Attitude and perceptions of GMU interns towards nutrition and nutrition education

Transcription

1 GMJ, ASM 2013;2(S2):S10-S16 Attitude and perceptions of GMU interns towards nutrition and nutrition education Gomathi KG 1*, Nelofer K 1, Shehnaz SI 2 1 Department of Biochemistry, 2 Department of Pharmacology, Gulf Medical University, Ajman, UAE *Presenting Author ABSTRACT Rise in lifestyle-related diseases including Diabetes and Cardiovascular disease has resulted in more physicians treating and advising patients regarding nutrition and beneficial nutritional modifications. Objective: To assess attitude to nutrition counseling and perceptions regarding nutrition knowledge, proficiency and nutrition education among GMU interns in various hospitals in the UAE. Materials and Methods: A questionnaire was developed with items spanning five domains including Attitude to nutrition counseling (10 items), Perceptions regarding nutrition knowledge (10 items), Perceptions regarding competencies in nutrition related areas (15 items), Behavior with respect to nutrition (5 items), Perceptions regarding nutrition education in the undergraduate medical curriculum (6 items) and Demographics (6 items). Responses were on a likert-like scale from strongly disagree to strongly agree (1-5). The questionnaire was validated by medical education faculty, physicians and nutritionists. Pilot testing was carried out on 3 medical graduates. Data collection from GMU interns in various hospitals is in progress. Results and conclusions: Preliminary analysis from 22 Interns shows very positive attitude and behaviour towards nutrition in health care. Nutrition counseling should be part of routine care by all physicians, regardless of specialty, I encourage patients to ask diet related questions, Physicians can have an effect on a patient s dietary behavior if they take the time to discuss the problem (median ) and Nutrition counseling is not an effective use of my professional time (median 2) suggest nutrition counseling is considered important. Regarding knowledge, all items received good s except potential harmful interactions between medications and food/herbal supplements. They feel confident regarding many nutrition-related competencies but are unsure of assessing fluid requirements based on activity and health. However regarding nutrition education, interns feel much more nutrition education is needed during both basic medical sciences and clinical clerkships. Nutrition education relevant to personal health and well-being is also required (median ). Keywords: attitude, diabetes, cardiovascular, nutrition INTRODUCTION Rapid transition to affluent and modern economies has changed the lifestyle in many countries of the world including UAE over the past few decades. Lifestyle and food habits in UAE and the other Gulf Countries have changed to become more sedentary and westernized. While most communicable diseases are under control in the UAE, dramatic rise in lifestyle related diseases including Diabetes and Cardiovascular disease has been observed 1. Primary physicians, especially in the developed world, are finding themselves treating more lifestyle diseases as well as advising patients regarding nutrition and beneficial nutritional modifications 2. While all medical schools across the world have nutrition and nutritionrelated topics in the curriculum, recent studies have indicated that the amount of nutrition education that medical students in the United States get continues to be inadequate 3. Although there are five medical schools in the UAE, there is no study regarding nutrition education in the curriculum of the medical students. An earlier study among Gulf Medical University (GMU) graduates had suggested 10

2 GMJ, ASM 2013;2(S2):S10-S16 that many medical graduates find nutrition education in their curriculum to be inadequate. The aim of this study was to assess attitude to nutrition and nutrition counseling as well as perceptions regarding nutrition knowledge, nutrition related competencies and nutrition education among GMU interns in various hospitals in the UAE. MATERIALS AND METHODS Development of the instrument: A survey questionnaire was developed based on the nutrition questionnaire used by Walsh et al and the attitude toward nutrition in patient care survey to assess attitude and perceptions regarding nutrition and nutrition education 5,6. More items were added, some deleted or modified after three rounds of discussion with faculty involved in teaching nutrition, basic medical sciences, clinical sciences as well as experts in medical education. The final questionnaire had items spanning five domains including Attitude to nutrition counseling (10 items), Perceptions regarding nutrition knowledge (10 items), Perceptions regarding competency in nutrition-related areas (15 items), Behavior with respect to nutrition (5 items), Perceptions regarding nutrition education in their curriculum (6 items) and Demographics (6 items). Responses were on a likert-like scale from strongly disagree to strongly agree (1-5). The questionnaire also had options for free responses. The questionnaire was validated for content by two physicians and two nutritionists. Pilot testing was carried out on 3 medical graduates and minor changes needed incorporated. Data collection and analysis: GMU Interns working in Sheikh Khalifa Hospital Ajman, Umm Al Quwain hospital and Al Mafraq Hospital Abu Dhabi were contacted for the study between June 2013 and September The questionnaire was self-administered and anonymous. Results were entered into Excel sheets and analyzed. Scores are reported as s or percentages. RESULTS Demographics: Only 22 GMU interns have completed the survey so far as the study is still in progress. Demographic details of the participants show the mean age to be 2 years while the range was between 22 and 30 years. 59% (13) were male and 36% (8) were female. One of the participants refused to reveal gender. 6 (27.2%) were of Arab ethnicity, 6 (27.2%) South Asian, 3 (13.%) Emirati, 1 (.5%) African and (18%) were of other ethnicities and 2 did not reveal ethnicity. 77% of the participants had not had any nutrition education other than in medical school while 22% (5) had done courses related to nutrition before joining medical school. 7 participants (32%) had family members who had food allergies/ intolerances which made them pay greater attention to nutrition. Of the participants, eight intended taking up surgery or related specialties, four of them were interested medicine and related specialties while many had not decided on their specialty. Attitude towards Nutrition and nutrition counseling: As shown in Table 1, most participants agreed that nutritional counseling should be a part of routine care by all physicians, strongly agreed that high risk patients should be counseled about dietary change and that a change toward healthier lifestyle is important at any stage in life. Many agreed that health education does little to promote adherence to a healthy lifestyle. Participants were uncertain whether most physicians are adequately trained to discuss nutrition with their patients. Perceptions regarding nutrition knowledge: As shown in Table 2, most of the interns perceived themselves as being knowledgeable regarding roles of fiber, omega and trans fatty acids, alcohol consumption and dietary habits that increased cancer risk. They were, however, unsure regarding nutritional requirements at various stages of life, 11

3 GMJ, ASM 2013;2(S2):S10-S16 Table 1: Interns attitude towards Nutrition and Nutrition counseling Statement 1. Nutrition counseling should be part of routine care by all physicians, regardless of specialty. 2. Nutrition counseling is not an effective use of my professional time All physicians should counsel high-risk patients about dietary change. 5. It is not worth the time to counsel patients with poor dietary patterns about nutrition. 5. A change toward a healthier lifestyle is important at any stage of life Most physicians are not adequately trained to discuss nutrition with patients Specific advice about how to make dietary changes will help patients improve their eating habits. 8. Physicians can have an effect on a patient s dietary behavior if they take the time to discuss the problem. 9. For most patients, health education does little to promote adherence to a healthy lifestyle. 10. Patients will rarely change their behaviour if they do not have active symptoms of a disease 2 Table 2: Perceptions regarding Nutrition Knowledge I am knowledgeable about 1. Nutritional requirements at various stages of life 3 2. Role of omega 3, omega 6 and trans fatty acids in heart health 3. Potentially harmful interactions between medications and food/herbal supplements 3. Nutrition concerns of patients with GI intolerances, maldigestion and malabsorption 5. Recognizing warning signs and symptoms of eating disorders 6. Role of fiber and phytonutrients such as carotenoids and flavonoids in health 7. Moderate alcohol consumption and its role in health and disease 8. Indications for enteral and parenteral nutrition 9. Dietary habits that increase cancer risk 10. Nutritional considerations in patients with chronic renal disease 3 interactions between medications and food/herbal supplements and nutritional considerations in chronic kidney disease. Perceptions regarding nutrition-related competencies: Table 3 shows perceptions of the interns regarding nutrition-related competencies. Participants agreed to being confident regarding almost all competencies except assessing fluid requirements based on activity and health regarding which many were unsure. Regarding behaviour related to nutrition (Table ), participants agreed that it important for them to address diet, perform some level of nutritional assessment with each patient, encourage patients to ask diet-related questions as well as recommend dietary changes prior to initiating drug therapy. They strongly agreed that it was important to refer patients with diet related problems to qualified nutritionist. 12

4 GMJ, ASM 2013;2(S2):S10-S16 Table 3: Perceptions regarding nutrition-related competencies I feel confident while: 1. Taking a dietary history of a patient 2. Calculating and interpreting body mass index and waist hip ratio 3. Assessing and counseling overweight patients regarding lifestyle changes. Providing advice to parents on healthy food choices and feeding practices. 5. Providing examples/suggesting foods for patients based on the food plate 6. Identifying and advising individuals at risk for nutrient deficiency 7. Recognizing nutritional anemia in children and adults 8. Assessing fluid requirements based on activity level and health 3 9. Discussing strategies for osteoporosis prevention and treatment including nutrition and lifestyle aspects 10. Recommending dietary patterns for patients with hypertension 11. Recognizing nutritional risk in elderly patients and adolescents 12. Providing nutritional strategies for patients losing weight due to chronic illness 13. Recommending dietary patterns for patients with type 2 diabetes 1. Prescribing single (B, C etc), multivitamin and mineral supplements 15. Advising patients with chronic diseases (eg Diabetes) on dietary adjustment while fasting for religious obligation (eg During Ramadan) Table : Behaviour related to Nutrition I feel it is important that I 1. address the importance of diet whenever I care for a patient 2. encourage patients to ask diet related questions 3. perform at least some level of nutritional assessment with each patient. refer patients with diet-related problems to qualified nutritionists/dietitians 5 5. whenever possible recommend dietary changes prior to initiating drug therapy Table 5: Perceptions regarding Nutrition Education Statement response 1. I am satisfied with the quantity of my nutrition education I am satisfied with the quality of my nutrition education My medical school curriculum should have had more time specifically dedicated to topics related to nutrition in the basic medical science years. My clinical years should have had a posting in the nutrition/dietetics department 5. My medical school curriculum should have had more nutrition content formally integrated into the clinical (clerkship) years. 6. My medical school nutrition curriculum should have included more material relevant to my personal health and well-being. 13

5 GMJ, ASM 2013;2(S2):S10-S16 Figure 1: Percentages of participants identifying nutrition related-topics where more emphasis is needed in the curriculum. In spite of having a perception of adequate knowledge and competencies, most participants (Table 5) were unsure regarding the quality and quantity of nutrition education and agreed that more time was needed for topics related to nutrition in both the basic medical sciences and the clinical clerkship years. They also felt more material relevant to their personal well-being should have been included in the curriculum. When asked to identify the nutritionrelated topics that required more instruction (Fig 1), almost all topics were identified to different extents. While an option was provided for free responses to encourage them to identify any other topics, no new topic was identified. Nutrition in primary care and nutritional assessment were identified by most, followed by other topics. DISCUSSION This was a study conducted on participants who had undergone the GMU undergraduate medical curriculum and were interning in hospitals in UAE. The idea behind this study was to get feedback regarding adequacy of Nutrition education in the undergraduate medical curriculum at GMU. In a pilot online survey done earlier, with GMU graduates working in various countries, 73.5% of the respondents felt that they had not received adequate nutrition instruction during their undergraduate medical curriculum in relation to their present work. Areas requiring more instruction were identified as Clinical Nutrition (73%), Nutrition in primary care settings (57%) and Evidence based nutrition (50%). The present study is an attempt to further explore the attitudes of interns towards nutrition and nutrition education and their perceptions regarding knowledge and competencies related to nutrition and to identify specific gaps in knowledge or competencies, if any. Most participants in this study agreed that nutritional counseling should be a part of routine care by all physicians, and that high risk patients should be counseled about dietary change. They also felt a change toward healthier lifestyle is important at any stage in life. This positive attitude towards nutrition is very encouraging. In our earlier study around 73% of the respondents felt nutrition education to be very important for doctors. Many in this study felt that 1

6 GMJ, ASM 2013;2(S2):S10-S16 health education does little to promote adherence to a healthy lifestyle and it may not be worth the time to counsel patients with poor nutritional habits regarding nutrition but agreed that specific advice about how to make dietary changes will help patients improve their eating habits and physicians can have an effect on a patient s dietary behavior if they take the time to discuss the problem. This suggests a perception that while general health education may not work, specific advice regarding dietary changes could help improve patients dietary habits. They were, however, uncertain whether most physicians are adequately trained to discuss nutrition with their patients. Most participants perceived themselves as having adequate knowledge regarding most aspects of nutrition related knowledge such as roles of fiber, omega and trans fatty acids, alcohol consumption and dietary habits that increased cancer risk. They were, however unsure regarding nutritional requirements at various stages of life, interactions between medications and food/herbal supplements and nutritional considerations in chronic kidney disease. Studies from the US also suggest that a large number of resident physicians (62%) report deficits in nutrition knowledge though they perceive nutrition counseling as a priority 7. Participants felt confident regarding almost all nutrition-related competencies except assessing fluid requirements based on activity and health regarding which they were unsure. This is extremely encouraging and suggests that most nutrition-related competencies appear to have been addressed in the undergraduate curriculum. Similarly almost all participants felt it important to address diet, perform some level of nutritional assessment with each patient, encourage patients to ask diet-related questions as well as recommend dietary changes prior to initiating drug therapy. In spite of perceptions of adequate knowledge and competencies in most nutrition-related areas, participants were unsure about the quality and quantity of nutrition education but agreed that more time was needed for topics related to nutrition in basic medical sciences as well as clinical clerkship years. They also felt more material relevant to their personal well-being should have been included in the curriculum. This agrees with reports in literature where lack of confidence in basic nutrition counseling due to perceived inadequate nutrition training in the medical school has been reported by physicians. About half the graduating medical students were found to rate their nutrition knowledge as inadequate 8,9. When asked to identify the nutritionrelated topics that required more instruction almost all topics were identified to different extents. Nutrition in primary care and nutritional assessment were identified by most, followed by other topics including nutritional assessment and evidence based nutrition. This corresponds reasonably well with areas identified by medical graduates in our earlier study which were Clinical Nutrition, Nutrition in primary care settings and Evidence based nutrition. A study from US suggests self-reported proficiency to be lowest for nutrition and disease management, micronutrients and alternative and complementary medicine 10. A recent report suggests nutrition education to be inadequate in Japanese medical schools 11. A proposal for improving medical school nutrition education included vertical integration into the clinical years and emphasis on nutritional assessment and support 12. CONCLUSIONS Most GMU interns working in various hospitals in the UAE had a very positive attitude towards nutrition and nutrition counseling. While they perceived themselves as having adequate nutritionrelated knowledge and competencies, many felt their nutrition education was inadequate and identified many topics as requiring more instruction with nutrition in primary care being identified by most. 15

7 GMJ, ASM 2013;2(S2):S10-S16 LIMITATIONS OF THE STUDY The survey was conducted only on a small number of GMU interns and all results are based on responses of the graduates. The survey is being continued with the more interns. ACKNOWLEDGEMENTS We wish to thank Dr Carolyn O Walsh for permission to use and adapt her survey instrument for our research and the GMU interns for completing the survey. We also wish to thank Ms Sherly Ajay, academic coordinator, Mr Celso and Ms Mikaila, coordinators at the Umm Al Quwain hospital and Khalifa hospital and Mr Santosh coordinator at the Mafraq hospital for their help. REFERENCES 1. Fact sheet UAE from the WHO site last accessed on 10th September Swift CS. Nutrition Trends: Implications for Diabetes Health Care Professionals Diabetes Spectrum January :23-25; doi: /diaspect Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in US medical schools: latest update of a national survey. Acad Med Sep;85(9): Gomathi KG, Shehnaz SI and Khan N. Perceptions of Gulf Medical University graduates regarding Nutrition education in the undergraduate medical curriculum. Proceedings of the th Annual Scientific meeting GMU. 2012: Walsh CO, Ziniel SI, Delichatsios HK et al. Nutrition attitudes and knowledge in medical students after completion of an integrated nutrition curriculum compared to a dedicated nutrition curriculum: a quasi-experimental study. BMC Medical Education. 2011;11: McGaghie WC, Van Horn L, Fitzgibbon M, et al. Development of a measure of attitude toward nutrition in patient care. Am J Prev Med 2001;20(1): Vetter ML, Herring SJ, Sood M, et al. What do resident physicians know about nutrition? An evaluation of attitudes, selfperceived proficiency and knowledge. J Am Coll Nutr Apr; 27 (2) : Levine BS, Wigren MM, Chapman DS, et al. A national 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 Feb;57(2) : Shai I, Shahar D, Fraser D. Attitudes of physicians and medical students toward nutrition s place in patient care and education at Ben-Gurion University. Educ Health (Abingdon). 2001;1(3): Mihalynuk TV, Coombs JB, Rosenfeld ME, et al. Survey correlations: proficiency and adequacy of nutrition training of medical students. J Am Coll Nutr Feb; 27 (1) :59-6. PubMed PMID: Orimo H, Ueno T, Yoshida H, et al. Nutrition education in Japanese medical schools: a follow-up survey. Asia Pac J Clin Nutr. 2013;22(1):1-9. doi: / apjcn Friedman G, Kushner R, Alger-Mayer S, et al. Proposal for Medical School Nutrition Education: Topics and Recommendations. J Parenter Enteral Nutr. 2010;3:0S. 16