Impact and evaluation of an online culinary nutrition course for health, education and industry professionals to promote vegetable knowledge and consumption

Abstract

Background

Poor diet, including inadequate vegetable intake, is a leading risk factor for noncommunicable disease. Culinary and nutrition education provided to trainee and practising health and education professionals is an emerging strategy to promote improved dietary intake, including vegetable consumption. We evaluated the impact and feasibility of an online culinary medicine and nutrition (CM/CN) short course for health, education and vegetable industry professionals. The course aimed to improve participants’ skills and confidence to prepare vegetables, knowledge of evidence‐based nutrition information and recommendations for improving vegetable consumption and diet quality.

Methods

A pre–post study consisting of two separate groups participating in two course rounds recruited practising professionals (n = 30) working in health; community, adult and/or culinary education; and the vegetable industry. Evaluation assessed diet quality, vegetable consumption barriers, cooking and food skill confidence, nutrition knowledge and process measures.

Results

Seventeen participants (68%) completed the programme. Pre‐ to postintervention statistically significant increases in vegetables (M 1.3, SD 2.2), fruit (M 1.6, SD 3.1), and breads and cereal (M 1.1, SD 1.7) intakes were observed. Statistically significant increases and large effect sizes for mean food skill confidence scores (M 8.9, SD 15.4, Cohen's d 0.56) and nutrition knowledge scores (M 6.2, SD 15.4, Cohen's d 0.83) were also observed pre‐ to postintervention.

Conclusions

The short online course was feasible and improved diet quality, food skill confidence and nutrition knowledge. Online CM/CN education for practising professionals represents a promising area of research. Future research involving a larger study sample and a more rigorous study design such as a randomised control trial is warranted.

Health, education and vegetable industry professionals can play a key role in improving culinary nutrition practices, nutrition knowledge and dietary intake of patients, students and clients

Key points

• The online asynchronous course was feasible to run and well received by health, education and vegetable industry professionals.

• After completing the 5‐week online culinary nutrition course, participants had increased vegetable intake, bread and cereal intake, food skill confidence and nutrition knowledge.

• Findings indicate larger studies, with randomised control trial design, and that examine the impact on professionals' patients, clients and students are warranted.

INTRODUCTION

Inadequate intake of vegetables, fruits and wholegrains and excess intake of energy‐dense, nutrient‐poor foods such as sugar sweetened beverages, lollies and take away foods are leading risk factors for noncommunicable diseases, including cardiovascular disease, diabetes and some cancers. ¹ , ² Low vegetable intake and variety has been shown to contribute to health burden, ³ , ⁴ with estimates showing that in Australia a 10% increase in vegetable consumption would have reduced cardiovascular disease and some cancers in 2015/16 resulting in reduced healthcare expenditure of AUD$99.9 million. ⁴

Higher‐level cooking skills and more frequent home cooking is associated with increased vegetable intake and higher diet quality. ⁵ , ⁶ , ⁷ Culinary nutrition (CN) promotes healthy sustainable dietary patterns by incorporating nutrition practice, food science and culinary arts. ⁸ CN interventions have been shown to improve diet‐related health and improve fruit and/or vegetable intake, knowledge, skill and confidence in cooking. ⁹ , ¹⁰ The use of practical instruction instead of theory or demonstration in culinary education has been identified as a more effective education strategy for long‐term behaviour change. ¹¹ Online CN education ¹² , ¹³ , ¹⁴ , ¹⁵ and online training of education professionals to deliver CN programmes ¹⁶ are becoming increasingly popular, particularly during the COVID‐19 pandemic. It is important that the information and skills taught are consistent with evidence‐based nutrition recommendations. Evaluation of effectiveness of online CN interventions in modifying dietary and health‐related outcomes is limited to only a few studies. ¹⁴ , ¹⁵ , ¹⁶

Health professionals are in a position to provide nutrition information to support health promotion, ¹⁷ , ¹⁸ and should have an understanding of the importance of supporting behaviour change. ¹⁹ However, currently there is limited provision of nutrition education in undergraduate medical curricular, ²⁰ and medical practitioners report a lack of training in regard to providing evidence‐based nutrition advice within medical practice. ²¹ Providing nutrition training to healthcare providers is therefore an important strategy to help prepare them for helping patients address modifiable diet‐related risk factors for chronic disease. ²¹ , ²² Culinary medicine (CM) offers a culinary focused, evidenced‐based, practical and patient‐centred approach to the prevention and management of diet‐related chronic disease. ²³ CM education programmes equip healthcare providers with the skills and knowledge to promote culinary and diet‐related health behaviour change in their patients or clients, while simultaneously promoting health behaviour change in the healthcare provider themselves. ²³ , ²⁴

CM education primarily targets student and trainee medical practitioners; ²⁵ however, practising health professionals from a range of health disciplines may also benefit as a form of continuing professional development (CPD). CPD for practising healthcare professionals that can be delivered remotely using technology such as video‐conferencing and online courses can benefit professionals living in diverse locations, and represent feasible alternatives to traditional face‐to‐face or classroom‐style learning. However, there is a need for more detailed and rigorous evaluation of the impact on learning outcomes and professional practice. ²⁶ Teaching professionals with training in culinary arts, who teach in community education settings, may also benefit from CN education. This has a dual purpose of potentially impacting the professional's own behaviour through the provision of CPD on evidence‐based, nutrition‐related health promotion and also potential impacts on the dietary‐related behaviours of their students. A scoping review by Asher et al. noted limited descriptions of CN training to facilitators to deliver CN interventions in community and adult education settings. ²⁵ Therefore, there is the opportunity to target CN education to not only healthcare providers but also to culinary and nutrition education professionals in community and adult education settings to improve the reach of these programmes.

No studies have trialled CN courses for vegetable industry professionals. However, vegetable industry professionals have knowledge and expertise in vegetable growing, varieties and culinary uses as well as frequent contact with workers along the vegetable supply chain and the general public. Therefore, they have opportunities to promote vegetable consumption but may not have formal, in‐depth nutrition education or culinary training required to support others. Research including vegetable industry professionals is needed.

The primary aim of the current study was to develop, deliver and evaluate the impact and feasibility of an online CM/CN short course for healthcare, education and vegetable industry professionals. The course was designed to improve their skills, knowledge and confidence to prepare vegetables, knowledge of evidence‐based information and recommendations for vegetable consumption, and dietary intake. The secondary aim was to address and further explore barriers to vegetable consumption among healthcare, education and vegetable industry professionals.

METHODS

Study design

The study was guided by the Cook‐Ed model for cooking programme planning, implementation and evaluation. ²⁷ Formative research included a scoping review examining the evidence related to CN education provided to health and education professionals. ²⁵ A cross‐sectional survey of healthcare and education professionals and their current cooking and food skills, nutrition knowledge, vegetable intake and variety, and barriers to provision of behaviour change education to clients, students and patients was also conducted and has been published elsewhere. ²⁸ Findings from this formative research informed the development of a five‐module, online, asynchronous instructor‐led CM/CN short course.

Evaluation was conducted as a pre–post study over two programme rounds with two separate groups. Surveys were completed online (Qualtrics LLC) at baseline and postprogramme. Preprogramme surveys were completed in November 2020 (Group 1) and February 2021 (Group 2). Postprogramme surveys links were sent to participants on programme completion and had to be completed within 8 weeks of commencing the course. Postprogramme surveys were completed in December 2020–January 2021 (Group 1) and April 2021 (Group 2). Sample size was pragmatic due to time, budget and COVID‐19‐related constraints, and to enable meaningful engagement of programme interventionist (RCA) within the online discussion forums and live Q&A sessions.

Participants and recruitment

Eligible participants included healthcare workers who saw clients/patients face to face; education professionals who worked in community nutrition, adult nutrition or culinary education; and vegetable industry professionals. Practising healthcare professionals from any health discipline and community‐based or professional CN educators may benefit from CPD targeting CN education and were therefore included. Culinary education professionals were targeted as they may not have the necessary nutrition knowledge or skills, yet have opportunities to promote healthy culinary skill development through culinary education. Vegetable industry professionals were eligible due to access to these professionals via convenience sampling and their opportunity to promote vegetable consumption, but may not have formal, in‐depth nutrition education or culinary training required to support others.

Additional eligibility criteria included access to the internet; English speaking; access to a working kitchen including refrigeration, a stove top and oven; kitchen utensils including a minimum of one saucepan and/or frypan, a stirring utensil, cutting board and knife, mixing bowl and serving plate. Exclusion criteria included being <18 years of age and prior course completion.

Participants were recruited using convenience sampling through advertising the study via email, word of mouth and internal communication through the University of Newcastle and via networks of the University of Newcastle research team and Rijk Zwaan Australia Pty Ltd. Recruitment opened 3 weeks prior to each of the two programme groups commencing mid‐November 2020 and mid‐January 2021.

Course content

Course content was guided by formative research. ²⁵ , ²⁸ Following the Cook‐Ed model planning Stage 1 ‘Define the cooking related need or problem’ ²⁷ the programme goal was to emphasise different vegetable preparation and cookery methods, for a variety of vegetables, due to inadequate intakes in the Australian population ¹ and the known health benefits related to increased vegetable intakes ² and variety. ³ Formative research, course development and delivery were conducted in collaboration with vegetable industry experts (F. T. and J. B.; see acknowledgements and author S. R. who were not study participants) given their knowledge and expertise in vegetable growing, selection, storage and preparation.

Following Stage 2 of the Cook‐Ed model ‘Consider behaviour change factors’, ²⁷ factors that may influence culinary practices of health and education professionals were explored using a cross‐sectional survey ²⁸ with findings used to inform course content.

In the Cook‐Ed model Stage 3 ‘Capacity Assessment’, ²⁷ and with consideration to the COVID‐19 pandemic, an online course was developed.

Guided by Cook‐Ed model Stage 4 ‘Develop programme content and facilitation guides’ ²⁷ course content was created in partnership with vegetable industry experts (F. T., J. B. and S. R.), research team members with experience in CN education (R. C. A., T. B., V. A. S. and C. E. C.), consumer behaviour (T. B.) and a qualified chef (R. C. A.).

Over the entire course, cooking activities were designed to demonstrate vegetable‐based dishes that could be used for each typical western‐style diet eating occasion (i.e., breakfast, lunch and dinner and side dishes, and snacks). Vegetable‐related food preparation, cooking and food skills reported by health and education professionals as having lowest confidence were prioritised for inclusion. ²⁸ These included ‘making sauces and gravy from scratch’ which led to the inclusion of a number of cooking activities using vegetable‐based sauces, ‘using vegetables as snacks’, and ‘buying food in season’ of which education for selection and use was emphasised through the ‘vegetable butchery’ videos. Low confidence scores for nonvegetable‐related cooking or food skills (e.g., ‘baking cakes/bread/buns’) were not prioritised as teaching these skills did not meet the objectives of the course. Home learning cooking activities were linked to nutrition education presentations, ‘vegetable butchery’ and cooking demonstration videos, a weekly discussion board, live Q&A sessions, test your knowledge questions and further reading suggestions (Figure 1).

Figure 1.

Summary of course topics, modules and programme structure

Nutrition education content was informed by findings of the health and education professionals survey. ²⁸ Nutrition education on ‘special vs “fad” diets’, ‘simple vegetable recipes for meals, sides, snacks’, ‘using limited ingredients or utilising leftovers’, ‘identifying healthy portion sizes’, ‘creating balanced meals’ and ‘understanding food labels’ was prioritised for inclusion based on survey findings. ²⁸ Although ‘cooking for different cultural groups’ was a highly requested topic, it was not possible to include it within the time constraints of the programme. Although health behaviour change counselling was reported as a barrier to providing nutrition education in practice ²⁸ and a requested topic, it was not within the scope of the current CM/CN programme. Instead, participants were directed to an online open course specifically designed to support nutrition communication skills for behaviour change (nutrition communication for health professionals: key concepts and applying skills) ⁵⁵ , ⁵⁶ which was available online at that time.

All course material was provided through Blackboard Open Education Platform (Blackboard Inc.). A new module was released weekly over the 5 weeks, which participants could complete in their own time, with each module expected to take between 2 and 3 h. Announcements were made via Blackboard to alert participants to new content, any upcoming live Q&A sessions and the release of postintervention surveys.

Data collection and tool development

Existing validated tools were used to measure diet quality, ²⁹ cooking and food skill confidence ³⁰ and nutrition knowledge. ³¹ Barriers to vegetable consumption were measured by adapting questions from a previous survey on vegetable preparation and cooking barriers among individuals living in low‐income households. ³²

Diet quality

The Australian Recommended Food Score (ARFS) was used to measure diet quality and vegetable variety. ²⁹ The ARFS has been validated previously in adults and has significant associations with a more comprehensive food frequency questionnaire. ³³ The food frequency questionnaire and ARFS both are significantly correlated with plasma carotenoids. ²⁹ , ³³ , ³⁴ The ARFS consists of 70‐questions to assess usual intake, scores range from 0 to 73. Points are scored for intake of the following: vegetables (21); fruit (12); meat‐based protein foods (7); vegetable protein foods (6); breads and cereals (13); dairy (11); water (1); spreads/sauces (2); additional points are scored for consuming vegetables ≥5 nights/week (1); choosing multigrain or wholemeal breads (1); and choosing reduced fat/skim or soy milk (1). Further details on ARFS have been published previously. ²⁹ , ³⁴

Barriers to vegetable consumption

Personal, interpersonal and environmental barriers to vegetable consumption were assessed by 13 questions adapted from Landry et al.'s modified questionnaire ³² with a further 3 added regarding attitudes to eating and preparing vegetables to assess barriers to vegetable consumption identified in literature ³² , ³⁵ , ³⁶ , ³⁷ and interventions designed to promote vegetable intake. ³⁸ , ³⁹ The additional questions were, ‘I currently eat enough vegetables to meet my needs’, ‘I do not like to eat vegetables’ and ‘I do not like to prepare vegetables’. Questions related to availability of vegetables were asked on a four‐point Likert scale (ranging from 1 = ‘never’ to 4 = ‘all of the time’). Questions related to barriers to purchasing vegetables, barriers to preparing, cooking and eating vegetables, and attitude to eating and preparing vegetables were assessed using a five‐point Likert scale (ranging from 1 = strongly disagree to 5 = strongly agree). Individual questionnaire items were summed and reported as a continuous variable.

Cooking and food skill confidence

A validated 33‐item questionnaire was used to measure cooking and food skill confidence. ³⁰ Responses were measured on an eight‐point Likert scale (ranging from 0 = never/rarely to 7 = very good). Cooking confidence measure scores were scored out of 98, and food skill confidence out of 147. To reflect study aims, an additional four questions were added. These included questions asking how often participants ‘make a salad dressing’, ‘make a salad from scratch’, ‘use vegetables as snacks’ and ‘keep fresh vegetables for salads or side dishes’.

Nutrition knowledge

Nutrition knowledge was measured using the validated 117‐item, revised Australian nutrition knowledge questionnaire (AUS‐R NKQ). ³¹ The AUS‐R NKQ is made up of four sections: questions on dietary recommendations (19), nutrients in food (53), food choices (10) and diet–disease relationships (35). A total score of 117 is generated from questionnaire responses, with correct answers resulting in 1 point and incorrect or ‘unsure’ responses in 0 points.

Process evaluation

At the completion of the programme, participants completed a 14‐question survey designed to capture information on participant satisfaction and feedback. Participants responded to statements on a five‐point Likert scale (ranging from 1 = strongly disagree to 5 = strongly agree). Statements were related to the ease of understanding the course (‘The culinary nutrition short course was easy to understand’), and separate statements were used to evaluate changes in quantity and variety of vegetable consumption and preparation and how participants discuss food and nutrition with their patients/clients as a result of the course. Participants were asked to indicate (tick all that apply) what components of the course (e.g., key reading, nutrition presentations, vegetable butchery videos) they found most beneficial, and which modules they found most beneficial (select up to three). Two questions evaluated how frequently they used the course and on average how much time they spent on the course. Participants were asked to indicate on a scale of 0 (not recommend) to 10 (strongly recommend) whether they would recommend the course to other professionals in their field. Two open‐ended questions captured qualitative feedback on the programme by asking, ‘Do you have any suggestions for how the researchers can improve the short course?’ and ‘Do you have any more comments about the short course that you think might be useful for the researchers?’ Qualitative responses were summarised by a member of the research team (R. C. A.).

Statistical analysis

STATA Statistical/Data Analysis software, version 15.1 (StataCorp) was used to conduct the statistical analysis. Data were checked to see if it was normally distributed. Continuous data were reported as mean (M) and standard deviation (SD). Categorical data were reported as frequencies. Preliminary efficacy to assess the changes in mean scores from pre to postintervention was analysed using paired t‐tests. Cohen's d (M1−M2/SDbaseline) was used to estimate effect sizes. A Cohen's d > 0.5 indicated a medium and >0.8 a large effect. ⁴⁰ Independent t‐tests were run to determine if there were any differences at baseline between completers and noncompleters. A sensitivity analysis was undertaken to include participants who did not complete the postprogramme survey. As data did not appear to be missing at random, last observation carried forward was used. Descriptive statistics and a thematic analysis were undertaken to report findings from the process evaluation.

RESULTS

Thirty participants consented to participate in the programme (Group 1 n = 13; Group 2 n = 17). Five participants who registered and completed the preprogramme survey did not go on to enrol in the online course (Group 1 n = 1; Group 2 n = 4). Of the remaining 25 participants who enrolled, 17 (68%) participants completed the postprogramme survey (Group 1 n = 10; Group 2 n = 7). Of the eight participants who did not complete the postprogramme survey, only one participant was rated as an ‘active participant’ in the course, defined as having engaged in either the discussion board, live Q&A session and/or ‘test your knowledge’ quiz in addition to other course content. Therefore, the primary data presented report results of the participants who completed both the pre‐ and postprogramme surveys.

Participant characteristics

Of the 17 participants who completed the online programme the majority were health professionals (n = 14), female (n = 15), had been practising for >10 years (n = 11) and were the primary person responsible for providing meals in their household (n = 14) (Table 1). There were no significant differences in baseline characteristics between completers and noncompleters (Supporting Information Table 1).

Table 1.

Summary of participant characteristics

Characteristics	n	%	M	SD
Community education	1	5.9
Health professional	14	82.4
Vegetable industry	2	11.8
Female	15	88.2
BMI	17	–	25.1	3.3
Age	17	–	44.6	12.9
Meal provision
Most of the time	14	82
Sometimes	1	5.9
About half of the time	1	5.9
Rarely	1	5.9
Never	0	0
Employment status
Full time	8	47.1
Part time	7	41.2
Self‐employed part time	2	11.8
Education
Postgraduate	6	35.3
Bachelor's degree	10	58.9
Trade certificate/diploma	1	5.9
Years practising
3–5 years	2	11.8
5–10 years	4	23.5
>10 years	11	64.1
Health discipline
Nursing	2	14.3
Medical officer	3	21.4
Physiotherapy	1	7.1
Occupational therapy	3	21.4
Dietitian	1	7.1
Podiatry	1	7.1
Dentistry	1	7.1
Dental assistant or oral health	1	7.1
Other (health promotion)	1	7.1
Health setting
Public hospital	6	42.9
Private hospital	1	7.1
Community health centre	3	21.4
Private practice	4	28.6
Other (not for profit, community outreach)	2	14.3
Interaction with patients/clients
Face to face with clients/patients	10	50
Face to face with family/carer	5	25
Small‐group education (>8)	4	20
Large‐group education (>10)	1	5
Average time spent with patients/clients (min)	17	–	37.9	25.1
Average number of patients/clients per week	17	–	30.5	33.4
Cooking and food skill confidence scores
Cooking skill confidence	16	–	78.4	14.7
Food skill confidence	17	–	98.5	16.1

Note: BMI, body mass index; M, mean; SD, standard deviation.

Diet quality (ARFS)

Table 2 summarises the overall diet quality and vegetable intakes pre‐ and postprogramme. Significant increases from preprogramme were observed for total diet quality as well as diet quality subscale scores for vegetables, fruit, breads and cereals, and spreads and sauces. The greatest effect sizes were observed for total diet quality (Cohen's d 0.73) and the fruit subscale scores (Cohen's d 0.68). The results of the sensitivity analysis also showed a significant increase from baseline for all the same variables, except fruit which was no longer significant. Effect sizes were much smaller, with none of the Cohen's d results showing a moderate effect (Supporting Information Table 2).

Table 2.

Australian Recommended Food Score (ARFS) diet quality and diet quality subscale scores pre‐ and postprogramme

	Baseline ( n   = 17)		Postprogramme ( n   = 17)		Mean difference (post–baseline)	Effect size
Outcome measure (maximum available score)	M	SD	M	SD	M	(Cohen's d )
ARFS – vegetables (21 points)	15.5	2.7	16.8	2.7	1.3*	0.48
ARFS – fruit (12)	5.4	2.4	6.9	2.2	1.6*	0.68a
ARFS – meat chicken, fish and seafood (7)	3.4	1.5	3.5	1.6	0.1	0.07
ARFS – nuts, eggs and vegetarian meat alternatives (6)	3.4	1.9	3.8	1.6	0.4	0.23
ARFS – breads and cereals (13)	5.4	2.3	6.5	2	1.1*	0.52a
ARFS – milk, cheese and yogurt (11)	3.1	1.7	3.2	1.6	0.1	0.04
ARFS – water (1)	0.9	0.3	0.9	0.2	0.1	0.20
ARFS – spreads and sauces (2)b	0.2	0.4	0.5	0.6	0.3*	0.55a
Total score (73)	37.3	6.7	42.2	6.9	4.9**	0.73a

Note: M, mean; SD, standard deviation. ***p < 0.001.

^a Cohen's d > 0.5 indicating medium effect.

^b Spreads and sauces, including yeast extract spread, tomato ketchup/barbecue sauce, contribute a large amount of B‐group vitamins or β‐carotene, respectively; therefore, they are included in the ARFS scoring. ⁵⁷

^* p < 0.05;

^** p < 0.01.

Barriers to vegetable consumption

Table 3 summarises participants' barriers to vegetable consumption. The only statistically significant finding was an increase in agreement with the statement ‘I currently eat enough vegetables to meet my needs’ from pre‐ to postprogramme. This remained significant in the sensitivity analysis including all 30 participants; however, the effect size was reduced (Supporting Information Table 3).

Table 3.

Self‐reported barriers to vegetable consumption pre‐ and post‐programme

Note: Items with a trend to reducing barriers (negative mean difference^b) are highlighted in green.

^aScoring: 1 (never) to 4 (all of the time).

^bScoring: 1 (strongly disagree) to 5 (strongly agree).

^cCohen's d > 0.5 indicating medium effect.

*p < 0.05;

**p < 0.01;

***p < 0.001.

Cooking skill confidence and food skill confidence scores

Cooking skill confidence did not increase significantly from pre‐ (M = 78.4, SD = 14.7) to postprogramme (M = 79.1, SD = 13.9). Food skill confidence scores, however, showed a significant increase in participants who ‘use vegetables as snacks’ (M = 1.2, SD = 0.5, p < 0.01; Cohen's d 0.9) and for total food skill confidence score (M = 8.9, SD = 15.4, p < 0.05; Cohen's d 0.56). These findings remained significant in the sensitivity analysis; however, effect sizes were reduced (Supporting Information Table 4).

Nutrition knowledge (AUS‐R NKQ)

Total nutrition knowledge (M = 6.2, SD = 6.3; Cohen's d 0.83) and diet–disease relationship subscale (M = 2.7, SD = 2.5; Cohen's d 0.93) scores significantly increased from pre‐ to postprogramme. Moderate effect sizes for nutrition knowledge subscales dietary recommendations (Cohen's d 0.64) and nutrients in food (Cohen's d 0.55) were also noted even though changes were not statistically significant. In the sensitivity analysis none of these findings remained significant (Supporting Information Tables 5 and 6).

Participant engagement and acceptability of the programme

Programme satisfaction is reported in Figure 2. Briefly, the majority (n = 15) of participants who completed the online programme agreed or strongly agreed that the programme encouraged them to eat a greater quantity and variety of vegetables. Similarly, the majority of participants (n = 13) reported that the programme encouraged them to prepare a greater quantity and variety of vegetables at home. Nearly all participants agreed or strongly agreed that they were satisfied with the course (n = 16) and found the course easy to understand (n = 15).

Figure 2.

Participant satisfaction with the culinary nutrition course

When participants were asked how long they spent per week engaging with the course, participants reported spending 1–2 h (n = 12), 2–3 h (n = 4) and <30 min per week (n = 1). The top three most beneficial modules identified by participants were ‘Food‐related health and disease’ (n = 10), ‘Diabetes risk reduction’ (n = 10) and ‘Cardiovascular disease prevention’ (n = 9), whereas the top three most beneficial components of the programme included the nutrition education presentations (n = 15, 88%), home‐based cooking activity (n = 12) and the recipe presentations (n = 10).

Qualitative feedback was positive overall. The themes identified to help improve the programme were regarding changes to content delivery, for example, more use of summaries, handouts and highlighting key messages (n = 6); visual presentation, for example, more pictures or diagrams in presentations and recipes (n = 4); and course content, for example, complexity of information (n = 4). Some participants indicated that the course had improved their confidence to speak with patients about nutrition (n = 2) and changed their dietary and cooking behaviour to include more variety (n = 1) and include the recipes used in the course (n = 1). One participant found difficulty adapting the recipes to suit dietary requirements (FODMAPS) and the need to modify the food budget to incorporate the home cooking activity.

DISCUSSION

The current study evaluated a 5‐week online, asynchronous CM/CN CPD programme for health, education and vegetable industry professionals. Findings from the current study showed that the course resulted in positive improvements in participants’ overall diet quality, with increased variety of vegetables, fruit, breads and cereals reported. Improvements in food skill confidence and nutrition knowledge were also reported. Overall, the course was well received by participants.

The current online CM/CN short course primarily enrolled health professionals, but also included some education and vegetable industry professionals. This is not surprising given the recruitment strategy used existing networks and differences in CPD requirements between health, education and vegetable industry professionals.

The retention rate in the current study (68%) was similar to those of other CM/CN programs that moved to online mode due to COVID‐19, which had retention rates ranging from 65% to 70%. ¹⁴ , ¹⁵ The retention rate is similar to a CM programme targeting practising medical professionals, ⁴¹ whereas a CM programme delivered to seven dually qualified health coaching and culinary professionals had a retention rate of 100%. ⁴² Previous online programs have shown that free online courses tend to have a large reduction from the number of participants who initially sign up versus those who complete the programme, with retention rates reported typically between 10% and 20%. ¹² , ⁴³ This suggests that people generally are interested in online programmes, but further incentives, such as obtaining CPD accreditation recognised by professional associations, may support improved retention in this population.

Significant improvements in diet quality, vegetable, fruit, and breads and cereals were observed in the current study. Baseline total ARFS, vegetable and vegetarian alternative subscales were higher than previously reported in the general population; ⁴⁴ all other ARFS subscales were similar. Across the course, significant improvements in overall diet quality and the vegetable subscale were expected due to the primary target of improving vegetable intakes. Additional improvements in the fruit subscale among completers and breads and cereals were also observed. These findings are similar to those of other CM/CN programmmes which have also demonstrated improvements in vegetables, fruit and grain intakes. ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ Although larger and longer‐term evaluations are still required, findings from the current study support previous conclusions that CM/CN programs positively impact the diets of participants. ⁹ , ¹⁰ , ²⁵

Commonly reported barriers to vegetable consumption include taste, lack of time, knowledge or skills to prepare, cost and availability of vegetables in the home. ³² , ³⁵ , ³⁶ , ³⁷ At baseline participants’ scores indicated low barriers to vegetable intake. Results should be interpreted with caution as it is possible that those who participated in the current study may have more interest in vegetable intake and nutrition‐related health. The low scores for barriers to vegetable intakes at baseline may explain why no significant changes in scores for barriers to vegetable intake were identified. However, although not statistically significant, there were trends to a further reduction in barriers postprogramme regarding access to cut up vegetables in the home, access to fresh vegetables at the store nearby, not knowing how to prepare vegetables, not having simple/quick recipes for vegetables and not liking vegetables. Previous interventions aimed at addressing barriers to vegetable consumption in the general population have been successful; ³⁸ , ³⁹ , ⁴⁹ however, those interventions were targeted at different populations, mostly healthy adults. Larger studies are required to evaluate whether CM/CN programmes can be used to overcome health, education and vegetable industry professional barriers to vegetable intakes and increase intakes sufficiently to confer health gains.

Cooking skills and nutrition knowledge significantly improved in participants who completed the online course. Previous CM/CN programmes run for health professionals have also reported an improvement in nutrition skills and knowledge postprogramme. ²⁵ In education professionals, it has been reported that a lack of nutrition knowledge is a barrier to supporting others under their care to make dietary changes. ⁵⁰ To our knowledge the effect of CM/CN programmes on cooking skills and nutrition knowledge has not been examined previously in vegetable industry professionals. CM/CN programmes, such as the current course, can be used to improve cooking skills and nutrition knowledge in professionals working in roles with opportunity to influence the diets of others. Improving nutrition skills and knowledge in health, education and vegetable industry professionals is the first step to supporting these professionals to assisting their patients/clients and students to make dietary changes. Findings from the current CM/CN course reflect this notion, with a majority of participants agreeing or strongly agreeing that this course helped how they discussed nutrition with their patients/clients.

The current CM/CN course was well received by participants, with those who completed it reporting that they found the course easy to understand and encouraged them to eat a greater quantity and variety of vegetables. To our knowledge this is the first CM/CN CPD course targeting health, education and vegetable industry professionals. More than half of participants reported that this course improved how they discussed food and nutrition with clients; although this was not the focus of the programme, the majority agreed with this statement. Future programmes could consider a module on how to discuss food and nutrition with their clients and patients. Considering the course was well received by participants, these results are promising for implementation and evaluation of future programmes, particularly with health professionals. However, larger interventions with a more heterogenous sample are still required to determine whether this applies to other professional groups such as those in education settings.

One of the strengths of the current study was that the online programme was run asynchronously; this allowed participants to access the course in their own time, and therefore this creates greater opportunities for CPD activities. ⁵¹ In addition, asynchronous online CM/CN programmes are cost effective and offer sustainable delivery methods which allows for scale‐up opportunities. Lastly, validated assessment tools were used to assess nutrition knowledge, cooking and food skill confidence and diet quality, and previously tested questions to measure barriers to vegetable intake within the current study. ²⁹ , ³⁰ , ³¹ , ³² The use of validated measures has been lacking in other CM/CN programmes. ⁹ , ¹⁰ , ²⁵ , ⁵² Limitations of the current study included that participants were recruited through convenience sampling, which may have resulted in selection bias, particularly because of the homogenous sample consisting of a high percentage of health professionals who hold postgraduate qualifications. Another limitation was that there was a higher‐than‐usual attrition rate (68%), particularly in Group 2 of the intervention (n = 4, 80%). Potentially a greater drop‐out rate in Group 2 occurred due to the timing of the programme for this group (early January‐April 2021); in Australia this timing of course recruitment occurred around the main time of the year people take annual leave and course completion during a period of multiple public holidays. The timing of future courses should be considered to ensure greater impact. In addition, COVID‐19 may have impacted the attrition rates as this programme was run during the pandemic. To account for these higher attrition rates last observation carried forward was applied to the analysis; however, one of the limitations of this approach is that it can underestimate the treatment effect, which was observed in the current study. ⁵³ Finally, there was no behaviour change component in the current programme as it was not within the scope of the current programme. Improving an individual's skills and knowledge alone has been shown previously to not be the driver of long‐term dietary change. ⁵⁴ However, participants were directed to an online open course specifically designed to support nutrition communication skills for behaviour change, ⁵⁵ , ⁵⁶ which were available online at the time.

Future research with larger samples sizes could consider longer‐term follow‐up to explore whether the dietary behaviours at the end of the programme are maintained. Creation of a CPD CM/CN programme that includes a behaviour change education component and evaluates the impact on practitioner's competency in nutrition counselling may be warranted. Further exploration of the impact on patients, clients and students counselled by trained practitioners may also be warranted.

CONCLUSION

CM/CN programmes which provide practical culinary and nutrition education are an emerging strategy being used to provide nutrition, food and cooking skills training to health professionals. The need for larger, high‐quality studies and more rigorous evaluation of these programmes in both health professional and other education and industry professionals is warranted. ²⁵ Evaluation on the impact on their patients, clients and students would add further rigour. The current research provides evidence to support feasibility and acceptability of CM/CN programmes targeting vegetable consumption, and findings can be used to inform future programmes. Findings from the current study support that this short, asynchronous, online programme is feasible and can elicit desired changes in diet quality, food skill confidence and nutrition knowledge.

AUTHOR CONTRIBUTIONS

Conceptualisation: Roberta C. Asher, Tamara Bucher, Vanessa A. Shrewsbury, Steven Roberts and Clare E. Collins. Methodology: Roberta C. Asher, Tamara Bucher, Vanessa A. Shrewsbury, Steven Roberts and Clare E. Collins. Formal analysis: Roberta C. Asher, Erin D. Clarke, Tamara Bucher and Clare E. Collins. Investigation: Roberta C. Asher. Writing – original draft preparation: Roberta C. Asher, Erin D. Clarke and Clare E. Collins. Writing – review and editing: Roberta C. Asher, Erin D. Clarke, Tamara Bucher, Vanessa A. Shrewsbury, Steven Roberts and Clare E. Collins. Visualisation: Roberta C. Asher and Erin D. Clarke. Supervision: Tamara Bucher, Vanessa A. Shrewsbury and Clare E. Collins. Project administration: Roberta C. Asher, Steven Roberts and Clare E. Collins. Funding acquisition: Steven Roberts and Clare E. Collins. All authors have read and agreed to the published version of the manuscript.

CONFLICT OF INTEREST

Steven Roberts is employee of Rijk Zwaan Australia. The rest of the authors declare no conflict of interest.

ETHICS STATEMENT

This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the University of Newcastle's Human Research Ethics Committee (approval number H‐2020‐0276). Written informed consent was obtained from all subjects/patients.

Supporting information

Supporting information.

Biographies

Roberta C. Asher is a dietitian, PhD candidate and research assistant at the University of Newcastle. Ms Asher's research work focuses on culinary nutrition programme development, delivery and evaluation. Ms Asher completed a Bachelor of Nutrition and Dietetics in 2010 after a 10‐year career as a trade‐qualified chef working in restaurant and international hotel kitchens in Australia and overseas. She has worked as a clinical dietitian, a community nutrition educator and a research assistant. In 2019, Ms Asher commenced her PhD at the University of Newcastle researching culinary nutrition education for people with intellectual disability.

Erin D. Clarke, PhD, is an accredited practising dietitian and researcher at the University of Newcastle, Australia. She completed her Bachelor of Nutrition and Dietetics in 2016 and a PhD in Nutrition and Dietetics in 2021, both at the University of Newcastle. She works both clinically as a practising dietitian and as a researcher. Her research interests include dietary assessment, dietary biomarkers and diet quality.

Tamara Bucher, PhD, is a food and consumer behaviour researcher at the University of Newcastle. She is the head of Discipline Food Science and Human Nutrition and the academic convenor of the Doctoral Training Centre in Food & Agribusiness. Dr Bucher holds a bachelor's and master's in biochemistry and has a master's degree in advanced studies in human nutrition and health from ETH Zurich (ETHZ), Switzerland. In her PhD, she developed and validated an innovative method for consumer behaviour research using ‘fake foods’. In 2014, Dr Bucher joined the University of Newcastle (UoN) Priority Research Center for Physical Activity and Nutrition (PRCPAN) with a Swiss National Science Fellowship. She and her team are investigating ambient influences on food choice and how we can use this knowledge to facilitate healthy choice and eating. She is also interested in wine research with a focus on alcohol reduction and use of new technology.

Vanessa A. Shrewsbury, PhD, BHlthSc Nutr&Diet Hons, is a dietitian and a postdoctoral researcher in the School of Health Sciences, at the University of Australia. Her research focuses on improving the dietary quality of children, adolescents and their families through increasing access to evidence‐based resources, including programmes to improve food and cooking skills.

Steven Roberts is managing director of Rijk Zwaan Australia, an international vegetable seed breeding company with its headquarters in the Netherlands. He is passionate about seeding change to raise the profile of vegetables. Together with its partners, Rijk Zwaan contributes to the world's food supply by developing new varieties and supplying top‐quality seeds to growers. Working with the company for over 25 years, Steven founded the website ‘Love My Salad’ in 2010 with an ambition to increase vegetable consumption and promote positive behavioural change by sharing the fun, joy and vitality of vegetables and salads.

Clare E. Collins, Laureate professor, is a fellow of the Australian Academy of Health and Medical Sciences, Nutrition Society of Australia and Dietitians Australia. Laureate Prof Collins research focuses on personalised nutrition technologies and programmes evaluating impact on diet‐related health across life stages and chronic disease.

Asher RC, Clarke ED, Bucher T, Shrewsbury VA, Roberts S, Collins CE. Impact and evaluation of an online culinary nutrition course for health, education and industry professionals to promote vegetable knowledge and consumption. J Hum Nutr Diet. 2023;36:967–980. 10.1111/jhn.13109