Integrating nutrition and culinary medicine into preclinical medical training.

BACKGROUND: Poor nutrition is a leading cause of preventable death, but is inconsistently taught in medical education and inadequately discussed in medical care. To overcome this problem, we developed a hybrid nutrition team-based learning/culinary medicine approach to integrate practical nutrition knowledge and basic cooking skills into the training of future health professionals. METHODS: Nutrition was integrated into the systems-based courses at a college of osteopathic medicine, complemented by culinary medicine sessions based on the Health meets Food curriculum (HmF; culinarymedicine.org). Students participated in the program for one year and two cohorts of students were included in this analysis. Outcomes were measured via online food frequency questionnaire (FFQ, Vioscreen, Viocare, Inc) and surveys administered via Qualtrics online survey software. Diet quality was measured using the Healthy Eating Index (HEI)-2015. Data were analyzed using SAS 9.4. RESULTS: One hundred and ninety-five first year students completed a baseline FFQ (97.5% response rate). Mean age of students was 26 years, 47% were female (n = 92/195). The average BMI of participants was 24.8 kg/m2 (range 17-45.4) and the majority of participants reported being active. Seventy-five students (38%) completed an end of year FFQ. Diet quality was poor among students at baseline (n = 195; 67.59 (SD 10.54)) and improved slightly but significantly at the end of year 1 (n = 75, 69.63 (SD: 12.42), p = 0.04). The survey was administered to the second cohort only; 63 students responded (53% response rate). Talking to patients about nutrition was seen as more relevant to future practice among respondents than talking to patients about safe sex, weight, tobacco, alcohol, other substance abuse and domestic violence. CONCLUSIONS: This study evaluated the nutrition and culinary medicine curriculum at a new college of osteopathic medicine. Students rated the program highly and attendance was excellent, even though not required. Student diet quality did not decline over the first year of medical school. Students rated talking to patients about nutrition as highly relevant, providing encouragement that they will do so in future practice. We believe our work shows that nutrition can be integrated into the training of future physicians and that it may pay dividends, particularly with the increasing awareness of the importance of preventive care.

Patient Malnutrition Risk or Number of Initial Nutrition Intervention Categories Can Be Used to Develop Registered Dietitian Nutritionist Staffing Models in the Inpatient Adult and Pediatric Hospital Setting: A Cohort Study.

BACKGROUND: More data are needed to guide evidence-based, inpatient registered dietitian nutritionist (RDN) staffing models. OBJECTIVE: Identify relationships between: 1) patient malnutrition risk or intervention categories and estimated total RDN care time ("care time"); and 2) care time and emergency department (ED) visits. DESIGN: This study was a prospective cohort study with data collection via RDN surveys, patient interviews, and medical record review. PARTICIPANTS/SETTING: Adult (n = 550) and pediatric (n = 345) patients enrolled at 32 adult and 27 pediatric US hospitals from August 2019 to January 2023. MAIN OUTCOME MEASURES: Care time and ED visits within 90 days of hospital discharge were measured. STATISTICAL ANALYSIS: Multilevel, generalized linear, and negative binomial regression models were used to evaluate relationships between patient characteristics and Box-Cox-transformed care time and the relationship between Box-Cox-transformed care time and total ED visits. RESULTS: After adjusting for patient characteristics, adult patients classified as at malnutrition risk vs not at risk required a mean of 8% (95% CI 5% to 11%) more care time. Pediatric patients at medium or high compared with low malnutrition risk needed a mean of 21% (95% CI 4% to 40%) and 31% (95% CI 12% to 54%) more care time, respectively. Number of initial RDN interventions categories per patient (0 to 1 vs 2 to 3 or 4+) was associated with a mean of 10% (95% CI 7% to 14%) or 8% (95% CI 2% to 15%) more care time for adults and 17% (95% CI 5% to 32%) and 39% (95% CI 21% to 61%) more care time for children, respectively. More estimated total RDN care time was associated with significantly higher incidence rate ratios of ED visits (adults: incidence rate ratio 2.8; 95% CI 1.1 to 7.2; children: incidence rate ratio 1.7; 95% CI 1.02 to 2.8). CONCLUSIONS: Patient malnutrition risk or breadth of nutrition interventions required can inform nutrition department staffing. Intervention studies may better define relationships between care time and medical outcomes.

Impact of a Registered Dietitian Nutritionist-Led Food as Medicine Program in the Food Retail Setting: A Feasibility Study.

BACKGROUND: Food as medicine (FAM) interventions have been associated with improved health outcomes. However, there is limited FAM evidence in food retail settings. OBJECTIVE: The objective was to evaluate the feasibility of a registered dietitian nutritionist-led FAM program that aims to detect changes in participants' nutrition problems and related nutrition and health outcomes, as documented by the Nutrition Care Process framework. DESIGN: The study was a descriptive feasibility nutrition intervention cohort analysis. PARTICIPANTS SETTING: A convenience sample of online food shoppers were enrolled in collaboration with a food retail chain (n = 39 participants completed the intervention and were included in primary analyses). INTERVENTION: Participants received nutrition care for 6 months either in person or via telehealth. The FAM intervention included tailored nutrition care that integrated software-generated meal plans and food shopping lists to support online food shopping. MAIN OUTCOME MEASURES: Progress of nutrition problems and diet quality (assessed via the Picture your Plate survey) were measured. Measurements included changes in anthropometric and biochemical parameters, blood pressure, and quality of life (assessed via the Centers for Disease Control and Prevention's Health Related Quality of Life-14 survey). STATISTICAL ANALYSES PERFORMED: Mann-Whitney U test, Pearson's χ2, and Wilcoxon signed-rank tests were used to detect differences. RESULTS: The most prevalent nutrition problems demonstrated improvement rates as follows: excessive energy intake, 81% (n = 21 of 26); excessive carbohydrate intake, 88% (n = 7 of 8); and obesity, 100% (n = 5 of 5). Exposure to the FAM intervention improved dietary quality, quality of life, body weight, waist circumference, and systolic pressure. CONCLUSIONS: FAM interventions can be carried out by in-store registered dietitian nutritionists in the supermarket setting. This feasibility study highlighted the need and opportunity for larger studies in which registered dietitian nutritionist-led FAM interventions, in collaboration with food retailers, may improve people's nutrition and health.

Identifying Children at Risk of Growth and Nutrient Deficiencies in the Food Allergy Clinic.

BACKGROUND: Food allergies affect growth in children by decreasing the availability of nutrients through decreased dietary intake, increased dietary needs, food-medication interactions, and psychosocial burden. Guidelines on food allergy management frequently recommend nutrition counseling and growth monitoring of children with food allergies. OBJECTIVE: To provide clear guidance for clinicians to identify children with food allergies who are at nutritional risk and ensure prompt intervention. METHODS: We provide a narrative review summarizing information from national and international guidelines, retrospective studies, population studies, review articles, case reports, and case series to identify those with food allergy at greatest nutritional risk, determine the impact of nutritional interventions on growth, and develop guidance for risk reduction in children with food allergies. RESULTS: Children with food allergies are at increased risk of nutritional deficiencies and poor growth. Nutritional assessment and intervention can improve outcomes. Identifying poor growth is an important step in the nutrition assessment. Therefore, growth should be assessed at each allergy evaluation. Interventions to ensure adequate dietary intake for growth include appropriately prescribed elimination diets, breast-feeding support and assessment, supplemental formula, vitamin and/or mineral supplementation, appropriate milk substitutes, and timely introduction of nutrient-dense complementary foods. Access to foods of appropriate nutritional value is an ongoing concern. CONCLUSION: Nutrition intervention or referral to registered dietitian nutritionists with additional training and/or experience in food allergy may result in improved growth and nutrition outcomes.

Comparison of virtual vs face-to-face medical nutrition therapy in patients with hyperlipidemia.

Since the COVID-19 pandemic, utilization of telemedicine visits has increased. The outcomes of virtual compared to face-to-face (F2F) visits for treating hyperlipidemia are uncharacterized. This observational study compared pre- to post-visit change in lipid markers between 41 virtual and 151 F2F visits with a registered dietitian nutritionist at the University of Michigan Preventive Cardiology program from 3/31/2019-9/31/2022. Total cholesterol (TC), high-density lipoprotein (HDL), and triglycerides (TG) were collected pre- and post-visit with a median 33 days between collections. Low-density lipoprotein (LDL-C) was calculated using the Sampson equation. We used paired T-tests to evaluate mean change in lipid markers for each visit type between pre and post timepoints, and linear regression to compare virtual to F2F visits. There was a significant decrease in TC, LDL-C, and non-HDL-C for both visit types. There was no significant difference in mean change in lipid markers between virtual and F2F visits. Telehealth is a promising strategy for increasing access to medical nutrition therapy.

Impact on diabetes outcomes and team skills of integrating dietetic services into interprofessional education and teamwork in primary care.

OBJECTIVES: Diabetes is a complex disease requiring daily self-management of diet and activity, yet many patients do not receive recommended self-management education, medical nutrition therapy, or team-based care that includes registered dietitian nutritionists (RDNs). Such service deficits contribute to challenges in meeting combined diabetes care goals. We evaluated the impact of adding RDN-supervised dietetic interns to an established primary care interprofessional education/teamwork model on patients' clinical outcomes and health professions students' team skills. METHODS: Electronic health records were retrospectively analyzed to evaluate the impact of interprofessional care teams including dietetic practitioners on patient outcomes and compare these changes to outcomes achieved with the previous model without such participation. Pre-test/post-test surveys were used to evaluate health professions students' self-reported changes in team skills. RESULTS: Patient outcomes for glycemic control, systolic blood pressure, triglycerides, and depression improved significantly, and emergency department visits decreased by 79% after interprofessional care. Average hemoglobin A1c levels decreased from 11.6% to 8.3% (p < .001), an additional 1.1% reduction over previous results, following incorporation of dietetic practitioners. Students reported increased team skills after interprofessional care participation. DISCUSSION: Health professions and dietetic program faculty should collaborate to develop interprofessional best practice primary care models for patients with diabetes.

The Role of the Neonatal Registered Dietitian Nutritionist: Past, Present, and Future.

Neonatal registered dietitian nutritionists (RDNs) are critical members of the neonatal intensive care unit (NICU) team due to their unique skillset of growth assessment, nutrition evaluation, and implementation of nutrition best practices. There is a paucity of data on appropriate staffing of neonatal RDNs in NICUs to promote improved patient outcomes. Here, the authors describe current neonatal RDN staffing and responsibilities in the US NICUs.

Validity and reliability of a questionnaire measuring EBDPs among registered dietitian nutritionist.

BACKGROUND: There is a lack of a valid and reliable instrument that measures objective and subjective knowledge of evidence-based dietetic practices (EBDP) among registered dietitian nutritionists (RDNs). The present study aimed to develop and assess the validity and reliability of an EBDP Questionnaire (EBDPQ) with objective knowledge items (i.e., quiz items) among RDNs in the USA. METHODS: Subscales from four existing evidence-based practice (EBP) instruments were combined and modified for dietetics. Content and face validity and internal consistency were used to assess the full survey. Survey responsiveness and test-retest reliability were evaluated within the objective knowledge subscale. Content experts (n = 11) and nutrition professionals (n = 16) completed validation reviews. Doctoral students enrolled in a research course (n = 12) were used to analyse survey responsiveness. Internal and test-retest relability analyses utilised RDN participants (time point 1, n = 482; time point 2, n = 335). RESULTS: Content validation resulted in a 38-item questionnaire. Average percent agreement among face validity reviewers was 95.1%. Only the pre-validation version of the objective knowledge subscale resulted in significantly higher post-course scores (Mdn = 11.50) compared to the pre-course (Mdn = 9.75, p = 0.05). The validated instrument had excellent internal consistency (Cronbach's α = 0.91); however, the objective knowledge subscale was low (Cronbach's α = 0.41). A good degree of reliability was found between the two time points (intraclass correlation coefficient = 0.71). CONCLUSIONS: The EBDPQ demonstrated adequate validity and reliability among RDNs. Future research should assess construct validity, with the responsiveness and objective knowledge subscale requiring additional evaluation through an EBDP course.

Patient Perception of Plant Based Diets for Kidney Disease.

OBJECTIVE: Plant-based diets can delay the progression of chronic kidney disease (CKD) and help manage complications and comorbid conditions such as hypertension, acidosis, diabetes, and cardiovascular disease. The objective of this study was to understand nephrology patients' familiarity, perception, and use of plant-based diets. DESIGN & METHODS: A survey was shared via the National Kidney Foundation's social media channels. Analysis included 844 responses. Survey items were evaluated with descriptive statistics. Differences across items were determined using chi-square tests. RESULTS: Most respondents were 61-70 years of age (26.7%, n = 225), female (56.5%, n = 477) and achieved a Bachelor's or advanced degree (49.9%, n = 421). The majority of respondents suffered from nondialysis-dependent CKD (34%) or received a kidney transplant (34%). About half (45%) of respondents were familiar with plant-based diets and most (58%) were aware that plant-based diets can improve CKD. Twenty-two percent reported following some version of a vegetarian diet, and 29% reported "eating less meat". Respondents were not confident (Mdn = 2, IQR = 2, on a scale of 1-5) in their ability to plan a balanced plant-based meal, and were moderately confident that a plant-based diet could help blood pressure (Mdn = 3, IQR = 2) and slow progression of CKD (Mdn = 3, IGR = 2). Family eating preference, meal planning skills, preference for meat, figuring out what is healthy to eat, food cost, time constraints, and ease of cooking were rated as equal barriers to following a plant-based diet (Mdn = 3). A sample meal plan, individual counseling session with a Registered Dietitian Nutritionist (RDN), handouts, and cooking classes were resources rated most helpful to transition to a plant-based diet (Mdn = 4). CONCLUSION: Approximately half of respondents were aware that plant-based diets can be beneficial for CKD. Many patients are following a vegetarian or plant-based eating pattern. More research should be done to see how effective RDNs are in educating and moving patients toward a plant-based eating pattern, as they are an underutilized resource in the CKD population.

Systematic Review of the Frequency of Registered Dietitian-Nutritionist Intervention in the Primary Care Setting for Diabetes Self-Management Education for Patients with Type II Diabetes.

PURPOSE: The purpose of this systematic review is to discuss the ideal frequency of Registered Dietitian-Nutritionist (RDN) contact required to improve glycemic control in patients with type 2 diabetes in the primary care setting. METHODS: Researchers completed a literature search between April 1 and June 30, 2020. Researchers identified 184 studies and included seven studies for full-text analysis. Eligible studies were required to occur in a primary care setting, use A1C as an outcome measure, and use some form of education or contact with an RDN. Study quality was assessed using the NIH Study Quality Assessment Tool. RESULTS: Compared to the usual care group of each study, increased contact with an RDN improved A1C lowering regardless of frequency (round-the-clock, monthly, biannually). The largest decreases occurred in the round-the-clockand quarterly touch groups. Studies varied in modality (inperson, telehealth, etc.) and type of intervention. The participants had A1Cs between 8.07% and 10.25% before intervention. With RDN contact of any frequency between provider visits and participants saw A1Cs decreased between 0.66% and 2.2%. CONCLUSION: Greater glycemic control in patients with type 2 diabetes in the primary care environment is linked to more frequent RDN contact than that advised by the American Diabetes Association Standards of Care.

Effectiveness of medical nutrition therapy in the management of adult dyslipidemia: A systematic review and meta-analysis.

Cardiovascular disease (CVD) is a leading cause of mortality in the United States. Many primary risk factors, such as dyslipidemia and blood pressure, are modifiable with diet and lifestyle interventions. Therefore, the objective of this systematic review and meta-analysis was to evaluate the effectiveness of medical nutrition therapy (MNT) interventions provided by registered dietitian nutritionists (RDN) or international equivalents, compared to usual care or no MNT, on lipid profile and blood pressure (secondary outcome) in adults with dyslipidemia. The databases MEDLINE, CINAHL, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews were searched for randomized controlled trials (RCTs) published between January 2005 and July 2021. Meta-analyses were performed using a random-effects model for lipid outcomes (seven RCTs, n=838), systolic blood pressure (SBP) (three RCTs, n=308), and diastolic blood pressure (DBP) (two RCTs, n=109). Compared to usual care or no intervention, MNT provided by RDNs improved total cholesterol (total-C) [mean difference (95% CI): -20.84 mg/dL (-40.60, -1.07), P=0.04]; low-density lipoprotein cholesterol (LDL-C) [-11.56 mg/dL (-21.10, -2.03), P=0.02]; triglycerides (TG) [-32.55 mg/dL (-57.78, -7.32), P=0.01];; and SBP [ -8.76 mm Hg (-14.06 lower to -3.45) P<0.01].High-density lipoprotein cholesterol (HDL-C) [1.75 mg/dl (-1.43, 4.92), P=0.28] and DBP [-2.9 mm Hg (-7.89 to 2.09), P=0.25] were unchanged. Certainty of evidence was moderate for total-C, LDL-C, and TG, and low for HDL-C, SBP, and DBP. In conclusion, in adults with dyslipidemia, MNT interventions provided by RDNs are effective for improving serum lipids/lipoproteins and SBP levels.

Knowledge and attitudes of lower Michigan primary care physicians towards dietary interventions: A cross-sectional survey.

Background: Dietary interventions are first-line therapies for the prevention and management of many chronic diseases, yet primary care physicians prescribe these interventions infrequently. Objectives: This study investigates primary care physicians' current knowledge and opinions regarding the delivery of dietary interventions. This work aims to identify modifiable barriers to prescribing dietary interventions to prevent and treat diet-related diseases. Methods: We designed and fielded an anonymous, cross-sectional survey of faculty and resident physicians across the Internal Medicine, Family Medicine, and Pediatrics departments in three academic and community hospitals in lower Michigan. Data were collected between January 15 and April 15, 2019. Self-rated knowledge and attitudes were measured on a 5-point Likert scale. Objective scores were calculated for each question as percentage answered correctly among all respondents. Objective knowledge scores were compared based on participants' years in practice. Results: Response rate was 23% (356 responses). The sample was 62.3% female and 75.3% non-Hispanic White, and 56.7% were age 40 or younger. Average objective knowledge score was 70.3% (±17.2) correct. Mean self-rated knowledge score was 2.51 (±0.96) on a scale of 1(Poor) - 5(Excellent). Overall agreement with a statement of importance of dietary interventions was 3.99 (±0.40) on a scale of 1 (strongly disagree) to 5 (strongly agree). A majority (91.7%) of respondents indicated they would like more opportunities to learn about the evidence supporting dietary interventions. Conclusions: Physicians desire to incorporate dietary interventions into their practice. Findings encourage the development of educational strategies to support dietary intervention use among primary care physicians.

Dietetics Students' Perceptions of Academic and Health Impacts of the COVID-19 Pandemic.

This study examined dietetics students' perceptions of coronavirus disease-2019 (COVID-19) pandemic impacts on academics and mental and physical health. Data were collected via a cross-sectional online survey in February to March 2021 from undergraduate dietetics students across the United States. Among the 526 students who participated, during the fall 2020 semester, 87% experienced increased stress, 64% reported mental health concerns, and 32% reported disordered eating. Sixty-two percent agreed their program met educational needs; however, 62% also agreed COVID-19 negatively impacted the quality of education and 49% agreed to learning less than normal. Pandemic impacts are critical to consider as students enter dietetic internships and start careers.

Teaching the Nutrition Focused Physical Exam (NFPE) To Medical Students Using an Interdisciplinary Approach.

Nutritional status greatly affects the health of patients, yet the time devoted to nutrition curriculum in medical school is minimal. We implemented a novel approach of teaching the Nutrition Focused Physical Exam (NFPE) as a tool to demonstrate the importance of assessing the nutritional status of patients and learning about malnutrition and nutrient deficiencies.

Oncology Registered Dietitian Nutritionists' Knowledge, Attitudes, and Practices Related to Food Insecurity among Cancer Survivors: A Qualitative Study.

BACKGROUND: Understanding the knowledge, attitudes, and practices pertaining to food insecurity among oncology registered dietitian nutritionists (RDNs) is critical to ensuring that cancer survivors have adequate nutrition-a fundamental component of successful treatment and recovery. OBJECTIVE: To qualitatively assess oncology RDNs' knowledge, attitudes, and practices regarding the food access needs of their patients using a qualitative semantic approach to thematic analysis. DESIGN: The qualitative cross-sectional study was conducted from September 2018 to January 2019. PARTICIPANTS AND SETTING: Forty-one oncology RDNs working with cancer survivors in various clinical settings across the United States participated. MAIN OUTCOME MEASURES: Participants completed a semistructured, in-depth interview via telephone, lasting an average of 49 minutes. STATISTICAL ANALYSES PERFORMED: Two coders (primary and secondary) trained in qualitative thematic data analysis methods used a semantic approach to thematic analysis to analyze transcripts. A qualitative and mixed methods online coding program Dedoose was used to organize and analyze the data. RESULTS: Participants defined food insecurity (FI) as a lack of access to nutritious foods and a lack of resources to purchase nutritious foods. RDNs stated they believe FI is a serious problem in the United Staes, has a greater influence on cancer survivors than healthy individuals and they have specific concerns about FI among their own patients. Despite their concerns, most expressed that they do not use a validated tool to identify FI, nor were they aware that any exists. Only a small proportion of the RDNs stated that they regularly ask patients about their food access needs. CONCLUSIONS: Although Oncology RDNs have heard of FI, they do not routinely assess patients' food security status with a validated tool, nor do they consistently ask patients directly about their food access needs. These findings suggest there is a need for developing education and training opportunities for oncology RDNs to enhance their ability to screen for and address FI with their patients.

The Perceived Value of the Board-Certified Specialist in Renal Nutrition Credential Among Registered Dietitian Nutritionists Who Hold the Credential.

OBJECTIVE: Health care professionals who hold a specialist certification typically have a high perceived value of their credential. However, the perceived value of the board-certified specialist in renal nutrition (CSR) credential has not been studied. This study evaluated the perceived value of the CSR credential among registered dietitian nutritionists (RDNs) using the Perceived Value of Certification Tool (PVCT©) and explored differences in perceived values among those who did and did not receive reimbursement for taking the credentialing examination. METHODS: A cross-sectional internet-based survey was sent to 553 RDNs who held the CSR credential. The survey included the 18-item PVCT© including 12 intrinsic and 6 extrinsic value statements. Total, intrinsic, and extrinsic value scores and percent agreement were calculated. Value scores were compared using the Mann-Whitney U test to assess differences between those who received reimbursement and those who did not. RESULTS: The response rate was 33.3% (n = 184). Twelve of 18 value statements had >80% agreement. The median PVCT© scores were 61.0 of 72.0 for total, 43.5 of 48.0 for intrinsic, and 18.0 of 24.0 for extrinsic values. Those who received reimbursement had significantly higher perceived extrinsic value scores than those who did not (P = .041). Intrinsic and total value scores were higher but not significantly different in those who received reimbursement. The statements with the highest percent agreement were "validates specialized knowledge" and "provides evidence of professional commitment", and the lowest value statement was "increases salary". CONCLUSIONS: RDNs have a high perceived value of the CSR credential. Those who received reimbursement for their credential examination had higher extrinsic value. Future research should explore the value of the CSR credential among RDNs without the CSR credential and among stakeholders.

Views of Registered Dietitians Compared to Speech-Language Pathologists on Artificial Nutrition and Hydration at the End of Life.

OBJECTIVE: To analyze and compare the knowledge and opinions of registered dietitian nutritionists (RDNs) about artificial nutrition and hydration (ANH) in a terminal illness. Beliefs of speech-language pathologists (SLPs) were also considered and compared against RDN data. METHODS: This is a descriptive analysis utilizing survey responses from RDNs and SLPs regarding ANH in a case study patient with advanced dementia. RESULTS: There was a strong belief among RDNs that ANH at end of life (EOL) would improve nutritional status, although a correlation was found between those in favor of ANH and believing it was ethical to withhold ANH at EOL (R2 = 0.109, p = 0.002). Responses indicated that SLPs need more education regarding ANH techniques, while RDNs felt ANH would improve aspiration risk. Place of employment, religion and age of respondents were also found to impact beliefs. CONCLUSION: Clinicians, specifically RDNs, working with patients at EOL need more evidenced-based education on the risks and benefits of ANH. Decisions regarding care of patients at EOL should be void of clinicians' personal bias which may affect ethical treatment in the clinical setting. Further controlled trials must be performed before claims can be made regarding ANH at EOL.