Cross-sectional questionnaire study to gather the teaching preferences and expectations of UK undergraduate medical students for culinary medicine learning

Aim To determine undergraduate medical students’ teaching preferences and expectations for Culinary Medicine (CM) learning with a view to informing development of a CM course at a UK medical school. Setting A single, urban UK medical school. Participants 180 undergraduate medical students. Study design A cross-sectional questionnaire study collecting quantitative and qualitative (free-text) data. Methods and outcome measures An online questionnaire consisting of 16 questions of various styles (Likert-type, multiple choice and free-text). Quantitative analysis of multiple choice and Likert-type scale questions was conducted. Qualitative thematic analysis was used to analyse the free-text responses and identify themes. Results Three core themes related to students’ understanding of CM were identified: (1) ‘CM Learning’: students’ perceived relevance of CM knowledge, perceived relevance of CM to healthcare and their expectations for teaching; (2) ‘The Relationship between Food and Health’: links between diet, social factors and health; and (3) ‘Evidence-based Medicine’: students’ perceptions about scientific principles underlying CM. Quantitative analysis revealed that, although 83% of students felt that learning CM is important for their future clinical practice, 56% felt unable to take a dietary history. 73% of students were dissatisfied with the quality, and 78% were dissatisfied with the quantity, of existing medical school teaching understood to be relevant to CM. Topics that students would like to be taught on a CM course included weight management and portion control. Students felt that problem-based style learning would be the most appropriate method for delivering CM teaching. Conclusions This study revealed that medical students felt their dietary counsulting skills could be improved with further clinically relevant teaching in the undergraduate medical curriculum. Students’ preferences for CM learning have been taken into consideration in the development of a CM course for fifth-year undergraduate students at a UK medical school, which is delivered during their General Practice placement.


Introduction
Culinary Medicine (CM) may be defined as "an evidence-based field in Medicine that blends the art of food and cooking with the science of Medicine". (1) A CM course can offer online learning, didactic teaching and practical hands-on culinary skills in a kitchen setting. The aim is to give students the knowledge and skills to help patients make informed decisions about accessing and eating healthy meals. The General Medical Council (GMC) expects UK medical school graduates to be competent in recognising ill health as a result of poor nutrition, and to be able to apply dietary knowledge to clinical practice. (2) However, it has been reported that medical students and doctors worldwide feel under-equipped to provide dietary advice for patients. (3)(4)(5)(6) Studies have found that medical students who receive CM training are more likely to have a positive attitude towards, and better knowledge of, diet and nutrition; adopt better health habits themselves; and are more competent and confident in dietary counselling. (7)(8)(9)(10) With input from experts in the field of CM, the Primary Care Medical Education Team at a UK medical school designed a CM course that was introduced into the Primary Care module of Year 5 of the undergraduate medical (MBBS) curriculum in September 2019. The aims of this CM course are to improve students' confidence in raising the topic of healthy eating, and giving simple dietary advice based on evidence-based recommendations; and to increase students' awareness about potential barriers to healthy eating (for example, cultural norms and low household income). This study was conducted to inform the development of the course by determining undergraduate medical students' learning needs and preferences in the area of CM.

Methods
We carried out a questionnaire study and collected quantitative and qualitative data using an online (Google Forms) questionnaire. JX (a fourth-year medical student and intern in the University College London (UCL) department of Primary Care and Population Health, carried out all data collection and led the analysis. The study was conducted at a single, urban UK medical school from December 2018 to April 2019.
Our study population was 1669 undergraduate medical students enrolled in the academic year 2018-19 (data obtained from UCL Student Data Analyst).
Our target sample size was calculated using an online calculator. (11) We aimed to obtain 313 survey responses for our results to be statistically significant at the 95% confidence interval with a 5% margin for error.
The questionnaire was advertised to all medical students via posters, social media and in student societies' e-newsletters, as well as word of mouth.
Informed consent was obtained from study participants at the start of the questionnaire. Students were required to read the participant information sheet (PIS) on the first page of the questionnaire and to confirm that they fully understood their role in the study and how the data collected could be used. Once confirmed, they were able to proceed to the questionnaire on the next page.
Questionnaires were completed anonymously and no participant-identifiable data was collected. The only personal data collected was year of study.
There was a total of 16 questions of various styles (Likert-type, multiple choice and free-text) across four main topics (see Table 1). At the end of the questionnaire, we provided a free-text box for additional general comments and weblinks for those who wished to learn more about CM.

Patient and Public Involvement
Prior to data collection, two medical students (third-year and fifth-year) were asked to pilot the questionnaire. These students suggested ideas for improvement, including re-wording of questions to improve clarity. The questionnaire was subsequently updated accordingly.

Ethical Approval
Ethical approval to carry out this study was received from University College London Research Ethics Committee (ref.12471/002).

Analysis
Qualitative Nvivo 12 (12) was used to store free-text data in order to conduct a qualitative thematic analysis and identify core themes. (13) JX and ShP independently coded all free-text responses, and discussed their different interpretations of the data. Codes were derived deductively from the questionnaire and inductively upon analysis of the free-text responses. (14) Careful consideration was given upon coding of the data: new codes were compared against preliminary codes and refined, and the data was re-coded using the updated set of codes. This improved the quality of analysis. (15) Similar codes were categorized under a sub-theme or core theme. JX and ShP checked that each theme contained data relevant to only that theme. Theoretical saturation was identified after coding the first 148 responses in an interim analysis.

Quantitative
We carried out descriptive statistics to describe which year group the students were in. We presented responses to Likert-type and multiple-choice questions using proportions and frequencies, and compared responses from pre-clinical (years 1-3) and clinical (years 4-6) students using Chi-squared and Fisher's Exact tests where possible. Statistical significance level was set to 5%. SPSS Statistics 25 (16) was used to conduct the quantitative analysis.

STUDY POPULATION
We obtained an 11% response rate (180 responses). Fourth-year medical students were particularly interested in participating in this study, contributing to 25% of respondents (see Figure 1), as they were to be the first cohort to receive CM training.

STUDENTS' UNDERSTANDING OF CULINARY MEDICINE
There was a wide range of expectations for CM teaching. Three core themes were identified (see Table 2). "a practical "kitchen session" could be very difficult to organise and the quality of it is likely to be poor" (Fifth Year).

"I don't really see how it is practical to teach practical culinary skills… I don't see what advantage this would confer as a) we aren't going to be cooking patient's food and b) we won't have time to show them how to cook a meal…being able to advise [patients] on heathy choices
and being able to give them adequate resources is more feasible" (Fourth Year).
A few students felt that shadowing HCPs would be a valuable learning experience.
"sitting in with diabetic nurses and going through some of the dietary restrictions [for] patients" (Fifth Year).
Other students expressed preference for more traditional teaching methods. Students suggested how CM could be integrated into the current MBBS curriculum.
A few clinical students felt that CM teaching should be taught alongside motivational interviewing. This would enable students to practice exploring patients' ideas, concerns and expectations regarding diet and health, and to work together with the patient towards mutual goals for health and wellbeing improvement.

"lifestyle advice [teaching] could be combined with the patient centred pathway teaching in year 5 on motivational interviewing" (Fifth Year).
Some students felt that it would be appropriate to dedicate one day in the MBBS curriculum to CM teaching, emphasising that teaching should not exceed this amount, as they felt that medical students are likely to already have a good understanding of what constitutes a healthy diet from teaching received elsewhere in the MBBS curriculum.
"it would make sense to have a culinary medicine day… any more than that would be excessive. Most students will already know the basics of constructing a good diet" (Fifth Year).
There were a range of opinions on which year of the MBBS curriculum CM training should be delivered in.

"integrate preclin[ical] science into FNM ['Fluids, Nutrition and Metabolism' -a module taught in Year 1 of the MBBS curriculum], then teach clinically in year 5" (Fourth Year).
"take this module as a final year medical student… as an optional extra module" (Fifth Year felt that they were incompetent and/or they lacked confidence in their communication skills, particularly in the pre-clinical years. 72% of pre-clinical and 43% clinical students felt unable to take a dietary history from a patient (p = 0.001, see Table 3). This indicates that students would value additional teaching on this, again, particularly in the pre-clinical years.
64% pre-clinical and 57% clinical students felt unable to apply principles, methods and knowledge relating to nutrition to medical practice and integrate these into patient care (p = 0.498, see Table 3). This suggests a gap in students' knowledge related to nutrition and an uncertainty of how to apply this knowledge to clinical practice to allow for patient-centred care.
7% pre-clinical and 10% clinical students felt able to provide dietary advice for patients with varying cultural, social and economic needs (p = 0.617, see Table 3). This reveals the need to increase students' awareness of the social factors specific to individual patients that influence diet and access to food, in order for enable students to provide patients with personalised dietary advice.
80% of pre-clinical and 86% of clinical students felt that CM training is important for their future clinical practice (p = 0.482, see Table 3). This implies that most students felt that an understanding of CM is relevant to, and required for, clinical practice.

PROVISION OF CM TRAINING
62% of students reported having received no prior CM training (see Figure 2).
68% pre-clinical and 77% clinical students were dissatisfied with the quality of CM training provided by the medical school. 72% of pre-clinical and 84% of clinical students were dissatisfied with the current quantity of CM training provided by the medical school (see Figure 3).

FEATURES OF CM TRAINING
Students were asked to suggest features of an ideal CM course, including course content and delivery. Students felt that it is most appropriate for a CM course to include teaching on weight management and portion control (157 responses), followed by the types of diet and their evidence base (156 responses). Nutrition psychology was the least popular topic (128 responses, see Figure 4).
Students felt that the most appropriate methods of providing CM training are problem-based learning (140 responses) and small-group seminars/ tutorials (138 responses, see Figure 2).
67% of students expressed a preference for CM training to be delivered in pre-clinical training (pre-clinical students 72%, clinical students 64%, p = 0.257).

Discussion
This is the first questionnaire study that has explored UK medical students' learning needs and preferences in the area of CM.
Our study findings revealed a variety of students' understandings and attitudes towards CM training. Some students positioned CM as highly relevant to patient care. These findings are consistent with a study carried out at an American University (8) , where students believed that CM training would improve their ability to facilitate dietary counselling, and that they would be able to apply the knowledge and skills from the training to improve patients' overall health.
Some students perceived CM as relevant to clinical years' training, whereas others felt this was a pre-clinical topic and not directly related to clinical practice with patients. A few students believed that CM was irrelevant to medical student training and anticipated that the task of dietary counselling would be delegated to other HCPs, such as dieticians. These findings are inconsistent with literature that suggests the health benefits of dietary advice given by doctors, especially in general practice. The CM course is currently being delivered in the year 5 general practice module. (17)(18)(19) Despite this, most students felt that CM training is important for their future clinical practice, although many did not feel confident in their knowledge, nor competent to provide specific dietary advice. These findings are similar to that of an Australian study (5) , in which the majority of preclinical medical students felt that it was important for doctors to have an understanding of nutrition in relation to conditions such as coeliac disease, but fewer than half were confident in applying their knowledge to clinical practice.
Furthermore, many students in our study believed that practical kitchen-based sessions would be an effective method of training. Their belief is consistent with a study (8) that found that medical students' confidence, nutrition knowledge and food identification skills improved after completing a CM course with hands-on culinary skills training.
Our findings suggest that an key components of a CM training course are: explaining the clinical and professional relevance of this learning, and supporting medical students in developing an understanding of how this knowledge might be applied in clinical practice to maximise opportunities for supporting health promotion and managing ill health.

Strengths and Limitations
An important potential limitation to consider is that CM is a relatively new term in medicine and is not widely used amongst HCPs in the UK. This is due to CM training not yet being included in the curriculum of the majority of UK medical schools. The authors anticipated that only students who were familiar with the term CM were likely to complete the questionnaire. Therefore, in order to encourage all students to participate, advertisements for the questionnaire, as well as the PIS on the first page of the questionnaire, emphasised that students do not need to have any understanding of CM or lifestyle medicine or nutrition in order to take part in this study.
Prior to data collection, the questionnaire was piloted by two current undergraduate medical students to confirm that the questions fulfill the study aim. This validation step increased the reliability of the questionnaire.
The questionnaire responses were received from one UK medical school only. This limits the transferability of the study findings to other medical schools. However, these findings may be useful in informing the development of future CM courses for undergraduate medical students elsewhere.
Also, the sample size was small (180), and the target number of questionnaire responses (313) was not achieved. However, theoretical saturation was reached after coding the first 148 responses in an interim analysis, implying that sufficient data has been obtained and strengthening the study's credibility.
Furthermore, thematic analysis of free-text responses was carried out independently by both JX and ShP. This allowed a range of interpretations on the data to be gathered.
However, most of the probability (p) values obtained for the quantitative data were greater than 0.05, implying that results were not significant at the 95% confidence interval and there may have been a greater than 5% probability that results were due to chance.

Implications
The findings from this study will be used to inform the development of a CM course for fifthyear undergraduate students at a UK medical school during their training in Primary Care. A number of recommendations can be made. A small number of our study participants had never come across the term CM. This suggests that there is a need for the CM course to define the key principles and aims of CM.
Students are currently taught CM through case-based discussions, practical culinary skills training and online learning. Our findings suggest that students would like to be taught using additional teaching methods, such as problem-based learning and small group-seminars/ tutorials. These could be trialled in the future.
The CM course is currently integrated into the penultimate year of the MBBS curriculum to allow students to draw explicit links between patients, whom they encounter in general practice, and CM knowledge. Students also expressed a desire for pre-clinical training, with the option of enrolling on a student-selected module in CM in clinical training. The new CM course at this medical school could be evaluated in the future to assess whether students' learning needs have been sufficiently addressed, whether the course achieves its aims, and whether CM training could be integrated into multiple areas of the MBBS curriculum in the future.
Furthermore, this questionnaire study could be repeated in the future using a larger sample size from different UK medical schools to explore how medical students feel about CM training across the UK.

Conclusions:
This study revealed that medical students felt that their dietary counselling skills could be improved with further clinically-relevant teaching in the undergraduate medical curriculum. Students' preferences for CM learning have been taken into consideration in the development of a CM course for fifth-year undergraduate students at a UK medical school during their General Practice placements.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y Article Summary

Strengths and Limitations of This Study
 The questionnaire was piloted to confirm readability and ensure questions fulfilled the study aim.  At interim analysis of the first 148 questionnaire responses, no new codes were generated during qualitative thematic analysis of free-text responses, signifying that theoretical saturation had been reached.  JX and ShP analysed the free-text responses independently to gather a wide range of interpretations of the data.  The study was conducted at one medical school only, limiting the transferability of the study findings to other medical schools.  The response rate (11%) was low which limits the generalisability of the results to the student population.

Introduction
Culinary Medicine (CM) may be defined as "an evidence-based field in Medicine that blends the art of food and cooking with the science of Medicine". (1) A CM course can offer online learning, didactic teaching and practical hands-on culinary skills in a kitchen setting. The aim is to give students the knowledge and skills to help patients make informed decisions about accessing and eating healthy meals. The General Medical Council (GMC) expects UK medical school graduates to be competent in recognising ill health as a result of poor nutrition, and to be able to apply dietary knowledge to clinical practice. (2) However, it has been reported that medical students and doctors worldwide feel under-equipped to provide dietary advice for patients. (3)(4)(5)(6) Studies have found that medical students who learn CM are likely to develop positive attitude towards, and better knowledge of, diet and nutrition; adopt better health habits themselves; and become more competent and confident in dietary counselling. (7)(8)(9)(10) The setting for this study was a single, urban UK medical school, with a five-year undergraduate medical (MBBS) curriculum plus an Integrated Bachelor of Science (iBSc) in third year. In their first year, students receive lectures on nutritional science, such as the digestion of macronutrients and gastrointestinal physiology, and public health nutrition. These lectures are delivered in the pre-clinical part of the MBBS curriculum.
The Primary Care Medical Education Team at this UK medical school collaborated with a team of doctors, dietitians and chefs from Culinary Medicine UK (11) to create a CM course that was introduced into the Primary Care module of the year five MBBS curriculum in September 2019. Set in a teaching kitchen, the one-day course teaches students culinary skills, evidence-based medicine related to dietary counselling, and motivational interviewing skills. Believed to be the first medical school in Europe to provide mandatory CM teaching, the aims of the course are to improve students' confidence in raising the topic of healthy eating and giving simple dietary advice based on evidence-based recommendations; and to increase students' awareness about potential barriers to healthy eating (for example, cultural norms and low household income). This study was conducted prior to the introduction of the  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y course to inform its development by determining students' teaching preferences and expectations for CM learning.

Methods
This was a cross-sectional questionnaire study, collecting quantitative and qualitative data using an online (Google Forms) questionnaire. JX (a fourth-year medical student and School for Primary Care Research (SPCR) intern in the University College London (UCL) department of Primary Care and Population Health), carried out all data collection and led the analysis.
The study was conducted at a single, urban UK medical school from December 2018 to April 2019.
The study population was 1669 undergraduate medical students enrolled in the academic year 2018/19 (data supplied by UCL Student Data Analyst).
The questionnaire was advertised on posters and via social media and student societies' enewsletters and word of mouth.
Informed consent was obtained from study participants at the start of the questionnaire. Students were required to read the participant information sheet (PIS) on the first page of the questionnaire and to confirm that they fully understood their role in the study and how the data collected would be used. Once confirmed, they were able to proceed to the questionnaire on the next page.
Questionnaires were completed anonymously, and no participant-identifiable data was collected. The only personal data collected was year of study.
There was a total of 16 questions of various styles (Likert-type, multiple choice and free-text) across four main topics (see Table 1). The first topic included establishing students' understanding of the term 'CM'. A free-text response was requested to explore the different ways students understood and interpreted the concept.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y At the end of the questionnaire, we provided a free-text box for additional general comments and weblinks for those students wished to learn more about CM.

Patient and Public Involvement
Prior to data collection, two medical students (iBSc third-year and fifth-year) were invited to pilot the questionnaire and comment on the readability. These students suggested re-wording of a few questions to improve clarity. The questionnaire was updated accordingly. Students were not invited to contribute to the study design, analysis or writing of this manuscript.

Ethical Approval
Ethical approval to carry out this study was received from UCL Research Ethics Committee (ref.12471/002).

Analysis
Qualitative NVivo 12 (12) was used to store free-text data in order to conduct a qualitative thematic analysis and identify core themes. (13) JX and ShP independently coded all free-text responses before sharing their interpretations with the qualitative results analysis team (JX, ShP and SP) to discuss any areas of dissonance or contrasting interpretation. Codes were derived deductively from the questionnaire (for example, 'Understanding of CM'), and inductively (for example, 'Social factors contributing to diet') upon analysis of the free-text responses. (14) Careful consideration was given upon coding of the data: new codes were compared against preliminary codes and refined, and the data was re-coded using the updated set of codes. This improved the quality of analysis. (15) 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y Quantitative SPSS Statistics 25 (16) was used to conduct the quantitative analysis. The quantitative results analysis team (JX and VV) carried out descriptive statistics to describe which year group the students were in. Responses to Likert-type and multiple-choice questions were presented using proportions and frequencies, and responses from pre-clinical (years 1-3) and clinical (years 4-6) students were compared using Chi-squared and Fisher's Exact tests where possible. Statistical significance level was set to 5%.

STUDY POPULATION
An 11% response rate (180 responses) was achieved. Fourth-year medical students were the largest contributors to the study (25% of respondents, see Figure 1). This may be because they were to be the first cohort to study the CM course.

STUDENTS' UNDERSTANDING OF CM
There was a wide range of expectations for CM teaching. Three core themes were identified (see Table 2). "how to conduct a consultation without body shaming" (Fifth Year).
Students stated that they would like to be taught how to recognise different eating habits and patterns in order to better understand patients' diets, increase doctor-patient rapport and better facilitate future planning discussions.
Other students were unfamiliar with the term CM.
"first time I came across this term" (Fifth Year).
Students who were in favour of a CM course stressed the importance of the topic and considered how the knowledge and skills that they will learn from the course will make them more competent to educate patients about diet patients and thus improve patients' health outcomes.
"this valuable knowledge… is applicable to every specialty" (Fifth Year).
"CM involves using nutrition to improve patient's health, including teaching patients how to eat and cook healthily" (Fourth Year).
However, some students felt that learning CM would not benefit them greatly. Students expressed worry that other topics in the current MBBS curriculum, which they felt were more useful than CM, might be compromised or completely removed.  However, other students expressed distaste for a practical kitchen session, questioning the feasibility of teaching in a kitchen and whether the skills gained would be useful in future clinical practice.
"a practical "kitchen session" could be very difficult to organise and the quality of it is likely to be poor" (Fifth Year).

"I don't really see how it is practical to teach practical culinary skills [or] what advantage this would confer… we aren't going to be cooking patients' food" (Fourth Year).
Some students suggested that opportunities to shadow HCPs with expertise in diet and nutrition would be a valuable learning experiences.

Core Theme 2: The Relationship Between Food and Health
Students described the links between diet, social factors and health.
Sub-theme 1: Diet and Physical and Mental Health Students recognised a link between diet and physical and/or mental health.
"nutrition and its impact on a patient's physical and mental wellbeing" (Third Year).
Students felt that diet plays a central role in preventing, treating and managing disease, and alleviating symptoms due to ill-health.
"Using knowledge of nutrition and lifestyle factors associated with diet to both prevent disease and to improve morbidity and mortality" (Fifth Year).
Students expressed a desire for the CM teaching to include teaching on mental health problems related to eating. Students also believed that doctors should have an understanding of cultural variation in diets to be able to provide patient-centred dietary advice. Students suggested that this will improve patients' understanding of diet and health and may increase patients' adherence to dietary advice.

"my mum cooks traditional Indian food on a daily basis and hence [my parents]
prefer seeing an Indian GP when they go to the doctors" (Third Year). Some students expressed concern over the extent of poorly evidenced diet and nutrition information that is publicly available.

"I'm… worried about the quality and the evidence base for [CM]. Diet and nutrition are… affected by… low-quality research" (Fifth Year).
Students suggested that the course should teach them evidence-based knowledge and skills to support patients in making dietary changes.
"evidence-based practice of influencing health through lifestyle changes in food consumption" (First Year).

PROVISION OF CM TEACHING
62% of students reported having received no prior CM teaching (see Figure 2).
68% pre-clinical and 77% clinical students were dissatisfied with the quality of teaching understood to be relevant to CM provided by the medical school. 72% of pre-clinical and 84% of clinical students were dissatisfied with the current quantity of teaching understood to be relevant to CM provided by the medical school (see Figure 3). Students were asked to suggest features of an ideal CM course, including course content and delivery. Students felt that it is most appropriate for a CM course to include teaching on weight management and portion control (157 responses, see Figure 4), followed by the types of diet and their evidence base (156 responses). Nutrition psychology was the least popular topic (128 responses).

FEATURES OF CM TEACHING
Students felt that the most appropriate methods of providing CM teaching are problem-based learning (140 responses, see Figure 2) and small-group seminars/ tutorials (138 responses).
67% of students expressed a preference for CM to be taught in pre-clinical training (preclinical students 72%, clinical students 64%, p = 0.257).

Discussion
Most medical students who participated in this study felt that learning CM is integral to their future role as a doctor. However, a few students anticipated that the task of dietary counselling would be delegated to other HCPs, such as dietitians. The latter views are contradicted by literature that suggest the health benefits for patients when dietary advice is given by doctors, especially in General Practice (17)(18)(19) . This supports the delivery of CM teaching in the year five General Practice placement in the MBBS curriculum. Also, the GMC states that all newly-graduated doctors should be capable of providing basic dietary advice. (2) . Furthermore, teaching on all three domains of nutrition education (basic nutritional science, public health and clinical nutrition) is recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). (20) Although 83% of students felt that learning CM is important for their future clinical practice, 67% did not feel confident in their knowledge, nor competent to provide specific dietary advice These findings are similar to that of an Australian study (5) , which found that the majority of pre-clinical medical students felt it was important for doctors to have an understanding of nutrition in relation to conditions, such as coeliac disease, but fewer than half were confident in applying their knowledge to clinical practice.
Clinical students reported higher levels of self-perceived confidence and competence in their abilities to conduct dietary counselling compared to pre-clinical students. This may be because clinical placements predominantly occur during years 4-6 of the MBBS curriculum, during which students are more likely to observe HCPs discussing diet and health with their patients. Students on these placements may have also been offered opportunities to practice dietary counselling with patients. The variation in clinical exposure and availability of practical learning opportunities may have contributed to the differences in self-reported capabilities between these two groups. One aim of placing the CM teaching in the General Practice placement is to enable students to draw upon their experiences of encounters with patients in General Practice and to share these experiences in group discussion about how to approach patient-based problems and cases effectively. Another aim is to allow students to apply the dietary counselling skills taught during the CM course to future interactions with patients, including during their on-going placements in General Practice.
This overall low self-perceived confidence and competence reported by questionnaire respondents may be related to their dissatisfaction with the quality and quantity of teaching perceived to be relevant to CM in the MBBS curriculum at the time of this study. This may suggest that this cohort of students had particular interest in, and therefore concern for, undergraduate medical education.
The findings from this study suggest that key components of a CM teaching course placed in the clinical part of an undergraduate medical curriculum are: explaining the clinical and professional relevance of drawing upon patient cases from General Practice placements to aid CM learning and supporting medical students in developing an understanding of how this knowledge might be applied in clinical practice to maximise opportunities for supporting health promotion and managing ill health. These findings were subsequently used to inform the development of a CM course at a UK medical school, as described below.

Strengths and Limitations
A strength of this study is that the questionnaire waspiloted by two undergraduate medical students, who checked the readability. The students also confirmed that the questions would enable medical students' teaching preferences and expectations for CM learning to be gathered. This validation step increased the reliability of the questionnaire.
Moreover, JX and ShP conducted the early stages of thematic analysis independently to allow for a wider breadth of interpretations to be captured. The analysis team (JX, ShP and SP) then synthesised and discussed the interpretations before reaching an agreement.
Additionally, the questionnaire response rate was low (11%) which limits the generalisability of the findings. The low response rate may be due to the fact that CM is a relatively new term in medicine and is not commonly used amongst HCPs in the UK. This may be because CM is not yet included on most UK medical schools' curricula. The authors anticipated that students with prior understanding and/or interest in CM, were more likely to complete the questionnaire. Therefore, in order to encourage students to participate, advertisements for the questionnaire, as well as the PIS, emphasised that all medical students were eligible to take part in the study and that a wide breadth of experiences and perspectives, including no prior understanding of CM, were welcome. Even with this additional encouragement, the response rate remained low. However, theoretical saturation was judged to have been reached after coding the first 148 responses in an interim analysis, implying that sufficient qualitative data had been gathered for the views of students to be represented in the free-text responses. This strengthened the credibility of the study.
Another limitation is that the questionnaire responses were received from one UK medical school only. Factors such as differences between medical school curricula may limit the transferability of the study findings to other medical schools.

Implications
The findings from this study have been used to inform the development of a CM course for fifth-year undergraduate students at a UK medical school during their General Practice placement.
A number of recommendations can be made:

2.
The CM course is currently integrated into the General Practice placement of the penultimate year of the MBBS curriculum to allow students to draw explicit links between CM knowledge and patients requiring dietary advice whom they encounter in General Practice. The course provides hands-on culinary skills training, evidencebased teaching in small group-seminars/tutorials, and patient-based integration of this knowledge in case-based discussions. These teaching methods were chosen as a result of the preferences expressed by students in this study. According to an American study (8) , medical students' nutrition knowledge and food identification skills improved following completion of a CM course with culinary skills training, suggesting that practical learning is an effective teaching method. 3. The course creators prepared relevant case discussions to maximise clinical relevance.
Course facilitators encourage students to prepare their own summaries of relevant cases encountered during their General Practice placements, supporting students to think about how they will apply the teaching in their future patient interactions following the course.

Integrating CM Teaching into the Clinical Curriculum
4. Students expressed a desire for more CM teaching in pre-clinical training and for an optional student-selected module in clinical training. The latter approach is offered at another UK medical school. (11) However, the course creators felt that it was important for all students to have a basic grounding in this knowledge and practical skills, whatever their future career intentions, hence the decision to make CM teaching compulsory in the MBBS curriculum. Other medical schools could use this as an exemplar of how to introduce CM into the clinical curriculum.
The questionnaire used in this study has been adapted into a post-course questionnaire to gather students' feedback on their CM learning experiences. The course is being continually evaluated to assess if students' learning needs are being satisfactorily addressed. The postcourse feedback data will be analysed in a separate study.
Furthermore, a repeat of this questionnaire study could be conducted at UK medical schools who do not currently provide CM teaching. This will enable those medical schools to explore how their students feel about learning CM as part of their undergraduate training and will gather students' teaching preferences and expectations.

Conclusion
This cross-sectional quantitative study has provided insight into medical students' understanding of and attitudes towards learning CM. The study has highlighted students' perceptions on how they feel CM knowledge and skills might help them to fulfil the GMC's Outcomes for Graduates and their future role as doctors. Students reported a lack of confidence in their dietary counselling skills and felt that they could benefit from further

Contributions
JX was the main author who lead the study design, data collection and analysis and write-up. SP (fourth author) was the chief investigator. SP and ShP (second author) co-supervised the study and contributed towards designing the study, participant recruitment and data analysis. VV (third author) supervised the statistical analysis. All authors provided input in the writeup and have approved the final manuscript.

Funding
This work was supported by the National Institute for Health Research School for Primary Care Research (NIHR SPCR) grant number 156780. VV receives Seedcorn Funding from the NIHR SPCR.

Competing Interests
None declared.

Patient Consent for Publication
Not required.

Provenance and Peer Review
This paper was not peer reviewed prior to submission.

Data Sharing Statement
The data generated from this study is not suitable for sharing beyond that contained within the report. Further information can be obtained from the corresponding author.

R&D / Sponsor Reference Number(s):
Not known at present.

Study Registration Number:
Not known at present.

DECLARATIONS
The undersigned confirm that the following protocol has been agreed and accepted and that the investigator agrees to conduct the study in compliance with the approved protocol and will adhere to the Research Governance Framework 2005 (as amended thereafter), the Trust Data & Information policy, Sponsor and other relevant SOPs and applicable Trust policies and legal frameworks.
I (investigator) agree to ensure that the confidential information contained in this document will not be used for any other purposes other than the evaluation or conduct of the clinical investigation without the prior written consent of the Sponsor.
I (investigator) also confirm that an honest accurate and transparent account of the study will be given; and that any deviations from the study as planned in this protocol will be explained and reported accordingly.

KEY ROLES AND RESPONSIBILITIES SPONSOR:
The sponsor is responsible for ensuring before a study begins that arrangements are in place for the research team to access resources and support to deliver the research as proposed and allocate responsibilities for the management, monitoring and reporting of the research. The Sponsor also has to be satisfied there is agreement on appropriate arrangements to record, report and review significant developments as the research proceeds, and approve any modifications to the design.

FUNDER:
The funder is the entity that will provide the funds (financial support) for the conduction of the study. Funders are expected to provide assistance to any enquiry, audit or investigation related to the funded work.

CHIEF INVESTIGATOR (CI):
Sophie Park is the chief investigator. The person who takes overall responsibility for the design, conduct and reporting of a study. If the study involves researchers at more than once site, the CI takes on the primary responsibility whether or not he/she is an investigator at any particular site.
The CI role is to complete and to ensure that all relevant regulatory approvals are in place before the study begins. Ensure arrangements are in place for good study conduct, robust monitoring and reporting, including prompt reporting of incidents, this includes putting in place adequate training for study staff to conduct the study as per the protocol and relevant standards.
The Chief Investigator is responsible for submission of annual reports as required. The Chief Investigator will notify the RE of the end of the study, including the reasons for the premature termination. Within one year after the end of study, the Chief Investigator will submit a final report with the results, including any publications/abstracts to the REC.

PRINCIPLE INVESTIGATOR (PI):
Individually or as leader of the researchers at a site; ensuring that the study is conducted as per the approved study protocol, and report/notify the relevant partiesthis includes the CI of any breaches or incidents related to the study.
PROJECT SUPERVISOR: Shoba Poduval has provided the principal researcher (Jessica Xie) with guidance at every stage of this project.
STATISTICIAN: a statistician based in the UCL department of Primary Care and Population Health will contribute to the data analysis.

PATIENT AND PARTICIPANT INVOLVEMENT (PPI)
: Two UCL medical students (one in fifth-year and one in third-year) will be recruited by the principal researcher through convenience sampling. PPI will be asked to provide feedback on the questionnaire questions, the recruitment flyer and will also be involved in the data analysis.

INTRODUCTION
Culinary Medicine is defined by La Puma and Marx (2008) as an "evidence-based field in Medicine that blends the art of food and cooking with the science of medicine". Culinary Medicine courses typically allow students to receive teaching about nutrition and its health-promoting properties, read the relevant literature, gain hands-on cooking experiences and apply the knowledge that they have learnt to provide appropriate dietary advice for patients in the clinical setting (Bendici, 2018).
The importance of nutrition and diet in undergraduate medical education teaching across all disciplines has long been under-recognized.
University College London (UCL) Medical School is in currently developing a Culinary Medicine course for its undergraduate students.

Research Question
A survey of the preferences and expectations of UK undergraduate medical students from a Culinary Medicine course.

Method
A quantitative questionnaire study with undergraduate medical students at a London medical school (see Appendix 1)

Aim
To determine University College London (UCL) medical students' learning needs and preferences in the area of Culinary Medicine with a view to informing development of a Culinary Medicine course at UCL.

Expected Outcomes
This study will determine undergraduate medical students' understanding of Culinary Medicine and their preferences and expectations of a Culinary Medicine course in their medical programme.
The results of this study will be used in the development of a Culinary Medicine course at UCL medical school for undergraduate students.

BACKGROUND AND RATIONALE Introduction to Area of Research
The UK is reported to be the most obese country in Western Europe. 27% of the UK population are classified as obese -a body mass index of 30 and above (The Organisation for Economic Cooperation and Development, 2017), and approximately one-third of children aged 2 to 15 in the UK are overweight or obese (Buck, 2018) . It is well-known that obesity is a risk factor for chronic diseases, such as cancer and heart disease. These diseases may be prevented or, in the case of Type  (2017), University of Cambridge graduate medical students, believe that the medical profession view this field as an unscientific subject that lies in the domain of dieticians, rather than doctors.
The evidence-base of Culinary Medicine has changed dramatically in the past few decades (Crawford and Aspry, 2016). There is growing interest in the relationship between food, eating, cooking and health and wellbeing in the medical profession and also in the public. For example, adopting an antiinflammatory diet has been found to be as, or even more, effective than prescription medication for arthritis ( The interest for Culinary Medicine in the UK has grown in the recent years. In 2017, Nutritank was founded -an online, student-led organisation created by medical students for medical students to learn Culinary Medicine. The organisation has expanded and to date exists as a university society at approximately 15 UK universities (Dillon, 2018 These students seemed unsure about the treatment and prevention of obesity. The findings of this study may suggest that these US medical students lack knowledge, and/or confidence in their knowledge, of nutrition. If medical students feel incompetent in Culinary Medicine, their personal interest in this field may decrease and they may be less likely to discuss the topic with patients because they feel that they are not confident in discussing diet and/or dietary change with patients. This may suggest to healthcare professionals and patients that Culinary Medicine is a less important component of the clinical consultation. Moreover, since Cooke et al. (2017) conducted their study with a small number (78) of US medical students who had volunteered to participate in the study, the study participants may have been more interested in, and therefore may be more knowledgeable about, Culinary Medicine and/obesity than a typical US medical student. Therefore, this decreases the likelihood that the study sample is representative of the US medical student population.
In the USA, Mlodinow and Barrett-Connor (1989) investigated physicians' and 24 medical students' knowledge of diet. Their study findings included that physicians are more knowledgeable about diet in relation to coronary heart disease, rather than caries, whereas it was the opposite case for medical students. This could reflect that these physicians believe that caries topic lies in the domain of dentists, rather than doctors.

Attitude towards Diet
The results of a questionnaire study conducted by Schlair et al. (2012) suggest that medical students' behaviours may influence their attitudes towards, and knowledge of, nutrition and ability to provide dietary counselling. Students with greater dietary self-efficacy and greater fruit and vegetable intake appeared to be more likely to have higher dietary counselling confidence and competence. Therefore, this may imply that promoting healthy lifestyle amongst medical students and professionals could improve their own wellbeing, which in turn may improve the wellbeing of their  Both the high response rates received for the baseline and follow-up surveys (98% and 86% respectively) and the fact that a comparison group was included to ensure that any changes in students' attitudes and behaviours were only attributable to participation in the course suggest that the results of the study may be valid. Observer bias was reduced as students were only identified by their unique confidential code, which was unknown to the investigators. However, the small sample size (137) limits the generalisability of the findings.
Additionally, it is important to note that data that is self-reported confidence is an subjective measure of counselling skills. Therefore, the results of studies conducted by Perstein et al.

Methods of Teaching Culinary Medicine
In a study conducted in the USA by Walsh et al. (2011), 131 medical students completed a Preventative Medicine Nutrition course (content was delivered on a weekly basis over a period of three to four months) and 135 medical students received nutrition training as part of an integrated nutrition curriculum (content was taught over three half-days). There was no statistical difference in knowledge and attitude scores between students who completed the dedicated nutrition course compared with those who received nutrition training as part of an integrated nutrition curriculum. The results suggest that medical students were more satisfied with the dedicated nutrition course rather than the integrated curriculum, which may imply that the former course structure may provide a more positive, engaging learning experience for students. The results of a questionnaire study conducted by Walsh et al. (2011) suggest that medical students prefer a dedicated nutrition course (content delivered on a weekly basis over a period of three to four months) over an integrated curriculum (content taught over three half-days). There was no statistical difference in knowledge and attitude scores between students who completed the dedicated nutrition course, compared to those who received nutrition training as part of an integrated nutrition curriculum. One strength of this study include was that five survey questions were included as validation items to control for possible response bias. However, the study findings should be interpreted with caution as one of the response rates (42.2%) was too low to meet the power calculation for statistically significant results at the 5% level and the sample size was small. Engel et al. (1997) conducted a study in the USA to evaluate the third-year medical students', general care nurses' (with no diabetes-related dietary training) and dieticians' knowledge of diabetes nutrition prior to and after completing a computer-assisted diabetes instruction (CAI), lasting a mean of 27.9 minutes. Medical students' mean knowledge score prior to CAI was similar to the mean score of the nurses, but after competing CAI, medical students' mean score was similar to the mean score of dieticians. Engel et al. (1997) suggest that future dietary training for medical students should involve CAI because, as the course involves self-paced learning and technology, it is a practical and efficient method of teaching medical students. However, this study did not include a gold-standard method of dietary training to compare this teaching method to, which may reduce the usefulness of the study findings. Additionally, the sample size (41) was very small, which may suggest that the study sample is unrepresentative of the medical student population. A study involving a larger sample size is required to determine whether the results from the study conducted by Engel et al. (1997) are generalisable.
Medical students who participated in the study by Cooke et al. (2017) offered multiple methods for the delivery of Culinary Medicine courses, for example, seminars. Students also requested more hands-on learning opportunities, such as practicing counselling skills with children and families. This may imply that these students did not have a preference for a single method of teaching or that they prefer to be taught a module using a variety of teaching methods.
Cooke et al. (2017) suggest that Culinary Medicine courses taught in medical schools should contain more applicable nutrition and childhood obesity-specific knowledge and nutrition-related behavioural change counselling skill building through observation and practice.  hypothesize that the active problem-based learning and counselling skills training components of the course were most effective in increasing students' confidence in counselling and that the self-assessment exercises engaged students' interest in the curriculum and encouraged them to make better lifestyle choices.

Personal Interest in This Research Topic
The researcher is a fourth-year medical student at UCL with a special interest in Culinary Medicine. Medicine are empowered, and can consequently educate and empower their patients, to have greater control over improving their own health and wellbeing through positive, cost-effective lifestyle changes (Grewal, 2016;Vettel, 2018;Ferreira, 2018). Thus, the researcher aims to create a study that they hope will yield results that will contribute to the development and improvement of a Culinary Medicine course for undergraduate UK medical students.

Rationale for This Study
There is growing evidence of the health benefits of improving dietary health. The National Institute for Health and Care Excellence (NICE) has emphasised on the importance the role of healthcare professionals in educating patients in nutrition and lifestyle. NICE envisages that, in less than two years' time, nutrition could become the first-line intervention to tackle conditions such as heart disease and cancer by 2020 (Womersley and Ripullone, 2017).
Yet, the literature suggests that suggest that medical students, and even fully-qualified doctors, feel under-equipped to engage patients in conversations about this topic and provide dietary advice. The General Medical Council (GMC) (2018) requires UK Medical School graduates to be competent in recognising ill health as a result of poor nutrition, and applying the principles, methods and dietary knowledge to medical practice and integrating these into patient care.
UCL Medical School is currently in the process of creating an undergraduate Culinary Medicine course.
Research on medical students and nutrition education and Culinary Medicine training has been primarily conducted in the USA (Mlodinow, 1989; Engel, 1997; Walsh 2011; Schlair, 2012; Cooke, 2017). Therefore, the results of these studies may not be transferable to the UK. It will be useful to understand what UK medical students value in a Culinary Medicine course. Incorporating features that students value (including topics and learning strategies) will optimize students' potential to learn about the importance of diet in Medicine, and therefore their potential to apply the knowledge in a clinical setting to improve the health and wellbeing of their patients.

Primary Objective
To determine UCL medical students' learning needs and preferences in the area of Culinary Medicine with a view to informing development of a culinary medicine course at UCL.

Secondary Objectives
 To determine undergraduate UCL medical students' understanding of Culinary Medicine and their preferences and expectations of a Culinary Medicine course in their medical programme.
 To determine the level of experiences and/or training in Culinary Medicine.

Study Design
The overall aim of this study is to determine University College London (UCL) medical students' learning needs and preferences in the area of Culinary Medicine with a view to informing development of a culinary medicine course at UCL. The proposed study design is a quantitative study. The researcher hopes to determine medical students' learning needs and preferences in the area of Culinary Medicine with a view to informing development of a culinary medicine course at a London Medical School. The researcher aims to collect data using a questionnaire (see Appendix 4).

Design
The questionnaire will be in electronic format (Google Forms) and a weblink to the questionnaire will be distributed via email to current students of UCL Medical School by The Royal Free, University College and Middlesex Medical Students' Association (RUMS MSA) on behalf of the researcher and student societies, such as UCL Medical Society, the RUMS review and RUMS Islamic Society. The researcher will also share the weblink to the questionnaire amongst colleagues and friends via university email (see Appendix 5).
The questionnaire will take approximately 15 minutes to complete.
Questionnaire studies enable data from a large number of study participants to be gathered without taking up too much of participants' time.
The The only piece of demographic data that will be collected is the year of medical school training. The researcher feels that this information is important because the data may reveal a correlation between the year of study and students' understanding of Culinary Medicine and their preferences and expectations of a Culinary Medicine course in their medical programme. The course may be adjusted according to the education needs and preferences of different year groups. Questionnaires will be anonymised to encourage participants to answer the questions honestly, with the hope of increasing the validity of the data collected.

Study Population
The study population is undergraduate medical students who are enrolled at UCL Medical School for the academic year 2018-19.
The researcher contacted the UCL Student Data Analyst to obtain the study population size, which is 1669.
A sample size calculation (https://www.surveymonkey.co.uk/mp/sample-size-calculator/) was done using total population (1669) of UCL medical students (undergraduates) in the academic year 2018-19. 313 responses are required for the results to be accurate at the 95% confidence level, with a 5% margin of error.
The researcher aims to receive approximately 330 responses to the questionnaire.

Duration of Enrolment and Follow-up
Participants will be recruited from November -December 2018.
There will be no participant follow-up. However, if participants wish, they may contact the researcher via email (an email address will be provided on the recruitment flyer) to ask for a summary of the study findings.

Methods Used to Determine the Appropriate Sample Size
A sample size calculation (https://www.surveymonkey.co.uk/mp/sample-size-calculator/) was done using total population (1669) of UCL medical students in the academic year 2018-19. 313 responses are required for the results to be accurate at the 95% confidence level, with a 5% margin of error.

Analysis Plan
The researcher will seek advice from their chief investigator, project supervisor and a statistician within the UCL Department of Primary care and Population Health when analysing the data collected from the quantitative part of the questionnaire.
The exact statistical analysis will depend on the distribution of the variables in the final sample. The researcher will use SPSS statistical software. The researcher will form a statistical analysis plan with the UCL statistician.
The researcher also intends on doing a thematic analysis of the free-text responses in the questionnaire. The method of thematic analysis is described by Braun and Clarke (2006) as follows: 1. Familiarisation with the raw data.
 The researcher will read and re-read the free-text responses. 2. Generating initial codes.
 Codes will be both informed by the questions and derived from the data (Stuckey, 2015).  Codes will be initially written on hard copies of transcripts and then input onto NVivo (11.4.3) software to allow for easier organisation of the codes.  The researcher will code the full data set. The researcher will ask a project supervisor with expertise in qualitative methods to code a subset of free-text responses to allow for different perspectives on the emerging data and themes to be gathered.
 A constant comparative method of analysis will be used: emerging codes will be compared against the existing list of codes and refined. Previous the free-text responses will be recoded using the revised list. This process will continue until no new codes emerge, ensuring thorough coding of all the free-text responses and more robust analysis (Hewitt-Taylor, 2001).
 The researcher will compare coded sections within, and between, the free-text responses to check the consistency of coding (Strauss and Corbin, 1990). 3. Searching for themes.
 Codes that share common elements will be grouped together under a sub-theme. Subthemes will be grouped together under a core theme (Strauss and Corbin, 1990). 4. Reviewing themes.
 The researcher will examine if the data within each theme is coherent.  The researcher will assess the validity of each theme in relation to the data set and ensured that there is no overlap between themes.
 The researcher will draw a thematic map to illustrate how the themes are related to one another. 5. Defining and naming themes.
 The researcher, chief investigator and project supervisor will offered their interpretations of the data. 6. Produce a report.
 The study will be disseminated.
This study is prone to response bias. Therefore, the questionnaire will consist of non-leading, short and clearly-written questions. The questions were independently reviewed by the chief investigator and project supervisor.
This study is prone to non-response bias. Therefore, the researcher will advertise the questionnaire via a wide range of university student societies and encourage these societies to advertise on multiple social media platforms, with the hope of increasing the questionnaire response rate and recruiting a wide range of students.

Data Collection Process
The researcher will pilot the questionnaire with three colleagues (medical students at UCL Medical School) before data collection begins to validate the readability and acceptability of the questions and to increase the reliability of the questionnaire. If any changes are made to the questionnaire, an updated version of the questionnaire will be created and used for the study.
Prior to completing the questionnaire, participants must read and understand the PIS and the consent form and complete the consent form.
The questionnaire will be in electronic format (Google Forms) that should take participants approximately 15 minutes to complete.

End of Study
The end of the study will be when the number of questionnaire responses reaches the sample size figure calculated according to the total population size, the data has been analysed and the results have been disseminated.

CONSENT
Informed consent will be obtained from study participants prior to the start of the questionnaire.
The first page of the online questionnaire will be the participant information sheet (PIS; see Appendix 6) and the consent form (see Appendix 7), which study participants must read and complete before they can start in the questionnaire.
Should study participants have any questions or concerns to raise with the researcher, the researcher will be contactable via e-mail or telephone and these contact details will be written in the PIS. With this information, the participants may decide if they would like to take part in the study.

Exclusion Criteria
Any persons who is not currently studying Medicine at UCL will be excluded from this study.

RECRUITMENT
Participants will be recruited from November -December 2018.
Participant recruitment will cease when the number of questionnaire responses reaches the sample size figure calculated according to the total population size.

Recruitment Method
Participants will be recruited from November -December 2018 from UCL Medical School only.
The researcher will ask RUMS MSA to distribute a weblink to the questionnaire to current students of UCL Medical School on behalf of the researcher. The researcher will also ask student societies, such as UCL Medical Society, the RUMS review and RUMS Islamic Society, to include a weblink to the questionnaire in their electronic newsletters. The researcher will also share the weblink to the questionnaire amongst colleagues and friends via university email (see Appendix 5).
There will be no participant follow-up. However, if participants wish, they may contact the researcher via email (an email address will be provided on the recruitment flyer) to ask for a summary of the study findings.

STATISTICAL METHODS
A sample size calculator (https://www.surveymonkey.co.uk/mp/sample-size-calculator/) was used to calculate a sample size of 313 for a total population of 1669 undergraduate medical students (academic year 2018-19) at the 95% confidence level, with a 5% margin of error. Therefore, the researcher aims to receive approximately 330 responses to the questionnaire.
The researcher will seek advice from their chief investigator, project supervisor and a statistician within the UCL Department of Primary care and Population Health when analysing the data collected from the quantitative part of the questionnaire.
The researcher will form an analysis plan with a UCL statistician based at the UCL department of Primary Care and Population Health.

PATIENT AND PUBLIC INVOLVEMENT (PPI) Participant Involvement
Two UCL medical students (one in fifth-year and one in third-year) will be recruited by the researcher through convenience sampling.
PPI will be asked to provide feedback on the quality and quantity of the questionnaire questions, for example if there is any ambiguity, and on the recruitment flyer. PPI will also be involved in the data analysis to check if the study findings are valid so will therefore have access to the S: drive in the UCL department of Primary Care and Population Health at the Royal Free Hospital Campus that will contain questionnaire responses and participant identification numbers.
PPI will be informed that they cannot participate in the study.
PPI will be reimbursed £50 each for their time.
No other members of the public or study participants will be involved in the planning and design of the study. Study participants will only be used as a source to collect data from.

Participant Withdrawal
During the recruitment and data collection processes, it is important that the researcher is transparent. It will be clearly stated in the PIS (see Appendix 6) that participants are not obliged to take part in this study and can withdraw from the study at any moment in time, without having to give a reason for their withdrawal.

Management of the Research
The members of the Medical School community who will have input in this study will be researcher, chief investigator and project supervisor(s), who are part of the UCL Department of Primary Care and Population Health at the Royal Free Hospital Campus.

Dissemination of Findings
The results of this study will be disseminated and a summary of the study findings will be provided for UCL Medical School. If participants wish, they may contact the researcher via email (an email address will be provided on the recruitment flyer) to ask for a summary of the study findings. Participants will be informed that the researcher may be contacted on the PIS and at the end of the questionnaire.

FUNDING AND SUPPLY OF EQUIPMENT
The study funding has been reviewed by the UCL/UCLH Research Office, and deemed sufficient to cover the requirements of the study. NHS costs will be supported via UCLH and/or the Local Clinical Research Network.

DATA HANDLING AND MANAGEMENT
There is a low risk of breach of confidentiality. This is because the only data that will be collected are the anonymised questionnaire responses and the year group of study participants. In keeping with UCL data protection regulations, year group is not considered personal data as data subjects cannot be identified either directly or indirectly by reference to their year group. The data will be collected electronically using Google Forms. No identifying data or pseudonymized data will be collected. Each response will be given an identification number but there will be no student identifiable data. Therefore, it will not be possible to trace the identification number and the response back to individual students.
The researcher will ask RUMS MSA to distribute a weblink to the anonymous questionnaire to current students of UCL Medical School on behalf of the researcher. The researcher will also ask student societies, such as UCL Medical Society, the RUMS review and RUMS Islamic Society, to include a weblink to the anonymous questionnaire in their electronic newsletters. Therefore, the researcher will have no access to email addresses of the potential study participants.
The researcher will input questionnaire responses onto an Excel spreadsheet. The researcher will save the questionnaire responses and identification numbers in a password-protected file on the S:drive in the UCL department of Primary Care and Population Health at the Royal Free Hospital Campus. Anonymous free-text questionnaire responses will be printed out for the analysis process. The physical copies of the free-text questionnaire responses will be stored in a locked cabinet at the UCL department of Primary Care and Population Health at the Royal Free Hospital Campus.
Only the principal researcher (Jessica Xie), project supervisor (Shoba Poduval), chief investigator (Sophie Park), the PPI and a statistician based at the UCL department of Primary Care and Population Health will have access to the password-protected file on the S:drive and therefore the data.
All data will be stored in compliance with the Data Protection Act.
Data protection registration number: Z6364106/2018/11/17. UCL department of Primary Care and Population Health policy: anonymised data will be stored within the department for 20 years.

MATERIAL/SAMPLE STORAGE
Not applicable to this study.

PEER AND REGULATORY REVIEW
The study will be peer reviewed by 2 academic staff from the Department of Primary Care and Population Health at UCL Medical School and PPI (two UCL medical students (one in fifth-year and one in third-year)).

ASSESMENT AND MANAGEMENT OF RISK
This is a low risk study. There are no risks to the participants in completing the questionnaire. Prior to starting the questionnaire, participants will be reminded that they may withdraw from the study at any moment in time, without having to provide a reason for withdrawal.

RECORDING AND REPORTING OF EVENTS AND INCIDENTS
Not necessary at present.

MONITORING AND AUDITING
Not necessary at present.

TRAINING
Not necessary at present.

INTELLECTUAL PROPERTY
Not necessary at present.

INDEMNITY ARRANGEMENTS
Covered by the UCL indemnity policy.

ARCHIVING
Not necessary at present.

PUBLICATION AND DISSEMINATION POLICY
The results of this project will be disseminated.
UCL Medical School will receive a report of the study findings. If participants wish, they may contact the researcher via email (an email address will be provided on the recruitment flyer) to ask for a summary of the study findings. Participants will be informed that the researcher may be contacted on the PIS and at the end of the questionnaire.

Communication and Understanding
Please place a tick for each statement as appropriate.

Dear [society name],
My name is Jessica Xie, a fourth-year medical student. I am writing to you to ask if you would please assist me in a research project.
UCL Medical School is currently developing a new Culinary Medicine course for its undergraduate medical students. With the help of staff at the UCL Primary Care and Population Health department, I have designed an online questionnaire for UCL medical students with the aim of gaining of an understanding of the preferences and priorities of students towards nutrition education. The results of this study will be used to aid the design and development of a Culinary Medicine course. The ultimate aim of this study is to improve the training of future UCL medical students.
I would be grateful if you would please distribute the following link to your society members and/or include the link on your website/ on your social media platforms/ in your e-newsletters/ in the next edition of the RUMS Review: [weblink to questionnaire] Please note that student participation in this study is entirely voluntary, is outlined in the link above and only students of UCL Medical School in the academic year 2018-19 are eligible to take part. The questionnaires are completed anonymously.

Study Title
A survey of the preferences and expectations of UK undergraduate medical students from a Culinary Medicine course.

Invitation to Take Part in A Research Project
You are being invited to take part in a research project. Before you decided it is important for you to understand why the research us being done and what participation will involve. Please take time to read the following information carefully and discuss it with others if you wish. Ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to take part. Thank you for reading this.
What is the project's purpose?
Culinary Medicine is a new evidence-based field in Medicine that combines nutrition and culinary knowledge to improve the health and wellbeing of patients.
University College London (UCL) Medical School is in currently developing a Culinary Medicine course for its undergraduate students.
The aim of this project is to determine UCL medical students' learning needs and preferences in the area of Culinary Medicine with a view to informing development of a Culinary Medicine course at UCL.
The objectives of this project are:  To determine undergraduate UCL medical students' understanding of Culinary Medicine and their preferences and expectations of a Culinary Medicine course in their medical programme.
 To determine the level of experiences and/or training in Culinary Medicine.  To determine undergraduate medical students' perception of their current abilities to facilitate discussion about diet and provide dietary advice for patients.
 To evaluate the level of satisfaction of undergraduate medical students with the current quality and quantity of Culinary Medicine training delivered by UCL Medical School.
This project will run from November 2018 -February 2019.

Why have I been chosen?
You have been chosen to take part in this study because you are currently a medical student at UCL. We have asked various UCL and RUMS student societies and organisations to distribute the weblink to this questionnaire to UCL medical students. This questionnaire should not be completed by anyone who is not currently a UCL medical student.
Do I have to take part?
It is up to you to decide whether or not to take part. If you do decide to take part, it is important that you read and fully understand this participant information sheet and read, fully understand and complete the consent form (next page). You may withdraw from the study at any point in time, without having to provide a reason for your withdrawal.
What will happen to me if I take part?
The study involves you completing an online questionnaire that should take no longer than 15 minutes to complete.
The questionnaires are completed anonymously. Your personal details (name, age and demographic data) will be not be recorded. We will ask for your year group of study. Therefore, it will not be possible for researchers to contact you What are the possible disadvantages or risks of taking part?
There is a very low risk of breach of confidentiality.
All the information that we collect from your questionnaire response will be kept strictly confidential, as no participant-identifying data will be collected.
Only the research and analysis team will have access to the data.
Your questionnaire responses will be used for research purposes only.
What are the possible benefits of taking part?
The importance of nutrition and diet in undergraduate medical education teaching across all disciplines has long been under-recognized. It is reported that the majority doctors in the UK feel incompetent to provide patients with lifestyle advice.
By taking part in this project, you may be contributing to the training of future UCL medical students, and therefore future doctors.
What if something goes wrong?
If you would like to raise any concerns or complaints, please contact the chief investigator, Dr Sophie Park, at sophie.park@ucl.ac.uk.
What will happen to the results of this research project?
Your questionnaire responses may be used to develop the Culinary Medicine course in the MBBS undergraduate programme that is due to be introduced into the curriculum in 2019.
We aim to finish collecting and analysing the data around February 2019. If you would like to obtain a copy of the results of this research project please contact the principal researcher, Jessica Xie at: jessica.xie.15@ucl.ac.uk.

Data Protection Privacy Notice
Notice: The data controller for this project will be University College London (UCL). The UCL Data Protection Office provides oversight of UCL activities involving the processing of personal data, and can be contacted at data-protection@ucl.ac.uk. UCL's Data Protection Officer can also be contacted at data-protection@ucl.ac.uk.
In keeping with UCL Data Protection regulations, year group is not considered personal data as data subjects cannot be identified either directly or indirectly by reference to their year group.
Provided that your responses do not contain any data that may suggest that you completed the questionnaire, we will not collect any identifying data or pseudonymized data from you. Each response will be given an identification number but there will be no person-identifiable data. Therefore, it will not be possible to trace the identification number and the response back to you.
You have certain rights under data protection legislation in relation to the personal information that is held about you. These rights apply only in particular circumstances and are subject to certain exemptions such as public interest (for example the prevention of crime). They include:  The right to access your personal information;  The right to rectification of your personal information;  The right to erasure of your personal data;  The right to restrict or object to the processing of your personal data;  The right to object to the use of your data for direct marketing purposes;  The right to data portability;  Where the justification for processing is based on your consent, the right to withdraw such consent at any time; and  The right to complain to the Information Commissioner's Office (ICO) about the use of your personal data.
If you are concerned about how your personal data is being processed, or if you would like to contact us about your rights, please contact UCL in the first instance at data-protection@ucl.ac.uk.
If you remain unsatisfied, you may wish to contact the ICO. Contact details, and further details of data subject rights, are available on the ICO website at: https://ico.org.uk/for-organisations/dataprotection-reform/overview-of-the-gdpr/individuals-rights/ Who is organising and funding the research?
This project is organised by the UCL department of Primary Care and Population Health and is funded by National Institute for Health Research (NIHR) School for Primary Care Research (SPCR).

Contact for further information
If you have any questions or comments, or would like to obtain a copy of the results please contact the principal researcher, Jessica Xie at: jessica.xie.15@ucl.ac.uk or the chief investigator, Dr Sophie Park, at sophie.park@ucl.ac.uk.
Thank you for reading this information sheet and for considering to take part in this research study. Name of Researcher: Jessica Xie 1. I confirm that I have read the participant information (above) for this study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.
2. I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason, without my medical care or legal rights being affected.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  3. I understand that the information collected about me will be used to support other research in the future, and may be shared anonymously with other researchers. 4. I understand that the information collected about me will be used to support other research in the future, and may be shared anonymously with other researchers.
• In September 2019, UCL Medical School will introduce "Primary Care Nutrition", a Culinary Medicine course, into the MBBSY5 curriculum.
• Help shape the MBBS course prior to its launch to maximise your learning potential and improve the training of future UCL medical students! • Study aim: to determine UCL medical students' learning needs and preferences in the area of Culinary Medicine with a view to informing development of a Culinary Medicine course at UCL.
• This questionnaire will take no longer than 5 minutes to complete.

1) Invitation to Take Part in A Research Project
You are being invited to take part in a research project which will involve you completing a questionnaire consisting of 15 questions. Before you decided it is important for you to understand why the research us being done and what participation will involve. Please take time to read the following information carefully and discuss it with others if you wish. Ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to take part. Thank you for reading this.
2) What is the project's purpose?
Culinary Medicine is a new evidence-based field in Medicine that combines nutrition and culinary knowledge to improve the health and wellbeing of patients.
The aim of this project is to determine UCL medical students' learning needs and preferences in the area of Culinary Medicine with a view to informing development of a Culinary Medicine course at UCL. 3) Why have I been asked to take part?
You have been asked to take part in this study because you are currently a medical student at UCL. We have asked various UCL and RUMS student societies and organisations to distribute the weblink to this questionnaire to UCL medical students. This questionnaire should not be completed by anyone who is not currently a UCL medical student.

4) Do I have to take part?
It is up to you to decide whether or not to take part. If you do decide to take part, it is important that you read and fully understand this participant information sheet and read, fully understand You may withdraw from the study at any point in time, without having to provide a reason for your withdrawal.

5) What will happen to me if I take part?
The study involves you completing an online questionnaire that should take no longer than 10 minutes to complete.
The questionnaires are completed anonymously. Your personal details (name, age and demographic data) will be not be recorded. We will ask for your year group of study. Therefore, it will not be possible for the researchers and data analysts to contact you. 6) What are the possible disadvantages or risks of taking part?
There is a very low risk of breach of confidentiality.
No participant-identifying data will be collected. All the information that we collect from your questionnaire response will be kept strictly confidential.
Only the research and analysis team will have access to the data. Data will not be passed onto third parties.
Your questionnaire responses will be used for research purposes only.

7)
What are the possible benefits of taking part?
The importance of nutrition and diet in undergraduate medical education teaching across all disciplines has long been under-recognised. It is reported that the majority of doctors in the UK feel incompetent to provide patients with lifestyle advice.
By taking part in this project, you may be contributing to the training of current and future UCL medical students, and therefore future doctors.

8) What if something goes wrong?
If you would like to raise any concerns or complaints, please contact the chief investigator, Dr Sophie Park, at sophie.park@ucl.ac.uk.
9) What will happen to the results of this research project?
Your questionnaire responses may be used to develop the Culinary Medicine course in the MBBS undergraduate programme that is due to be introduced into the curriculum in 2019.
We aim to finish collecting and analysing the data around February 2019. If you would like to obtain a copy of the results of this research project please contact the principal researcher, Jessica Xie, at: jessica.xie.15@ucl.ac.uk.

10) Data Protection Privacy Notice
Notice: The data controller for this project will be University College London (UCL). The UCL Data Protection Office provides oversight of UCL activities involving the processing of personal data, and can be contacted at data-protection@ucl.ac.uk. UCL's Data Protection Officer can also be contacted at data-protection@ucl.ac.uk.
Further information on how UCL uses participant information can be found here: www.ucl.ac.uk/legal-services/privacy/participants-health-and-care-research-privacy-notice 53.
The only data that will be collected are the anonymised questionnaire responses and the year group of study participants.
In keeping with UCL Data Protection regulations, year group is not considered personal data as data subjects cannot be identified either directly or indirectly by reference to their year group.
Provided that your responses do not contain any data that may suggest that you completed the questionnaire, we will not collect any identifying data or pseudonymized data from you. Each response will be given an identification number but there will be no person-identifiable data. Therefore, it will not be possible to trace the identification number and the response back to you.
You have certain rights under data protection legislation in relation to the personal information that is held about you. These rights apply only in particular circumstances and are subject to certain exemptions such as public interest (for example the prevention of crime). They include: • The right to access your personal information; • The right to rectification of your personal information; • The right to erasure of your personal data; • The right to restrict or object to the processing of your personal data; • The right to object to the use of your data for direct marketing purposes; • The right to data portability; • Where the justification for processing is based on your consent, the right to withdraw such consent at any time; and • The right to complain to the Information Commissioner's Office (ICO) about the use of your personal data.
If you are concerned about how your personal data is being processed, or if you would like to contact us about your rights, please contact UCL in the first instance at data-protection@ucl.ac.uk.
If you remain unsatisfied, you may wish to contact the ICO. Contact details, and further details of data subject rights, are available on the ICO website at: https://ico.org.uk/for-organisations/dataprotection-reform/overview-of-the-gdpr/individuals-rights/. Thank you for reading this information sheet and for considering to take part in this research study.

Please tick each box to consent to taking part in this study. *
Check all that apply.
I confirm that I have read the participant information (above) for this study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.
I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason, without my medical education or legal rights being affected.
I understand that the information collected about me will be used to support other research in the future, and may be shared anonymously with other researchers.

No
Other:

Strengths and Limitations of This Study
 The questionnaire was piloted to confirm readability and ensure that questions addressed the study aim.  At interim analysis of the first 148 questionnaire responses, no new codes were generated during qualitative thematic analysis of free-text responses, signifying that theoretical data saturation had been reached.  The study was conducted at one medical school only, limiting the transferability of the study findings to other medical schools.  The response rate (11%) was low which limits the generalisability of the results to the student population.

Introduction
Culinary Medicine (CM) may be defined as "an evidence-based field in Medicine that blends the art of food and cooking with the science of Medicine". (1) A CM course can offer online learning, didactic teaching and practical hands-on culinary skills in a kitchen setting. The aim is to give students the knowledge and skills to help patients make informed decisions about accessing and eating healthy meals. The General Medical Council (GMC) expects UK medical school graduates to be competent in recognising ill health as a result of poor nutrition, and to be able to apply dietary knowledge to clinical practice. (2) However, it has been reported that medical students and doctors worldwide feel under-equipped to provide dietary advice for patients. (3)(4)(5)(6) Studies have found that medical students who learn CM are likely to develop positive attitude towards, and better knowledge of, diet and nutrition; adopt better health habits themselves; and become more competent and confident in dietary counselling. (7)(8)(9)(10) The setting for this study was a single, urban UK medical school, with a five-year undergraduate medical (MBBS) curriculum plus an Integrated Bachelor of Science (iBSc) in the third year. The first three years are the pre-clinical part of the MBBS curriculum. In their first year, students receive lectures on nutritional science, such as the digestion of macronutrients and gastrointestinal physiology, and public health nutrition.
The Primary Care Medical Education Team at this UK medical school collaborated with a team of doctors, dietitians and chefs from Culinary Medicine UK (11) to create a CM course that was introduced into the Primary Care module of the fifth year of the MBBS curriculum in September 2019. Teaching consisted of online learning and one day of face-to-face teaching in a teaching kitchen. The course teaches students culinary skills, evidence-based medicine related to dietary counselling and motivational interviewing skills. Believed to be the first medical school in Europe to provide mandatory CM teaching, the aims of the course are to improve students' confidence in raising the subject of healthy eating and in giving simple dietary advice based on evidence-based recommendations; and to increase students' awareness of potential barriers to healthy eating (for example, cultural norms and low household income). This study was conducted prior to the introduction of the CM course to  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59

Methods
This was a cross-sectional questionnaire study, collecting quantitative and qualitative data using an online (Google Forms) questionnaire. JX (a fourth-year medical student and National Institute for Health Research School for Primary Care Research (NIHR SPCR) intern in the University College London (UCL) Research Department of Primary Care and Population Health), led the study design, data collection and analysis.
The study was conducted at a single, urban UK medical school from December 2018 to April 2019.
The study population was 1669 undergraduate medical students enrolled in the academic year 2018/19 (data supplied by UCL Student Data Analyst).

The Questionnaire
There was a total of 16 questions of various styles (Likert-type, multiple choice and free-text) across four main topics (see Table 1). The first topic included establishing students' understanding of the term 'CM'. A free-text response was requested to explore the differences in students' understanding and interpretation of the concept.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y At the end of the questionnaire, a free-text box was provided for additional general comments, as well as weblinks for students who wished to learn more about CM.

Patient and Public Involvement
Prior to data collection, two medical students (iBSc third-year and MBBS fifth-year) were invited to pilot the questionnaire and comment on the readability. These students suggested re-wording of a few questions to improve clarity. The questionnaire was updated accordingly. Students were not invited to contribute to the study design, analysis or writing of this manuscript.

Data Collection
The questionnaire was advertised on posters and via social media and student societies' enewsletters.

Ethical Approval
Ethical approval to carry out this study was received from UCL Research Ethics Committee (ref.12471/002).
Study participants were asked provide informed consent by reading the participant information sheet (PIS) on the first page of the questionnaire and confirming that they fully understood their role in the study and how the data collected would be used. Once consent had been gained, participants were able to proceed to the questionnaire on the next page.
Questionnaires were completed anonymously. No participant-identifiable data was collected. The only personal data collected was year of study, but participants could not be identified from the information that they provided.

Analysis
Qualitative NVivo 12 (12) was used to store free-text data in order to conduct a qualitative thematic analysis and identify core themes. (13) JX and ShP independently coded all free-text responses before sharing their interpretations with the qualitative results analysis team (JX, ShP and SP) to discuss any areas of dissonance or contrasting interpretation. Codes were derived deductively from the questionnaire (for example, 'Understanding of CM'), and inductively (for example, 'Social factors contributing to diet') upon data analysis. (14) Careful consideration was given upon coding: new codes were compared against preliminary codes and refined, and the data was re-coded using the updated set of codes. This improved the quality of analysis. (15) Similar codes were categorized under a sub-theme or core theme. No new codes emerged after coding responses from the first 148 students in an interim analysis, suggesting that theoretical data saturation had been reached.

STUDY POPULATION
An 11% response rate (180 responses) was achieved. Fourth-year students were the largest contributors to the study (25% of respondents, see Figure 1).

STUDENTS' UNDERSTANDING OF CM
There was a wide range of expectations for CM teaching. Three core themes were identified (see Table 2). Learning how to facilitate discussions about diet with patients arose as a key topic.
"conduct a consultation without body shaming" (Fifth Year).
"first time I came across this term" (Fifth Year).
Students who were in favour of a CM course stressed the importance of the topic and considered how the knowledge and skills that they will learn from the course will make them more competent to educate patients about diet and thus improve patients' health outcomes.
"this valuable knowledge… is applicable to every specialty" (Fifth Year).
"CM involves using nutrition to improve patient's health, including teaching patients how to eat and cook healthily" (Fourth Year).
However, some students felt that learning CM would not benefit them greatly. Students expressed worry that other topics in the current MBBS curriculum, which they felt were more useful than CM, might be compromised or completely removed.

"other parts of the curriculum… should be better developed and prioritised" (Third Year).
Sub-theme 2: Students' Perceived Relevance of CM to Healthcare Professional Practice A variety of perspectives on how CM relates to medical specialities arose.
Students associated CM with nutrition and lifestyle medicine.
"part of the wider discipline of 'lifestyle medicine'" (Third Year).
Students felt that it may be more appropriate for HCPs who have greater clinical expertise in diet and nutrition compared to doctors to counsel patients about diet.
"allied health professionals… are better suited in coaching patients in dietary change, such as dietitians" (Fifth Year).

Sub-theme 3: How to Approach Learning CM
There was a wide variety of opinions on the most appropriate methods for teaching undergraduate medical students CM. Students who were enthusiastic about the idea of learning culinary skills anticipated that practical learning would be engaging and would also allow them to gain knowledge and skills that would enable them to improve their own health and wellbeing.
"a practical kitchen/cooking session… would add variety" (First Year).
"practical kitchen sessions would provide great insight into how to prepare healthy meals for students as well as future doctors" (Fourth Year).
However, other students questioned the feasibility of teaching in a kitchen and whether the skills gained would be useful in future clinical practice.

"lifestyle advice [teaching] could be combined with the patient centred pathway teaching in year 5 on motivational interviewing" (Fifth Year).
Some students felt that it would be appropriate to dedicate up to one day to learning CM and explained that medical students are likely to already have a basic understanding of what constitutes a healthy diet from teaching received elsewhere in the MBBS curriculum.
"CM day… any more than that would be excessive. Most students will already know the basics of constructing a good diet" (Fifth Year).
There were a range of opinions on which year(s) of the MBBS curriculum the CM course should be delivered in.

Core Theme 2: The Relationship Between Food and Health
Students described their views on the links between diet, social factors and health.

Sub-theme 1: Diet and Physical and Mental Health
Students highlighted the role of diet in preventing, treating and managing disease, and alleviating symptoms due to ill-health.
"nutrition and lifestyle factors associated with diet to both prevent disease and to improve morbidity and mortality" (Fifth Year).

Core Theme 3: Evidence-Based Medicine
Students expressed mixed opinions about the evidence base for CM.

PROVISION OF CM TEACHING
62% of students reported having received no prior teaching perceived to be related to CM (see Figure 2).
68% pre-clinical and 77% clinical students were dissatisfied with the quality of existing medical school teaching understood to be relevant to CM. 72% of pre-clinical and 84% of clinical students were dissatisfied with quantity of existing medical school teaching understood to be relevant to CM (see Figure 3).

FEATURES OF CM TEACHING
Students felt that it is most appropriate for a CM course to include teaching on weight management and portion control (157 responses, see Figure 4), closely followed by the types of diet and their evidence base (156 responses). Nutrition psychology was the least popular topic (128 responses).
Students felt that the most appropriate methods of providing CM teaching are problem-based learning (140 responses, see Figure 2) and small-group seminars/ tutorials (138 responses).
67% of students expressed a preference for CM to be taught in pre-clinical training (preclinical students 72%, clinical students 64%, p = 0.257).

Discussion
Although 83% of students in this study felt that learning CM is important for their future clinical practice, 67% did not feel confident in their knowledge, nor competent to provide specific dietary advice. These findings are similar to that of an Australian study (5) , which found that most pre-clinical medical students felt that it is important for doctors to have an understanding of nutrition in relation to medical conditions, such as coeliac disease, but fewer than half were confident in applying their knowledge to clinical practice.
Some students in this study anticipated that the task of dietary counselling would be delegated to other HCPs, such as dietitians, rather than doctors. The latter views are contradicted by literature that suggest the health benefits for patients when dietary advice is given by doctors, especially in General Practice. (18)(19)(20) This supports the delivery of CM teaching in the year five General Practice placement in the MBBS curriculum. The first aim is to enable students to draw upon their experiences of encounters with patients in General Practice and to share these experiences in group discussion about how to approach case-based The CM course was introduced in September 2019. This medical school now meets the nutrition education recommendation for undergraduate medical students of the European Society for Clinical Nutrition and Metabolism (ESPEN), (21) which recommends the provision of teaching in three domains: basic nutritional science, public health and clinical nutrition.
There may be several reasons why clinical students in this study reported higher levels of self-perceived confidence and competence in their abilities to facilitate discussions about diet and nutrition with patients, compared to pre-clinical students. Firstly, nutrition teaching outside of CM teaching is delivered in first year of the MBBS curriculum only. During the time that this questionnaire study was receiving responses (December 2018 to April 2019), students in their first year would not yet have received this teaching. Therefore, their knowledge in this area may have been limited. Secondly, clinical exposure predominantly takes place during years four to six of the MBBS curriculum. Senior students therefore have increased patient contact and are more likely to observe HCPs discussing diet and health with patients. Students may have also been offered the opportunity to counsel these patients themselves. Such experiences are likely to have increased clinical students' confidence in this area and may have contributed to the differences in self-reported capabilities between these two groups.
This overall low self-perceived confidence and competence reported by questionnaire respondents may be related to their dissatisfaction with the quality and quantity of preexisting teaching perceived to be relevant to CM in the MBBS curriculum at the time of this study. This may suggest that this cohort of students had particular interest in, and therefore concern for, undergraduate medical education.
The findings from this study suggest that key components of a CM teaching course placed in the clinical part of an undergraduate medical curriculum are: (i) explaining the clinical and professional relevance of drawing upon patient cases from General Practice placements to aid CM learning; and (ii) supporting medical students in developing an understanding of how this knowledge might be applied in clinical practice to maximise opportunities for supporting health promotion and managing ill health. These findings were subsequently used to inform the development of a CM course at a UK medical school, as described below.

Strengths and Limitations
A strength of this study is that the questionnaire was piloted by two undergraduate medical students, who checked the readability. The students also confirmed that the questions would enable medical students' teaching preferences and expectations for CM learning to be gathered. This validation step increased the reliability of the questionnaire.
Moreover, JX and ShP conducted the early stages of thematic analysis independently to allow for a wider breadth of interpretations to be captured. The analysis team (JX, ShP and SP) then synthesised and discussed the interpretations before reaching an agreement. The questionnaire response rate was low (11%) which limits the generalisability of the findings. The low response rate may be due to the fact that CM is a relatively new term in Medicine and is not commonly used amongst HCPs in the UK and CM is not yet included on most UK medical schools' curricula. The authors anticipated that students with prior understanding and/or interest in CM, were more likely to complete the questionnaire. Therefore, in an attempt to increase the response rate, advertisements for the questionnaire, as well as the PIS, emphasised that all medical students were eligible to take part in the study and that a wide breadth of experiences and perspectives, including no prior understanding of CM, were welcome. Even with this additional encouragement, the response rate remained low. However, theoretical saturation of the qualitative data was judged to have been reached after coding the first 148 responses in an interim analysis, implying that sufficient qualitative data had been gathered for the views of students to be represented in the free-text responses. This strengthened the credibility of the study.
Another limitation is that questionnaire responses were received from one UK medical school only. Factors such as differences between medical school curricula may limit the transferability of the study findings to other medical schools.

Implications
The findings from this study have been used to inform the development of a CM course for undergraduate students at a UK medical school during their year five General Practice placement.

CM Course Content
The course includes a wide range of teaching topics. The aim is for teaching to meet the learning needs of students, which were identified in this study, as well as GMC (2) requirements for nutrition education. The course topics are weight management and portion control, nutritional screening tools, taking a dietary history, motivational interviewing skills, addressing the dietary needs of patients with varying cultural and ethnic backgrounds, types of diet and their evidence-base, and practical culinary skills and food preparation.

CM Teaching Methods
The teaching methods that students in this study expressed preferences for have been included in the course to optimise their learning potential. These teaching methods include an online module, a face-to-face tutorial, case-based discussions, motivational interviewing roleplay and culinary skills training. The latter has been suggested to be an effective teaching method to improve students' nutrition knowledge and food identification skills. (8) The course creators prepared patient cases for discussion to maximise clinical relevance. Students also prepare their own summaries of relevant patient cases encountered during their General Practice placements, and are supported by course facilitators to think about how they will apply the principles from CM teaching in future consultations.

Future Research in This Area
The questionnaire that was created for this study has been adapted into a post-course questionnaire and is being used to gather students' feedback on their CM learning experiences. The feedback data will be analysed in a separate study.
Conducting this cross-sectional questionnaire study at other medical schools will enable faculties to determine whether there is a need to introduce or improve CM teaching at their medical school to better meet their students' needs and expectations for CM learning and/or GMC (2) requirements for nutrition education.
Future qualitative research in this area will allow deeper exploration of students' thoughts regarding CM teaching.

Conclusion
This cross-sectional quantitative study has provided insight into medical students' understanding of and attitudes towards learning CM. The study has highlighted students' perceptions of how they feel CM knowledge and skills might help them to meet the GMC's Outcomes for Graduates and fulfil their future role as doctors. Students reported a lack of confidence in their dietary counselling skills and felt that they could benefit from further integrated and clinically-relevant teaching. Students' preferences for CM teaching have been taken into consideration in the development of a CM course for fifth-year undergraduate students at a UK medical school during their General Practice placements. This medical school is an exemplar of how CM teaching can be introduced into the clinical component of an undergraduate medical curriculum.

Contributions
JX: main author and lead for the study design, participant recruitment, data collection and analysis and write-up. SP: chief investigator, co-supervisor and contributed to the study design, data analysis and write-up. ShP: co-supervisor and contributed to the study design, participant recruitment, data analysis and write-up. VV: supervised the statistical analysis and write-up.

Results/findings
Synthesis and interpretation -Main findings (e.g., interpretations, inferences, and themes); might include development of a theory or model, or integration with prior research or theory Page 6, line 3page 10, line 17 Links to empirical data -Evidence (e.g., quotes, field notes, text excerpts, photographs) to substantiate analytic findings Page 6, line 3page 10, line 17

Discussion
Integration with prior work, implications, transferability, and contribution(s) to the field -Short summary of main findings; explanation of how findings and conclusions connect to, support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of application/generalizability; identification of unique contribution(s) to scholarship in a discipline or field **The rationale should briefly discuss the justification for choosing that theory, approach, method, or technique rather than other options available, the assumptions and limitations implicit in those choices, and how those choices influence study conclusions and transferability. As appropriate, the rationale for several items might be discussed together.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60