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 Table of Contents  
STUDENT CONTRIBUTION
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 74-78

Cooking demonstrations to teach nutrition counseling and social determinants of health


1 Department of Medicine and Medical Education, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
2 Albert Schweitzer Fellowship of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA

Date of Submission14-Sep-2019
Date of Acceptance12-Sep-2020
Date of Web Publication08-Dec-2020

Correspondence Address:
Hannah Hashimi
C/O C. Harada, UAB SOM, 1720 Second Ave S, Volker 102-D, Birmingham, AL 35294
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_234_19

  Abstract 


Background: Future physicians should feel comfortable educating patients on disease-specific diets, and culinary medicine is an innovative approach to preparing medical students for this task. We present an engaged-learning program where medical students give community cooking demonstrations to gain experience counseling adults on nutrition and simultaneously develop understanding of the social determinants of health. Student volunteers undergo training in culinary skills, nutrition, motivational interviewing, and social determinants of health. They then lead cooking demonstrations at a local farmers’ market and later participate in a group debriefing session with faculty. Methods: Postexperience surveys were obtained. The primary outcome evaluated was feasibility of this educational intervention. Secondary outcomes were (1) student perception of the value of the program and (2) student self-rated learning of nutrition science, nutrition education, and social determinants of health. Results: A total of 117 students participated in the program over 3 years and 57% answered the postexperience survey. Students filled 91% of available volunteer slots (79 first-, 26 second-, 3 third-, and 9 fourth-year students). In a postexperience survey, 94.7% responded that the experience resulted in learning about nutrition education and 82.4% reported learning about social determinants of health. In commentary, students note that medical education was enhanced by interacting with community members. Discussion: Culinary education in a community setting is a feasible medical school service-learning activity that is well received by students. It can enhance learning of nutrition counseling skills and improve student understanding of the social determinants of health.

Keywords: Diet, food, and nutrition, education, health education, medical, undergraduate, service learning


How to cite this article:
Hashimi H, Boggs K, Harada CN. Cooking demonstrations to teach nutrition counseling and social determinants of health. Educ Health 2020;33:74-8

How to cite this URL:
Hashimi H, Boggs K, Harada CN. Cooking demonstrations to teach nutrition counseling and social determinants of health. Educ Health [serial online] 2020 [cited 2021 Aug 5];33:74-8. Available from: https://www.educationforhealth.net/text.asp?2020/33/2/74/302484




  Background Top


Since the Nutrition Academic Award released the “Nutrition Curriculum Guide for Training Physician Practice Behavior Skills and Attitudes Across the Curriculum,” there has been a push for nutrition curriculum in undergraduate medical education.[1] In addition, the American Heart Association released a call to medical schools to implement innovative ways to teach nutrition as a preventive measure for patients with chronic diseases.[2] One hands-on approach emerging at various institutions is “culinary medicine,” which is a method where students integrate basic medical knowledge into health promotion through basic culinary techniques.[3]

While there has been emphasis on using this approach to teach medical students about nutrition,[3],[4],[5] few have applied this learning strategy to incorporate the social determinants of health. Future physicians should be taught to apply basic principles of nutrition to vulnerable patient populations facing socioeconomic barriers to healthy eating. We aimed to address this need by developing an innovative program, in which medical students experience culinary medicine while also providing nutrition counseling to adults in an under-resourced community setting.


  Intervention Top


Cooking Healthily On a Penny (CHOP) is a community-engaged learning program teaching medical students to apply nutritional knowledge by giving weekly cooking demonstrations at a local farmer’s market. CHOP is offered as a supplemental service learning experience during the first-semester biochemistry course. Approximately fifty students can elect to participate in CHOP on a first-come, first-served basis. The program consists of a 3-h training session, a 2-h farmer’s market cooking demonstration, and an optional 1-hour debriefing. The process of planning and implementing CHOP, which takes place over 4–5 months, is depicted in [Figure 1].
Figure 1: Cooking Healthily On a Penny planning and implementation process

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During the training, students receive instruction in social determinants of health, motivational interviewing, disease-based nutrition science, food insecurity, and a hands-on cooking lesson. We provide a student manual, which outlines how to set up the booth, cooking, and clean-up instructions [Figure 2].
Figure 2: Sample page from Cooking Healthily On a Penny student manual

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Run by a local nonprofit agency, the market was chosen based on its location in a food desert and its mission to address health disparities. All recipes were developed to cost less than the Alabama Supplemental Nutrition Assistance Program allotment of $4.25 per serving,[6] averaging $1.34 per serving. Recipes utilize minimal utensils and heating elements. Based on our location in the deep South of the United States, it highlights “Southern” and “African-heritage” flavors. Each week focuses on a specific theme, designed to reinforce the core preclinical curriculum, such as restricted sodium, reduced carbohydrates, and increasing vitamins and proteins. Students used the demonstration process and printed materials to start conversations about healthy eating habits with market patrons. Students were then invited to a debriefing session attended by medical school faculty, including a nutrition expert and clinician, to reflect upon their experience and discuss areas for program improvement.


  Methods Top


After completing the CHOP experience, students completed an anonymous postexperience survey utilizing a Likert-type rating scale followed by free-text response questions. The primary outcome was the feasibility of applying the culinary medicine approach in an under-resourced community setting. Our secondary outcomes were (1) student perceptions of the program value and (2) student self-rated learning of nutrition science, nutrition education, and social determinants of health.

We analyzed free-text responses for recurring themes using a modified grounded theory approach. As each new theme emerged, its validity was determined by searching for its presence in previously coded texts, and exemplary quotes were selected to contextualize emergent themes. This study was exempted after review by the University of Alabama at Birmingham Institutional Review Board.


  Results Top


Over 3 years, 117 medical students participated in CHOP, representing a 91% “fill rate” for all available volunteer slots. Incomplete filling reflects absences at training (students who failed to attend the training were not allowed to volunteer) and last-minute personal conflicts. First-year medical students were given priority for the experience, and upper-classmen were invited to any remaining spots. Twenty-six second-, three third-, and nine fourth-year students participated during this time. Nine students participated more than once.

Fifty-seven students (49% of all participants) attended the debriefing session and completed the postexperience survey. [Figure 3] shows their responses. Nearly 91.3% agreed or strongly agreed they would recommend the experience to other medical students. In the first 2 years (38 responses), 60.5% and 42.2% also agreed that they learned something about nutrition and cooking, respectively. In year 3 (19 responses), we asked if students learned skills for nutrition education and 94.7% agreed or strongly agreed they did. In that year, 84.2% also responded affirmatively they learned about social determinants of health.
Figure 3: Postexperience survey response rates

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There were several recurring themes in the free-text responses on the survey. The first was that the program is appealing because it provides hands-on, practical learning. The second was that students enjoyed the opportunity to interact with community members. Typical quotations include “I enjoyed having interactions with these people, even though they weren’t patients.” A third theme was that students reported their communication skills improved. For example, one student said, “You have to change up your approach to match the specific person’s level of knowledge.”

There were also many suggestions for improving the program including adding variety to the recipes, attracting a larger audience of market patrons, and offering more opportunities for students to participate. One common theme initially was the need for more robust education on nutrition science, although after changes to the training curriculum, this improved.


  Discussion Top


The “culinary medicine” approach to nutrition education can be adapted using a service-learning approach for medical student education. We found this program is feasible, and it continues to thrive and expand each year at our institution. Our secondary outcomes were also positive. The program has been well received by our medical students, whose most frequent request is more opportunities to participate. Student self-rated nutrition science learning was lower than self-rated learning about nutrition education and social determinants of health as a result of participation.

Reports in “culinary medicine education” literature usually report improvements in provider behaviors, nutritional knowledge, and confidence in patient counseling.[3] We initially designed this experience to teach medical students about nutrition, but we found through feedback they were also learning about social factors impacting health. This is likely due to the service-learning approach we took, with a focus on understanding the needs of the vulnerable population served by the market. This supports the findings of others, who have reported that community-engaged experience is successful in teaching dietetics.[7] When compared to traditional medical education, real-world experience has also been shown to be more effective in changing behaviors.[5],[8] Hence, it should not be surprising this experience was more highly valued by students for the hands-on skills building in communication and nutrition counseling.

We learned a number of important lessons in developing this program. First, the training initially placed more emphasis on culinary skills than nutrition education, and students felt unprepared to counsel. Second, students were critical of recipe selections. In response to student desire for more hot dishes, we added hot plates to incorporate stews, eggs, and fish-based recipes. We later added more breakfast recipes due to student concerns about the time of day cooking demonstrations were held.

Another challenge was low patron volume at the market in general and gathering a large enough audience for cooking demonstrations. Throughout the program, we adapted to draw in more patrons by offering premade samples and walking around the market to approach patrons instead of waiting passively at a table. Consideration of incentives to visit the table, such as market credit, could improve the number and quality of teaching interactions, our students have with market patrons. In the future, we plan to involve market patrons more during recipe selection, which could bolster community participation.

A fourth lesson learned concerns poor student attendance at debriefing sessions, which were nonmandatory. It has been shown that debriefing improves postexperience learning, regardless of type.[9] Future consideration includes making attendance mandatory or reducing the time from activity to structured reflection.

Our evaluation of this intervention is limited by several factors. Our secondary outcomes are based on subjective self-reporting, and response rates to our survey were low. In addition to higher response rates, it would be more instructive to include an objective assessment of changes in student knowledge and skills after the intervention. Future study is also required to understand the impact of this intervention in the community. In addition, this program was performed at a single institution, and although we believe it could be easily replicable, adaptations will be required based on institutional and community factors.

Overall, this program was not only feasible but received top box scoring from students as a method of teaching social determinants of health and nutrition education through culinary medicine. Participants say they gained confidence in patient counseling and developed meaningful connections to people from different backgrounds. Culinary education in a community setting can be a rewarding learning experience for medical students.

Acknowledgments

We are grateful to Sally Allocca, Executive Director of P.E.E.R., Inc., for partnering with us to bring CHOP into the community. We are also grateful to Craig Hoesley, MD, Senior Associate Dean for Medical Education, for his support of service-learning programming in the UAB School of Medicine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
National Lung, Heart & Blood Institute. Nutrition Curriculum Guide for Training Physician Practice Behavior Skills and Attitudes Across the Curriculum; 2002. Available from: https://www.nhlbi.nih.ov/sites/default/files/media/docs/NAA%20Nutrition%20Curriculum%20Guide.pdf. [Last accessed on 2019 Jun 04].  Back to cited text no. 1
    
2.
Aspry KE, Van Horn L, Carson JA, Wylie-Rosett J, Kushner RF, Lichtenstein AH, et al. Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: A science advisory from the American heart association. Circulation 2018;137:e821-e841.  Back to cited text no. 2
    
3.
Polak R, Phillips EM, Nordgren J, La Puma J, La Barba J, Cucuzzella M, et al. Health-related culinary education: A summary of representative emerging programs for health professionals and patients. Glob Adv Health Med 2016;5:61-8.  Back to cited text no. 3
    
4.
Pang B, Memel Z, Diamant C, Clarke E, Chou S, Gregory H. Culinary medicine and community partnership: Hands-on culinary skills training to empower medical students to provide patient-centered nutrition education. Med Educ Online 2019;24:1630238.  Back to cited text no. 4
    
5.
Ring M, Cheung E, Mahadevan R, Folkens S, Edens N. Cooking up health: A novel culinary medicine and service learning elective for health professional students. J Altern Complement Med 2019;25:61-72.  Back to cited text no. 5
    
6.
United States Department of Agriculture Food and Nutrition Service. Supplemental Nutrition Assistance Program State Activity Report Fiscal Year 2016; 2017. Available from: https://www.fns.usda.gov/pd/snap-state-activity-reports. [Last accessed on 2019 Jun 04].  Back to cited text no. 6
    
7.
Kim Y, Clasen C, Canfield A. Effectiveness of service learning and learning through service in dietetics education. J Allied Health 2003;32:275-8.  Back to cited text no. 7
    
8.
Monlezun DJ, Dart L, Vanbeber A, Smith-Barbaro P, Costilla V, Samuel C, et al. Machine learning-augmented propensity score-adjusted multilevel mixed effects panel analysis of hands-on cooking and nutrition education versus traditional curriculum for medical students as preventive cardiology: Multisite cohort study of 3,248 trainees over 5 years. Biomed Res Int 2018;2018:5051289.  Back to cited text no. 8
    
9.
Levett-Jones T, Lapkin S. The effectiveness of debriefing in simulation-based learning for health professionals: A systematic review. JBI Libr Syst Rev 2012;10:3295-337.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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