January 2016 Issue

Educating Doctors About Nutrition
By Juliann Schaeffer
Today's Dietitian
Vol. 18 No. 1 P. 40

The Goldring Center for Culinary Medicine at Tulane University offers an unprecedented approach to teaching nutrition and culinary skills to medical students and physicians to help prevent and manage chronic disease in patients.

It's no secret the nutrition education many medical students receive today leaves much to be desired. The Institute of Medicine and the Association of American Medical Colleges currently recommend medical students receive 25 hours of dedicated nutrition education over a four-year span. Whether that's sufficient is an argument unto itself, but many colleges aren't even meeting that goal.

To help turn the tide, a novel teaching kitchen at Tulane University in New Orleans (the nation's first at a medical school), called the Goldring Center for Culinary Medicine, is trying to change the way medical schools teach nutrition and food topics. With hands-on culinary classes that integrate clinical and nutrition education, the center aims to arm doctors and medical students with not only nutrition basics, but also practical cooking tips to better address the many chronic diseases so common today with a nutrition component.

The center's not only getting docs in the kitchen—its novel paradigm is catching on nationwide.

State of Nutrition 101 in Medical School
According to a 2013 survey from the University of North Carolina at Chapel Hill, which has studied the state of nutrition education in medical schools for the past decade, the majority of medical schools (71%) didn't meet those 25 hours of nutrition education.

Of those schools that are offering the full recommended hours, "nutrition programming" is often slid in under topics such as metabolism or gut absorption or vitamin cofactors in biochemistry class, says Timothy Harlan, MD, assistant dean for clinical services at Tulane University School of Medicine, and executive director of the Goldring Center for Culinary Medicine.

What are the implications of that reality? Physicians aren't learning enough about nutrition and how it plays a significant role in preventing and treating chronic illnesses, such as cardiovascular disease, diabetes, and obesity, which are so prevalent in the US population. And while dietitians are well versed in how best to use food for the prevention and treatment of chronic disease, patients won't hear about this if they never visit an RD's office.

Where patients are likely to end up, however, is in a primary care physician's office, where they're likely to receive a diabetes diagnosis or a high blood cholesterol warning. But when doctors aren't skilled in what diet helps patients manage diabetes, or which foods will help reduce blood cholesterol, patients can leave their appointment overwhelmed and unable to change their diet to improve their health.

Yet when doctors are armed with basic knowledge of how nutrition can prevent and treat disease—as well as practical tips for how to improve diet—Harlan says they're better able to discuss the importance of food and that of dietitians, too.

"Unfortunately, as I think most dietitians know very well, we don't and have not traditionally given our medical students a great deal of information on how they can have a dialogue with their patients about food, diet, and nutrition," Harlan says. "So we're filling that gap in the market."

Inside the Center
The Goldring Center for Culinary Medicine is a number of things, Harlan says, but first and foremost it's a state-of-the-art 4,500-square-foot teaching kitchen, owned and operated by Tulane Medical School. Its core mission is ambitious, with one main goal: to more sufficiently educate medical students about nutrition. But it should be noted that while Goldring may begin with medical students, its aim doesn't end there.

In addition to professional programming, which also involves CME, the center offers kids and families cooking classes to teach healthful eating basics to the community at large. The kitchen houses four to six community classes each week and three classes for medical students.

In all, the programming has grown to offer a number of different learning opportunities, including the following:
• a six-module beginner series for adults;
• a six-module intermediate series;
• a six-module series for families;
• a six-module series for kids;
• a nine-module series for first and second year medical students, with additional disease-specific programming for third and fourth year students;
• a seven-module series for residents, one for family physicians, and one tailored for pediatrics; and
• 15 CME modules for practicing physicians, nurse practitioners, physician assistants, RDs, and pharmacists.

"We are pretty successful, all in all, with deploying that programming to the medical students, and have very good research that shows that we moved the needle pretty dramatically on their understanding of these core concepts that the Institute of Medicine says we should be teaching students," Harlan says.

Its success can be seen not just in its outgoing students but also in the number of other schools who have adopted its programming. As of this writing, 17 other medical schools have integrated Goldring's culinary nutrition programming into their curriculum. Most utilize the programming as a four-credit elective, though Harlan theorizes schools will continue to adopt more rigorous required culinary nutrition classes into their curriculum as time passes—just as Tulane has done.

When Goldring opened four years ago, Tulane medical students were offered culinary medicine modules as an elective, with about 20% of the student population choosing them. From there, the reach and requirements have continued to expand. "Last spring, last year's first-year medical students were required to take one module," Harlan says. "This year, medical students will be required to take two modules, and one in their sophomore year. That will probably grow into two more modules in their third and fourth years, for a total of five modules over their schooling."

But that doesn't mean Tulane is satisfied with its popularity or success. Partly due to the novel nature of this endeavor paired with the huge potential it houses for the future of health care, Harlan says he and his team are committed to determining the center's effectiveness and tweaking the programming until it's just right.

Toward that goal, Harlan and others from Tulane and other partner schools meet annually to parse through the curriculum and revise where necessary. This isn't just a show but a clear sign of dedication toward continuous quality improvement. To date, the curriculum has been revised seven times, with more than 200 changes.

"Our goal is to provide the students with programming that's meaningful for them, in a way that they get it," he says.

And for anyone concerned that Goldring wants to turn its doctors into dietitians, Harlan says that's certainly not so. "With our programming, we translate the information that they learn the first two years into the conversation that they can have with their patients about food," he says.

In fact, one of the most important objectives of the curriculum is to enable medical students and doctors to appreciate the value of nutrition in disease prevention and management, address nutrition in the care plan, and provide accurate nutrition advice, Harlan says.

Yet as health care moves more in the direction of population health management and chronic disease management, Harlan says medical professionals are working more in a team capacity. And from where primary care physicians stand, that nutrition component is vital for them to have.

"We do know that when physicians talk about these issues with their patients, that patients, generally speaking, tend to follow their advice at a much higher rate," Harlan says, "especially when the physician is very knowledgeable about the particular topic, particularly lifestyle."

Class Overview
Goldring's professional programming, for medical students, residents, and CME, uses an inverted classroom design. That means students study the educational aspects online ahead of time and come to class prepared to get their hands dirty. Once in the teaching kitchen, the hands-on modules begin with case study learning.

"For the professional programming, we divide the students up into teams of four," Harlan says. "We give them a case study and we [let them discuss it among themselves], where they get about 35 minutes to solve the case study together as a team."

Because these classes are for medical students, Harlan says case studies address not just the nutrition component but also the clinical piece, often pharmaceuticals as well. For example, a case study for the vegetarian module might involve a 27-year-old woman who just received her Master of Business Administration degree. She decided to become vegan to help her lose weight. She says she's tired and amenorrheic and is on the lower end of the BMI scale.

"While many of the team questions will focus on the protein and vegetarianism as the core of the module, one of the teams gets the question, 'How much is she drinking? Is it too much?'" Harlan says. "It turns out she's drinking five to six alcohol units a day. [We ask students], 'How are you going to have a conversation with her about her alcohol consumption and how that fits into a healthy diet?'"

Another question refers to the amenorrhea and calls for the students to order a pregnancy test. So medical students aren't learning about only nutrition, but nutrition as a piece in a greater puzzle, of which they'll be considering multiple pieces at once.

All classes host between 15 and 20 students and are three hours long, with one-half hands-on cooking and one-half discussion and eating, says Leah Sarris, executive chef and program director for the Goldring Center.

There's an educational component: "Each group answers specific questions pertaining to the [medical] condition and patient counseling," Sarris says. "[The class] integrates physiology, biochemistry, and clinical practice with culinary medicine. Basically, they learn how to translate the information they're learning in order to help their patients."

Then there's the cooking component: Teams all get a recipe specific to the class topic and spend an hour cooking together. The curriculum is largely based on Mediterranean diet principles and translated for easy application and integration into the American kitchen.

Afterward, teams sit down together and eat their spoils, family style. This is where the practical piece comes in, in the form of a class discussion that teases out the key points of the topic and how to translate them to patients.

"Teams plate a portion of [the food] at the end based off of an appropriate serving size," Sarris says. "After production, we discuss what they made and tie in culinary medicine and nutritional pearls. We discuss caloric and nutrient density, portion size, presentation, plate size, and any other topics relevant to that class."

"This is a discussion where the class leader leads the teams through a discussion of the food," Harlan says. "Why is this important? How does it pertain? And what are the key messages you're going to pass along to your patient? We try to deliver those very short, simple key messages for the students so they can, over the course of time, figure out what they're going to say to patients and how they're going to say it in a very short period of time."

Harlan and Sarris agree that teaching is truly a team effort at Goldring, with chefs or RDs typically leading the culinary aspects of the classes and medical faculty chiming in on the clinical piece of the puzzle. In some schools licensing Goldring's curriculum, RDs are either partnering with chefs or chef/RDs are giving classes to disseminate information. In other schools, culinary nutrition educators are doing that, with the assistance of dietetics interns.

"We bring together chefs, dietitians, culinary interns, physicians, and other medical professionals so it is truly interdisciplinary," Sarris says. "We learn a lot from each other."

Nutrition Nuts and Bolts
As mentioned, Goldring's nutrition programming isn't an effort to turn doctors into dietitians but to allow them to have meaningful conversations with their patients about food and nutrition. According to Harlan, at Goldring, students are taught to take very simple dietary histories and offer succinct counseling or culinary tips, with a longitudinal focus.

"Many physicians will see those patients over and over for many years," Harlan says. "And that's a bit of a luxury for us. He says doctors don't have to address all medical and nutrition aspects all in one visit because they'll see those same patients again.

For example, for the intro class "Disease Implications of Diet: An Introduction to Culinary Medicine," the basics of culinary medicine and the Mediterranean diet are discussed. For the culinary component, students make four different spaghetti recipes that help illustrate how small changes (white pasta vs whole wheat and meat sauce vs a sauce containing lentils) can make a big nutritional impact.

"Last but not least, we focus on how the size and shape of the plate or bowl can have a large impact on the perception of how much food there is and therefore can influence how much food people actually eat," Sarris says.

A class on hypertension focuses on reducing sodium through building flavors and textures with meals, such as Asian Peanut Chicken with Noodles, having no more than 500 mg of sodium per serving.

A class on the pediatric diet shows students how to create more balanced meals, incorporating fruits and veggies in kid-friendly ways. "We span the spectrum of childhood so we show how to make baby food (purées) as well as kid-friendly meals," Sarris says. Salad on a stick and cinnamon roasted chickpeas are two of the recipes students learn to make.

And in a diabetes class that focuses on carbohydrates, faculty focus on remaking snacks, beverages, and desserts—places where empty carbs often hang out.

The Pie in the Sky
The greater goal of offering more medical professionals this culinary nutrition education is that it increases patient care and population health in the long run. Harlan's team is attempting to document their efforts and successes toward that goal, but acknowledges that such a huge undertaking will take time.

However, he's cognizant of the goal and is watching students closely, carefully collecting data on how students and patients are impacted by this programming. Thus far, he's encouraged. One randomized controlled trial that examined the effects of Goldring's nutrition programming included 27 patients with type 2 diabetes and found that the teaching kitchen helped improve HbA1c, blood pressure, and cholesterol for patients.1

"The pie in the sky is that we teach a physician or a nurse practitioner and that changes the conversation they have with their patients about food, diet, and nutrition," Harlan says. "That I teach a physician and we somehow prove that his or her patient population is healthier for it. That's going to take a long time," he adds. "But I think there's a lot of opportunity for us to figure that piece out."

Amy Myrdal Miller, MS, RDN, FAND, founder and president of Farmer's Daughter Consulting, LLC, was elated to hear of Goldring's aims and what it could mean for dietitians. "How progressive to not only include nutrition in medical school education but to also include culinary training," she says. "The graduates from that program could definitely become great allies for dietitians across the country, especially RD/RDNs who have culinary training and are willing to partner with these physicians on nutrition and culinary programs for patients in both group and one-on-one settings."

In her work with The Culinary Institute of America, Myrdal Miller served as the conference codirector for Healthy Kitchens, Healthy Lives, an annual four-day CME conference designed to offer health care professionals nutrition science and practical culinary tips. She's heard from physicians themselves what a giant impact this information can have.

"One of the most powerful outcomes of that event was hearing from physicians who a) never appreciated how our dietary choices impact our health, and b) never recognized dietitians are powerful partners in helping patients make better food and health decisions."

But will giving physicians such nutrition education in any way negate the place of dietitians? Myrdal Miller, for one, isn't worried about that potential. "Yes, some physicians, when armed with a little nutrition knowledge, will think they can address all of their patients' nutrition needs," she says. "But the really wise ones recognize there's very little they can do during a seven- to eight-minute office visit and that the most powerful thing they can say to a patient is, 'I want you to see a dietitian, who can help you better than I can.'"

— Juliann Schaeffer is a freelance health writer and editor based in Alburtis, Pennsylvania, and a frequent contributor to Today's Dietitian.

Reference
1. Monlezun DJ, Kasprowicz E, Tosh KW, et al. Medical school-based teaching kitchen improves HbA1c, blood pressure, and cholesterol for patients with type 2 diabetes: results from a novel randomized controlled trial. Diabetes Res Clin Pract. 2015;109(2):420-426.

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