Do Doctors Know That it Takes More Than an Apple a Day? Impact of Formal Nutrition Training on Family Medicine Residents’ Nutrition Knowledge, Confidence, Attitudes, and Counselling Abilities.

Do Doctors Know That it Takes More Than an Apple a Day? Impact of Formal Nutrition Training on Family Medicine Residents’ Nutrition Knowledge, Confidence, Attitudes, and Counselling Abilities. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Do Doctors Know That it Takes More Than an Apple a Day? Impact of Formal Nutrition Training on Family Medicine Residents’ Nutrition Knowledge, Confidence, Attitudes, and Counselling Abilities. Katherine Connor Ostoich, Rejina Kamrul, Adam Clay This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6059388/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Malnutrition and poor dietary intake are major health challenges today. 1,2,3,4,5 There are well-established benefits of nutrition interventions, but a lack of formalized nutrition training in medical school and residency. 3,6,7,8 There is also little published information regarding nutrition training impact on residents. Physicians lack knowledge, skills, confidence, and training to effectively counsel in daily practice. 1,3,9,10,11,12 Consequently, there is urgent need to improve nutrition training in medicine. Methods: This pre-post study evaluated the impact of an online nutrition course provided to family medicine residents. Time was provided at Academic Half Day to complete the course as well as pre- and post-course surveys with knowledge tests through SurveyMonkey. Descriptive statistics were used to evaluate responses. The project was approved by the University of Saskatchewan Behavioural Research Board (Beh 4433). Results: Thirteen residents completed the pre-course questionnaire (response rate = 76%). Of these, ten (77%) felt they received inadequate nutrition training and all thought patients would benefit from improved nutrition counselling. Six residents completed the post-course questionnaire (response rate = 24%). All post-course respondents thought the course was beneficial and that it should be offered to all Canadian family medicine residents, with majority believing it should be mandatory. Respondents’ nutrition knowledge, confidence, beliefs on importance of nutrition counselling, and nutrition counselling in practice appear to increase/improve after training. Conclusions: Implementation of formal nutrition training during residency positively influences family medicine residents’ nutrition knowledge, attitudes, personal dietary patterns, and rates of nutrition counselling. Recommendations: Future research with larger sample sizes is needed to support these conclusions and improve nutrition training during residency. Future studies should look at nutrition training in other specialties as well as examine the rate and quality of nutrition counselling after residency completion. General Practice Nutrition & Dietetics nutrition education medicine medical training residency Background Malnutrition and the prevalence of poor dietary intake is one of the greatest health challenges of the 21st century. Globally, malnutrition, both over- and under-, underlie most major illnesses and deaths and affect all ages, socioeconomic groups, and medical specialities. 1 There are 11 million deaths annually worldwide attributable to dietary factors, placing poor diet ahead of any other risk factor for death in the world. 2 The medical, surgical, psychological, and socioeconomic repercussions of this dietary related pandemic are enormous, yet there continues to be insufficient nutrition education provided during medical training. 1 – 7 Many clinical guidelines identify lifestyle modifications, including dietary interventions, as first-line management of common conditions such as diabetes, hypertension, coronary artery disease and hyperlipidemia. 6 , 8 , 9 In randomized clinical trials, dietary intervention has proven to prevent and manage important and common diseases. 10 Furthermore, a healthy lifestyle has been shown to be as effective as medication, or even more effective, in the prevention and management of chronic disease. 9 There is well-established evidence that nutrition interventions reduce morbidity and mortality, and accordingly, lead to reduction in costs related to the treatment and care of patients. 6 , 9 Physicians are in an ideal position to provide dietary advice and are generally considered credible sources of nutrition information. A 2016 study revealed that 85% of patients trusted nutrition advice from their general practitioner. 1 Despite this trust, given lack of nutrition training in medical school and residency, physicians are in no better position than the general public to understand the composition and importance of a healthy diet. 8 Physicians do not feel comfortable or adequately prepared to provide effective nutrition counselling. They recognize that they lack the education and training in medical nutrition needed to counsel their patients and to ensure continuity of nutrition care in collaboration with other healthcare professionals. 3 , 5 , 6 , 7 , 11 Therefore, physicians continue to be preoccupied combatting the consequences of malnutrition rather than preventing disease. Educating healthcare professionals on nutrition and healthy dietary practices provides an opportunity to improve both physician and patient wellbeing. The substantial body of evidence that supports the benefits of nutrition interventions have not yet adequately translated into medical training or practice. Only a small proportion of physicians routinely offer nutrition care and efforts are haphazard. 1 , 4 Referral rates to registered dieticians and other nutrition professionals remain low. 9 As a result of poor nutrition care, patients seek out alternative, variably qualified nutrition advisors for information. Physicians claim to perceive clinical nutrition as a priority in primary care, but lack the knowledge, skills, confidence, and training to effectively counsel in their daily practice. 1 , 3 , 5 , 6 , 7 , 12 Most residents, faculty, and fellows have agreed that additional training in nutrition would allow them to provide better clinical care. 9 If family physicians are to be prepared to inform their patients regarding nutrition and to make appropriate referrals, improvements in the nutrition curriculum offered in family practice residency programs will be required. There is limited published information to date demonstrating the impact of formal nutrition training of residents, especially in Canada. Research carried out has shown that nutrition counselling by healthcare practitioners has the potential to improve after receiving nutrition education and patient resources. 9 , 13 , 14 Following an online nutrition course, residents scores on nutrition knowledge tests increased and they were more likely to believe it was their role to provide detailed nutrition information to patients, readily endorsing the view that a healthy diet is important for self-care. 8 Lastly, nutrition education in residency has positively predicted frequency of residents’ dietary counselling practices and improved their personal dietary intake. 13 , 15 , 16 A strong correlation has been shown between physician’s recommendations being followed and the physician actually practicing their advice themselves. 1 Physicians health status directly affects the quality of their preventive health counselling and their patient outcomes. 17 Consequently, there is urgent need to make appropriate formal nutrition training available during medical education to address the current pandemic of nutrition-related disease and prevent its projected growth. Research Question Does implementation of formal nutrition training during residency positively influence residents’ nutrition knowledge, attitudes, personal dietary patterns, and rates of nutrition counselling with patients in clinical practice? Methodology This pre-post study evaluated the impact of a nutrition training intervention on a group of 24 family medicine residents based in Regina, Saskatchewan, who were either in their first or second year of residency. The nutrition training intervention was a short, online, self-paced, 4-hour course, designed for clinicians, that explores the global importance of nutrition in medicine, macronutrients, evidence-based dietary patterns, nutrition in relation to certain medical conditions, motivational interviewing, and nutrition counselling. This course, developed by the educational nonprofit, Gaples Institute, is called Nutrition Science for Health and Longevity: What Every Clinician Needs to Know and it has been approved for continuing medication education. Four hours during the residents’ academic half day was provided in February 2024 to complete this course; attendance at academic half day is mandatory for family medicine residents in Regina as it is an educational requirement. Inclusion of the course was approved by the local academic half day coordinator as other topics would be. Additional time was provided during two separate academic half days, 1 hour during each, for completion of the pre- and post-course questionnaires. Residents involved in this study had the option to complete surveys and have their nutrition knowledge tested before and after the online course through SurveyMonkey. Informed consent to participate was obtained from all participants in the study. Pre- and post-course surveys were linked for each participant using a participant identified code. Survey questions inquired about previous nutrition education, self-perceived importance of nutrition in medicine and health, attitudes towards nutrition counselling, current nutrition counselling practices, and current dietary patterns. The survey following the course also inquired about residents’ predictions of the role of nutrition in their future practice. Moreover, questions that were asked on the nutrition knowledge test covered information including Canadian recommendations on daily nutritional intake, nutrition terms, macronutrients, effect of diet on lab values, and diagnosis or management of nutrition-related illnesses. Questions were created based on the nutrition course used in this study, on nutrition questionnaires/tests utilized in previous studies, and on current Canadian guidelines. 7 , 9 , 18 , 19 This project was approved by the University of Saskatchewan Behavioural Research Board (Beh 4433). Please refer to the appendix for the questionnaire and Certificate of Approval. Descriptive statistics were used to evaluate responses. Knowledge test scores were calculated based on total number of correct answers; partial marks were given in questions with more than one correct answer. Wilcoxon signed-rank test was used to compare quantitative pre- and post-course knowledge test scores. Results Pre-course questionnaire was completed by 13 residents (response rate = 76%). Post-course questionnaire was completed by 6 residents (response rate = 24%). Table 1 outlines the demographics of the respondents. Table 1 Participant demographics. Values represent frequency (%). Location of medical school Canada 5 (38.5%) Outside of Canada 8 (61.5%) Postgraduate Year FMR1 5 (38.5%) FMR2 8 (61.5%) Hours of nutrition education/training during medical school 1–2 hours 1 (7.7%) 3–6 hours 8 (61.5%) 7–9 hours 2 (15.4%) > 10 hours 2 (15.4%) Hours of nutrition education/training received during residency 0 hours 3 (23.1%) < 1 hour 4 (30.8%) 1–2 hours 4 (30.8%) 3–6 hours 2 (15.4%) The responses to questions concerning attitudes, practices, and beliefs regarding nutrition prior to the online nutrition course are displayed in Tables 2 and 3 . The majority of participants felt family medicine residents do not receive adequate nutrition training and strongly agree that they would benefit from additional training to help provide better clinical care to patients. All respondents thought patients would benefit from more frequent, longer, or more detailed conversations about nutrition during appointments. Beliefs on the importance of discussing nutrition and diet with patients increased after the course. Respondents’ confidence in counselling and answering questions with patients related to diet/nutrition also increased post-course. Intake of fruits and vegetables reported by participants was higher after the course was completed. A related samples Wilcoxon signed-rank test showed knowledge increased after the nutrition course (p = 0.027). Table 2 Responses to questions concerning attitudes, practices and beliefs regarding nutrition asked prior to the online education. Values represent frequency (%). Do you feel Family Medicine residents receive adequate nutrition training? No 10 (76.9%) Unsure 2 (15.4%) Yes 1 (7.7%) I would benefit from additional nutrition training to help me provide better clinical care to patients including prevention of disease, maintenance of health, and treatment of disease. Agree 4 (30.8%) Strongly agree 9 (69.2%) What percentage of patients visits do you speak about nutrition or diet? 1–25% 5 (38.5%) 26–50% 5 (38.5%) 51–75% 2 (15.4%) 76–99% 1 (7.7%) Average length spent counselling a patient about nutrition 0 minutes 2 (15.4%) 1–2 minutes 6 (46.2%) 3–6 minutes 5 (38.5%) How often do you refer a patient to a dietician? Never 1 (7.7%) Once a month 10 (76.9%) Once a week 2 (15.4%) Table 3 Responses to questions concerning attitudes, practices and beliefs regarding nutrition asked prior to the online education. Values represent frequency (%) or median (IQR). Pre (all) Pre (complete) Post Number of servings of fruits and vegetables eaten by resident on average day. 1–2 servings 4 (30.8%) 2 (33.3%) 0 (0%) 3–6 servings 9 (69.2%) 4 (66.7%) 6 (100%) Do you think it is important for physicians to discuss nutrition and diet with patients? Somewhat important 1 (7.7%) 1 (16.7%) 0 (0%) Very important 12 (92.3%) 5 (83.3%) 6 (100%) What statement best describes your view on the physician's role in nutrition counselling? I believe my role involves providing personalized, detailed nutrition information and advice to patients, including answering any questions they might have. 4 (30.8%) 2 (33.3%) 3 (50%) I believe my role involves providing very basic, general nutrition and dietary information or advice to patients. 7 (53.8%) 4 (66.7%) 3 (50%) I believe my role is limited in the expectation and my ability to provide any nutrition information or advice to patients. 2 (15.4%) 0 (0%) 0 (0%) How knowledgeable do you feel about nutrition? Adequate knowledge 4 (30.8%) 3 (50.0%) 2 (33.3%) Basic knowledge 8 (61.5%) 2 (33.3%) 3 (50.0%) Superior knowledge 1 (7.7%) 1 (16.7%) 1 (16.7%) How confident do you feel in counselling and answering questions for patients related to diet and nutrition? Neutral 8 (61.5%) 4 (66.7%) 2 (33.3%) Somewhat confident 4 (30.8%) 1 (16.7%) 3 (50.0%) Very confident 1 (7.7%) 1 (16.7%) 1 (16.7%) Do you think patients would benefit from having more frequent, longer, or more detailed conversations about nutrition during their appointments? Yes 13 (100%) 6 (100%) 6 (100%) Knowledge Score /30, median (IQR) 20.2 (20.3–22.3) 22.3 (20.5–24.5) 25.7 (23.8–27.1) Table 4 presents responses to questions regarding post-course beliefs on the value of the nutrition course and its impact on diet and counselling. Most participants believed personal dietary habits did not change after the nutrition course. Nutrition counselling increased/improved after the course and all participants plan on counselling more and making more referrals to dieticians post-course compared to pre-course. Respondents were not homogenous in their opinions on whether they had received adequate nutrition training during residency before or after the course. Notwithstanding, all participants thought the nutrition course was beneficial and that this course or a similar one should be offered to all Canadian family medicine residents, with the majority believing it should be a mandatory part of the program. Table 4 Post-course beliefs on value of the course and impact of the course on diet and counselling. Values represent frequency (%). How has your diet changed since taking the nutrition course? No change 4 (66.7%) Somewhat healthier 2 (33.3%) Has your nutrition counselling with patients changed since taking the nutrition course? No change 1 (16.7%) Somewhat increased/improved 5 (83.3%) How often do you plan on nutrition counselling in practice going forward compared to before the nutrition course? Significantly more 1 (16.7%) Somewhat more 5 (83.3%) How often do you plan on referring a patient to a dietician compared to before the nutrition course? Significantly more 3 (50.0%) Somewhat more 3 (50.0%) I have had adequate nutrition training during residency. Disagree 2 (33.3%) Neutral 2 (33.3%) Agree 2 (33.3%) This nutrition course offered during AHD was beneficial. Agree 1 (16.7%) Strongly agree 5 (83.3%) Do you believe this nutrition course or a similar one should be offered to all Canadian Family Medicine residents? Yes 6 (100%) Do you believe this nutrition course or a similar one should be mandatory to complete as part of Family Medicine residency training in Canada? No, it should be optional 2 (33.3%) Yes 4 (66.7%) Do you believe this nutrition course or a similar one should be offered to Canadian residents in other specialties? Yes, all specialties 3 (50.0%) Yes, certain specialties 3 (50.0%) Discussion The findings from this study support the literature available on the topic. Resident respondents believed they do not receive adequate nutrition training. Historically, it has been found there is a lack of adequate nutrition teaching provided to medical students and residents. 1–4,6−8,10–13,17,22,24,26, 27 This could be due to time constraints within training programs, priorities given to other topics/areas of training, lack of financial incentives for nutrition training/counselling, or lack of preceptor knowledge in the area. 13 This research demonstrated that participants usually spend time discussing nutrition/diet with patients in less than half of visits, which is interesting given that respondents believe patients would benefit from having more frequent, longer, or more detailed conversations about nutrition during appointments. This was found in previous research, which showed that nutrition counselling only occurs in about one third of all primary care office visits. 9 These findings could be resulting from visit time constraints, lack of perceived importance of the effectiveness of nutrition interventions, or lack of physicians’ nutrition knowledge. Post-course completion, there was improvement in nutrition knowledge and counselling demonstrated. A statistically significant increase in nutrition test scores was found after the course was completed. This type of knowledge improvement after formal nutrition intervention has been seen in multiple studies previously. 8 , 15 , 16 In addition, post-course, residents’ beliefs on the importance of discussing nutrition/diet with patients increased, their nutrition counselling increased/improved, and they plan on counselling more and making more referrals to dieticians in the future. The literature supports that nutrition interventions lead to increased belief in the importance of nutrition and a healthy diet 8 , 16 , but there have been mixed results on the impact of nutrition interventions on counselling frequency and duration. 8 , 13 The respondents in this study felt that their confidence in counselling and answering questions with patients related to diet/nutrition increased post-course. This is exhibited in previous literature, where nutrition intervention showed potential to increase confidence and self-efficacy in nutrition education/counselling. 9 Participants in this study did not believe their diets changed after the nutrition course, however, their reported intake of fruits and vegetables increased post-course compared to pre-course. Research has shown that better resident dietary habits are associated with higher frequency of dietary counselling with patients. 13 Better physician health also has potential to improve patient outcomes. 17 Consequently, it could be predicted that formal nutrition education can lead to increased nutrition counselling and better patient outcomes. Overall, respondents were not homogenous in their opinions on whether they received adequate nutrition training during residency after the nutrition course was completed, but all thought the course was beneficial and that it or a similar course should be offered to all Canadian family medicine residents, with the majority believing it should be a mandatory component of the program. Future research in this area is needed to help support these conclusions and consequently, lead to improvement of nutrition training during residency. This future research should include larger and broader sample sizes, with resident participants from varying geographic locations across Canada. The course could also be implemented into residency programs in other medical specialties to investigate whether they would benefit equally from this additional training. Lastly, future studies should compare the rate and quality of nutrition counselling in clinical practice after residency completion by physicians who undertook formal nutrition training compared to physicians who did not have the training. Despite the promising findings from this formal nutrition intervention, there are multiple limitations of this study that should be considered. Firstly, the sample size of 24 Canadian family medicine residents was limited due to funding availability. Secondly, there was limited response by the family medicine residents, with 13 residents completing the pre-course questionnaires, and only 6 residents completing the post-course questionnaires. This poor uptake could be due to priority of time being given to other tasks, low interest in nutrition, lack of belief of nutrition’s importance/efficacy in health, or decision/task exhaustion by residents. Thirdly, measurement error may have falsified information provided by the residents in their subjective responses to questionnaires. Lastly, response bias in answers to the questionnaires could have played a role as the residents in the study were colleagues of the study investigators and authors. Conclusions Implementation of formal nutrition training during residency positively influences family medicine residents’ nutrition knowledge, attitudes, and rates of nutrition counselling with patients in clinical practice. Although the residents did not believe their personal dietary habits had changed after the intervention, there was an increase in respondents’ reported fruit and vegetable intake. Declarations Abbreviations: Not Applicable Ethics Approval and Consent to Participate: Informed consent to participate was obtained from all participants in the study. This project was approved by the University of Saskatchewan Behavioural Research Board (Beh 4433). Data Availability: Data will be securely stored on SurveyMonkey. Electronic copies of the results and analysis files will be saved to the University of Saskatchewan’s OneDrive. Data will be stored in password protected files. Data will be retained as per University of Saskatchewan guidelines. Electronic files will be deleted at the end of the retention period. Competing Interests: There are no relevant competing interests to declare. Funding: Nutrition course registration funding was approved and supported by the Resident Scholarship Fund of the Department of Academic Family Medicine at the University of Saskatchewan. Authors’ Contributions: KCO wrote the manuscript and would like to acknowledge AC and RK for their continuous support and revisions. Acknowledgements: S.Devries, executive director at Gaples Institute, should also be acknowledged for his continued collaboration and assistance during this research. References Blunt SB, Kafatos A (2019) Clinical Nutrition Education of Doctors and Medical Students: Solving the Catch 22. Adv Nutr 10(2):345–350. 10.1093/advances/nmy082 Crowley J, Ball L, Hiddink GJ (2019) Nutrition in Medical Education: A Systematic Review. Lancet 3(9):379–389. 10.1016/S2542-5196(19)30171-8 Daley BJ, Cherry-Bukowiec J, Van Way CW 3rd, Collier B, Gramlich L, McMahon MM, McClave SA (2016) Current Status of Nutrition Training in Graduate medical Education From a Survey of Residency Program Directors: A Formal Nutrition Education Course is Necessary. J Parenter Enter Nutr 40(1):95–99. 10.1177/0148607115571155 Aspry KE, Van Horn L, Carson JAS, Wylie-Rosett J, Kushner RF, Lichtenstein AH, Devries S, Freeman AM, Crawford A, Kirs-Etherton P (2018) Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association. Circulation 137(23):821–841. 10.1161/CIR.0000000000000563 Han SL, Auer R, Cornuz J, Marques-Vidal P (2016) Clinical Nutrition in Primary Care: An Evaluation of Resident Physicians’ Attitudes and Self-Perceived Proficiency. Clin Nutr ESPEN 15:69–74. 10.1016/j.clnesp.2016.06.005 Lenders CM, Deen DD, Bistrian B, Edwards MS, Seidner DL, McMahon MM, Kohlmeier M, Krebs NF (2014) Residency and Specialties Training in Nutrition: A Call for Action. Am J Clin Nutr 99(5):1174–1183. 10.3945/ajcn.113.073528 Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL (2009) What Do Resident Physicians Know About Nutrition? An Evaluation of Attitudes, Self-Perceived Proficiency and Knowledge. J Am Coll Nutr 27(2):287–298. 10.1080/07315724.2008.10719702 Shafto K, Shah A, Smith J, Wang Q, Devries S, Kreitzer MJ, Baxley F (2020) Impact of an Online Nutrition Course to Address a Gap in Medical Education: A Feasibility Study. PRiMER 4:5. 10.22454/PRiMER.2020.368659 Harkin N, Johnston E, Mathew T, Guo Y, Schwartzbard A, Berger J, Gianos E (2018) Physician’s Dietary Knowledge, Attitudes, and Counseling Practices: The Experience of a Single Health Care Center at Changing the Landscape for Dietary Education. Am J Lifestyle Med 13(3):292–300. 10.1177/1559827618809934 Devries S, Willet W, Bonow RO (2019) Nutrition Education in Medical School, Residency Training, and Practice. JAMA 321(14):1351–1352. 10.1001/jama.2019.1581 Deen D, Spencer E, Kolasa K (2003) Nutrition Education in Family Practice Residency Programs. Fam Med 35(2):105–111 PMID:12607807 DeLegge MH, Alger-Mayer S, Van Way III, Gramlich CW (2010) Specialty Residency Training in Medical Nutrition Education. J Parenter Enter Nutr 34(6):47–56. 10.1177/0148607110378017 Khandelwal S, Zemore SE, Hemmerling A (2018) Nutrition Education in Internal Medicine Residency Programs and Predictors of Residents’ Dietary Counseling Practices. J Med Educ Curric Dev 5:2382120518763360. 10.1177/2382120518763360 Fitzgerald JD, Andrade JM, Curl SL, Smith EB, Torna E, Nelson DS (2021) Development of Nutrition Counselling Resources for Family Medicine Using the Knowledge to Action Framework. Fam Pract 38(1):32–37. 10.1093/fampra/cmaa020 Kirby RK, Chauncey KB, Jones BG (1995) The Effectiveness of a Nutrition Education Program for Family Practice Residents Conducted by a Family Practice Resident-Dietician. Fam Med 27(9):576–580 PMID:8829982 Lazarus K, Weinsier RL, Boker JR (1993) Nutrition Knowledge and Practices of Physicians in a Family-Practice Residency Program: The Effect of an Education Program Provided by a Physician Nutrition Specialist. Am J Clin Nutr 58(3):319–325. 10.1093/ajcn/58.3.319 Baute V, Sampath-Kumar R, Nelson S, Basil B (2018) Nutrition Education for the Health-Care Provider Improves Patient Outcomes. Global Adv Health Med 7:2164956118795995. 10.1177/2164956118795995 Shafto K, Shah A, Smith J, Wang QD, Kreitzer S, Baxley MJ (2020) F. Impact of an Online Nutrition Course to Address a Gap in Medical Education: A Feasibility Study. Peer-Reviewed Reports in Medical Education. ; 4, 5. PMID: 32537605 Castillo M, Feinstein R, Tsang J, Fisher M (2016) Basic Nutrition Knowledge of Recent Medical Graduates Entering a Pediatric Residency Program. Int J Adolesc Med Health 28(4):357–361. 10.1515/ijamh-2015-0019 Morton KF, Pantalos DC, Ziegler C, Patel PD (2021) A Place for Plant-based Nutrition in US Medical School Curriculum: A Survey-Based Study. Am J Lifestyle Med 16(3). 10.1177/155982762098867 Sutherland M, Mckenney K, Shanahan H, McKenney M, Elkbuli A (2020) The Need for Nutritional Education Reform in US Medical Education System. Am Surg 87(7). 10.1177/0003134820971621 Cassidy-Vu L, Kirk J (2020) Assessing the Need for a Structured Nutrition Curriculum in a Primary Care Residency Program. J Am Coll Nutr 39(3):243–248. 10.1080/07315724.2019.1644251 Van Horn L, Lenders CM, Pratt CA, Beech B, Carney PA, Dietz W, DiMaria-Ghalili R, Harlan T, Hash R, Kohlmeier M, Kolasa K, Krebs NF, Kushner RF, Lieh-Lai M, Lindsley J, Meacham S, Nicastro H, Nowson C, Palmer C, Paniagua M, Philips E, Ray S, Rose S, Salive M, Schofield M, Thompson K, Trilk JL, Twillman G, White JD, Zappala G, Vargas A, Lynch C (2019) Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination. Adv Nutr 10(6):1181–1200. 10.1093/advances/nmz083 Grammatikopoulou MG, Katsouda A, Lekka K, Tsantekidis K, Bouras E, Kasapidou E, Poulia K, Chourdakis M (2019) Is Continuing Medical Educaiton Sufficient? Assessing the Clinical Nutrition Knowledge of medical Doctors. Nutrition 57:69–73. 10.1016/j.nut.2018.05.013 Aggarwal M, Devries S, Freeman A, Ostfeld R, Gaggin H, Taub P, Rzeszut AK, Allen K, Conti RC (2018) The Deficit of Nutrition Education of Physicians. Am J Med 131(4):339–345. 10.1016/j.amjmed.2017.11.036 Devries S, Dalen JE, Eisenberg DM, Maizes V, Ornish D, Prasad A, Sierpina V, Weil AT, Willet WA (2014) Deficiency of Nutrition Education in Medical Training. Am J Med 127(9):804–806. 10.1016/j.amjmed.2014.04.003 Adams KM, Kohlmeier M, Powell M, Zeisel SH (2010) Nutrition in Medicine: Nutrition Education for Medical Students and Residents. Nutr Clin Pract 25(5):471–480. 10.1177/0884533610379606 Weinsier RL, Boker JR, Brooks CM, Olson AK, Mark DA, St Jeor ST, Stallings VA, Winick M, Heber D (1991) Nutrition Training in Graduate Medical (Residency) Education: A Survey of Selected Training Programs. Am J Clin Nutr 54(6):957–962. 10.1093/ajcn/54.6.957 Additional Declarations The authors declare no competing interests. Supplementary Files AppendixandQuestionnaires.docx Appendix and Questionnaires Revisions1.docx Revisions Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6059388","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":429558567,"identity":"1b321e69-119c-45cd-b038-189ed5291bc7","order_by":0,"name":"Katherine Connor Ostoich","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYDCCwwzMDyQqbEBMZqK1sBlYnEkjRcsBBgaJyrbDJGjhO85jYHCD7Xzi/Pbjjw0YauwIa5E8zGPwcAbP7cQNZ3KMExiOJRPWYnCYd4OxhARQC0MO8wHGBiIcB9Ii/cfgXOL8/uePgVrqidMiIZFwILHhRoJxAmPDYWL8wv/NQOJAsvGGG2+MDRKOHSeshe/8seQHkv/sZOf3pz+W+FBTTVgLKkggVcMoGAWjYBSMAuwAAJ4JPPHwqcLhAAAAAElFTkSuQmCC","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":true,"prefix":"","firstName":"Katherine","middleName":"Connor","lastName":"Ostoich","suffix":""},{"id":429558568,"identity":"1d2bbe96-1f22-449c-915f-84af96beba2b","order_by":1,"name":"Rejina Kamrul","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Rejina","middleName":"","lastName":"Kamrul","suffix":""},{"id":429558569,"identity":"f80a605f-9eff-430d-9291-e0a03501b4d7","order_by":2,"name":"Adam Clay","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Clay","suffix":""}],"badges":[],"createdAt":"2025-02-19 00:24:04","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6059388/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6059388/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78730600,"identity":"c6b31888-9612-4186-93aa-d437d744cd49","added_by":"auto","created_at":"2025-03-18 07:28:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":566256,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6059388/v1/64119b80-d70a-4100-9b0d-f84f1c1395b2.pdf"},{"id":78729608,"identity":"919146df-58cd-4195-a855-d4932a508779","added_by":"auto","created_at":"2025-03-18 07:12:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":576515,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix and Questionnaires\u003c/p\u003e","description":"","filename":"AppendixandQuestionnaires.docx","url":"https://assets-eu.researchsquare.com/files/rs-6059388/v1/3cf031268e08e7f062a9d603.docx"},{"id":78728953,"identity":"6f061438-04a7-4e3b-b5d3-c6b46b4ff413","added_by":"auto","created_at":"2025-03-18 07:04:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13611,"visible":true,"origin":"","legend":"\u003cp\u003eRevisions\u003c/p\u003e","description":"","filename":"Revisions1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6059388/v1/a6fce223699b6248be9140a9.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eDo Doctors Know That it Takes More Than an Apple a Day? Impact of Formal Nutrition Training on Family Medicine Residents’ Nutrition Knowledge, Confidence, Attitudes, and Counselling Abilities.\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eMalnutrition and the prevalence of poor dietary intake is one of the greatest health challenges of the 21st century. Globally, malnutrition, both over- and under-, underlie most major illnesses and deaths and affect all ages, socioeconomic groups, and medical specialities.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e There are 11\u0026nbsp;million deaths annually worldwide attributable to dietary factors, placing poor diet ahead of any other risk factor for death in the world.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The medical, surgical, psychological, and socioeconomic repercussions of this dietary related pandemic are enormous, yet there continues to be insufficient nutrition education provided during medical training.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMany clinical guidelines identify lifestyle modifications, including dietary interventions, as first-line management of common conditions such as diabetes, hypertension, coronary artery disease and hyperlipidemia.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In randomized clinical trials, dietary intervention has proven to prevent and manage important and common diseases.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Furthermore, a healthy lifestyle has been shown to be as effective as medication, or even more effective, in the prevention and management of chronic disease.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e There is well-established evidence that nutrition interventions reduce morbidity and mortality, and accordingly, lead to reduction in costs related to the treatment and care of patients.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePhysicians are in an ideal position to provide dietary advice and are generally considered credible sources of nutrition information. A 2016 study revealed that 85% of patients trusted nutrition advice from their general practitioner.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Despite this trust, given lack of nutrition training in medical school and residency, physicians are in no better position than the general public to understand the composition and importance of a healthy diet.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Physicians do not feel comfortable or adequately prepared to provide effective nutrition counselling. They recognize that they lack the education and training in medical nutrition needed to counsel their patients and to ensure continuity of nutrition care in collaboration with other healthcare professionals.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Therefore, physicians continue to be preoccupied combatting the consequences of malnutrition rather than preventing disease. Educating healthcare professionals on nutrition and healthy dietary practices provides an opportunity to improve both physician and patient wellbeing.\u003c/p\u003e \u003cp\u003eThe substantial body of evidence that supports the benefits of nutrition interventions have not yet adequately translated into medical training or practice. Only a small proportion of physicians routinely offer nutrition care and efforts are haphazard.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Referral rates to registered dieticians and other nutrition professionals remain low.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e As a result of poor nutrition care, patients seek out alternative, variably qualified nutrition advisors for information. Physicians claim to perceive clinical nutrition as a priority in primary care, but lack the knowledge, skills, confidence, and training to effectively counsel in their daily practice.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMost residents, faculty, and fellows have agreed that additional training in nutrition would allow them to provide better clinical care.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e If family physicians are to be prepared to inform their patients regarding nutrition and to make appropriate referrals, improvements in the nutrition curriculum offered in family practice residency programs will be required.\u003c/p\u003e \u003cp\u003eThere is limited published information to date demonstrating the impact of formal nutrition training of residents, especially in Canada. Research carried out has shown that nutrition counselling by healthcare practitioners has the potential to improve after receiving nutrition education and patient resources.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Following an online nutrition course, residents scores on nutrition knowledge tests increased and they were more likely to believe it was their role to provide detailed nutrition information to patients, readily endorsing the view that a healthy diet is important for self-care.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Lastly, nutrition education in residency has positively predicted frequency of residents’ dietary counselling practices and improved their personal dietary intake.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e A strong correlation has been shown between physician’s recommendations being followed and the physician actually practicing their advice themselves.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Physicians health status directly affects the quality of their preventive health counselling and their patient outcomes.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eConsequently, there is urgent need to make appropriate formal nutrition training available during medical education to address the current pandemic of nutrition-related disease and prevent its projected growth.\u003c/p\u003e\n\u003ch3\u003eResearch Question\u003c/h3\u003e\n\u003cp\u003eDoes implementation of formal nutrition training during residency positively influence residents’ nutrition knowledge, attitudes, personal dietary patterns, and rates of nutrition counselling with patients in clinical practice?\u003c/p\u003e "},{"header":"Methodology","content":"\u003cp\u003eThis pre-post study evaluated the impact of a nutrition training intervention on a group of 24 family medicine residents based in Regina, Saskatchewan, who were either in their first or second year of residency. The nutrition training intervention was a short, online, self-paced, 4-hour course, designed for clinicians, that explores the global importance of nutrition in medicine, macronutrients, evidence-based dietary patterns, nutrition in relation to certain medical conditions, motivational interviewing, and nutrition counselling. This course, developed by the educational nonprofit, Gaples Institute, is called \u003cem\u003eNutrition Science for Health and Longevity: What Every Clinician Needs to Know\u003c/em\u003e and it has been approved for continuing medication education.\u003c/p\u003e\u003cp\u003eFour hours during the residents’ academic half day was provided in February 2024 to complete this course; attendance at academic half day is mandatory for family medicine residents in Regina as it is an educational requirement. Inclusion of the course was approved by the local academic half day coordinator as other topics would be. Additional time was provided during two separate academic half days, 1 hour during each, for completion of the pre- and post-course questionnaires.\u003c/p\u003e\u003cp\u003eResidents involved in this study had the option to complete surveys and have their nutrition knowledge tested before and after the online course through SurveyMonkey. Informed consent to participate was obtained from all participants in the study. Pre- and post-course surveys were linked for each participant using a participant identified code. Survey questions inquired about previous nutrition education, self-perceived importance of nutrition in medicine and health, attitudes towards nutrition counselling, current nutrition counselling practices, and current dietary patterns. The survey following the course also inquired about residents’ predictions of the role of nutrition in their future practice. Moreover, questions that were asked on the nutrition knowledge test covered information including Canadian recommendations on daily nutritional intake, nutrition terms, macronutrients, effect of diet on lab values, and diagnosis or management of nutrition-related illnesses. Questions were created based on the nutrition course used in this study, on nutrition questionnaires/tests utilized in previous studies, and on current Canadian guidelines.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This project was approved by the University of Saskatchewan Behavioural Research Board (Beh 4433). Please refer to the appendix for the questionnaire and Certificate of Approval.\u003c/p\u003e\u003cp\u003eDescriptive statistics were used to evaluate responses. Knowledge test scores were calculated based on total number of correct answers; partial marks were given in questions with more than one correct answer. Wilcoxon signed-rank test was used to compare quantitative pre- and post-course knowledge test scores.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePre-course questionnaire was completed by 13 residents (response rate\u0026thinsp;=\u0026thinsp;76%). Post-course questionnaire was completed by 6 residents (response rate\u0026thinsp;=\u0026thinsp;24%). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the demographics of the respondents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant demographics. Values represent frequency (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLocation of medical school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutside of Canada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePostgraduate Year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFMR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFMR2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHours of nutrition education/training during medical school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u0026ndash;9 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHours of nutrition education/training received during residency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe responses to questions concerning attitudes, practices, and beliefs regarding nutrition prior to the online nutrition course are displayed in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The majority of participants felt family medicine residents do not receive adequate nutrition training and strongly agree that they would benefit from additional training to help provide better clinical care to patients. All respondents thought patients would benefit from more frequent, longer, or more detailed conversations about nutrition during appointments. Beliefs on the importance of discussing nutrition and diet with patients increased after the course. Respondents\u0026rsquo; confidence in counselling and answering questions with patients related to diet/nutrition also increased post-course. Intake of fruits and vegetables reported by participants was higher after the course was completed. A related samples Wilcoxon signed-rank test showed knowledge increased after the nutrition course (p\u0026thinsp;=\u0026thinsp;0.027).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResponses to questions concerning attitudes, practices and beliefs regarding nutrition asked prior to the online education. Values represent frequency (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDo you feel Family Medicine residents receive adequate nutrition training?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (76.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eI would benefit from additional nutrition training to help me provide better clinical care to patients including prevention of disease, maintenance of health, and treatment of disease.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrongly agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (69.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eWhat percentage of patients visits do you speak about nutrition or diet?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026ndash;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u0026ndash;75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u0026ndash;99%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAverage length spent counselling a patient about nutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (46.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;6 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHow often do you refer a patient to a dietician?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (76.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResponses to questions concerning attitudes, practices and beliefs regarding nutrition asked prior to the online education. Values represent frequency (%) or median (IQR).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003e(all)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003e(complete)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of servings of fruits and vegetables eaten by resident on average day.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 servings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;6 servings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (69.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDo you think it is important for physicians to discuss nutrition and diet with patients?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWhat statement best describes your view on the physician's role in nutrition counselling?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI believe my role involves providing personalized, detailed nutrition information and advice to patients, including answering any questions they might have.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI believe my role involves providing very basic, general nutrition and dietary information or advice to patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (53.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI believe my role is limited in the expectation and my ability to provide any nutrition information or advice to patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHow knowledgeable do you feel about nutrition?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdequate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuperior knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHow confident do you feel in counselling and answering questions for patients related to diet and nutrition?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think patients would benefit from having more frequent, longer, or more detailed conversations about nutrition during their appointments?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge Score /30,\u003c/p\u003e \u003cp\u003emedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003cp\u003e(20.3\u0026ndash;22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003cp\u003e(20.5\u0026ndash;24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003cp\u003e(23.8\u0026ndash;27.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents responses to questions regarding post-course beliefs on the value of the nutrition course and its impact on diet and counselling. Most participants believed personal dietary habits did not change after the nutrition course. Nutrition counselling increased/improved after the course and all participants plan on counselling more and making more referrals to dieticians post-course compared to pre-course. Respondents were not homogenous in their opinions on whether they had received adequate nutrition training during residency before or after the course. Notwithstanding, all participants thought the nutrition course was beneficial and that this course or a similar one should be offered to all Canadian family medicine residents, with the majority believing it should be a mandatory part of the program.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-course beliefs on value of the course and impact of the course on diet and counselling. Values represent frequency (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHow has your diet changed since taking the nutrition course?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat healthier\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHas your nutrition counselling with patients changed since taking the nutrition course?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat increased/improved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHow often do you plan on nutrition counselling in practice going forward compared to before the nutrition course?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSignificantly more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHow often do you plan on referring a patient to a dietician compared to before the nutrition course?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSignificantly more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eI have had adequate nutrition training during residency.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eThis nutrition course offered during AHD was beneficial.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrongly agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you believe this nutrition course or a similar one should be offered to all Canadian Family Medicine residents?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDo you believe this nutrition course or a similar one should be mandatory to complete as part of Family Medicine residency training in Canada?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo, it should be optional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDo you believe this nutrition course or a similar one should be offered to Canadian residents in other specialties?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, all specialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, certain specialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from this study support the literature available on the topic. Resident respondents believed they do not receive adequate nutrition training. Historically, it has been found there is a lack of adequate nutrition teaching provided to medical students and residents.\u003csup\u003e1\u0026ndash;4,6\u0026minus;8,10\u0026ndash;13,17,22,24,26, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This could be due to time constraints within training programs, priorities given to other topics/areas of training, lack of financial incentives for nutrition training/counselling, or lack of preceptor knowledge in the area.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e This research demonstrated that participants usually spend time discussing nutrition/diet with patients in less than half of visits, which is interesting given that respondents believe patients would benefit from having more frequent, longer, or more detailed conversations about nutrition during appointments. This was found in previous research, which showed that nutrition counselling only occurs in about one third of all primary care office visits.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e These findings could be resulting from visit time constraints, lack of perceived importance of the effectiveness of nutrition interventions, or lack of physicians\u0026rsquo; nutrition knowledge.\u003c/p\u003e \u003cp\u003ePost-course completion, there was improvement in nutrition knowledge and counselling demonstrated. A statistically significant increase in nutrition test scores was found after the course was completed. This type of knowledge improvement after formal nutrition intervention has been seen in multiple studies previously.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e In addition, post-course, residents\u0026rsquo; beliefs on the importance of discussing nutrition/diet with patients increased, their nutrition counselling increased/improved, and they plan on counselling more and making more referrals to dieticians in the future. The literature supports that nutrition interventions lead to increased belief in the importance of nutrition and a healthy diet\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, but there have been mixed results on the impact of nutrition interventions on counselling frequency and duration.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The respondents in this study felt that their confidence in counselling and answering questions with patients related to diet/nutrition increased post-course. This is exhibited in previous literature, where nutrition intervention showed potential to increase confidence and self-efficacy in nutrition education/counselling.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eParticipants in this study did not believe their diets changed after the nutrition course, however, their reported intake of fruits and vegetables increased post-course compared to pre-course. Research has shown that better resident dietary habits are associated with higher frequency of dietary counselling with patients.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Better physician health also has potential to improve patient outcomes.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Consequently, it could be predicted that formal nutrition education can lead to increased nutrition counselling and better patient outcomes.\u003c/p\u003e \u003cp\u003eOverall, respondents were not homogenous in their opinions on whether they received adequate nutrition training during residency after the nutrition course was completed, but all thought the course was beneficial and that it or a similar course should be offered to all Canadian family medicine residents, with the majority believing it should be a mandatory component of the program.\u003c/p\u003e \u003cp\u003eFuture research in this area is needed to help support these conclusions and consequently, lead to improvement of nutrition training during residency. This future research should include larger and broader sample sizes, with resident participants from varying geographic locations across Canada. The course could also be implemented into residency programs in other medical specialties to investigate whether they would benefit equally from this additional training. Lastly, future studies should compare the rate and quality of nutrition counselling in clinical practice after residency completion by physicians who undertook formal nutrition training compared to physicians who did not have the training.\u003c/p\u003e \u003cp\u003eDespite the promising findings from this formal nutrition intervention, there are multiple limitations of this study that should be considered. Firstly, the sample size of 24 Canadian family medicine residents was limited due to funding availability. Secondly, there was limited response by the family medicine residents, with 13 residents completing the pre-course questionnaires, and only 6 residents completing the post-course questionnaires. This poor uptake could be due to priority of time being given to other tasks, low interest in nutrition, lack of belief of nutrition\u0026rsquo;s importance/efficacy in health, or decision/task exhaustion by residents. Thirdly, measurement error may have falsified information provided by the residents in their subjective responses to questionnaires. Lastly, response bias in answers to the questionnaires could have played a role as the residents in the study were colleagues of the study investigators and authors.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eImplementation of formal nutrition training during residency positively influences family medicine residents\u0026rsquo; nutrition knowledge, attitudes, and rates of nutrition counselling with patients in clinical practice. Although the residents did not believe their personal dietary habits had changed after the intervention, there was an increase in respondents\u0026rsquo; reported fruit and vegetable intake.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAbbreviations:\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eEthics Approval and Consent to Participate:\u003c/p\u003e\n\u003cp\u003eInformed consent to participate was obtained from all participants in the study. This project was approved by the University of Saskatchewan Behavioural Research Board (Beh 4433).\u003c/p\u003e\n\u003cp\u003eData Availability:\u003c/p\u003e\n\u003cp\u003eData will be securely stored on SurveyMonkey. Electronic copies of the results and analysis files will be saved to the University of Saskatchewan’s OneDrive. Data will be stored in password protected files. Data will be retained as per University of Saskatchewan guidelines. Electronic files will be deleted at the end of the retention period.\u003c/p\u003e\n\u003cp\u003eCompeting Interests:\u003c/p\u003e\n\u003cp\u003eThere are no relevant competing interests to declare.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eNutrition course registration funding was approved and supported by the Resident Scholarship Fund of the Department of Academic Family Medicine at the University of Saskatchewan.\u003c/p\u003e\n\u003cp\u003eAuthors’ Contributions:\u003c/p\u003e\n\u003cp\u003eKCO wrote the manuscript and would like to acknowledge AC and RK for their continuous support and revisions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eS.Devries, executive director at Gaples Institute, should also be acknowledged for his continued collaboration and assistance during this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBlunt SB, Kafatos A (2019) Clinical Nutrition Education of Doctors and Medical Students: Solving the Catch 22. Adv Nutr 10(2):345\u0026ndash;350. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/advances/nmy082\u003c/span\u003e\u003cspan address=\"10.1093/advances/nmy082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrowley J, Ball L, Hiddink GJ (2019) Nutrition in Medical Education: A Systematic Review. Lancet 3(9):379\u0026ndash;389. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2542-5196(19)30171-8\u003c/span\u003e\u003cspan address=\"10.1016/S2542-5196(19)30171-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaley BJ, Cherry-Bukowiec J, Van Way CW 3rd, Collier B, Gramlich L, McMahon MM, McClave SA (2016) Current Status of Nutrition Training in Graduate medical Education From a Survey of Residency Program Directors: A Formal Nutrition Education Course is Necessary. J Parenter Enter Nutr 40(1):95\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0148607115571155\u003c/span\u003e\u003cspan address=\"10.1177/0148607115571155\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAspry KE, Van Horn L, Carson JAS, Wylie-Rosett J, Kushner RF, Lichtenstein AH, Devries S, Freeman AM, Crawford A, Kirs-Etherton P (2018) Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association. Circulation 137(23):821\u0026ndash;841. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/CIR.0000000000000563\u003c/span\u003e\u003cspan address=\"10.1161/CIR.0000000000000563\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan SL, Auer R, Cornuz J, Marques-Vidal P (2016) Clinical Nutrition in Primary Care: An Evaluation of Resident Physicians\u0026rsquo; Attitudes and Self-Perceived Proficiency. Clin Nutr ESPEN 15:69\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clnesp.2016.06.005\u003c/span\u003e\u003cspan address=\"10.1016/j.clnesp.2016.06.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLenders CM, Deen DD, Bistrian B, Edwards MS, Seidner DL, McMahon MM, Kohlmeier M, Krebs NF (2014) Residency and Specialties Training in Nutrition: A Call for Action. Am J Clin Nutr 99(5):1174\u0026ndash;1183. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3945/ajcn.113.073528\u003c/span\u003e\u003cspan address=\"10.3945/ajcn.113.073528\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVetter ML, Herring SJ, Sood M, Shah NR, Kalet AL (2009) What Do Resident Physicians Know About Nutrition? An Evaluation of Attitudes, Self-Perceived Proficiency and Knowledge. J Am Coll Nutr 27(2):287\u0026ndash;298. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/07315724.2008.10719702\u003c/span\u003e\u003cspan address=\"10.1080/07315724.2008.10719702\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShafto K, Shah A, Smith J, Wang Q, Devries S, Kreitzer MJ, Baxley F (2020) Impact of an Online Nutrition Course to Address a Gap in Medical Education: A Feasibility Study. PRiMER 4:5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.22454/PRiMER.2020.368659\u003c/span\u003e\u003cspan address=\"10.22454/PRiMER.2020.368659\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarkin N, Johnston E, Mathew T, Guo Y, Schwartzbard A, Berger J, Gianos E (2018) Physician\u0026rsquo;s Dietary Knowledge, Attitudes, and Counseling Practices: The Experience of a Single Health Care Center at Changing the Landscape for Dietary Education. Am J Lifestyle Med 13(3):292\u0026ndash;300. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1559827618809934\u003c/span\u003e\u003cspan address=\"10.1177/1559827618809934\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevries S, Willet W, Bonow RO (2019) Nutrition Education in Medical School, Residency Training, and Practice. JAMA 321(14):1351\u0026ndash;1352. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2019.1581\u003c/span\u003e\u003cspan address=\"10.1001/jama.2019.1581\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeen D, Spencer E, Kolasa K (2003) Nutrition Education in Family Practice Residency Programs. Fam Med 35(2):105\u0026ndash;111 PMID:12607807\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeLegge MH, Alger-Mayer S, Van Way III, Gramlich CW (2010) Specialty Residency Training in Medical Nutrition Education. J Parenter Enter Nutr 34(6):47\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0148607110378017\u003c/span\u003e\u003cspan address=\"10.1177/0148607110378017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhandelwal S, Zemore SE, Hemmerling A (2018) Nutrition Education in Internal Medicine Residency Programs and Predictors of Residents\u0026rsquo; Dietary Counseling Practices. J Med Educ Curric Dev 5:2382120518763360. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2382120518763360\u003c/span\u003e\u003cspan address=\"10.1177/2382120518763360\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzgerald JD, Andrade JM, Curl SL, Smith EB, Torna E, Nelson DS (2021) Development of Nutrition Counselling Resources for Family Medicine Using the Knowledge to Action Framework. Fam Pract 38(1):32\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/fampra/cmaa020\u003c/span\u003e\u003cspan address=\"10.1093/fampra/cmaa020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirby RK, Chauncey KB, Jones BG (1995) The Effectiveness of a Nutrition Education Program for Family Practice Residents Conducted by a Family Practice Resident-Dietician. Fam Med 27(9):576\u0026ndash;580 PMID:8829982\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLazarus K, Weinsier RL, Boker JR (1993) Nutrition Knowledge and Practices of Physicians in a Family-Practice Residency Program: The Effect of an Education Program Provided by a Physician Nutrition Specialist. Am J Clin Nutr 58(3):319\u0026ndash;325. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ajcn/58.3.319\u003c/span\u003e\u003cspan address=\"10.1093/ajcn/58.3.319\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaute V, Sampath-Kumar R, Nelson S, Basil B (2018) Nutrition Education for the Health-Care Provider Improves Patient Outcomes. Global Adv Health Med 7:2164956118795995. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2164956118795995\u003c/span\u003e\u003cspan address=\"10.1177/2164956118795995\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShafto K, Shah A, Smith J, Wang QD, Kreitzer S, Baxley MJ (2020) F. Impact of an Online Nutrition Course to Address a Gap in Medical Education: A Feasibility Study. Peer-Reviewed Reports in Medical Education. ; 4, 5. PMID: 32537605\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastillo M, Feinstein R, Tsang J, Fisher M (2016) Basic Nutrition Knowledge of Recent Medical Graduates Entering a Pediatric Residency Program. Int J Adolesc Med Health 28(4):357\u0026ndash;361. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1515/ijamh-2015-0019\u003c/span\u003e\u003cspan address=\"10.1515/ijamh-2015-0019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorton KF, Pantalos DC, Ziegler C, Patel PD (2021) A Place for Plant-based Nutrition in US Medical School Curriculum: A Survey-Based Study. Am J Lifestyle Med 16(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/155982762098867\u003c/span\u003e\u003cspan address=\"10.1177/155982762098867\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutherland M, Mckenney K, Shanahan H, McKenney M, Elkbuli A (2020) The Need for Nutritional Education Reform in US Medical Education System. Am Surg 87(7). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0003134820971621\u003c/span\u003e\u003cspan address=\"10.1177/0003134820971621\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCassidy-Vu L, Kirk J (2020) Assessing the Need for a Structured Nutrition Curriculum in a Primary Care Residency Program. J Am Coll Nutr 39(3):243\u0026ndash;248. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/07315724.2019.1644251\u003c/span\u003e\u003cspan address=\"10.1080/07315724.2019.1644251\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Horn L, Lenders CM, Pratt CA, Beech B, Carney PA, Dietz W, DiMaria-Ghalili R, Harlan T, Hash R, Kohlmeier M, Kolasa K, Krebs NF, Kushner RF, Lieh-Lai M, Lindsley J, Meacham S, Nicastro H, Nowson C, Palmer C, Paniagua M, Philips E, Ray S, Rose S, Salive M, Schofield M, Thompson K, Trilk JL, Twillman G, White JD, Zappala G, Vargas A, Lynch C (2019) Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination. Adv Nutr 10(6):1181\u0026ndash;1200. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/advances/nmz083\u003c/span\u003e\u003cspan address=\"10.1093/advances/nmz083\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrammatikopoulou MG, Katsouda A, Lekka K, Tsantekidis K, Bouras E, Kasapidou E, Poulia K, Chourdakis M (2019) Is Continuing Medical Educaiton Sufficient? Assessing the Clinical Nutrition Knowledge of medical Doctors. Nutrition 57:69\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nut.2018.05.013\u003c/span\u003e\u003cspan address=\"10.1016/j.nut.2018.05.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAggarwal M, Devries S, Freeman A, Ostfeld R, Gaggin H, Taub P, Rzeszut AK, Allen K, Conti RC (2018) The Deficit of Nutrition Education of Physicians. Am J Med 131(4):339\u0026ndash;345. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjmed.2017.11.036\u003c/span\u003e\u003cspan address=\"10.1016/j.amjmed.2017.11.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevries S, Dalen JE, Eisenberg DM, Maizes V, Ornish D, Prasad A, Sierpina V, Weil AT, Willet WA (2014) Deficiency of Nutrition Education in Medical Training. Am J Med 127(9):804\u0026ndash;806. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjmed.2014.04.003\u003c/span\u003e\u003cspan address=\"10.1016/j.amjmed.2014.04.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams KM, Kohlmeier M, Powell M, Zeisel SH (2010) Nutrition in Medicine: Nutrition Education for Medical Students and Residents. Nutr Clin Pract 25(5):471\u0026ndash;480. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0884533610379606\u003c/span\u003e\u003cspan address=\"10.1177/0884533610379606\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinsier RL, Boker JR, Brooks CM, Olson AK, Mark DA, St Jeor ST, Stallings VA, Winick M, Heber D (1991) Nutrition Training in Graduate Medical (Residency) Education: A Survey of Selected Training Programs. Am J Clin Nutr 54(6):957\u0026ndash;962. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ajcn/54.6.957\u003c/span\u003e\u003cspan address=\"10.1093/ajcn/54.6.957\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"nutrition, education, medicine, medical, training, residency","lastPublishedDoi":"10.21203/rs.3.rs-6059388/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6059388/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMalnutrition and poor dietary intake are major health challenges today.\u003csup\u003e1,2,3,4,5\u003c/sup\u003e There are well-established benefits of nutrition interventions, but a lack of formalized nutrition training in medical school and residency.\u003csup\u003e3,6,7,8\u003c/sup\u003e There is also little published information regarding nutrition training impact on residents. Physicians lack knowledge, skills, confidence, and training to effectively counsel in daily practice.\u003csup\u003e 1,3,9,10,11,12\u003c/sup\u003e Consequently, there is urgent need to improve nutrition training in medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis pre-post study evaluated the impact of an online nutrition course provided to family medicine residents. Time was provided at Academic Half Day to complete the course as well as pre- and post-course surveys with knowledge tests through SurveyMonkey. Descriptive statistics were used to evaluate responses. The project was approved by the University of Saskatchewan Behavioural Research Board (Beh 4433).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThirteen residents completed the pre-course questionnaire (response rate = 76%). Of these, ten (77%) felt they received inadequate nutrition training and all thought patients would benefit from improved nutrition counselling. Six residents completed the post-course questionnaire (response rate = 24%). All post-course respondents thought the course was beneficial and that it should be offered to all Canadian family medicine residents, with majority believing it should be mandatory. Respondents’ nutrition knowledge, confidence, beliefs on importance of nutrition counselling, and nutrition counselling in practice appear to increase/improve after training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eImplementation of formal nutrition training during residency positively influences family medicine residents’ nutrition knowledge, attitudes, personal dietary patterns, and rates of nutrition counselling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations: \u003c/strong\u003eFuture research with larger sample sizes is needed to support these conclusions and improve nutrition training during residency. Future studies should look at nutrition training in other specialties as well as examine the rate and quality of nutrition counselling after residency completion.\u003c/p\u003e","manuscriptTitle":"Do Doctors Know That it Takes More Than an Apple a Day? Impact of Formal Nutrition Training on Family Medicine Residents’ Nutrition Knowledge, Confidence, Attitudes, and Counselling Abilities.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-18 07:04:09","doi":"10.21203/rs.3.rs-6059388/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"007f87d1-15a7-4f69-8844-188366df042c","owner":[],"postedDate":"March 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":45749114,"name":"General Practice"},{"id":45749115,"name":"Nutrition \u0026 Dietetics"}],"tags":[],"updatedAt":"2025-03-18T07:04:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-18 07:04:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6059388","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6059388","identity":"rs-6059388","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}