College students are an important target audience for lifestyle medicine—a medical specialty focused on evidence-based interventions for improving healthy lifestyle behaviors encompassing diet, exercise, and wellness. College health is a major concern, especially around stress management, sleep deprivation, weight management, nutrition, physical activity, and alcohol use [1-4]. College is a critical time for experimenting, exerting autonomy, and determining how to make choices that result in happiness and productivity. College also marks a critical time for the acquisition and maintenance of healthy habits.

Researchers and educators have been investigating the lifestyle choices of college students for decades, and studies demonstrate that unhealthy habits such as physical inactivity and poor nutritional choices become exaggerated in college. In one study, researchers tracked individual college students’ body weight and body composition and demonstrated an increased prevalence of student obesity from 17.5% (23/131) to 30.5% (40/131) between entering and graduating from college [5]. Given the obesity and diabetes epidemics in the United States and worldwide, teaching college students about healthy lifestyles can play an important role in preventing cardiovascular disease, cancer, and respiratory disease. In a different study examining the efficacy of a single 1-hour motivational intervention for college students on obesity, researchers found that students who participated in the intervention did not have significant body mass index (BMI) reductions at the 3-month follow-up when compared with control students [6]. They concluded that prolonged interventions may be necessary for a significant impact on student health. Addressing and undoing the unhealthy habits that prevail in college will take more than a 1-hour intervention.

Research on the health of college students has been completed by investigators around the world, including countries such as China [7,8], Ethiopia [9], Lebanon [10], Saudi Arabia [11], Qatar [12], Sudan [13], Serbia [14], Bahrain [15], Arab countries [16], Puerto Rico [17], Spain [18], and the United States [4,19,20]. College students’ health and behaviors are of interest because of the mental stress and anxiety that many students experience [21,22], as well as the use of excessive alcohol [23-25], smoking habits [26], drug use [27], weight [28-30], sleep problems [31,32], lack of physical activity [4], poor diets [33-35], and overall unhealthy lifestyles of college students [36-38].

Many interventions to increase the health and well-being of college students have been investigated. A systematic review and recent meta-analysis of computer-delivered Web-based interventions to improve depression, anxiety, and psychological well-being of college students demonstrated that cognitive, behavioral, and mindfulness interventions were effective in reducing stress [39]. In a systematic review of dietary interventions in college students, the authors’ analysis of 14 papers found that in-person interventions showed promise in improving students’ dietary behaviors, but these changes were minimal [40]. Interventions that included self-monitoring and goal setting maximized outcomes. In this same review, Web-based interventions were less effective overall but seemed to show efficacy with students who resisted change or considered changing their eating habits. This review also looked at environmental approaches that could increase the visual cues to action for selecting healthy options. There is evidence that in-person and Web-based interventions can help college students address stress and can nudge students in the direction of making healthy dietary choices.

Research has also focused on the effect that academic major selection and academic class selection have on the lifestyle behaviors of students. In one study, researchers examined the correlation between a college student’s chosen major and his or her dietary choices. It revealed that female nutrition majors had healthier habits and made superior food choices compared with female non-nutrition majors [41]. It is not clear whether the students who chose nutrition as a major had healthier habits before going into college, whether their education helped to inform them about healthy eating, or whether it was a combination of factors that led female nutrition students to have healthier eating habits. An examination of self-reports of students in a health sciences university in Bahrain revealed that a high percentage of health science students had unhealthy dietary habits and sedentary behaviors, with 48% (43/90) of male students physically inactive and 84% (463/552) of female students physically inactive on a daily basis [42]. This study revealed that students who focused on health sciences and on taking classes in health were not necessarily following a healthy lifestyle. Health sciences is a broad topic, and there is a vast array of courses that could be included in the curricula. Research demonstrates that a student’s interest in the topic of health does not mean that he or she adheres to a healthy lifestyle. The integration of nutrition education within the second year of medical school in the cardiovascular module was associated with improved heart-healthy eating habits [43].

A semester-long college course in lifestyle medicine could address many of the unhealthy habits that college students tend to adopt and sustain during college. Lifestyle medicine is the science and application of healthy lifestyles as interventions for the prevention and treatment of diseases such as heart disease, diabetes, stroke, obesity, dementia, and cancer, all of which are affected by lifestyle choices. It is the evidence-based specialty bridging the research and science of physical activity, nutrition, stress management and resilience, smoking cessation, sleep hygiene, social support, and other healthy habits to individuals through clinical practice in health care [44]. Lifestyle interventions include exercise prescriptions, nutrition prescriptions, stress management and resilience training, smoking cessation programs, sleep evaluations and recommendations, identifying and encouraging social connections, harnessing individuals’ strengths, and using positive emotions such as gratitude and laughter as medicine to empower individuals to reach their optimal state of health and well-being [45]. By providing a greater depth of knowledge concerning basic health information, guidelines, and research findings as well as prolonged exposure to lifestyle medicine tenets and by creating opportunities to practice healthy lifestyles throughout the semester, a lifestyle medicine class for undergraduates can empower students with the knowledge, skills, tools, and experiences necessary to adopt and sustain healthy habits for a lifetime.

With the American College of Lifestyle Medicine and the American College of Preventive Medicine working to create curricula for medical students, students in the health professions, and practicing physicians coupled with the newly formed American Board of Lifestyle Medicine creating a national board examination for certification in lifestyle medicine, lifestyle medicine is becoming mainstream for the treatment and prevention of chronic diseases such as diabetes, heart disease, obesity, stroke, and cancer. This paper aims to outline a curriculum for undergraduate- and graduate-level coursework that strives not only to impart an understanding of core lifestyle medicine concepts and skills as described in the existing literature but also to provide a place where students can reflect upon their own daily choices and work on their own behavior change project for a semester.

The overarching goal of the Introduction to Lifestyle Medicine Course was to demonstrate how lifestyle medicine principles and interventions apply to individual health behaviors, examining both short- and long-term health outcomes. Educational interventions on nutrition and exercise have been shown to improve student self-efficacy relating to various lifestyle-related preventive behaviors [46]. The Introduction to Lifestyle Medicine Course uses evidence-based principles that aim to increase student confidence, which enables students to co-create goals for themselves while progressing toward the adoption of healthy habits and completing their required behavior change project. By utilizing the coach approach, students are able to collaborate, negotiate, and partner with individuals to identify obstacles to change, strategies around the obstacles, character strengths, motivators, social supports, and methods of accountability that will enable lasting change. There is an emphasis on the student as both learner and teacher. All members of the course are acknowledged for their own life experience, and students share their wisdom during Web-based class discussions and discussion posts.

Introduction to Lifestyle Medicine Course students gain a solid understanding of the main components of lifestyle medicine. The history of the development of lifestyle medicine is the first focus of the course and provides the groundwork on which the rest of the material is built. Understanding cultural trends and national guidelines in lifestyle behaviors, such as exercise, diet, and stress management, encourages the students to consider the social ecological model of change, with a focus on how one’s environment helps to shape one’s behavior. The course brings the science from the medical literature and practical strategies from clinical experience to the students aspiring to instill healthful lifestyle behaviors in themselves, their family and friends, as well as future patients and clients. By the end of the 13-week course, the students have a solid understanding of the importance of practicing healthy habits.

Learning how to counsel people about lifestyle modification is the primary mode of delivery for lifestyle medicine. Motivational interviewing, appreciative inquiry, and other health coaching techniques are useful counseling methods in the clinical environment. Their use has been described in the medical literature as tools for patients to guide them to create and sustain behavioral change [55-57]. These concepts illustrate to college students that behavior change is not simply about “willpower” and “deciding to do it”—beliefs that all too often result in stigma toward self and others who need to change their behavior [58].

For lifestyle medicine, the core competencies for primary care physicians were recommendations by a blue ribbon panel, which comprised physicians from the American Medical Association, the American Osteopathic Association, the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, the American College of Preventive Medicine, and the American College of Lifestyle Medicine. They are outlined in Textbox 1 and were originally delineated in the Journal of the American Medical Association [59]. The Introduction to Lifestyle Medicine Course addresses all of the 15 core competencies except for application of office systems and technologies to support lifestyle medicine in the office setting. This competency was not relevant for students who were not currently practicing medicine and was not included in the course curriculum. A practicing lifestyle medicine physician should possess the following: knowledge, skills, attributes, and values.

The Web-based weekly class sections invite the students to apply the material discussed in class to themselves and their own lives (See Table 1). These periods of reflection allow the students to consider how they might make healthy changes while in college.

This Web-based, distance learning college lifestyle medicine course also includes a behavior change project because knowledge is powerful, but it is not powerful enough to instill lasting change. Thus, as part of the required work, the students examine and work on their own habits. Students are encouraged to focus on a behavior or healthy habit that they are seeking to adopt for themselves. They are asked to log their current activity and situation with that particular behavior, noting triggers, rewards, and emotions around it. Then, they are asked to create a behavior change plan with SMART (specific, measurable, achievable, results-focused and time-bound) goals and to establish a tracking and accountability methodology that works for them. At the end of the semester, the students write a brief (3-5 pages) report on their experience of trying to change a behavior. Review of these reports reveals that some students in the class quit smoking, lost weight, added exercise into their routines, sat for shorter periods of time, increased their ability to handle stress, added fruits and vegetables to their diets, and cut down on their alcohol intake.