|ORIGINAL RESEARCH ARTICLE
|Year : 2017 | Volume
| Issue : 2 | Page : 156-162
Medical students' perceived educational needs to prevent and treat childhood obesity
Natalie K Cooke, Sarah L Ash, L Suzanne Goodell
Department of Food, Bioprocessing, and Nutrition Sciences, North Carolina State University, Raleigh, NC 27695, USA
|Date of Web Publication||19-Sep-2017|
Natalie K Cooke
Department of Food, Bioprocessing, and Nutrition Sciences, North Carolina State University, Campus Box 7624, Raleigh, NC 27695
Source of Support: None, Conflict of Interest: None
Background: Medical schools are challenged to incorporate more prevention-based education into curricula, offering an opportunity to revisit approaches to nutrition education. The objective of this study was to explore United States (US) medical students' understanding of childhood obesity, specifically barriers to childhood obesity prevention and treatment and students' perceived educational deficits. Methods: The research team conducted phone interviews with 78 3rd- and 4th-year medical students, representing 25 different medical schools across the US. Using a semi-structured interview guide, researchers asked students to describe the etiology of childhood obesity and reflect on where they acquired knowledge of the etiology and what additional resources they would need to treat obese children. Using a phenomenological approach to analysis, researchers identified five dominant emergent themes. Results: Student-perceived barriers to childhood obesity prevention and treatment in clinical care included student-centered (e.g., lack of knowledge), patient-centered (e.g., lack of access), and healthcare system-centered barriers (e.g., limited time). Students requested more applicable nutrition information and counseling skills relevant to preventing and treating childhood obesity; however, they tended to identify others (e.g., parents, schools), rather than themselves, when asked to describe how childhood obesity should be prevented or treated. Discussion: To provide students with an understanding of their role in preventing and treating childhood obesity, US medical schools need to provide students with childhood obesity-specific and general nutrition education. To build their self-efficacy in nutrition counseling, schools can use a combination of observation and practice led by skilled physicians and other healthcare providers. Increasing students' self-efficacy through training may help them overcome perceived barriers to childhood obesity prevention and treatment.
Keywords: Childhood obesity, interviews, medical education, qualitative research
|How to cite this article:|
Cooke NK, Ash SL, Goodell L S. Medical students' perceived educational needs to prevent and treat childhood obesity. Educ Health 2017;30:156-62
| Background|| |
Once thought to be a problem in only high-income countries, obesity is now a global epidemic, impacting low-, middle-, and high-income countries. Obesity was recently classified as a disease, drawing attention to the importance of prevention and treatment in clinical settings. United States (US) medical schools now promote prevention-based medical education, and recent healthcare system policies point to the timely need to alter US medical school curricula accordingly.
Globally, overweight and obesity impact more than 2 billion people. Within the US, childhood obesity affects 17% of children 2–19 years of age, threatening their physical and psychological health ,, and significantly increasing healthcare costs. Physicians can play a key role in early prevention because they see children at frequent, regular intervals  and because patients believe physicians hold the authority to help them lose weight. To facilitate pediatric weight management, physicians need to encourage patients to limit consumption of sugar-sweetened beverages and energy dense foods, consume high-fiber diets rich in fruits and vegetables, and participate in daily physical activity with limited screen time. Nutrition behavior change counseling can help promote healthier eating practices; therefore, physicians-in-training need to understand both nutrition information and counseling practices to engage patients in change.
Unfortunately, nutrition education in medical school is often limited, both in the US ,, and in other countries. In the US, this inadequacy has been reported since the 1950s, and the most recent reports indicate that medical schools provide an average of only 19.6 hours of nutrition-related education. These statistics reflect nutrition education as a whole, which suggests that childhood obesity content is even more limited. Not surprisingly, this lack of training is reflected in the beliefs and actions of practicing physicians, who express low self-efficacy in obesity management. Only half of pediatricians report using nutrition behavior change counseling, and fewer than half follow recommendations  or believe they can help obese patients lose weight. Few feel competent in treating childhood obesity, and most do not address weight concerns in overweight children. This is not just a US phenomenon, rather lack of nutrition knowledge is seen in other parts of the world,,,, with both medical students and physicians expressing desire for more nutrition education in medical school. These inadequacies highlight the need to increase nutrition knowledge and build nutrition counseling self-efficacy among medical students around the world.
The medical community has expressed the need for medical nutrition education reform,,, urging that the time for change is now. The research to date has been primarily quantitative;,,, however, qualitative methodologies could reveal the complexity of US medical students' experiences. Therefore, we employed a qualitative, phenomenological approach , to explore medical students' educational experiences relative to the etiology, prevention, and treatment of childhood obesity.
| Methods|| |
Participants and recruitment
Participants were 3rd- and 4th-year students at allopathic and osteopathic medical schools in the US who were recruited through listservs or referral from another medical student. The final sample (n = 78) was determined by saturation, with students representing 25 medical schools in 16 different states in each of the four major census regions of the US. Students' ages ranged from 23 to 44 years, and they came from a variety of educational backgrounds [Table 1]. The Institutional Review Board at North Carolina State University granted ethical approval.
|Table 1: Participant demographics of qualitative interviews with United States allopathic and osteopathic medical students (n=78)|
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Data collection and analysis
Before data collection, we developed a standardized interview guide to explore medical student views through open-ended questions and probes [Table 2]. Each of the four research assistants engaged in standardized qualitative research training before beginning data collection. Each phone interview lasted for 30–90 minutes and was digitally audio-recorded. We transcribed interviews verbatim except two files lost due to technical difficulties, where we used interviewer notes instead.
|Table 2: Major interview questions and probes asked of United States allopathic and osteopathic medical students (n=78) during qualitative interviews|
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While data were being collected, we held weekly meetings to determine saturation and begin preliminary data analysis through reflexive critical dialogue and identification of preliminary dominant emergent themes. After reaching saturation, we developed a coding manual containing twenty codes organized into seven coding categories, with the structure being guided by preliminary dominant emergent themes. During secondary analysis, four coders used the coding manual to individually code transcripts. Before beginning the individual coding process, coders became familiar with the process by all individually coding the same transcript and reviewing differences. After coders felt comfortable with the process of coding, we randomly assigned one-third of the transcripts to three of the four coders. The remaining, primary coder coded all of the transcripts and reviewed all transcripts. During these weekly meetings, coders discussed difficulties with codes to reduce coder drift  and determined dominant emergent themes. After entering codes into NVivo9 Qualitative Software, we then reviewed quotes in each coding category to determine a comprehensive understanding of the phenomenon and a final list of dominant emergent themes within and across coding categories.
| Results|| |
Analysis surfaced five dominant emergent themes relative to the phenomenon of medical students' perceived barriers and needs associated with their childhood obesity training [Table 3]. Students' descriptions of barriers were revealed throughout the interviews in their discussion of the etiology of childhood obesity and their reflection of where they learned about the causes, consequences, prevention, and treatment of childhood obesity. Their perceived needs associated with training surfaced primarily from the end of the interview when asked about the importance of nutrition or what information, resources, and skills they would need to treat childhood obesity.
|Table 3: United States medical student-perceived barriers and requested needs relative to childhood obesity prevention and treatment|
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Medical student-centered barriers
Medical students described a variety of student-centered barriers, with the most prevalent one being limited nutrition education in medical school. Students said that they learned nutritional biochemistry but not basic nutrition knowledge to share with patients. Recognizing their nutrition coursework was limited, students said they felt unprepared to provide nutrition recommendations in a clinical setting. One student said, “If someone were to tell me right now, 'We have an obese child, can you help put this child on… a healthy diet?' I don't know what I would say.” Students explained that their nutrition coursework was not applicable to patients and they were not prepared to counsel patients. One student said, “When (my future patients) ask me something about nutrition, I'm going to have to Google (it)… because I don't feel like I have a very solid foundation.”
In addition, some students felt their clinical rotations did not provide them with enough experience to prevent and treat childhood obesity. Some students explained that they either did not have the opportunity to see obese children in their clinical rotations or that if they did, obesity was not addressed.
The medical students recognized that childhood obesity is a complex issue mitigated by many internal and external factors. This acknowledgment allowed them to understand there are many barriers patients face when trying to lead a healthy lifestyle, including socioeconomic status and limited access to healthy food and safe play. One student said, “(A) ccess to things like healthy food is going to be important. I didn't really believe this until I saw for myself here (where my medical school is located). It's really hard to eat healthy if the only food source within two or three miles of your house is fast food restaurants.”
In addition, students said that patients might not be able to prepare healthy foods because of limited time. One student described this frustration by saying, “I can't write a prescription for you to get vegetables at your store. I can't write a prescription for you to be able to leave work 2 hours early to go exercise.” Students recognized that their patients might have limited nutrition knowledge, preventing them from being able to choose and prepare healthy foods. One said, “I'm sure there are plenty of people out there that don't know what's healthy and what's not healthy.” Students understood these barriers prevent patients from healthy lifestyles but did not feel confident helping patients overcome the barriers.
Healthcare system-centered barriers
Students expressed problems with a healthcare system that prevented them from delivering the type of care they thought necessary. Students explained that because of limited in-office time with patients, it is difficult to provide nutrition counseling. One student said, “I think you're very limited in what you can do as a physician in the set-up of general clinic because… it's complicated and requires behavior intervention… (T) here's really not enough time for that.” Students saw this limitation in clinical experience and reported that their preceptors discussed frustration with limited time. Students saw that physicians felt a need to treat the immediate medical concern instead of the more distant concern of childhood obesity. One student explained that childhood obesity is often not addressed because “if you don't deal with this (immediate) thing in your office right now, today, there's going to be a bad outcome tomorrow.” This student went on to say, “Well, if you have problems with obesity, well come back… and we'll address it.” Students frequently reported that the need to treat immediate needs kept them from gaining experience with counseling patients. Students also expressed that minimal follow-up with patients often left them without a chance for patient feedback.
In addition to their discussion of barriers, students also displayed a sense of disconnect between the causes of childhood obesity and their specific role in prevention and treatment. Few students described themselves as fitting into the solution but instead described other solutions, including parent education provided by community programs and changes needed in the school system. The limited perception of their role in the solution might be because of the healthcare system barriers, lack of training, and not feeling equipped to overcome barriers.
Need for knowledge
These students wanted more nutrition education, which they said could be provided through didactic portions of medical school, pediatric rotations, or lunch seminars. Students explained they learned about adult obesity but not childhood obesity. One student said, “We have lectures on asthma, why do we not have a lecture on childhood obesity? And not just in terms of teaching us about the epidemiology of it but actually teaching us… what you do with your patients, and even showing us some of those skills and resources we might need later.” As this student also expressed, students want this nutrition information to be easily relatable to patients, including the practical aspects of how to maintain a healthy lifestyle. One student said, “(Physicians) need to know what they can tell patients to get them to improve their lifestyle… specific concrete advice they can give them regarding diet – where to eat, what to eat, when to eat, (and) how to eat.”
Some students also wanted specific tips and hints for finding and preparing healthy food that could be shared with patients. Not only did students say they want information that patients can understand, but they also said that they want evidence-based nutrition knowledge. They valued recommendations based on scientific literature but reported that medical school did not provide them with this information.
Need for counseling skills
In addition to more knowledge, students also said they need more skill building in nutrition counseling. Students requested more opportunities for practicing counseling skills with children and families. They reported having had opportunities to practice motivational interviewing related to other health behaviors but wanted experience with childhood obesity counseling. One student explained how this might be facilitated: “A childhood obesity clinic… (where) we could spend some time – that would be useful. And then we would feel comfortable knowing… (how) to motivationally interview people.” Students said they needed to know how to speak to children about the emotionally charged subject of childhood obesity and how to provide effective family counseling that is culturally sensitive.
| Discussion|| |
The US medical students in this study described a limited amount and depth of nutrition education in their medical curricula, similar to previous studies in the US and globally.,,, The lack of emphasis on childhood obesity, in particular, might lead students to believe that prevention and treatment are not a priority. In addition, given that nutrition has historically been under-represented on examinations, it is possible that students believe that nutrition, in general, is not as important as more heavily-tested subjects, and further, that it is not their responsibility to answer patients' nutrition-related questions. While registered dietitians are the experts in nutrition counseling, physicians need to be able to address their patients' nutrition-related concerns and be competent in nutrition assessment and education, including those related to childhood obesity. During preclerkship coursework, students could learn basic nutrition information (e.g., tips for finding and preparing healthy foods) or even be exposed to behavior change activities that could be shared with patients. However, given time constraints, clerkships might offer a more realistic opportunity for students to gain this knowledge from registered dietitians.
In addition to a lack of nutrition knowledge, students described a lack of time for nutrition counseling during clinical rotations, feeling the need to treat more immediate medical concerns, mirroring reports from practicing healthcare providers.,,,, In addition, students seemed unsure regarding the feasibility of obesity prevention and treatment, similar to previous research., In fact, despite repeated probing, these students rarely described a role for themselves in this aspect of health care. That is, they tended to describe community programs' obesity-related efforts but not their own, a phenomenon also seen in prehealthcare undergraduates. Once again, when a component of healthcare is not emphasized – in this case preceptors modeling the physician's role in obesity prevention and treatment – students may not see it as important. To mitigate this, medical schools can provide students with a better understanding of their role within the broader context of a social ecological framework.
To address students' perceived need for more counseling skills, nutrition behavior change counseling trainings can be designed to increase both knowledge and self-efficacy ,, by incorporating both observation (modeling) and practice (mastery of skills). Having preceptor “buy-in” as role models is important; however, the preceptors' own lack of skills  might need to be addressed first., Registered dietitians with the appropriate background could also serve this role.
Throughout the study, we sought to increase trustworthiness of the data using nonjudgmental and unbiased language during interviews, member-checking at the end of each interview,, and multiple trained researchers in data collection and analysis., However, despite these efforts, there were limitations. Because this was a volunteer sample, students might have been more interested in the subject or more educated than the general population of medical students. We attempted to decrease this effect by offering a gift card raffle ticket incentive. However, the study subjects over-represent the percentage of students pursuing pediatrics and family medicine careers and those graduating with Masters of Public Health degrees, so the sample may not have fully captured all medical students' experiences. Given the nature of the referral recruitment strategy, students might have shared interview questions with friends even though we asked them not to do so. In addition, due to timing, students might not have started their pediatrics rotation, where they might have received the training they requested. While we did not ask specifically if the participant had completed their pediatrics rotation, all students were 3rd- and 4th-year medical students who had begun their clinical rotations and were aware of the nature of their training. Finally, because these findings describe the phenomenon of nutrition education in US medical schools, they are not necessarily generalizable to other countries. However, given similar global trends that indicate lack of physician nutrition knowledge,,,, these results may spur similar evaluations in other countries.
Medical schools may use the findings of this study to adapt their curricula to include more applicable nutrition and childhood obesity-specific knowledge and nutrition-related behavioral change counseling skill building through observation and practice. Given curricular time constraints, medical schools may choose to incorporate this training to varying degrees, with the ultimate goal of preparing physicians who are both competent in the basics of nutrition and also able to collaborate with other, more skilled nutrition experts in the healthcare field. Future research could explore the impact of these different levels of curricular changes on students' self-efficacy in childhood obesity prevention and treatment, specifically through a self-efficacy survey, like the Childhood Obesity Prevention Self-Efficacy Survey.
We are grateful for research assistants De'Ja Alexander, Amanda Antono, Brittany Lang, Megan Lee, Alice Raad, Samantha Walker, and Jennifer Wheeley, who contributed their talents to data collection and/or analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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