were the importance and the structure for including nutrition and fitness information in a patient’s clinical chart note.
Fitness assessment
A trained staff member demonstrated to the student several fitness materials that could be easily incorporated into medical practice: the Physical Activity Readiness Questionnaire (PAR-Q) and Patient Activity Counseling Protocols (PACE). The PAR-Q serves as a screening tool to quickly and easily identify adults for whom physical activity might not be appropriate. PACE contains two sections: a short fitness assessment, designed to be completed by a patient in a waiting room, that determines the patient’s current level of physical activity and readiness to change; and a choice of three counseling protocols based on the patient’s appropriate stage of change, either "not ready to change," "ready to change" or "active" (meeting physical activity guidelines).
The staff member also assessed each student’s fitness level privately, using the YMCA 3-min Step Test. The YMCA 3-min Step Test is a simple fitness assessment that can be used with healthy adults. The test involves stepping up and down at a rate of 24 steps/min for 3 min; a tape recording of the correct cadence (96 beats/min) is played to assist the participant in keeping the correct pace. Following the step test, the participant immediately sits down and, within 5 s, the tester starts counting the pulse for 1 min. The score for the test, the total 1-min postexercise heart rate, reflects the heart’s ability to recover quickly. Comparing this value with a standard chart offers an estimated fitness level based on the participant’s gender and age.
CHAMPS stations
Students spent 1–2 h visiting the Cardiovascular Health Assessment, Management and Prevention Services (CHAMPS) located at the UIHC. During this visit, students had the opportunity to tour the facility and to observe what services are available to inpatients and outpatients who are recovering from heart surgery or cardiovascular disease. Students observed patients going through cardiac rehabilitation or taking classes in nutrition, stress reduction or physical activity. They then had the opportunity to experience for themselves the process of a fitness assessment on the treadmill.
Meal and discussion
After completion of all activities in the GCRC and CHAMPS on the second afternoon of each rotation, students returned to the GCRC Day Room for a low fat meal and discussion. GCRC staff used colorful tablecloths and decorations to transform the room into a festive Mexican setting. We served a low fat Mexican meal prepared by the GCRC kitchen: baked corn chips and salsa, chicken fajitas or vegetarian bean burritos, Mexican rice, condiments (tomatoes, lettuce, nonfat sour cream, avocado, black olives) and strawberry ice. During dinner, a pair of licensed dietitians led a lively group discussion that covered topics such as an overview of fatty acids in the diet, the role of fatty acids in the development of CVD, the role of phytochemicals and how to discuss fatty acid/diet issues with patients. A series of case study-type questions were discussed in pairs and then as a group. A summary of the questions is presented in Table 2
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Results from each station were provided to each student individually. Data were also analyzed using the group composite.
Student evaluations
Students filled out evaluations immediately after their time in the GCRC. They rated each of the activities according to how the information gained in each station would be of value with future patients or on a personal basis. Students listed their most and least favorite aspects of the experience, along with suggestions for improvement.
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RESULTS |
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TOPABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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Descriptive statistics for the group of University of Iowa 3rd-y medical students seen so far are presented in Table 3
. The group was composed of 42% women. The age of the students ranged from 23 to 41 y old, with an average age of 26.
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Body mass index.
The students’ weight and height were used to determine their body mass index (BMI). BMI provides an indication of body type, as well as disease risk. It accounts for differences in body composition by defining the level of adiposity according to the relationship of weight to height, eliminating the dependency on frame size. Women had a mean BMI of 23.2 ± 2.9 and men had a mean BMI of 24.1 ± 2.7. As shown in Figure 1
, 22% of women and 43% of men are overweight according to the National Institutes of Health classification. A small percentage of both genders are obese (3% of women and 2% of men).
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). Saturated fat intake was 9% of daily caloric intake in women and 11% in men.
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).
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). More men than women have high normal and stage 1 and stage 2 hypertension (Fig. 5
).
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, the majority of men (78%) fall in the optimal body composition range, whereas the majority of women (49%) fall in the moderately high body composition range.
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, the majority of men (69%) fell in the optimal body composition range, whereas the majority of women (46%) fell in the moderately high body composition range.
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, the mean student BMD in the hip was 1.02 ± 0.09 gm/cm2 for women and 1.12 ± 0.17 gm/cm2 for men; mean BMD in the whole body was 1.16 ± 0.14 gm/cm2 for women and 1.28 ± 0.14 gm/cm2 for men.
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indicate, this group of medical students has bone density greater than the mean for their age group.
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. Based on the RDA value for calcium of 1000 mg/d for both men and women in this age range, the women as a group are just barely adequate in their intake of calcium, whereas the men are well above the recommended level.
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indicates a high level of students who meet the NCEPIII guidelines for serum lipids. The lowest percentage for both genders is HDL where only 73% of men meet NCEPIII guidelines. Figures 2
and 3
show that high fat intake and lower fitness levels may contribute to this lower level of HDL in male 3rd-y medical students.
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Students rated each of the stations in this program highly, as presented in Table 5
. In addition, 100% of the students responded "yes" when asked if they believed their medical education was enhanced as a result of participating in this activity.
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DISCUSSION |
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TOPABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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This hands-on approach to learning about risk factors for cardiovascular health has been successful on many levels. Even though this program was initially planned as a 1-y pilot program, student interest and evaluations have been so positive that the University of Iowa School of Medicine has decided to include the program in the 3rd-y curriculum for the following year as well. This allows us the opportunity to provide this same opportunity for self-learning to another group of future physicians. Results from the student data indicate that medical students as a group generally tend to be healthy and physically active. However, many of the students became aware, through this experience, that there are aspects to their lifestyles that are potentially unhealthy; by discovering them at an early age, they have the chance to improve their chances for a healthy life.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Supported in part by National Heart, Lung and Blood Institute and University of Iowa General Clinical Research Center.
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LITERATURE CITED |
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TOPABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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1. Levine, B. S., Wigren, M. M., Chapman, D. S., Kerner, J. F., Bergman, R. L. & Rivlin, R. S. (1993) A motivational survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of clinical nutrition in medical practice. Am. J. Clin. Nutr. 57:115-119.
2. Young, E. A., Weser, E., McBride, H. M., Page, C. P. & Littlefield, J. H. (1983) Development of core competencies in clinical nutrition. Am. J. Clin. Nutr. 30:800-810.
This article has been cited by other articles:
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  N. F Krebs and L. E Primak Comprehensive integration of nutrition into medical training. Am. J. Clinical Nutrition, April 1, 2006; 83(4): 945S - 950S. [Abstract] [Full Text] [PDF]
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L. A Hark Lessons learned from nutrition curricular enhancements. Am. J. Clinical Nutrition, April 1, 2006; 83(4): 968S - 970S. [Abstract] [Full Text] [PDF]
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