Education in lifestyle medicine for future physicians – a strategy to reduce the burden of cardiovascular disease
Lifestyle medicine (LM) has been defined as the ‘evidence-based practice of assisting individuals and families to adopt and sustain behaviours that can improve health and quality of life’ . Tackling lifestyle risk factors such as smoking, unhealthy diet, and physical inactivity is a key part of the prevention of non-communicable diseases such as cardiovascular disease (CVD) . Physicians and other health staff are key resources in prevention, both in direct interaction with individual patients and as advocates for healthy behaviours on the societal level . Despite the benefits of LM, the topic is addressed only in a minor part of physicians’ patient encounters . Better knowledge of how behavioural and lifestyle factors influence health and more training in counselling methods is needed to improve physicians’ ability in lifestyle counselling . Medical education plays a key role to assure quality in LM, reducing unhealthy behaviours and decreasing risk . LM should be taught throughout medical education . In 2016, the American Heart Association (AHA) released a scientific statement specifying what knowledge and skills medical students need to be taught in order to achieve sufficient competence in LM . There are various approaches to teaching LM in undergraduate medical programmes . Some approaches focus on longitudinal, integrated tracks for LM, starting early and aiming to give students ample opportunity to practice lifestyle counselling skills . Other examples include internet-based curricula or separate courses for LM . At the postgraduate level, training in LM may be included in the recidency curriculum either as a mandatory component or as an elective course . Other initatives to increase LM content in medical education include the Lifestyle Medicine Collaboration Initiative, which offers high-quality LM curricular content that can be used for LM education . The Swedish undergraduate medical programme comprises 11 semesters and is based on 17 national qualitative targets that have to be met to attain a degree in medicine. One of these qualitative targets specifically identifies competency in preventive medicine: ‘ … the student should demonstrate the ability to initiate and undertake health promotion and preventive measures in health care for both individuals and groups of patients.’ Prevention and LM are usually integrated throughout the medical programme, especially as part of primary care pathways. Curricula include theoretical knowledge of prevention and lifestyle risk factors, as well as skills in the evaluation of lifestyle risk factors and behavioural and motivational techniques. Several universities also have courses with focus on prevention in general, including LM, usually in conjunction with social medicine. However, research indicates that examinations on prevention at Swedish medical programmes focus on pharmacological or technical intervention rather than lifestyle changes . The Swedish Higher Education Authority recurrently conducts external quality assurance of higher education programmes based on the Standards and Guidelines for Quality Assurance in the European Higher Education Area (ESG) . A review of the national qualitative target on prevention from 2013 found that curricula at several of the Swedish medical schools had room for improvement in education on prevention and lifestyle medicine . Despite the need for education in LM, the subject is not sufficiently taught in most medical programmes . This may be understandable due to the challenges of adding and assessing new content to an already overloaded curriculum . Previous research have described key factors for successful implementation of LM curricula in undergraduate medical education . However, since the organizational context, stakeholders and legal demands differ greatly between countries and institutions, we believe that a plethora of evidence with different approaches to implementation can help educators develop LM in their settings. This case report describes a curriculum development project aiming to increase the focus on LM in a Swedish medical programme. The primary aim of the study was to explore the feasibility of integrating a structured LM curriculum into an existing comprehensive curriculum of a medical programme and assess the effects on the curricular content and student learning.   The project was carried out during 3 semesters, from spring 2017 up to and including spring 2018, and a final report was submitted to the program board in September 2018 . All courses and students at the programme were encompassed by the project. The process used for this curriculum development project follow the six steps outlined by Thomas et al. . The six-step approach is grounded in the theory on outcome-based education . In line with their theory, the steps were not conducted in sequence but rather as parallel processes . Step 1: General needs assessment The general needs assessment was based on the literature described in the introduction, clearly stating the need for increased LM content in medical education, as well as conclusions from the external quality evaluation on prevention in medical education by the Swedish Higher Education Authority . It was assumed that improved training in prevention and LM already at the undergraduate level would bring potential benefits for both patients, the health care system and society at large. Actions taken A curriculum development project was initiated in January 2017. The project focused on the four lifestyle habits with the highest evidence grade of association with disease: use of tobacco, harmful use of alcohol, physical inactivity and unhealthy eating habits. The education on councelling and preventive strategies was based on the National guidelines published by the Swedish National Board of Health and Welfare . Step 2: Targeted needs assessment The medical programme at Karolinska Institutet (KI) comprised 11 core courses organized into seven themes that form a gradual progression starting with courses dominated by basic science followed by clinical courses, which combine clinical clerkships with theoretical schooling (Supplementary Table S1). The last core course in the programme focuses on public and environmental health and includes global health issues as well as a system perspective on health and prevention. All core courses also include longitudinal tracks for ‘professional development’ and ‘scientific development’, as well as clerkships in primary care. The targeted learners were all students in the medical programme at KI. The targeted learning environment was constituted by the current curriculum at the programme, and the related conditions of the students at the programme. Actions taken The current curriculum was analysed in order to identify existing training and assessment in LM. A gap analysis of the curriculum was used to formulate the goals and objectives of the development project. The analysis was initiated in a central programme committee consisting of course directors and teacher representatives from all courses and longitudinal tracks (professional development, scientific development and primary care) within the medical programme. The representaives had varied academic positions, including docents and senior lecturers. The committee initiated the analysis, after which representatives were divided into smaller groups of around 2-4 persons according to courses (representatives from courses from the same theme worked together) and longitudinal tracks. There were 3 additional joint meetings with representatives from all working groups to discuss progress and prepare a report to the programme board (see step 6: evaluation). The analysis showed that the medical programme at KI was characterised by a gradual progression in both learning objectives and examinations. However, the programme lacked a coherent pedagogical strategy concerning prevention and LM. The analysis identified several learning activities and examinations focusing on LM already included in the program. These covered the theoretical aspects of LM throughout the program. However, the practical aspects, such as competence and training in behavioural science and counselling, were neither systematically taught nor tested for in a majority of the clinical semesters. Identified gaps included practical training in lifestyle counselling, examinations and a structured progression in the subject throughout the programme. Step 3: Goals and objectives The main goal of the project was to fulfil the national qualitative target for prevention and LM. The project also aimed to increase the amount of educational activities on the prevention and LM throughout the programme, although this objective was not quantified. There were no objectives focusing on patient outcomes during the project. Actions taken Based on the national qualitative target, the working groups created objectives adapted to the existing medical programme curriculum and learning context, in the form of intended learning outcomes (ILOs) using the gap analysis described in the previous step. The work process followed the same pattern as described above with parallell work in groups and discussion at joint meetings. Inspiration for the ILOs was taken from the AHA statement on achieving lifestyle counselling competence in medical training . demonstrates the created ILOs for students. Step 4: Educational Strategies It was concluded that all of the programme’s courses and longitudinal tracks were needed to contribute to educating the students on prevention and LM. As such, the strategy was for the subjects to be integrated as a recurrent topic throughout the five-and-a-half-year programme. This offers opportunity for the relevant competencies to be taught and practiced over time and in a variety of settings. Actions taken Prevention was ensured to be included as part of formative and summative examinations. How the subject was to be integrated into the existing courses was suggested by the individual course directors. The project group focused on harmonising efforts in order to ensure a structured progression in learning activities and examinations throughout the programme. The assessments of the created ILOs were allocated between the core courses, with a mission to secure constructive alignment of learning activities and examination for each objective. The responsibility to ensure examinations was distributed among the 4 major clinical courses of the programme: unhealthy diet in Clinical medicine (semester 5-6), tobacco use in Clinical medicine – Surgery (semester 7), harmful use of alcohol in Clinial medicine – Neuro, senses and psyche (semester 9), and physical inactivity in Clinical medicine – Emphasis on Reproduction and development (semester 10). Ensuring summative examinations was considered especially important, as it is known that assessments also drive student learning . Step 5: Implementation Support from the management is crucial for a successful implementation. The project was initiated and sanctioned by the programme board and discussed in central committees of the programme. In order to ensure support throughout the programme, directors from all core courses were involved in the project; as such, the project had a clear bottom-up-approach. Time for the project was allocated within their duties as course directors. Actions taken New prevention and LM content was included in a variety of learning activities such as lectures, seminars, practical exercises and essay assignments throughout the programme. Some areas in immediate need for improvement were identified; as an example, lectures were added on the methodology of behavioural change. LM was also included in the already existing assignments throughout the programme. This was especially encouraged in learning activities during clinical clerkships where students could practice lifestyle counselling in real patient encounters. Summative, practical examinations were integrated into existing objective structured clinical examinations (OSCE) and sit-ins within the clinical courses at the programme. Step 6: Evaluation The project evaluation aimed to capture both the feasibility of the project as well as learner experience and knowledge retainment. Evaluation was conducted using: (1) data on learning activities and examinations before and after the project, as described in the project report to the programme board; (2) grade of adherence to the national qualitative target on preventive medicine from the external evaluation report in August 2019; (3) data on curricular content, integration and student performance from a survey to course directors in June 2020; and (4) data on students’ perceived quality from course surveys and exit polls. Student data were collected both while the project was ongoing and changes to the courses were being implemented (spring 2017 – spring 2018) and after the project had been finalized and all changes were in place (fall 2018–spring 2020). Actions taken A rated value statement was added in the existing course surveys to evaluate students’ attitude towards the subject: ‘The course increased my knowledge of how to improve patients’ health and prevent disease’ (5 degree response scale: 1 ‘to a very small extent’; 2 ‘to a small extent’; 3 ‘partly’; 4 ‘to a large extent’; and 5 ‘to a very large extent’). The course surveys were administered to all students in the programme at the end of each course. Furthermore, a rated value statement was included in the programme exit poll: ‘I am well prepared for the demands of my future profession on my ability to work with health promotion and prevention’. The statement had a 4-point response scale in spring 2017 (‘to a very low degree’ (scored as 1), ‘to a low degree’ (2), ‘to a high degree’ (3), and ‘to a very high degree’ (4)). From fall 2017 and forward, the exit poll was restructured due to circumstances outside of our control, and all questions were converted to a 6-point scale, one extreme being ‘to a very low degree’ (scored as 1) and the other extreme being ‘to a very high degree’ (scored as 6). The in-between options that were scored as 2-5 were not specified. The exit poll was administered once per semester to all students completing the 11 th semester of the programme and thus finishing their undergraduate medical education. Since both the course surveys and the exit poll were anonymous and researchers only had access to aggregated data, consent was not deemed necessary nor possible to obtain from the students. We did not have information on the number of respondents. Both the course surveys and the exit poll had been used for regular quality assurance in the medical programme for several years and were as such considered to be reliable and valid instruments. Results from the course surveys were presented as aggregated means per semester, with each course weighted equally. As we did not have information on the number of respondents, we could not calculate an aggreagared standard deviation (SD), and as such, the SD range was presented instead. For the exit poll, results were presented as means and SD per semester. No statistical test was performed on the survey data. In addition, a survey was sent to course directors for the 11 core courses of the programme in June 2020. The course directors were all teachers at the medical programme at KI. They were informed of the project, and their consent to participate was assumed if they answered the survey. For the courses Clinical medicine (semester 5–6) and Clinical medicine – surgery (semester 7), which have an organizational structure with 4 parallell courses at 4 different sites, each including a fourth of the students, the survey was sent to all 4 course directors. The introductory course had 2 course directors who both answered the survey. The survey contained 3 questions: (1) ‘In your opinion, compared to the project, is the subject taught to a greater or lesser extent on the course today’ (scale 1–5, 1 = ‘less than during the project’, 3 = ‘the same as during the project’, 5 = ‘more than during the project‘); (2) ‘in your opinion, are learning activities and examinations regarding prevention and lifestyle medicine integrated into other parts of the course and connect to the course as a whole’ (scale 1–5, 1 = ‘not at all connected with the rest of the course’, 3 = ‘somewhat connected with the rest of the course’, 5 = ‘seamlessly integrated with the rest of the course’); and (3) ‘to what extent do students on the course pass examinations (e.g., exam questions or OSCE stations) about prevention and lifestyle medicine’ (scale 1–5, 1 = ‘not at all, very few students reach ILOs’, 3 = ‘about half the students reach the ILOs’, and 5 = ‘practically all students reach ILOs’). Results of the survey were calculated as means of all respondents with each course weighted equally to avoid overrepresentation of the courses with multiple informant or a different organizational structure. As we only used answers from 7 courses to calculate means, normality could not be assumed, and as such, we did not calculate SD. Free text answers to each question were read by all authors to get a sense of the whole, after which relevant content was extracted through discussion between the authors. As the data were limited, the questions were specific and we focused on manifest content, we did not see a need for a formal coding process in the analysis.   The general needs assessment was based on the literature described in the introduction, clearly stating the need for increased LM content in medical education, as well as conclusions from the external quality evaluation on prevention in medical education by the Swedish Higher Education Authority . It was assumed that improved training in prevention and LM already at the undergraduate level would bring potential benefits for both patients, the health care system and society at large. Actions taken A curriculum development project was initiated in January 2017. The project focused on the four lifestyle habits with the highest evidence grade of association with disease: use of tobacco, harmful use of alcohol, physical inactivity and unhealthy eating habits. The education on councelling and preventive strategies was based on the National guidelines published by the Swedish National Board of Health and Welfare .   A curriculum development project was initiated in January 2017. The project focused on the four lifestyle habits with the highest evidence grade of association with disease: use of tobacco, harmful use of alcohol, physical inactivity and unhealthy eating habits. The education on councelling and preventive strategies was based on the National guidelines published by the Swedish National Board of Health and Welfare .   The medical programme at Karolinska Institutet (KI) comprised 11 core courses organized into seven themes that form a gradual progression starting with courses dominated by basic science followed by clinical courses, which combine clinical clerkships with theoretical schooling (Supplementary Table S1). The last core course in the programme focuses on public and environmental health and includes global health issues as well as a system perspective on health and prevention. All core courses also include longitudinal tracks for ‘professional development’ and ‘scientific development’, as well as clerkships in primary care. The targeted learners were all students in the medical programme at KI. The targeted learning environment was constituted by the current curriculum at the programme, and the related conditions of the students at the programme. Actions taken The current curriculum was analysed in order to identify existing training and assessment in LM. A gap analysis of the curriculum was used to formulate the goals and objectives of the development project. The analysis was initiated in a central programme committee consisting of course directors and teacher representatives from all courses and longitudinal tracks (professional development, scientific development and primary care) within the medical programme. The representaives had varied academic positions, including docents and senior lecturers. The committee initiated the analysis, after which representatives were divided into smaller groups of around 2-4 persons according to courses (representatives from courses from the same theme worked together) and longitudinal tracks. There were 3 additional joint meetings with representatives from all working groups to discuss progress and prepare a report to the programme board (see step 6: evaluation). The analysis showed that the medical programme at KI was characterised by a gradual progression in both learning objectives and examinations. However, the programme lacked a coherent pedagogical strategy concerning prevention and LM. The analysis identified several learning activities and examinations focusing on LM already included in the program. These covered the theoretical aspects of LM throughout the program. However, the practical aspects, such as competence and training in behavioural science and counselling, were neither systematically taught nor tested for in a majority of the clinical semesters. Identified gaps included practical training in lifestyle counselling, examinations and a structured progression in the subject throughout the programme.   The current curriculum was analysed in order to identify existing training and assessment in LM. A gap analysis of the curriculum was used to formulate the goals and objectives of the development project. The analysis was initiated in a central programme committee consisting of course directors and teacher representatives from all courses and longitudinal tracks (professional development, scientific development and primary care) within the medical programme. The representaives had varied academic positions, including docents and senior lecturers. The committee initiated the analysis, after which representatives were divided into smaller groups of around 2-4 persons according to courses (representatives from courses from the same theme worked together) and longitudinal tracks. There were 3 additional joint meetings with representatives from all working groups to discuss progress and prepare a report to the programme board (see step 6: evaluation). The analysis showed that the medical programme at KI was characterised by a gradual progression in both learning objectives and examinations. However, the programme lacked a coherent pedagogical strategy concerning prevention and LM. The analysis identified several learning activities and examinations focusing on LM already included in the program. These covered the theoretical aspects of LM throughout the program. However, the practical aspects, such as competence and training in behavioural science and counselling, were neither systematically taught nor tested for in a majority of the clinical semesters. Identified gaps included practical training in lifestyle counselling, examinations and a structured progression in the subject throughout the programme.   The main goal of the project was to fulfil the national qualitative target for prevention and LM. The project also aimed to increase the amount of educational activities on the prevention and LM throughout the programme, although this objective was not quantified. There were no objectives focusing on patient outcomes during the project. Actions taken Based on the national qualitative target, the working groups created objectives adapted to the existing medical programme curriculum and learning context, in the form of intended learning outcomes (ILOs) using the gap analysis described in the previous step. The work process followed the same pattern as described above with parallell work in groups and discussion at joint meetings. Inspiration for the ILOs was taken from the AHA statement on achieving lifestyle counselling competence in medical training . demonstrates the created ILOs for students.   Based on the national qualitative target, the working groups created objectives adapted to the existing medical programme curriculum and learning context, in the form of intended learning outcomes (ILOs) using the gap analysis described in the previous step. The work process followed the same pattern as described above with parallell work in groups and discussion at joint meetings. Inspiration for the ILOs was taken from the AHA statement on achieving lifestyle counselling competence in medical training . demonstrates the created ILOs for students.   It was concluded that all of the programme’s courses and longitudinal tracks were needed to contribute to educating the students on prevention and LM. As such, the strategy was for the subjects to be integrated as a recurrent topic throughout the five-and-a-half-year programme. This offers opportunity for the relevant competencies to be taught and practiced over time and in a variety of settings. Actions taken Prevention was ensured to be included as part of formative and summative examinations. How the subject was to be integrated into the existing courses was suggested by the individual course directors. The project group focused on harmonising efforts in order to ensure a structured progression in learning activities and examinations throughout the programme. The assessments of the created ILOs were allocated between the core courses, with a mission to secure constructive alignment of learning activities and examination for each objective. The responsibility to ensure examinations was distributed among the 4 major clinical courses of the programme: unhealthy diet in Clinical medicine (semester 5-6), tobacco use in Clinical medicine – Surgery (semester 7), harmful use of alcohol in Clinial medicine – Neuro, senses and psyche (semester 9), and physical inactivity in Clinical medicine – Emphasis on Reproduction and development (semester 10). Ensuring summative examinations was considered especially important, as it is known that assessments also drive student learning .   Prevention was ensured to be included as part of formative and summative examinations. How the subject was to be integrated into the existing courses was suggested by the individual course directors. The project group focused on harmonising efforts in order to ensure a structured progression in learning activities and examinations throughout the programme. The assessments of the created ILOs were allocated between the core courses, with a mission to secure constructive alignment of learning activities and examination for each objective. The responsibility to ensure examinations was distributed among the 4 major clinical courses of the programme: unhealthy diet in Clinical medicine (semester 5-6), tobacco use in Clinical medicine – Surgery (semester 7), harmful use of alcohol in Clinial medicine – Neuro, senses and psyche (semester 9), and physical inactivity in Clinical medicine – Emphasis on Reproduction and development (semester 10). Ensuring summative examinations was considered especially important, as it is known that assessments also drive student learning .   Support from the management is crucial for a successful implementation. The project was initiated and sanctioned by the programme board and discussed in central committees of the programme. In order to ensure support throughout the programme, directors from all core courses were involved in the project; as such, the project had a clear bottom-up-approach. Time for the project was allocated within their duties as course directors. Actions taken New prevention and LM content was included in a variety of learning activities such as lectures, seminars, practical exercises and essay assignments throughout the programme. Some areas in immediate need for improvement were identified; as an example, lectures were added on the methodology of behavioural change. LM was also included in the already existing assignments throughout the programme. This was especially encouraged in learning activities during clinical clerkships where students could practice lifestyle counselling in real patient encounters. Summative, practical examinations were integrated into existing objective structured clinical examinations (OSCE) and sit-ins within the clinical courses at the programme.   New prevention and LM content was included in a variety of learning activities such as lectures, seminars, practical exercises and essay assignments throughout the programme. Some areas in immediate need for improvement were identified; as an example, lectures were added on the methodology of behavioural change. LM was also included in the already existing assignments throughout the programme. This was especially encouraged in learning activities during clinical clerkships where students could practice lifestyle counselling in real patient encounters. Summative, practical examinations were integrated into existing objective structured clinical examinations (OSCE) and sit-ins within the clinical courses at the programme.   The project evaluation aimed to capture both the feasibility of the project as well as learner experience and knowledge retainment. Evaluation was conducted using: (1) data on learning activities and examinations before and after the project, as described in the project report to the programme board; (2) grade of adherence to the national qualitative target on preventive medicine from the external evaluation report in August 2019; (3) data on curricular content, integration and student performance from a survey to course directors in June 2020; and (4) data on students’ perceived quality from course surveys and exit polls. Student data were collected both while the project was ongoing and changes to the courses were being implemented (spring 2017 – spring 2018) and after the project had been finalized and all changes were in place (fall 2018–spring 2020). Actions taken A rated value statement was added in the existing course surveys to evaluate students’ attitude towards the subject: ‘The course increased my knowledge of how to improve patients’ health and prevent disease’ (5 degree response scale: 1 ‘to a very small extent’; 2 ‘to a small extent’; 3 ‘partly’; 4 ‘to a large extent’; and 5 ‘to a very large extent’). The course surveys were administered to all students in the programme at the end of each course. Furthermore, a rated value statement was included in the programme exit poll: ‘I am well prepared for the demands of my future profession on my ability to work with health promotion and prevention’. The statement had a 4-point response scale in spring 2017 (‘to a very low degree’ (scored as 1), ‘to a low degree’ (2), ‘to a high degree’ (3), and ‘to a very high degree’ (4)). From fall 2017 and forward, the exit poll was restructured due to circumstances outside of our control, and all questions were converted to a 6-point scale, one extreme being ‘to a very low degree’ (scored as 1) and the other extreme being ‘to a very high degree’ (scored as 6). The in-between options that were scored as 2-5 were not specified. The exit poll was administered once per semester to all students completing the 11 th semester of the programme and thus finishing their undergraduate medical education. Since both the course surveys and the exit poll were anonymous and researchers only had access to aggregated data, consent was not deemed necessary nor possible to obtain from the students. We did not have information on the number of respondents. Both the course surveys and the exit poll had been used for regular quality assurance in the medical programme for several years and were as such considered to be reliable and valid instruments. Results from the course surveys were presented as aggregated means per semester, with each course weighted equally. As we did not have information on the number of respondents, we could not calculate an aggreagared standard deviation (SD), and as such, the SD range was presented instead. For the exit poll, results were presented as means and SD per semester. No statistical test was performed on the survey data. In addition, a survey was sent to course directors for the 11 core courses of the programme in June 2020. The course directors were all teachers at the medical programme at KI. They were informed of the project, and their consent to participate was assumed if they answered the survey. For the courses Clinical medicine (semester 5–6) and Clinical medicine – surgery (semester 7), which have an organizational structure with 4 parallell courses at 4 different sites, each including a fourth of the students, the survey was sent to all 4 course directors. The introductory course had 2 course directors who both answered the survey. The survey contained 3 questions: (1) ‘In your opinion, compared to the project, is the subject taught to a greater or lesser extent on the course today’ (scale 1–5, 1 = ‘less than during the project’, 3 = ‘the same as during the project’, 5 = ‘more than during the project‘); (2) ‘in your opinion, are learning activities and examinations regarding prevention and lifestyle medicine integrated into other parts of the course and connect to the course as a whole’ (scale 1–5, 1 = ‘not at all connected with the rest of the course’, 3 = ‘somewhat connected with the rest of the course’, 5 = ‘seamlessly integrated with the rest of the course’); and (3) ‘to what extent do students on the course pass examinations (e.g., exam questions or OSCE stations) about prevention and lifestyle medicine’ (scale 1–5, 1 = ‘not at all, very few students reach ILOs’, 3 = ‘about half the students reach the ILOs’, and 5 = ‘practically all students reach ILOs’). Results of the survey were calculated as means of all respondents with each course weighted equally to avoid overrepresentation of the courses with multiple informant or a different organizational structure. As we only used answers from 7 courses to calculate means, normality could not be assumed, and as such, we did not calculate SD. Free text answers to each question were read by all authors to get a sense of the whole, after which relevant content was extracted through discussion between the authors. As the data were limited, the questions were specific and we focused on manifest content, we did not see a need for a formal coding process in the analysis.   A rated value statement was added in the existing course surveys to evaluate students’ attitude towards the subject: ‘The course increased my knowledge of how to improve patients’ health and prevent disease’ (5 degree response scale: 1 ‘to a very small extent’; 2 ‘to a small extent’; 3 ‘partly’; 4 ‘to a large extent’; and 5 ‘to a very large extent’). The course surveys were administered to all students in the programme at the end of each course. Furthermore, a rated value statement was included in the programme exit poll: ‘I am well prepared for the demands of my future profession on my ability to work with health promotion and prevention’. The statement had a 4-point response scale in spring 2017 (‘to a very low degree’ (scored as 1), ‘to a low degree’ (2), ‘to a high degree’ (3), and ‘to a very high degree’ (4)). From fall 2017 and forward, the exit poll was restructured due to circumstances outside of our control, and all questions were converted to a 6-point scale, one extreme being ‘to a very low degree’ (scored as 1) and the other extreme being ‘to a very high degree’ (scored as 6). The in-between options that were scored as 2-5 were not specified. The exit poll was administered once per semester to all students completing the 11 th semester of the programme and thus finishing their undergraduate medical education. Since both the course surveys and the exit poll were anonymous and researchers only had access to aggregated data, consent was not deemed necessary nor possible to obtain from the students. We did not have information on the number of respondents. Both the course surveys and the exit poll had been used for regular quality assurance in the medical programme for several years and were as such considered to be reliable and valid instruments. Results from the course surveys were presented as aggregated means per semester, with each course weighted equally. As we did not have information on the number of respondents, we could not calculate an aggreagared standard deviation (SD), and as such, the SD range was presented instead. For the exit poll, results were presented as means and SD per semester. No statistical test was performed on the survey data. In addition, a survey was sent to course directors for the 11 core courses of the programme in June 2020. The course directors were all teachers at the medical programme at KI. They were informed of the project, and their consent to participate was assumed if they answered the survey. For the courses Clinical medicine (semester 5–6) and Clinical medicine – surgery (semester 7), which have an organizational structure with 4 parallell courses at 4 different sites, each including a fourth of the students, the survey was sent to all 4 course directors. The introductory course had 2 course directors who both answered the survey. The survey contained 3 questions: (1) ‘In your opinion, compared to the project, is the subject taught to a greater or lesser extent on the course today’ (scale 1–5, 1 = ‘less than during the project’, 3 = ‘the same as during the project’, 5 = ‘more than during the project‘); (2) ‘in your opinion, are learning activities and examinations regarding prevention and lifestyle medicine integrated into other parts of the course and connect to the course as a whole’ (scale 1–5, 1 = ‘not at all connected with the rest of the course’, 3 = ‘somewhat connected with the rest of the course’, 5 = ‘seamlessly integrated with the rest of the course’); and (3) ‘to what extent do students on the course pass examinations (e.g., exam questions or OSCE stations) about prevention and lifestyle medicine’ (scale 1–5, 1 = ‘not at all, very few students reach ILOs’, 3 = ‘about half the students reach the ILOs’, and 5 = ‘practically all students reach ILOs’). Results of the survey were calculated as means of all respondents with each course weighted equally to avoid overrepresentation of the courses with multiple informant or a different organizational structure. As we only used answers from 7 courses to calculate means, normality could not be assumed, and as such, we did not calculate SD. Free text answers to each question were read by all authors to get a sense of the whole, after which relevant content was extracted through discussion between the authors. As the data were limited, the questions were specific and we focused on manifest content, we did not see a need for a formal coding process in the analysis.   Curricular content and external reviewers’ perceived quality illustrates the new lifestyle medicine curriculum in the medical programme, with progression from basic to advanced seminar and project assignments and assessments during medical training. The external evaluation focused on the curricular alignment of the programme, from ILO to examination, as well as the organization of the subject within the programme. The report concluded that the topic was well covered and integrated into the curriculum, although with a clearer focus on individual prevention than on prevention at a societal level. Teachers’ perception of integration and curricular content Representatives from 8 out of 11 core courses responded to the questionnaire. demonstrates results from the survey from the relevant core courses (introductory course during semester 1 and clinical courses). For the courses with multiple respondents (Clinical Medicine and Clinical Medicine – Surgery with 4 parallell tracks with different course directs and Introductory course with 2 course directors), the table reports mean values from all course directors. According to the survey, 71% of courses reported a lasting increase in the course material pertaining to the learning objectives 2 years after the termination of the project, defined as answering 4 or 5 on a 5 degree scale (see for full question and response options). The rest stated in free-text comments that such material was already included in the course and that no changes were required during the project. No course reported a reduced level of education in prevention and lifestyle counselling. Furthermore, 71% of courses reported that the subject was very or fully integrated into the overall course curriculum, defined as 4 or 5 on a 5-degree scale. Free-text comments revealed that courses had different approaches to integrating the material into the course. For some courses, preventive medicine as a broad subject had been integrated, although lifestyle counselling specifically was only included in some parts of the course. There was a consensus amongst the respondents that students passed the formal examinations on prevention and lifestyle counselling in both written and practical examinations to a large extent. Students’ perceived quality Results from the course surveys and exit poll are shown in . For course evaluations, all semesters reported a mean above 4 (SD 0.4–1.1) on a 5 point scale to the question if the course increased their knowledge on how to improve patients’ health and prevent disease, where 5 corresponds to ‘to a very large extent’. For the exit poll, results varied between 3.7 and 4.4 (SD 1.1–1.4) on a 6-point scale to the question if the students were well prepared for the their future profession with regards to their ability to work with health promotion and prevention, where 6 corresponds to ‘to a very high degree’. The number of students responding to the course surveys and the exit polls were unknown to us, as we only had access to aggregated data.   illustrates the new lifestyle medicine curriculum in the medical programme, with progression from basic to advanced seminar and project assignments and assessments during medical training. The external evaluation focused on the curricular alignment of the programme, from ILO to examination, as well as the organization of the subject within the programme. The report concluded that the topic was well covered and integrated into the curriculum, although with a clearer focus on individual prevention than on prevention at a societal level.   Representatives from 8 out of 11 core courses responded to the questionnaire. demonstrates results from the survey from the relevant core courses (introductory course during semester 1 and clinical courses). For the courses with multiple respondents (Clinical Medicine and Clinical Medicine – Surgery with 4 parallell tracks with different course directs and Introductory course with 2 course directors), the table reports mean values from all course directors. According to the survey, 71% of courses reported a lasting increase in the course material pertaining to the learning objectives 2 years after the termination of the project, defined as answering 4 or 5 on a 5 degree scale (see for full question and response options). The rest stated in free-text comments that such material was already included in the course and that no changes were required during the project. No course reported a reduced level of education in prevention and lifestyle counselling. Furthermore, 71% of courses reported that the subject was very or fully integrated into the overall course curriculum, defined as 4 or 5 on a 5-degree scale. Free-text comments revealed that courses had different approaches to integrating the material into the course. For some courses, preventive medicine as a broad subject had been integrated, although lifestyle counselling specifically was only included in some parts of the course. There was a consensus amongst the respondents that students passed the formal examinations on prevention and lifestyle counselling in both written and practical examinations to a large extent.   Results from the course surveys and exit poll are shown in . For course evaluations, all semesters reported a mean above 4 (SD 0.4–1.1) on a 5 point scale to the question if the course increased their knowledge on how to improve patients’ health and prevent disease, where 5 corresponds to ‘to a very large extent’. For the exit poll, results varied between 3.7 and 4.4 (SD 1.1–1.4) on a 6-point scale to the question if the students were well prepared for the their future profession with regards to their ability to work with health promotion and prevention, where 6 corresponds to ‘to a very high degree’. The number of students responding to the course surveys and the exit polls were unknown to us, as we only had access to aggregated data.   This case report demonstrates that it is feasible to introduce prevention and LM education into an existing curriculum despite potential problems of content overload. Furthermore, we show sustainable high ratings on related questions in course surveys and exit polls during and after the implementation. A key strategy for success was to not add this area of knowledge and skill training to the curriculum at the expense of other areas, but to adequately integrate it in the appropriate learning context and include these aspects in the already existing lectures, seminars, assignments, and training. There are numerous ways in which LM can be taught in medical programmes. Hauer et al found that successful curricula for teaching behavioural change were often based on behavioural science theory and offered students the opportunity to practice their skills . Similarly, Dacey et al. found that successful curricula for teaching counselling in physical activity shared practical training for students as a common trait . In our case, decisions about the didactic approach were not centrally mandated but delegated to course directors and teachers with deep knowledge of the prerequisites and possibilities among students and in the local context. This strategy is in line with Hivert et al who stated that it is important that decisions about application of new curricula are adapted to local conditions . Training and education in LM also have to be matched with examinations on the topic. This point has been specifically raised by Dent et al. with regards to preventive medicine : There is little point in developing a curriculum where an aim is to orientate the student to medicine in the community and to health promotion if the students perceive that what is valued by the senior teachers is hospital practice, curative medicine and research. Although previous research suggests numerous strategies for teaching LM in the medical curriculum, a challenge for educators is to include prevention and LM into the medical curriculum, where the subject will undoubtedly compete with other parts of the medical curriculum for time and resources . Longitudinal integration of the subject may be a way of overcoming these challenges . However, although curricular development is rarely easy, educators may need guidance on how to achieve this in their programs. In 2019, Trilk et al  provided a detailed description of their process of developing and integrating prevention and LM into their curriculum. We believe that our case study provides an additional perspective to this challenging process, arming educators with additional strategies to achieve this difficult task. Another important aspect to consider when designing a LM curricula is student motivation, an aspect often overlooked in medical education . The vertical integration design of LM in this case report is an approach that has previously been applied as a way of increasing student motivation . In similarity with how other authors that have achieved this, a key strategy was the involvement from faculty to ensure support and avoid competition with other subjects in the curriculum . The ILOs used in our project are also founded on the previous literature . Our study complements the existing work partly as it demonstrates how the vertical intregration can be achieved in a longer programme (11 semesters), with a clear progressive structure. We also demonstrate a lasting increase in the lifestyle medicine course material several semesters after the project ended, which is encouraging for educators hoping to achieve the same. Further important to point out is that the field of health promotion and prevention invariably involves and strengthens interprofessional education. It will also put focus on medical ethics, health economy and health systems, global health, behavioural medicine, patient centred care, patient involvement in care and health professionals and patient as partners in care and shared care. Health promotion and preventive work are also of high importance for providing equal care across geographic, educational and socioeconomic differences and, not the least, sustainability in all dimensions.   A strength of this study is that we use information from both students and faculty and an external review in the evaluation of the curriculum project. Another strength is that the evaluation continued for several semesters after the termination of the projects, which can demonstrate a lasting effect on the curricular content from the project. One limitation of this study is the difficulty of evaluating educational interventions. Evaluation of training and education effects is a complex task. Kirkpatrick defines four possible effect levels of educational intervention: reaction, knowledge, behaviour, and outcome . He also stated that though the relevance of the intervention increases at each level, the difficulty and complexity of evaluation increase in parallel. Given the design of this case study, it was only possible to assess the effects on the first two levels. At the reaction level, we showed a high and lasting level of perceived quality among both students and course directors, a result supported by numerous previous studies . At the knowledge level, we showed a high degree of knowledge and skills as assessed in the formal examinations of students. It would have been valuable to add more objective measures on performance and behaviour. However, LM in clinical practice is a complex team-based task. We argue that it is not doable to evaluate the causality between a curriculum development project and the effect on competence gain in clinical practice. Such effects are next to impossible to evaluate in a systematic manner, as so many other factors will influence the population health . Although we used established surveys to measure student perceptions, the question we used were not tested for validity and reliability. We also did not have access to a number of respondents or response rates in the surveys used to measure the student perception, which is a clear limitation and reduced to the possibility to perform statistical tests on the data. Another limitation of this study is that student’s perception of the quality of the programme was not measured before the project’s initiation. As such, it is not possible to derive to what extent the project affected that perception. However, the first recorded data point could be thought of as a pre-measurement as the majority of changes had not been implemented at this point. We can nevertheless determine that there was no decrease in the student perception on the quality of education in prevention and LM during the time after the project, indicating that there is a lasting focus on these issues throughout the programme. Similarly, the questions used in the survey to the teachers were not evaluated for reliability and validity before the survey. As the respondents were all course directors with high knowledge of the course contents and the questions were clear and specific, we believe the survey provides valid data for our context. We chose only to send the survey to the course directors, and it is possible that a survey to more members of faculty would have given a more nuanced representation of the curricular content after the project. Finally, the free text answers in the survey were not systematically coded during the analysis, which is a possible limitation.   This case report reinforces that it is feasible to integrate prevention and LM into an existing curriculum of medical programmes. The report focuses on the four lifestyle habits identified by WHO as the most important in relation to health and disease. As a long-term strategy of the reducing risk for CVD, prevention and LM are essential components of future medical programme curricula. Our ambition and intention were to show that curricular development in this important area was possible in spite of problems with curriculum overload and to show that it could be integrated rather than added as separate modules in the existing curriculum. However, education in prevention and LM are more than just a question of competencies; early exposure to LM and other aspects of prevention may help future physicians to view disease not as a problem to solve but as a risk that can be mitigated. As medical education lays the foundation for the lifelong learning of future physicians, integrating LM into all aspects of medical education has the potential to change medical students’ perspective on what diseases are and how they can be prevented and treated. In Sweden, we now take this a step further on a national level by developing a new six-year medical programme. The design of new medical programme will be grounded in outcome-based education principles . The results from this project are now valuable in the implementation of prevention content in the six-year program. The qualitative targets in this new programme puts a promising and greater emphasis on the need for future physicians to gain competence in prevention, health promotion, LM and in strategies for life-long learning. We conclude that the long-term clinical implication of this initiative has the potential to reduce the burden of non-communicable diseases such as cardiovascular disease.   supplement table.docx   