This study reports on the diet quality among a group of US medical students and primary care residents. On a scale of 13–39, where higher scores indicate better diet quality, 32 is the mean REAP-S score for adults eating a typical omnivorous diet; this has been recommended as a cutoff for comparison [2, 14]. Our overall sample had a mean REAP-S score of 29.7, confirming that the diet quality of these medical professional trainees is below average. Our findings are consistent with an overall trend in the US of a decline in diet quality [15, 23, 25,26,27].
We found that students had significantly higher total REAP-S scores, and thus better self-reported diet quality, than residents, supporting our first research hypothesis. Additionally, those with lower BMIs had higher REAP-S scores than those with higher BMIs, confirming our second hypothesis. There was not an interaction between role (student vs. resident) and BMI on diet quality, as predicted by our third research hypothesis.
Diet quality can be influenced by multiple systematic, individual, and local variables, including cultural and food environments, sociodemographic factors, and insomnia [27, 28]. There are several factors which may explain differences in overall REAP-S scores between students and residents, and to lower-than-average overall REAP-S scores for both groups.
Poor sleep may contribute to poor diet quality in healthcare students and residents. Sleep regularity has been found to be one of the most important variables related to food intake in a study of adolescents who are overweight or obese, and shorter sleep duration was directly correlated to lower total REAP scores and higher calories and fat intake [29]. Medical students have documented higher magnitudes of sleep deprivation compared to the general population [30]. Additionally, one study found that a shortened sleep cycle was associated with poor diet quality in medical students [31]. Residents likely face an even greater sleep deficit than medical students, with shift work and night calls occurring much more frequently [30, 32, 33]. This may explain, in part, their lower REAP-S scores.
Our data collection occurred during the COVID-19 pandemic (2020–2022), which has been shown to have a detrimental influence on diet quality [15]. A recent study found that several factors contributed to lower diet quality during the pandemic, including decreased time for food preparation and lower interest in healthy eating as well as increased frequency in eating away from home, higher food insecurity, increased anxiety, depression or boredom, and stockpiling of junk food [34]. Generally, the experiences of medical students and residents during the pandemic were vastly different, perhaps leading to differences in effects on diet quality. Students transitioned to distance learning, providing them with greater opportunity to prepare food at home. At the same time residents’ work schedules remained the same or became more intense.
Stress may be another contributing factor. The role of stress in diet quality is well-established, and medical students routinely experience higher stress levels than the same-age non-medical peers [35, 36]. Stress has been found to have been exacerbated during the pandemic in students [28, 34, 37, 38]. Moreover, residents have experienced more occupational stress during the pandemic than at any other time in the history of the medical profession [35, 36, 39].
The only specific REAP-S item on which our students and residents differed significantly was skipping breakfast, a factor that, in and of itself, has been found to contribute to poorer diet quality [38]. Residents reported “Rarely/Never” skipping breakfast at a much lower proportion than students. This finding corresponds to a previous study that found that residents increased the frequency with which they skipped breakfast in their first year of residency [40]. Differences in breakfast consumption between students and residents may contribute to the overall difference between residents and students on the total REAP-S scores.
A particular strength of our study was the use of the REAP-S, which has been validated in medical professional trainees and used extensively in other populations. Moreover, the REAP-S has recently been selected by the American Heart Association as one of three rapid diet assessment screening tools for cardiovascular disease risk reduction that are optimal for use in a clinical setting [9]. Previous studies with medical students that have reported on dietary and lifestyle practices [20] provided information on daily caloric intake and specific food intake but did not report on comprehensive dietary quality, [16, 21] whereas the REAP-S has been shown to correlate with cardiometabolic health of the surveyed population.
Our study has limitations inherent in any survey study examining self-reported data. The sample in this type of study is self-selecting, introducing possible bias. Data were collected from one midwestern institution, and the response rate was smaller than desired. Results may not be generalizable to other student and resident populations. Additionally, while students were surveyed at the height of the COVID-19 lockdown (June, 2020), residents were surveyed a year later, following the release of the COVID-19 vaccine. This may have contributed to group differences in weight and dietary behaviors. Another limitation is that we did not include measures of sleep, stress, and other possible pandemic-related factors such as change in work schedules, loss of loved ones, loneliness, food insecurity, that may be related to diet quality [41].
Implications for research and practice
There are few precedent comprehensive studies in the US on medical trainee diet quality for comparison, so the role of sleep and stress, or other possible drivers of poor diet quality, cannot be teased out in this cohort. Future studies should examine the impact that poor sleep quality and increased stress have on diet quality in a cohort of medical trainees. Newer research in this area should use the updated REAP-S v.2 [42].
The overwhelmingly positive response to our question on the willingness to make changes in eating habits to be healthier is an encouraging finding. Reducing meals away from home and increasing nutrition knowledge and beliefs are associated with improved diet quality [43]. Recent evidence suggests that even brief nutritional training can increase medical students’ nutrition awareness [16]. Several such programs, such as Nutrition in Medicine, Healthy Kitchen, and Culinary Medicine, have been demonstrated to be helpful [44,45,46,47]. Future research should more closely examine how these efforts are related to improved diet quality in trainees. Because we collected our data during the COVID-19 pandemic, additional research is also needed to see if our results are replicated under more normal conditions.
Nutritional training has also been found to improve physician self-efficacy in dietary counseling for patients [48]. As trainees move into practice, an emphasis on nutrition education may translate into better nutrition counseling for their patients. Future studies could examine whether familiarizing medical trainees with additional screening tools may result in better nutritional care for patients. The REAP-S, accompanied by the WAVE, a tool that facilitates dialog between physicians and patients on Weight, Activity, Variety (of foods), and Excess (consumption), contain specific details on how diet quality can be improved and are designed to be used in clinical settings [49].
Less-than-optimal diet quality in our medical trainees may have significant long-term consequences. Poor REAP-S scores and increasing weight have been found to be correlated with cardiometabolic abnormalities, suggesting the potential for long-term adverse health outcomes in our study cohort [23]. However, the willingness to improve diet quality in our trainees affirms the potential for improvement. Longitudinal assessments and targeted nutritional education interventions may help maintain and improve the health of our future healthcare workforce.
Our study provides a quantitative assessment of the diet quality of medical students and primary care residents at an academic medical center in the midwestern United States. Both primary care residents and medical students had lower-than-average diet quality, with residents having lower quality when compared to medical students. We advocate for nutritional education, self-practice skills, wellness efforts, and sleep hygiene across the medical education continuum to improve diet quality for our future workforce. Ultimately, healthy providers will be influential in improving the diet quality of their patients and the health of the nation to mitigate the ever-increasing burdens of chronic care.
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