This study examined the effect of a curricular change at HMS on medical student attitudes and knowledge about nutrition, using modifications of previously developed surveys and questionnaires. There were no differences between students with the two curricula in attitudes towards nutrition in patient care, as measured by the NIPS survey, or in nutrition knowledge, as measured by the NiM-based test and USMLE scores. However, students with the integrated ICN curriculum were less satisfied with both the quantity and quality of their nutrition education. Additionally, ICN students were more likely to use the optional online nutrition modules and, with borderline significance, to report greater desire for additional time dedicated to nutrition. These results suggest that a transition to an integrated curriculum does not necessarily have a detrimental effect on attitudes and knowledge about nutrition, although students may seek additional material to supplement what they perceive as inadequate classroom exposure.
These findings may reassure medical educators working to incorporate nutrition into pre-clinical curricula at a time when an increase in time devoted to nutrition is unlikely. They also provide further evidence that, when asked about nutrition education, students tend to consider only teaching that occurred during a session devoted specifically to nutrition [16
]. Therefore, it is not surprising that ICN students reported lower satisfaction with the quantity of their nutrition education, given a decrease in dedicated nutrition time from 28 hours over 14 weeks to 9 hours over 3 days. One medical school successfully targeted this issue by orienting students to the integrated curriculum and attaching a logo to all nutrition material throughout the curriculum [22
]; other schools employing an integrated curriculum may consider a similar strategy.
Our study has several strengths. This is the first study to test both attitudes and knowledge in one medical school during a curricular transition. Because comparisons were made within the same school, the student population was likely similar from one year to the next, as reflected in our demographic findings. Additionally, the course director and faculty did not change, so differences between the groups would likely not be attributable to differences in teaching style or ability. In addition, time and clinical exposure after the second-year course were controlled for by administering the survey to each group two years after its required nutrition curriculum.
Several study limitations warrant comment. The participation rate was moderate, though comparable to similar studies [14
], and thus selection bias may be present. Demographic data of non-responders was not available, but it is possible that, compared with responders, non-responders may be less interested in nutrition, less likely to complete the NiM modules, and less likely to enter primary care fields. These factors are likely similar between the two groups. Students were not randomized; instead the quasi-experimental design was used to take advantage of the planned curricular change. Each group was surveyed at only one time point at the end of medical school, so we cannot assess pre- and post-course changes in attitudes and knowledge. The survey was administered to each group two years after completion of the respective curricula; it is possible that unmeasured confounding events occurred during that time. Also, as the two groups were surveyed one year apart from each other, it is possible that historical events in the intervening year affected the attitudes and knowledge of the second group. It is not clear whether the results would generalize to other medical schools. The knowledge section was developed to capitalize on the existing multiple choice questions and DI data of the NiM website. It is possible that we may have found a difference in knowledge scores had we instead developed questions based on the PMN syllabus. Lastly, as this study focused on pre-clinical curricular choices, it did not address the effect of continued nutrition education opportunities during clinical training and practice, the importance of which has been previously described [16
] and which has led to the recent development of the NiM program, Nutrition Education for Practicing Physicians [23