Introduction
Globally, 11 million deaths annually are attributable to dietary factors, placing poor diet ahead of any other risk factors for death in the world, yet medical doctors receive limited training in nutrition (GBD 2017 Diet Collaborators, 2019). Obesity increases risk of major chronic diseases, including heart disease, diabetes, depression, and many cancers, as well as premature death. According to the Centers for Disease Control and Prevention (n.d.), obesity is a complex health issue that may include behavior, genetics, illnesses, medications, and/or psychological factors. Non-Hispanic Black adults had the highest prevalence of self-reported obesity (41.7%), followed by non-Hispanic American Indian or Alaska Native adults (38.4%), Hispanic adults (36.1%), non-Hispanic White adults (31.0%), and non-Hispanic Asian adults (11.7%) (Centers for Disease Control and Prevention, 2022). Differences in social determinants of health (SDOH) affect chronic disease outcomes and risks, including obesity, among racial, ethnic, and socioeconomic groups as well as in different geographies and among people with different physical abilities (Centers for Disease Control and Prevention, n.d.).
According to Morrison and Bennett (2016), during the 20th century, changes in the field of health were accompanied by changing patterns of disease. In 1900, most diseases were short-duration, infectious diseases, but by the end of the century, behavior and lifestyle were the underlying causes of most diseases. These changes have influenced the cost of medical care, the definition of health, and an indication that a biopsychosocial approach may provide a better model than the biomedical model. Of the nation’s $4.1 trillion in annual health care expenditures, 90% are for people with chronic and mental health conditions (Centers for Disease Control and Prevention, n.d.).
A paradigm shift is needed in medical education so that medical schools shape global health by incorporating LM as part of the curriculum and training for future physicians (Hivert et al., 2016). A rising incidence of chronic health conditions has led to an even greater need for nutrition education content in medical school curriculum so physicians may appropriately counsel patients about lifestyle factors (Cresci et al., 2019). However, many doctors do not provide nutrition or other lifestyle recommendations to their patients because of time constraints with patients during their appointments, as well as lack of necessary knowledge about how diet and physical activity affect specific medical conditions (Hivert et al., 2016). For decades, physicians have emphasized the importance of practicing evidence-based medicine and many physicians would agree with the premise that regular physical activity, weight management, sound nutrition, and not smoking all result in significant health benefits (Rippe, 2018). Yet despite this belief, many physicians’ trainings are focused on how to treat chronic illnesses after they have occurred, and little training is focused on prevention (Lacagnina et al., 2018).
Since changing patterns of disease have shifted from short-duration, infectious diseases in the 1900s to behavior and lifestyle changes resulting in chronic diseases in the 2000s, the field of health needs to adopt the biopsychosocial model, rather than the biomedical model (Morrison & Bennett, 2016). The biopsychosocial model of health views health as a positive condition and disease as the result of a combination of biological, psychological, and social influences. According to Trilk et al. (2019), the need for medical education to move beyond basic science/biochemical nutrition is needed to train medical students to effectively engage with patients for nutritional behavior change.
According to the Centers for Disease Control and Prevention (n.d.), social determinants of health include the conditions in which we live, learn, work, and play. It can be difficult to make healthy food choices and get enough physical activity if these conditions do not support health. Places such as childcare centers, schools, or communities affect eating patterns and activity through the foods and drinks they offer and the physical activity opportunities they provide (Centers for Disease Control and Prevention, n.d.).
The importance of a healthy lifestyle in preventing and treating non-communicable diseases (NCDs) is indisputable, which includes embracing the importance of healthy lifestyle promotion, counseling, and follow-up in future medical practice (Hivert et al., 2016). Training in LM provides a new way to deliver health care to prevent, treat, and cure chronic diseases that are responsible for most health care costs. According to Lacagnina et al. (2018), LM is focused on a good quality of life, and a high level of health and well-being. The LM core competencies address prevention areas such as nutrition, physical activity, sleep health, emotional wellness, mindfulness, tobacco cessation, and alcohol use.
An LM team works with the patient by educating and supporting them about how to live healthier lifestyles. The LM team works together to promote preventive health care. The LM team may include a physician as the LM consultant. Other team members typically include a registered dietitian (RD) or registered dietitian nutritionist (RDN), an exercise specialist, a psychological counselor, and a sleep specialist. The team of health care providers focuses specifically on mitigating risk factors, encouraging prevention, and addressing the underlying cause(s) of the disease (Lacagnina et al., 2018). The LM team consists of health care providers who encourage prevention and address underlying causes. This teamwork approach treats not only the biological factors, but also the psychological and social factors that contribute to chronic disease. Therefore, it is prevention focused.
Problem Statement
Many doctors do not provide nutrition and other lifestyle recommendations to their patients for many reasons. A lack of nutrition education and training, and time constraints with patients during appointments, may explain why doctors tend to not include nutrition advice in their care plans (Adamski et al., 2018). Physicians do not feel comfortable, confident, or adequately prepared to provide nutrition counseling, which may be related to suboptimal knowledge of basic nutrition science facts and understanding of potential nutrition interventions (Adams et al., 2010). Medical training often focuses on pharmacological treatment, while the dissemination of knowledge about the benefits of healthy diet, physical activity, and not smoking as part of non-communicable disease (NCD) prevention and management is marginal. (Hivert et al., 2016).
The need for medical education to move beyond basic science/biochemical nutrition is needed to train medical students to effectively engage with patients for nutritional behavior change (Trilk et al., 2019). The importance of a healthy lifestyle in preventing and treating NCDs is indisputable but there needs to be a change in culture. This shift is needed to improve public health, positively affecting future medical practice, and embracing the importance of healthy lifestyle promotion, counseling, and follow-up (Hivert et al., 2016).
To fill the gap of educating and supporting patients about how to live healthier lifestyles, an LM team works with the patient. The LM team works together to promote preventive health care. A primary care physician trained in LM should possess the knowledge, skills, attributes, and values that utilize a biopsychosocial model. The competencies of leadership, knowledge, assessment skills, management skills, and use of office and community support are included to address lifestyle causes and treatments for most medical problems in society (American College of Lifestyle Medicine, 2020).
Purpose Statement
The purpose of this study was to explore the perception of fourth-year medical students about their competence as an LM counselor. This may be the first study to survey fourth-year medical students from medical schools with LM curricula and examine their perceptions of their competence in providing lifestyle counseling. This study was created to assess the perceptions of fourth-year medical students in providing LM counseling to patients. It was also designed to examine the perceptions of fourth-year medical students’ competence in leading the LM team to promote preventive health. The research question was postulated based on the five core competencies of LM: leadership, knowledge, assessment skills, management skills, and use of office and community support (American College of Lifestyle Medicine, 2020).
Significance of the Study
This study is important to address fourth-year students’ perceptions of their competence as a lifestyle counselor. Physicians feel ill-prepared and lack confidence to provide adequate lifestyle counseling in the domains of physical activity, nutrition, weight management, and tobacco use (Hivert et al., 2016). The traditional view of health is based on the biomedical model, which views health as the absence of disease, and disease as a result from exposure to a pathogen. Since chronic diseases are the leading cause of mortality in the United States, and are a global concern, it is time to shift to the biopsychosocial model of health and train future physicians in LM.
Method
The study explored the perceptions of fourth-year medical students about their competence as an LM counselor. Open coding was used to address RQ1 and RQ2. Participant responses were reviewed to identify themes in perceptions of providing LM counseling and leading an LM team. A Pearson’s r correlation analysis was used to address RQ3, calculating the correlation coefficients for perceived competency in leadership and knowledge, and the other variables of interest.
Research Questions and Hypotheses
The study was designed to address the following research questions:
RQ1: What are the perceptions of fourth-year medical students in providing lifestyle medicine counseling to patients?
RQ2: What are the perceptions of fourth-year medical students’ competence in leading the lifestyle medicine team to promote preventive health care?
RQ3: Is there a significant correlation between perceived competency in leadership and knowledge, and assessment skills, and management skills, and use of office and community support?
H0: There is no significant correlation between perceived competency in leadership and knowledge, and assessment skills, and management skills, and use of office and community support.
Population of Interest
Students from a variety of different medical schools listed on the American College of Lifestyle Medicine (ACLM) webpage were selected to participate. The medical schools were contacted through email to ask permission to survey the fourth-year medical students. Permission was granted from four purposely selected medical schools, to reflect a variety of participants.
Liaisons were provided a unique identifier survey link for each of the medical schools from SurveyMonkey to the students. They provided the link to fourth-year medical students who were invited to participate in a survey to rate their perceived competence in providing lifestyle counseling. Students from a school of osteopathic medicine, a state medical school, a faith-based medical school, and a Canadian medical school were included in the survey.
A total of 53 fourth-year medical students from the four medical schools participated in the study. There were 17 participants from a Canadian medical school, four from a college of osteopathic medicine, 24 from a private, faith-based medical school, and eight from a state university medical school. Of the 53 participants, 45 were between the ages of 25-34, 3 were between 18-24, 3 were between 35-44, and 2 did not report their age.
Study Design
The study incorporated a survey design, to assess their self-perception of their competence in providing counseling about unhealthy behaviors for patients. In addition, the participants were asked to provide a self-perception of their competence in leading an LM team to promote preventive health care. Survey participants were asked to rate their responses to a series of items based on the American College of Lifestyle Medicine (ACLM) recommended core competencies of LM as defined by the ACLM (2020)) by responding to the electronic survey. A Likert scale (1-5) was provided for each item for participants to indicate their level of self-perception and competence for each item in the survey. Survey participants were instructed to choose the rating that best represents their perception of their competence in performing each of the items included in the survey listed.
A designated contact person was identified as the liaison for the survey. A link to the survey administered via SurveyMonkey was provided via email to the respective liaisons for distribution to fourth-year medical students. After the first survey results were received, a two-week follow-up email was sent to the liaisons at each school to send to the fourth-year medical students that served two purposes. First, a thank you to those who have already completed and submitted the survey. Second, a reminder to those who had not completed the survey, that by taking a few minutes to complete it, their responses were important and the data that was being collected is as complete as possible and greatly appreciated. The email also reminded them that their responses were anonymous.
Instrument(s) and Psychometrics
The survey instrument was based on the core competencies as identified by the ACLM (2020). According to Lianov & Johnson (2010), the suggested LM competencies for primary care physicians are leadership, knowledge, assessment skills, management skills, and use of office and community support. The core recommended competencies were developed by a panel of subject matter experts from the ACLM, and individual national experts in nutrition, exercise, and LM that convened in Washington, DC, July 2009 (American College of Lifestyle Medicine, 2020).
The survey instrument also applied the six pillars of LM, which include a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connections (American College of Lifestyle Medicine, 2019). The core competencies, inclusive of the six pillars, are instrumental in reversing chronic disease with evidence-based LM.
The participants were asked to rate their competence in providing physician counseling to patients to adopt healthy lifestyle behaviors. They were asked to use a Likert scale that included strongly agree, agree, neither agree or disagree, disagree, or strongly disagree to rate themselves for each competency and sub-category. The survey was based on the competencies of leadership, knowledge, assessment skills, management skills, and use of office and community support. Each competency included specific sub-categories as defined by the ACLM.
Demographic information was limited to age, level of training in lifestyle and/or culinary medicine, and confirmation that the participant was a fourth-year medical student. The demographic variables and the school became the independent variables, and the survey items were the dependent variables of the study.
Data Collection
Data was collected via SurveyMonkey. The anonymous feature in SurveyMonkey was used, so that identifying information such as IP addresses and email addresses was not collected. Before beginning the survey, the survey participants were provided with an informed consent statement and agreed to the terms before the survey was opened.
Cooperation with the medical school liaisons was required to distribute the survey to participants. Follow-up email reminders were sent on an interval schedule until the survey closed. Students from each medical school received a unique link that identified the respective medical school of the respondent, but the names of the schools remained confidential. These identifications were used only for data comparison purposes.
Data Analysis
All data for this study was collected via SurveyMonkey. Data was collected, managed, and stored within a password protected SurveyMonkey account accessible only by the researcher. Data was exported to SPSS software using an automated process within SurveyMonkey.
Results
Reported experience with LM included seven in an LM track/specialty, six in LM in core curriculum (M1 – M2), 14 in LM in clerkship (M3 – M4), six in an LM required course, two in an LM elective course, zero in culinary medicine, six in none of the above, and nine who chose other. The nine who chose other, added additional comments for clarification. Reasons provided for the choice of other was through own experience, prior to medical school, personal interest and going above and beyond curriculum, Facebook, family, club, and emails.
Is there a significant correlation between perceived competency in leadership and knowledge, and assessment skills, and management skills, and use of office and community support? The correlations are illustrated in Table 1.
The results were significant, with a strong positive correlation between average assessment skills and average management, r = 0.612, n = 48, p <0.001. The results were significant, with a strong positive correlation between average assessment skills and average knowledge, r = 0.566, n = 48, p <0.001. The results were significant, with a strong positive correlation between average assessment skills and average support, r = 0.563, n = 48, p <0.001. The results were significant, with strong positive correlation between average knowledge and average management, r = 0.488, n = 50, p <0.001. The results were significant, with a moderate positive correlation between average management and average support, r = 0.391, n = 50, p = 0.005. The results were significant, with moderate positive correlation between average knowledge and average support, r = 0.356, n = 50, p = 0.011. The results were significant, with a low positive correlation between average assessment skills and average leadership, r = 0.284, n = 49, p = 0.048.
The results were not significant, with low positive correlation between average knowledge and average leadership, r = 0.050, n = 52, p = 0.723. The results were not significant, with a low positive correlation between average leadership and average management, r = 0.198, n = 51, p = 0.164. The results were not significant, with a low positive correlation between average leadership and average support, r = 0.197, n = 51, p = 0.165.
Discussion
The biopsychosocial model views health as a positive condition and a disease as the result of a combination of biological, psychological, and social influences (Morrison & Bennett, 2016). The psychological and social influences of health need to be addressed, in addition to biological, because community factors also influence health. According to the Centers for Disease Control and Prevention (n.d.) SDOH that influence obesity include community factors such as the affordability of healthy food options, peer and social supports, marketing and promotion, and policies that determine community design.
Training in LM provides a new way to deliver health care to prevent, treat, and cure chronic diseases that are responsible for most health care costs. In addition, LM is focused on a good quality of life, and high level of health and well-being (Lacagnina et al., 2018). Implementing a comprehensive curriculum that addresses personal wellness strategies, basic science concepts related to nutrition, and diagnosis and management of diseases that are related to nutrition, highlights the importance of nutrition in health and disease (Cresci et al., 2019).
Academic programs in LM are designed to equip students with the knowledge, skills, and attitudes necessary to provide preventive health care and promote health and wellness in their future practice (American College of Lifestyle Medicine, 2019). Prescribing lifestyle medicine includes knowledge of nutrition, physical activity, and behavioral change strategies, as well as clinical skills such as taking medical histories, conducting physical exams, and interpreting lab tests. In addition, it is important that physicians be trained in motivational interviewing and cultural competence to effectively engage with patients (Lianov & Johnson, 2010).
The survey questions were postulated based on the five core competencies of LM: leadership, knowledge, assessment skills, management skills, and use of office and community support (American College of Lifestyle Medicine, 2020). It is important to note that the core competencies in LM were developed by a variety of health care organizations. These included the American Medical Association (AMA), the American Osteopathic Association (AOA), the American Academy of Family Physicians (AAFP), the American College of Physicians (AC), the American Academy of Pediatrics (AAP), and the American College of Preventative Medicine (ACPM) (American College of Lifestyle Medicine, 2020).
In addition to the core competencies of LM, the survey instrument also applied the six pillars of LM, which include a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connections (American College of Lifestyle Medicine, 2019).
Overall, the results revealed that there is a significant strong positive correlation between average assessment skills and average management, average assessment skills and average knowledge, average assessment skills and average support, and average knowledge and average management. These results reflect that fourth-year medical students generally have positive perceptions of providing LM counseling to patients. Many students report feeling a strong sense of responsibility to educate patients on preventive measures and to empower them to make lifestyle changes that could improve their health. Students also report feeling confident in their ability to provide LM counseling and believe that they can make a positive impact on the health of their patients (Lee et al., 2021).
The results were not significant, with low positive correlation between average knowledge and average leadership, r = 0.050, n = 52, p = 0.723. It may be surmised that there was a low positive correlation between perceived competence and practice of healthy behaviors, as some medical students indicated that they did not practice healthy behaviors themselves. This hindered their ability to promote healthy behaviors, as they were not setting a good example. If they could not set a good example, their perceived competence in providing patients with information about nutrition, physical activity, stress management, etc. was likely diminished. Therefore, physicians should practice healthy lifestyle habits as a basis for providing more effective lifestyle counseling to patients with chronic diseases (Lee et al., 2021).
The results were not significant, with a low positive correlation between average leadership and average management, r = 0.198, n = 51, p = 0.164. Fourth-year medical students reported having low levels of competence in promoting healthy behaviors, using nationally recognized practice guidelines for hypertension, smoking cessation, and establishing relationships with patients and families to affect and sustain behavioral change, providing evidence-based counseling and developing evidence-based, achievable, and specific action plans (such as lifestyle prescriptions), helping patients manage and sustain healthy lifestyle practices, and referring them to other health care professionals for lifestyle-related conditions. While the theoretical approach to working in an interdisciplinary LM team is introduced in the curriculum, perhaps practical experience during residency may improve these competencies. It is important for health care organizations to create policies to support the development of lifestyle medicine teams and provide ongoing training and support to ensure team members can effectively practice lifestyle medicine (Lacagnina et al., 2018).
The results were not significant, with a low positive correlation between average leadership and average support, r = 0.197, n = 51, p = 0.165. The results indicated that since the survey participants may not have yet worked in an interdisciplinary team of health care providers, developed and applied office systems and practices to support lifestyle medical care including decision support technology, measured processes and outcomes to improve the quality of LM interventions in individuals and groups of patients, and used appropriate community referral resources that supports the implementation of healthy lifestyles, that practical experience in residency may improve these competencies.
Since this may be the first study to be conducted in which fourth-year medical school student reported their perception of their competence in providing counseling about unhealthy behaviors, this study may provide insight to future studies on LM curriculum and preparing physicians to provide counseling to patients about unhealthy behaviors. This study advances the current research literature on the positive implications of incorporating LM in medical school curriculum. This study was particularly focused on the core competencies of LM for primary care physicians: leadership, knowledge, assessment skills, management skills, and use of office and community support.
The results revealed that there was a significant, strong positive correlation between average assessment skills and average management, between average assessment skills and average knowledge, between average assessment skills and average support, and between average knowledge and average management. There was a significant, moderate positive correlation between average management and average support, and between average knowledge and average support. Also, there was a significant, low positive correlation between average assessment skills and average leadership.
Preventing chronic diseases, or managing symptoms when prevention is not possible, could reduce the $4.1 trillion being spent on treatment of chronic diseases. Three main risks that need to be addressed in prevention and treatment are cigarette smoking, physical inactivity, and excessive alcohol use. Cigarette smoking is the leading cause of preventable death and disease for over 16 million Americans, who have at least one disease caused by smoking. The Centers for Disease Control and Prevention (n.d.) also lists physical inactivity being linked to heart disease, type two diabetes, some cancer, and obesity; and excessive alcohol use being responsible for one in 10 deaths among working-age adults.
The Centers for Disease Control and Prevention (n.d.) suggests that by making healthy choices, people reduce their likelihood of getting chronic diseases and they improve their quality of life. These healthy choices include, but are not limited to, quitting smoking, eating healthy, getting regular physical activity, eating a healthy and balanced diet, maintaining a healthy weight, avoiding tobacco use, and limiting alcohol consumption. The study’s significant positive correlations provide insight into not just treating and managing chronic disease, but also the role of physicians in providing counseling to patients as a form of preventative care. LM has the potential to reduce health care costs, improve patient outcomes, and increase patient engagement in preventive care (Rippe, 2018).
Limitations
There are significant limitations to this study. First, the survey involved fourth-year medical students at only four non-randomly selected medical schools. Limitations such as bias due to self-reported data and weaknesses of cross-sectional data collection were also possible. The medical schools that participated did not provide the total number of fourth-year students in each LM program, so it was unclear what percentage participated in the study.
Time limitations and access to fourth-year medical students resulted in a smaller sample size. More than four medical schools with a four-year LM curriculum were asked to participate, but only four agreed. Some medical school administrators declined participation because they did not want to overburden students with additional surveys at the end of the academic term and year. Gaining access to fourth-year medical students the last semester before graduation was challenging. Future studies need to consider the time it takes to make contact, gain approvals, and identify liaisons for survey distribution. Collaboration with medical school administrators is needed to identify liaisons and receive necessary approvals weeks to months in advance.
Conclusion
Including LM core competencies in medical school curriculum may increase the level of competence future physicians have in providing counseling to patients about unhealthy behaviors. Through the core competency areas of leadership, knowledge, assessment skills, management skills, and the use of office and community support, future physicians may serve as LM team leaders to provide nutrition and other lifestyle recommendations to their patients. Through education on the LM core competencies, physicians may be better equipped to provide information to patients about diet, physical activity, weight management, not smoking, sleep, and other wellness strategies. Perceived competence may lead to promotion of preventive care to address the global problem of major chronic diseases. An evidence-based, lifestyle medicine–driven approach to improving health care may be beneficial to fill the gap of educating and supporting patients about how to live healthier lifestyles.