Original Article

The Diet Quality of Medical Students in the United States During the Early COVID-19 Pandemic

Mira Yousef¹, Birgit Khandalavala²

doi: http://dx.doi.org/10.5195/ijms.2022.1039

Volume 10, Number 2: 158-164
Received 06 05 2021: Rev-request 09 06 2021: Rev-request 08 03 2022: Rev-recd 10 07 2021: Rev-recd 14 04 2022: Accepted 18 04 2022

ABSTRACT

Background:

Medical students report lacking the knowledge to conduct nutrition counseling for patients and practice good dietary quality in their personal life. This cross-sectional study describes the dietary quality of medical students at one Midwestern College of medicine during the early COVID-19 pandemic in the United States of America.

Methods:

Cross-sectional study based on a survey applied to medical students (n=102) during spring 2020. We used the Rapid Eating Assessment for Participants–Shortened (REAP-S) to assess dietary quality during the COVID-19 pandemic. The response rate was 27%. The primary outcome was to obtain total mean REAP-S scores and identify variables related to poor diet quality.

Results:

A mean REAP-S score of 30.5, SD=3.9 (range 13-39) was obtained (67% of ideal dietary quality). Body weight remained the same for 54.9% of students, 25.7% gained weight, and 18.8% lost weight during the late spring of 2020. Students with BMI < 24.9 kg/m2 (mean REAP-S score of 31.6±3.6) had a significantly better dietary quality (p < 0.001) compared to students with BMI > 25 kg/m2 (mean REAP-S score of 28.9±3.9). Students with a self-reported “less healthy” diet (mean REAP-S=28.2±3.3) had significantly worse dietary quality (p < 0.001) compared to those who either maintained a healthy diet (mean REAP-S=31.1±3.8) or improved diet (mean REAP-s=31.9±3.6). Of note, 89.2% of students indicated that they want to improve their diet.

Conclusion:

The dietary quality of participants was found to be sub-optimal during the early COVID-19 pandemic, potentially impacting our future medical workforce's long-term health adversely.

Keywords: Medical students; Diet; Body mass index; COVID-19 pandemic; Diet surveys. (Source: MeSH-NLM).

Introduction

A healthy diet is critical for good health, the mitigation of the chronic disease and optimal functioning for the general population, as well as for future healthcare providers.¹ Despite the growing crisis of chronic disease prevalence in healthcare in the United States (US) driven by poor lifestyle choices, medical student education has been well documented to be deficient in delivering comprehensive nutrition training for many years.^2–4 Graduating medical students have reported lacking the knowledge and skills necessary to conduct adequate nutrition counseling for patients.⁴ Furthermore, in a recent study of first-year medical students, a discrepancy between knowledge and self-practice of good dietary quality was found.⁵ There is a significant evidence-practice gap between the nutrition education provided to medical students and the students' nutrition knowledge, skills, and attitudes needed for the comprehensive care of patients.⁶ It is anticipated that such deficiencies may have profound and dire health-related adverse outcomes for the patient population, particularly as the obesity epidemic continues to escalate even further, with continued higher rates projected in the upcoming decade.⁷ In addition, poor self-nutrition care could portend poorer health outcomes for future healthcare providers.⁵

The optimal overall quality of a diet may have a greater impact on health than the more reductionistic view of individual macronutrients in the diet, such as just one food group or food item, and as a result, indices of healthy eating to determine dietary quality have been developed.⁸ The Healthy Eating Index (HEI) has been developed by the Center of Nutrition Policy and Promotion to monitor the diet quality of the US population and aligns with the National guidelines from the US Dietary Guidelines for Americans. The HEI is regularly updated to remain consistent with newer recommendations.⁸ Since the HEI is a lengthy tool, a team of researchers developed and validated the Rapid Eating Assessment for Participants (REAP) to improve nutrition training in US medical schools.^9,10 In 2004, the REAP was further shortened to the Rapid Eating Assessment for Participants-Shortened Version (REAP-S), and in addition, was validated against nutrient intakes using the 1998 Block Food Frequency Questionnaire in 110 medical students.¹¹ Moreover, the REAP-S survey can assess the dietary quality of food intake in a clinical or research setting, requires less than 10 minutes to complete without the need for trained staff to deliver or interpret results, and has negligible costs, unlike the lengthier and more cumbersome HEI.¹¹ In a previous study, including omnivores, the REAP-S was used in a US population and correlated with metabolic outcomes.^9,10 Prior to the outbreak of the COVID-19 pandemic, there were no reports addressing dietary quality from medical students in the United States.

During the COVID-19 pandemic in 2020, emerging international reports indicated that healthy eating was declining in the general population.^12,13 In the US, medical students were not considered essential workers and in-person teaching and clinical activities were terminated at the University of Nebraska Medical Center on 16^th March 2020.¹⁴ The medical university campus was closed, and medical students were asked to isolate themselves at home while teaching and transitioned to remote learning only until the end of June 2020. While this period was not a strictly enforced “lockdown”, normal life abruptly came to a complete halt across this midwestern state, and only essential services were kept open. Eating meals away from home was drastically reduced due to the closing of restaurants and cafeterias, restricted travel, and fear of being in public areas. Medical students now had more time and access to healthy cooking in their home kitchens, with groceries stores remaining open. On the contrary, less healthy eating patterns and poor diet quality, such as skipping breakfast, increasing sugary foods, and snacking at home, could be an issue.

There was a gap in the knowledge of the dietary quality of medical students in the US and its impact on health during this unprecedented time in modern history, and as far as we can tell, there are no similar studies published in the literature. Hence, the goal of our study was to investigate dietary quality using the REAP-S at a US midwestern college of medicine, at the end of the three-month isolation at home period, due to the COVID-19 pandemic. Our overarching goal was to determine any significant changes in dietary quality and body weight and to inform future mitigation strategies if adverse effects from the early course of the COVID-19 pandemic on medical students were observed.

Methods

Study Design

This was a cross-sectional single-center study. Special consent was obtained from the Dean of the College of Medicine and the COVID-19 research task force. Institutional Review Board (IRB #492-20-EX) clearance was granted from the affiliated university medical center.

Study Population/Participants

The study population of medical students was chosen since no previous study has been done on this population. This information would add important new data for early targeted interventions if an adverse impact of the COVID–19 pandemic was observed.

The study population consisted of medical students with active Email addresses on file (n=383) enrolled at the University of Nebraska Medical Center College of Medicine for the upcoming 2020-2021 academic year. Fourth-year medical students could no longer be reached since they had already graduated, reducing the number of potential participants. The complete medical college program consists of four years of medical school with approximately 130 students per class. The study was conducted at the end of June 2020, when medical students had been learning remotely and isolated at home for the previous three months (March-June 2020). Medical students who were diagnosed with COVID-19 (n=2) were excluded from the study as dietary quality may have been significantly impacted due to sickness and loss of taste and smell.

Study Process

Three hundred and eighty-three e-mails inviting participation were sent to all enrolled medical students with instructions for accessing the web-based survey. Surveys remained open for two weeks. A reminder e-mail was sent at the end of the first week. Participants were asked to reference an average week in June 2020 when answering the survey questions to specifically target diet quality during the pandemic. Responses were captured anonymously in a secure database.

Survey Tool

The 16-item, self-reported REAP-S questionnaire was used to measure dietary quality. The survey asks about food consumption during the week prior to the survey to be recalled by the study participant. Only the first 13 questions are scored and capture eating behavior, dietary patterns and types and quantities of food groups eaten. Each question is scored on a 3-point Likert scale (range 1-3 for each question). Total possible scores for the 13 questions range from 13-39, with higher scores indicative of better diet quality. Questions 14 through 16 of the REAP-S are not captured in the total score and collect information on current cooking and eating habits (eating at home versus eating out) and the willingness to improve eating patterns.^9,10 Sociodemographic questions on race, ethnicity, marital status, and current Body Mass Index (BMI) categories were included in the preface of the survey. Four additional questions were added to capture changes due to the COVID-19 pandemic, as described in Table 1.

Outcomes

The study's primary outcome was to obtain total mean REAP-S scores for all medical students as a single cross-sectional cohort study group. Secondary outcomes included two sub-analyses. The first sub-analysis compared the mean REAP-S scores in a self-reported BMI groups. We categorized BMI of all the medical students into two the BMI categories consisting of 1. BMI < 24.9 kg/m² (normal weight and below) and 2. BMI > 25 kg/m² (overweight and obese). The second sub-analysis similarly compared the mean REAP-S scores in self-reported change in diet categories from pre-pandemic to end of isolation at home, March – June 2020. The three sub-groups based on the question on change in diet were a. “less healthy,” b. “about the same,” or c. “healthier.”

Statistical Analysis

For the statistical analysis, data are reported as mean ± standard deviation. Monte Carlo significance for the Pearson Chi-Square and the Fisher's Exact Test were conducted due to the smaller sample size. The significance levels (p-values) were set at 0.05 (two-tails). Partial correlation analyses were used for differences between groups using the one-way Analysis of Variance (ANOVA) and Tukey test. Statistical Package for the Social Sciences (SSPS) system version 25.0 was utilized for all statistical proceedings.

Results

Invitations for survey participation with a link to the anonymous database were emailed to all enrolled 383 medical students, and 104 medical students responded (response rate of 27%). Two medical students reported COVID-19 infections and were excluded; hence 102 surveys were evaluated (Figure 1). As expected from the predominantly Caucasian racial makeup of a US midwestern state, 88.2% of the medical students reported their race as being Caucasian, and 11.9% were African American or other races. 78.4% were not married, 19.6 % were married, 1% were divorced, and another 1% preferred not to answer. 55.4% of students declared to have remained the same weight over the three months of isolation at home, while 25.7% reported weight gain and 18.8% reported a weight loss. 58 students (58.5%) were in the BMI category < 24.9 kg/m^2. and 40 (40.4%) were in the BMI category > 25kg/m². The remaining students either preferred not to report their BMI (1 student) or had incomplete survey responses and were excluded (3 students).

Figure 1

Process Flow Diagram of Survey Participants.

The mean REAP-S scores are provided for each item and tabulated for the study group (Table 2, Table 3). During an average week of June 2020, the mean REAP-S score was 30.5 (Standard deviation: ±) ±3.9 for all the medical students, with a possible range of 13-39. There was no significant difference between the average scores of any of the individual question items, with the average being 2.3 (with a possible range of 1-3). Statistical analyses using ANOVAs did not reveal any significant difference in mean REAP-S scores between race, ethnicity, or marital status.

Our first sub-analysis compared the mean REAP-S scores for medical students (n = 99 with complete data) between self-reported BMI groups, and one student preferred not to report BMI (Table 4). 58 (58.5%) of medical students with BMI < 24.9 kg/m² had a mean REAP-S score of 31.6±3.6, compared to 40 (40.4%) medical students with BMI >25 kg/m² and a mean REAP-S score of 28.9±3.9. This difference in mean REAP-S scores between the two BMI categories was found to be significantly different (p < 0.001).

The second sub-analysis compared the mean REAP-S scores for medical students (n = 99 with complete data) between self-reported changes in diet quality categories during the stay-at-home period (Table 4). The group consisting of 30 (30.3%) medical students that reported a decline in their diet to “less healthy” had mean REAP-S scores of 28.2±3.3. The 38 (38.4%) medical students who maintained a healthy diet had a mean REAP-S score of 31.1±3.8, and 31 (31.3%) medical students who reported improvement in their diet had a mean REAP-S score of 31.9±3.6. There was no statistically significant difference in mean REAP-S scores between those who indicated their diet did not change and those who indicated their diets were “more healthy,” while there was a significant difference in mean REAP-S scores in the group that had a decrease in the diet quality due to more unhealthy options compared to their peers who were able to maintain or even improve diet (p < 0.001).

A combined 91 students (89.2%) indicated that they would be “somewhat willing “or “very willing” to change eating habits to be healthier (Figure 2). Willingness to make changes in eating habits ranged from 5 students (4.9%) rating their willingness as “very unwilling,” 3 students (2.9%) as “somewhat unwilling,” 2 students (2.0%) as neither willing nor unwilling.” 43 students (42.2%) stated that they are “somewhat willing” and 49 students (48.0%) were “very willing” to change eating habits in order to be healthier.

Figure 2

Willingness of Medical Student Participants to Make Healthy Changes in their Eating Habit.

Legend: Survey response from 102 participants

Discussion

This is the first study to report on the preliminary negative impact of home isolation on a single cohort of US medical students due to the COVID-19 pandemic during the late spring of 2020. The overall dietary quality of this cohort of medical students was noted to be suboptimal, with low REAP-S scores and even lower dietary quality scores noted in the subgroup of medical students with overweight and obesity compared to their peers with normal weight. Not entirely unexpectedly, a third of the medical students reported an improvement in their diet during the pandemic, but the REAP-S scores from this sub-group cannot confirm a change in dietary quality from the population's baseline. The dietary quality was lower in those medical students who had self-declared “less healthy” changes during the COVID-19 pandemic compared to their peers who reported being able to maintain a healthy diet or even improve their diet. While most medical students maintained their weight, a little over a quarter of the medical students reported weight gain in these three months, and a minority reported weight loss.

In the most recent 2015 Healthy Eating Index, the HEI score for younger adults in the general population, is 58.3 out of a possible range of 0-100 points (58.3%). The average REAP-S score of our surveyed medical students was 30.5, with a range of possible scores from 13-39 (67%). HEI scores ranging from 51-80% of the total score reflect diets that “need improvement.” Our study would concur with findings from the HEI regarding the general population that this cohort of US medical students also consuming a suboptimal dietary quality. Though marginally, the dietary quality of medical students is better than the normal population, in such a highly educated group, there were no ideal scores, indicating that all medical students could improve their dietary quality.

A particular strength of our study was the use of the REAP-S tool, which was previously validated for medical students.^9,10 The survey could be conducted virtually and safely during the pandemic. The REAP-S survey tool has many benefits and has been well studied; it has been found to correlate to dietary quality as measured by the premier standard of US dietary quality, the HEI,⁸ and with well-documented markers of dietary quality such as the nutrient density of the diet,¹⁵ the Potential Renal Acid Load (PRAL)¹⁶, urine pH¹⁷ and plasma vitamin C concentrations.^18,19

Additionally, lower scores on the REAP-S have been found to be directly associated with metabolic abnormalities, including obesity, hypertension, lipid abnormalities and insulin resistance.¹⁰ Prior to the pandemic, the mean REAP-S score for young and healthy university students with normal weight, consuming a typical omnivorous diet was 32 (range 13-39).⁹ The students with REAP-S scores below 32 were detected to have significant metabolic abnormalities.¹⁸ By comparison, the mean REAP-S score from our similar cohort was 30.5, indicating that this cohort of midwestern medical students could be at an increased metabolic risk.

Our findings determined that medical students who are overweight or obese have a significantly poorer dietary quality than their normal-weight peers. These groups of medical students who are overweight or obese could be even more likely to be at higher increased future metabolic risk and experience greater weight gain, as observed in a recent small study on patients with obesity, the majority of whom gained significant weight within a month of the pandemic.¹³ Similarly, the subgroup of students that self-reported a significant decline in their diet during the pandemic had a lower dietary quality score and could be at additional risk of metabolic disorders such as insulin resistance and hyperlipidemia.¹⁰

A majority of medical students in this study cohort did not report weight gain; however, a little over a quarter did note weight gain, while a smaller minority had weight loss. Any weight gain is well known to be difficult to keep off and long-term consequences may develop.²⁰ Our observation of the adverse impact of the isolation period of the pandemic on diet was similar to that seen in an Australian study of university students reporting 20% excess eating during the pandemic isolation.¹² We did not find similar percentages of weight loss seen in the study reported from medical students from Croatia.²¹

The limitations of any self-reported diet survey are well known to include self-reporting bias and under-reporting. ²² Faulty recall is another issue, and in one international COVID-19 study, the Block Food Frequency Questionnaire was used, but due to greater inherent error of bias recall, the authors of this study elected not to pursue this as a survey tool.²³ Limitations due to the brevity of the survey may have led to the omission of further details on family composition, the impact of stress, socioeconomic status and other confounders that may have impacted diet quality and lifestyle changes. We were also limited by the restrictions and special permission for medical student research as well as new COVID-19 research requirements. We recognized the additional stress levels of medical students due to remote learning, the COVID-19 pandemic, and overstretched resources, and as a result, kept the survey items to the minimum.^13,22 We also could not include the fourth-year medical students who had graduated in the middle of June 2020, reducing the number of potential participants.

Since the time of our study, there have been new and more comprehensive surveys available from international studies on COVID-19, but these have not been validated by US medical students.^22,24 We anticipate that these tools can be used in future studies.

The overwhelming positive response to our question on the willingness to change eating habits was indicative of the large gap in nutritional training and self-practice of healthy eating in US medical students. Our study highlights and reinforces the need for greater education on nutrition and self-care for our medical trainees and future clinical health care workforce.^6,25 In the US, curricula and programs such as Nutrition in Medicine, Healthy Kitchen, and Culinary Medicine have been helpful.^26–28

Local facilities can be incorporated, as demonstrated by the culinary medicine program at Tulane University, and at our institute, we have collaborated with a local culinary institute to help with medical student education.^28,29 At the global level, the World Health Organization (WHO) has established diet recommendations such as reducing snacking, eating breakfast and good dietary quality meals to optimize health throughout the COVID-19 pandemic.³⁰ A comprehensive multi-level framework of action to support nutrition and food security during the COVID-19 pandemic, using the various levels of ecological health modes from the individual, community level, national level, and global level has been developed to serve as a guideline.²⁵

The dietary quality of medical students at one midwestern US college of medicine was found to be suboptimal during the early part of the COVID-19 pandemic. We anticipate that the results of our study can be used to inform future interventions on improving the quality of medical students' diet, and eventually translate into improved delivery of nutritionally enhanced clinical care to patients. We advocate medical schools enhance nutritional teaching and self-practice skills to bridge the knowledge-practice gap. It is critical to optimize the health of our future healthcare workforce, particularly during times of extreme stress.

Summary – Accelerating Translation

Title:

The Diet Quality of Medical Students in the United States during the Early COVID-19 Pandemic

Main Problem to Solve:

Medical students report lacking the knowledge to conduct nutrition counseling for patients and practice good dietary quality in their personal life.

Aim of Study:

This cross-sectional study describes the dietary quality of medical students at one midwestern college of medicine during the early COVID-19 pandemic.

Methodology:

Medical students (n = 102) enrolled at the time of this study in the spring of 2020 were surveyed utilizing the Rapid Eating Assessment for Participants–Shortened (REAP-S). The response rate was 27%.

Results:

One hundred and two medical students were included. A mean REAP-S score of 30.5 (67% of ideal dietary quality) was obtained. Body weight remained the same for 54.9% of students, 25.7% gained weight, and 18.8% lost weight during the late spring of 2020. Students with BMI < 24.9 kg/m2 had a significantly better dietary quality than those with BMI > 25 kg/m2. Students with self-reported “less healthy” diets had significantly worse dietary quality than those who either maintained a healthy or improved diet. Of note, 89.2% of students indicated that they want to improve their diet.

Conclusion:

The dietary quality of participants was found to be sub-optimal during the early COVID-19 pandemic, with potential to adversely impact the long-term health of our future medical workforce.

Conflict of Interest Statement & Funding

The authors declare no conflict of interest. No grants, financial support, or any other contribution were received to conduct the study.

Author Contributions

Conceptualization, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing-Original Draft Preparation, Writing-Review & Editing: MY; BK, Data Curation: MY, Supervision: BK

Acknowledgments

Dean of the medical school and medical students, Frauke Wilcox for administrative assistance and Dr. Jenenne Geske (JG) for statistical support.

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Mira Yousef, 1 BA. College of Medicine, University of Nebraska Medical Center, United States.

Birgit Khandalavala, 2 MBBS. Department of Family Medicine, University of Nebraska Medical Center, United States.

About the Author: Mira Yousef is currently a 3^rd year medical student at the University of Nebraska Medical Center in Omaha, NE, a 4-year program. She is a member of an enhanced medical education track focused on underserved health.

Correspondence: Mira Yousef, Address: 1400 R St, Lincoln, NE 68588, United States. Email: mira.yousef@unmc.edu

Editor: Francisco J. Bonilla-Escobar Student Editors: Brandon Belbeck, Adam Dinoff Copyeditor: Mohammad Amin Khazeei Tabari Proofreader: Joseph Tonge Layout Editor: Lucianne Adhiambo Odiero Process: Peer-reviewed

Cite as: Yousef M, Khandalavala B. The Diet Quality of Medical Students in the United States During the Early COVID-19 Pandemic. Int J Med Stud. 2022 Apr-Jun; 10(2):158-64.

Copyright © 2022 Mira Yousef, Birgit Khandalavala

This work is licensed under a Creative Commons Attribution 4.0 International License.

International Journal of Medical Students, VOLUME 10, NUMBER 2, April 2022