Nutrition and Lifestyle Coaching: An Interprofessional Course for Pharmacy, Medical, and Dietetic Students

Background Poor nutrition and lifestyle choices are major contributors to the development and progression of various chronic diseases. Enhancing patients’ awareness of healthy nutrition and lifestyle habits by interprofessional healthcare teams can play a significant role in tackling many chronic diseases, particularly in underserved communities with inequitable access to healthcare and educational opportunities. However, healthcare professionals are not adequately prepared to provide effective, culturally competent nutrition and lifestyle coaching due to a lack of emphasis on these topics in the curricula of many healthcare professional programs. Objective This study introduces a virtual, interprofessional, team-based elective course to address the curricular gap in nutrition education among healthcare professional programs. Methods Quantitative and qualitative pre-/post-surveys were utilized to evaluate course impact on student’s knowledge, confidence in coaching families, and interprofessional competencies. Quantitative pre-/post-training scores were analyzed by a two-tailed, Mann-Whitney test, where P < 0.05 indicated a significant difference. Additionally, student learning outcomes were assessed using readiness assurance tests and application exercises, along with end-of-course presentations and mock interviews. Results Pre-/post-course assessments (n = 16) demonstrated significant improvement in students’ confidence in coaching families (20%; P = 0.01) and knowledge of coaching curriculum (87%; P < 0.001). Improvement in different interprofessional competencies ranged between 15% (P = 0.002) and 46% (P < 0.001). Course material/activities, facilitation, impact on learning new knowledge/skills/mindset, and application in future practice were applauded by 81-94% of students. Conclusion Positive outcomes of this course encourage future offerings and systematic incorporation of similar training in healthcare professional programs to prepare clinicians capable of transforming lives through interprofessional, patient-centered nutrition and lifestyle coaching.


Introduction
Poor diet, lack of physical activity, and excessive weight gain are costly public health issues.These are linked to the onset of many chronic diseases [1] and result in an expected decrease in longevity [2].In 2020 -2021, life expectancy at birth in the United States has shown the biggest two-year decline since 1921 -1923 [3].These factors are implicated in the development and progression of a variety of chronic diseases, including heart disease, cancer, stroke, and diabetes mellitus, which become more prominent in underserved communities with inequitable access to healthcare.Poor lifestyle-related chronic diseases represent a major burden on the United States healthcare system and account for a significant percentage of annual deaths [3,4].Lifestyle-related diseases can be effectively reduced through diet modifications, increased regular physical activity, and other positive lifestyle changes, such as smoking cessation and managing stress [5][6][7].Healthcare professional teams can play a significant role in increasing patient awareness and assisting in the initiation of healthful lifestyle choices.This includes promoting the practice of following a healthy diet and incorporating physical activity as part of positive lifestyle choices that lead to health benefits, especially in underserved communities that generally demonstrate lower levels of health literacy and fewer nutrition and lifestyle educational opportunities.Hence, it is crucial to prepare the upcoming generation of healthcare professionals, so they are adequately trained on the basics of nutrition, healthy food, and lifestyle choices, along with mastering the interprofessional, culturally competent, patient-centered delivery of these concepts to inspire positive behavioral change and achieve effective preventive care.This necessitates placing special emphasis on interprofessional nutrition and lifestyle coaching in healthcare professional programs' curricula.Currently, most healthcare professional programs do not incorporate meaningful, indepth nutrition and healthy lifestyle education [8].Nutrition and lifestyle education is either not sufficiently addressed or scantly embedded into other required courses without adequate training of healthcare students on real-life clinical application and healthy lifestyle coaching tips.
To address this curricular gap, an interprofessional team of educators in the arenas of medicine, dietetics, pharmacy, and cardiovascular research designed an interprofessional elective course focused on nutrition and lifestyle coaching for health professions students.The course aims to equip future frontline healthcare professionals with the foundational knowledge and skills to promote healthy lifestyle choices.This course was based on our previously published nutrition and lifestyle coaching program [9], with the inclusion of more comprehensive assessment tools.The elective course was facilitated in an interprofessional, teambased learning (TBL) format and included a series of nutrition and lifestyle coaching modules with interactive real-life application exercises.This interprofessional TBL instructional approach allowed medical, pharmacy, and dietetic students to learn with, from, and about one another in an active learning environment that enhances the attainment of Interprofessional Education Collaborative (IPEC) core competencies [10] i.e., ethics and values, communication, teamwork, and defining roles and responsibilities of each healthcare profession in educating patients about healthy nutrition and lifestyles [11].IPEC core competencies and overall learning outcomes were in alignment with interprofessional education

Materials And Methods
A total of 25 students participated partially or fully in the interprofessional team-based learning (TBL) elective course: 13 pharmacy students from California Health Sciences University, seven osteopathic medical students from Kansas City University and A.T. Still University, and five dietetic students from California State University, Fresno.Sixteen students completed post-course assessments.
The one-credit elective course comprised of eight, two-hour classes, which were held virtually via Zoom due to COVID-19 pandemic restrictions.The first session covered an overview of the causes of obesity and methods of adiposity assessment.The second session detailed the role of nutrition and lifestyle choices in cardiovascular diseases.The third and fourth sessions outlined considerations in culturally competent coaching and motivational interviewing.The fifth and sixth sessions covered the application of the 5-2-1-0 nutrition and lifestyle coaching curriculum that is founded on the promotion of consuming five servings of fruits/vegetables, spending two hours or less of recreational screen time, engaging in at least one hour of physical activity, and avoiding sugary beverages.Students were also trained on the utility of the 15-minute obesity prevention protocol published in the pediatric obesity clinical decision support chart, second edition, by the American Academy of Pediatrics.As part of the course assessments, students were invited to individually prepare an audio-recorded presentation that summarizes key principles and strategies related to nutrition and lifestyle coaching and their application in solving a patient case following the pharmacists' patient care process (PPCP).PPCP provides a stepwise approach that starts with collecting patient information pertinent to medical history and current clinical condition, assessing collected information for appropriate diagnosis and recommendations for optimal care, developing a personalized patient-centered healthcare plan, collaborative implementation of the plan with the patient and other healthcare professional members of the team, and finally monitoring and evaluating the effectiveness of the care plan and suggesting modifications, if needed (PPCP steps adopted from Joint Commission of Pharmacy Practitioners, 2014).In addition, students were given the opportunity to apply the acquired coaching and motivational interviewing skills by running a mock interview following the pediatric obesity clinical decision support chart 15-minute obesity prevention protocol.The final two sessions of the course included instructor feedback on students' recorded presentations and mock interviews.The course concluded with a student representative from each discipline (i.e., pharmacy, osteopathic medical, and dietetic programs) presenting a summary of the knowledge, skills, and behaviors acquired throughout the elective course.
The interprofessional TBL elective course included pre-class readiness material, individual readiness assurance tests (iRATs) and team readiness assurance tests (tRATs) at the beginning of each class, instructor-led debriefing on RATs guided by a PowerPoint presentation, and 4S-designed team application exercises founded on the following constructs: significant problem, same problem, specific choice, and simultaneous reporting.The tRATs and team application exercises enabled students from interdisciplinary healthcare professional programs to learn with, from, and about one another's ethical values, roles and responsibilities, and to practice professional, effective communication among an interprofessional team, in alignment with IPEC core competencies.
Students' learning outcomes were assessed using iRATS, tRATs, and team application exercises in each class, along with an end-of-course audio-recorded presentation that summarizes key foundational concepts learned from the course and their application in a patient case, and a mock interview to demonstrate coaching and motivational interviewing skills using a 15-minute obesity prevention protocol.In addition, students' progress was evaluated by a mixed methods approach using both quantitative and qualitative surveys.The quantitative pre-/post-surveys assessed progress in students' confidence in mentoring families, knowledge of the 5-2-1-0 curriculum, awareness of healthy nutrition, daily dietary habits, and interprofessional competencies.The qualitative end-of-course survey enabled students to reflect on course strengths, areas for improvement, and insights.
Following course completion, students were offered the opportunity to apply learned skills by providing nutrition and lifestyle coaching for underserved community members in the Calwa neighborhood, located in Southeast Fresno County in California (Figure 1).

Platform and Volunteer Real-Life Opportunities to Coach Underserved Communities.
A schematic outlining the interprofessional educational (IPE) framework for training healthcare professional students i.e., pharmacy, dietetic, and medical students, on culturally competent nutrition and lifestyle coaching for underserved communities.This IPE framework is facilitated by an interprofessional team of educators to ensure a quality learning environment that addresses the discussed topics holistically from clinical, research, and community perspectives.Additionally, the schematic demonstrates the voluntary follow-up real-life opportunities for trained students to apply the acquired skills through coaching the underserved Hispanic community in the Calwa neighborhood, Fresno, California.
Quantitative pre-/post-survey scores are demonstrated as the means ± SE following statistical analysis using the two-tailed, Mann-Whitney test, where P < 0.05 indicated a statistically significant difference.Statistical analysis was performed using GraphPad Prism Software, version 9.4.1.
This study was approved by the institutional review board (IRB) at Rocky Vista University under an Expedited category (RVU IRB# 2019-0019).

Results
Pre-/post-course surveys were administered to evaluate the impact of the elective course on students' confidence in handling questions related to obesity, preparedness to facilitate coaching sessions on healthy lifestyle choices, knowledge of the 5-2-1-0 curriculum, and its utility in goal setting for coached families.Students' responses were scored using a 1 to 5 Likert scale with the following metrics:  Statistical analysis was performed using a two-tailed, Mann-Whitney test, where P < 0.05 indicated a statistically significant difference.
To evaluate the impact of the elective course on nutrition self-efficacy and regular eating habits, students were invited to fill out a nine-question Nutrition Perception Screening Questionnaire (NPSQ9) [12] before and after the course.NPSQ9 posed five questions that reflect the ability to remain steady on healthy foods and four questions that evaluated dietary habits, including the rate of selecting healthy food options and substituting meals with snacks.Post-course students' scores demonstrated increasing trends by 10% in nutrition self-efficacy (from 2.41 ± 0.17 to 2.66 ± 0.13, P = 0.39) (Figure 3A) and by 6% in eating habits (from 2.38 ± 0.19 to 2.53 ± 0.18, P = 0.67) (Figure 3B), but neither improving trends were statistically significant.(A) The Nutrition Self-Efficacy domain of the questionnaire comprised five questions on the ability to manage to stick to healthy foods despite different barriers that may be encountered.Post-course students' scores demonstrated an increasing trend of 10% (from 2.41 ± 0.17 to 2.66 ± 0.13, P = 0.39).
(B) The Eating Habits domain of the questionnaire comprised four questions on the frequency of eating healthy foods and the thinking process to decide on healthy eating.Post-course students' scores demonstrated an increasing trend of 6% in eating habits (from 2.38 ± 0.19 to 2.53 ± 0.18, P = 0.67).
Statistical analysis was performed using a two-tailed, Mann-Whitney test, where P < 0.05 indicated a statistically significant difference.
(C) The Roles domain comprised four questions on comprehending the roles and responsibilities of different healthcare specialties in patient care.Post-course students' scores demonstrated a 25% increase (from 5.00 ± 0.44 to 6.25 ± 0.26, P = 0.005).
(D) The Patient-Centered domain comprised three questions on conducting patient-centered care for families.Post-course students' scores demonstrated a 46% increase (from 4.27 ± 0.47 to 6.25 ± 0.33, P < 0.001).
(F) The Team domain comprised two questions on teamwork to develop an effective patient care plan with clear responsibilities within the overlapping scopes of practice among healthcare team members.Post-course students' scores demonstrated a 23% increase (from 5.13 ± 0.26 to 6.33 ± 0.19, P = 0.002).
Statistical analysis was performed using a two-tailed, Mann-Whitney test, where P < 0.05 indicated a statistically significant difference.
Students' satisfaction with the learning experience was assessed using a voluntary, anonymous post-course survey.Students' responses showed that 63% of students completed all of the pre-class readiness material, whereas 37% completed only part of the pre-class readiness material.In addition, students' responses demonstrated an overall satisfaction with the course design, material, and facilitation as indicated by the percentage of strongly agree/agree responses to the questions outlined in Table 1.Ninety-four percent (94%) of students applauded the course focus and learning outcomes and its relevance to their professional interests and development.Ninety-four percent (94%) of the students indicated that the design of the module activities is in alignment with the learning outcomes.Eighty-one percent (81%) of the students reported that the pre-class readiness material was beneficial.Ninety-four percent (94%) indicated that the scope covered during the session was appropriate for the allocated time.Eighty-eight percent (88%) of the students applauded the effective facilitation of the sessions and their engagement in active learning.Ninety-four (94%) of the students demonstrated that they overall enjoyed the sessions.Ninety-four percent (94%) of the students expressed that they have gained new knowledge, skills, or mindset.Ninety-four percent (94%) of the students demonstrated that they plan to use what they learned in the future.Detailed quantitative data of the post-course survey is presented in Table 1.

All Some None
How  Representative students' comments on course strengths, areas for improvement, insights, and how the knowledge and skills from this course will be used in the future are outlined in Table 2.

Students' Comments
What parts of this training do you expect to use in the future?Thinking of the soonest opportunity, describe where, when, and how.

Discussion
Acquiring basic nutrition and lifestyle knowledge and culturally competent coaching skills is crucial for all healthcare practitioners.Many future healthcare professional students are not adequately educated in this field or trained on how to effectively disseminate this information.The interprofessional, TBL elective course presented in this manuscript aimed to fill a knowledge and skills gap among students in training to become pharmacists, physicians, or registered dietitians.The focused content included nutrition basics and lifestyle factors associated with cardiovascular leading causes of death in the United States, along with culturally competent coaching techniques to effectively deliver the newly acquired knowledge to underserved communities.Students have successfully achieved the designed learning outcomes as demonstrated by various assessment methods, including individual-and team-based quizzes, clinical applications, presentations, and mock coaching interviews.The engaging interprofessional, TBL environment triggered intra-and inter-team discussions between healthcare professional students from different disciplines, which fostered a more profound understanding of the material from various perspectives.
After completing the course, students were offered a volunteer opportunity to facilitate nutrition and lifestyle coaching sessions for a local underserved community in the Calwa neighborhood, Fresno, California.Calwa neighborhood is dominated by Hispanics (83.1 %) who are heavily involved in the farming industry.Calwa residents exhibit a rate of 12.74 emergency department visits for heart attacks per 10,000 individuals, placing Calwa in the 92nd percentile rank of cardiovascular disease prevalence nationally.Multiple students who were trained through our initial voluntary program [9] and the elective course presented in this manuscript were able to coach 58 underserved community members in Calwa.Coaching sessions were led by Spanish-speaking students to accommodate the linguistic needs of Calwa families.
Coaching sessions were supported by visual brochures highlighting the 5-2-1-0 curriculum constructs at a literacy level that suits the community.Families were provided with educational brochures in Spanish in addition to grant-funded gift cards to promote healthy eating.
The influence of healthcare professionals who serve as community role models by practicing healthy nutrition and lifestyle habits can be far-reaching.While there was no post-course statistically significant increase in students' nutrition self-efficacy and dietary habits, there was an upward trend indicating incremental progress.The lack of statistical significance could be due to the small number of participating students in this cohort or the need for longer-term follow-up as sustainable change of habits can take several months.Future course offerings will include a one-year follow-up to evaluate the sustainability of acquired knowledge, competencies, and healthful behavioral change over time.Increasing the sample size of participating students will be achieved by proposing the course inclusion in the core curriculum rather than offering it as an elective.The positive outcomes of the course and its value in equipping healthcare professional students with foundational skills for their future practice encourage us to propose its inclusion as a core course in alignment with interprofessional education accreditation standards of different health professions programs.This should ensure the exposure of all students to the essential nutrition and lifestyle coaching content presented in this course.Moreover, the interprofessional nature of the course will enable its offering to various healthcare professional programs locally, regionally, and nationally, to prove the generalizability of the course outcomes in different institutions.
Other nutrition and lifestyle training programs for healthcare professional students have been previously reported.This includes the Coaching, Health and Movement (CHAMPS) program [15], which was conducted only for medical students, and was further developed into our previously published voluntary interprofessional, team-based dietary coaching training program for pharmacy and dietetic students [9].This voluntary program was then transformed into the elective course described herein with more developed assessment tools and increased diversity in participating healthcare professional student disciplines e.g., pharmacy, medical, and dietetic students.Offering this training opportunity in the form of an elective course is more appealing and rewarding to students, which increases chances of student exposure to these crucial culturally competent coaching skills and supports program sustainability to meet patient needs in underserved communities.
Overall, the elective course described in this manuscript provided healthcare professional students with foundational knowledge, skills, and practical tools to conduct nutrition and lifestyle coaching sessions for their patients, families, and communities.Students valued the interprofessional team discussions, clinical scenarios, course organization, and the resources provided in the course material.However, based on students' feedback, there are multiple areas for improvement that will be taken into consideration in future course offerings.This includes increasing the number of iRAT questions, providing technology training to better prepare students for recorded presentations and mock interview assignments, using more challenging clinical application exercises, and during team application exercises, assigning a lead student to facilitate the discussion.The continuous quality improvement (CQI) process will be reinstituted in future course offerings by gathering student feedback through anonymous quantitative and qualitative surveys along with individual interviews or focus groups for more profound insights.In addition, to evaluate the course's effectiveness in preparing students for real-life nutrition and lifestyle coaching, feedback will be gathered from community members after coaching sessions by trained students.Finally, some refinements will be considered in the study design of future course offerings.A crossover design that provides a control student group will be pursued for a more rigorous comparative analysis of the course's effectiveness.Additionally, while this study was focused on evaluating student learning outcomes, future studies will assess the health outcomes of underserved community members coached by trained students, including changes in their nutrition self-efficacy and dietary/lifestyle habits.
The interprofessional training and community engagement framework presented herein can be adopted by various healthcare professional programs.Nonetheless, multiple aspects should be taken into consideration to ensure successful implementation.The logistics of organizing IPE activities represent a common challenge, which can be mitigated by proactive planning to identify mutually agreeable dates/times in the academic calendars of participating programs.Nutrition and lifestyle education material should be tailored to the health literacy level of the target community.Community members should be engaged in planning accessible healthy nutrition alternatives that fit their culture and financial capacity.It is also essential to meet community linguistic needs by involving student coaches fluent in the community's spoken language.

Conclusions
Nutrition and lifestyle education is an interdisciplinary topic that can be discussed from clinical, pharmacological, dietetic, and cultural perspectives.This overlap set the stage for the interprofessional team-based facilitation of our proposed elective course.The interprofessional, TBL platform helped healthcare professional students understand the significance of teamwork and effective interpersonal communication in providing enhanced patient care experience.In their future practice, trained students will be more open to work collaboratively with healthcare professionals from other specialties and rely upon one another's knowledge and skills as true interdisciplinary team members towards increasing the quality of patient care.The course includes clinical application exercises and mock coaching interviews with direct 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, and 5 = Strongly Agree.Compared to pre-course scores, post-course responses demonstrated a 20% increase in students' preparedness for mentoring/coaching families (from

FIGURE 2 :
FIGURE 2: Pre-/Post-Course Assessment of Students' Confidence in Family Mentoring and Knowledge of Coaching Curriculum.(A)The Mentorship domain of the survey comprised three questions on students' confidence about answering questions on obesity, preparedness to discuss with families obesity prevalence and the importance of living healthy lifestyles, and preparedness to coach families on healthy lifestyle choices.Post-course students' scores demonstrated a 20% increase (from 3.61 ± 0.23 to 4.33 ± 0.16, P = 0.01).(B)The Knowledge domain of the survey comprised one question on students' understanding of the 5-2-1-0 nutrition and lifestyle coaching curriculum and how to set a goal with families.Post-course students' scores demonstrated an 87% increase (from 2.43 ± 0.42 to 4.54 ± 0.14, P < 0.001).

FIGURE 3 :
FIGURE 3: Assessment of Students' Progress in Nutrition Self-Efficacy and Dietary Habits using Nutrition Perception Screening Questionnaire 9 (NPSQ9).
much of the pre-class readiness material have you completed?