Cooking After Cancer: the structure and implementation of a community-based cooking program for cancer survivors.

Abstract

Cancer survivors are a growing population that may particularly benefit from nutrition and lifestyle interventions. Community-based programs teaching healthy cooking skills are increasingly popular and offer an opportunity to support survivors within communities. The objective of this study is to describe the curriculum and implementation of a cooking class program designed for cancer survivors, housed within an established community-based organization. First, we evaluated the class curriculum for specific constructs. An evidence-based measure of healthy cooking constructs, the Healthy Cooking Index (HCI), was used to analyze included recipes and revealed both summative cooking quality scores and individual constructs underlying the overall curriculum. Second, a self-report questionnaire based on the HCI was conducted during the first and last class of the six-week series. This allowed for a comparison between baseline cooking practices of participants and class curricula, as well as changes in reported practices after class participation. Using the HCI items and coding system, we found the curriculum focused on seven recurring constructs (measuring fat and oil, using citrus, herbs and spices, low fat cooking methods, olive oil, and adding fruit and vegetables). Baseline reports demonstrated that many participants already practiced the main constructs driving the curriculum. As a potential result of this overlap, no changes in practices were found between the first and last session among class participants. Cooking classes for cancer survivors should be structured to not only reinforce positive existing behaviors, but also to promote other healthy cooking practices and reduce less healthy behaviors such as using red meat and animal fats. The HCI can be used to understand the underlying constructs of existing cooking class curricula and current practices of survivor populations, allowing for a more tailored approach to practical nutrition education in this high-risk group.

Background:

Promoting good nutrition among cancer survivors is a priority given the elevated risk for cardiovascular and metabolic disease, as well as secondary cancer occurrence in this population, which is projected to include over 20 million people in the United States within the next two decades [1–4]. The cancer diagnosis can serve as a “teachable moment” for patients and their families to engage in health promoting behaviors including healthy eating and food preparation [5]. However, although the American Institute for Cancer Research and the American Cancer Society offer dietary guidelines specific to those with a history of cancer, adherence is low among survivors [6–8]. Thus, offering guidelines alone may not be sufficient to promote long-term behavior change in this group. The World Cancer Research Fund has recommended practical cooking skill training to improve diet patterns, support health, and reduce subsequent cancer risk [9]. Community cooking programs have the potential to improve survivor adherence to nutrition recommendations, which may in turn reduce recurrence of disease [10,11].

Cooking programs have become increasingly popular in recent decades and evidence suggests hands-on cooking classes may be more effective than nutrition education alone in changing dietary behavior [12]. Community-based programs that already provide participatory cooking classes may offer a feasible way to reach cancer survivors once treatment is completed. As engaging cancer survivors in nutrition interventions can be challenging, and cooking classes may be outside the scope of many hospitals and outpatient centers, all opportunities to leverage existing infrastructure to deliver practical nutrition information to cancer survivors in community settings should be explored.

Community programs and public health initiatives targeting survivor wellness have emerged to support patients as they reintegrate into more normal home routines [13–15]. One example program is The Happy Kitchen/La Cocina Alegre®, a program of the Austin, Texas-based Sustainable Food Center (SFC), which has added a Cooking After Cancer class series to its general cooking class catalog. Programs tailored to survivors may help bridge the gap between dietary recommendations and actual home eating behaviors among those with a history of cancer; however, such classes are not regulated by any healthcare authority and their impact is not well understood [16]. An examination of the curriculum and preliminary efficacy of the Cooking After Cancer class series will allow for a better understanding of program structure and potential impact.

Currently, there are no standardized guidelines of healthy cooking practices and program content varies widely. In turn, examining the underlying constructs of cooking program curricula and evaluating participant progress is challenging. To help address this issue, we previously designed an index of healthy cooking behaviors based on a conceptual framework from the extant evidence on food preparation and health [17]. The original framework consisted of 17 behaviors across 5 domains of cooking behavior. We then used these behaviors to guide participatory cooking classes for pediatric cancer patients and survivors [18] as well as high-risk groups in a cancer prevention program [19]. We found that Healthy Cooking Index (HCI) items (i.e. specific cooking behaviors with the potential to optimize nutritional content of meals) were relevant to the usual cooking habits of both survivor and prevention groups. Further, we demonstrated that using more positive HCI behaviors and less negative HCI behaviors was associated with favorable diet quality [20]. The present study expands this research into a community setting, using the HCI in the context of a community-based cooking program for survivors. The goal of this study is to identify the constructs underlying Cooking After Cancer, a community-based cooking class curriculum designed for cancer survivors in Austin, Texas, and to examine participant baseline cooking habits and changes after class completion using the HCI.

Methods:

Our community partner was SFC, a non-profit organization in Austin, Texas. SFC has operated as a non-profit since 1993. SFC was formerly known as Austin Community Gardens, which was started in 1975. The mission of SFC is “to cultivate a just and regenerative food system so people and the environment can thrive.” The Happy Kitchen is a program of SFC, focused on the conduct of community-based cooking classes. Cooking After Cancer is one of several cooking programs run by the Happy Kitchen. All cooking classes are free, open to the public, and completely voluntary. SFC’s Cooking After Cancer class was available in English for six weeks in the Spring 2019. The six-session format included cooking and nutrition education. Each weekly session lasted approximately one and a half hours (from 6:00pm to 7:30pm on Monday evenings) and was taught by three trained peer facilitators, all of whom had a personal connection to cancer through their own experience, family, or work.

Cooking After Cancer was developed out of The Happy Kitchen’s standard community cooking class curriculum in 2008 after a needs assessment of Austin cancer support services revealed a gap in nutrition resources for local survivors. Cooking After Cancer includes the same basic cooking and nutrition information as the standard series, with additional detail on topics such as digestion, nutrient density, inflammation, blood sugar, and protein needs, which are particularly relevant to cancer survivorship. Cooking After Cancer is currently offered twice annually; outreach is conducted through community partners working with cancer patients and survivors, and a waiting list of interested participants is maintained. The class was promoted via email, social media, phone calls, and text messages. No strict eligibility criteria was used for class attendance, but the series was recommended for survivors who are at least 4 months out of treatment and their caregivers. As the majority of outreach partners work specifically with breast cancer survivors, most participants had a history of breast cancer. Survivors of other cancers also attended. Free childcare and transportation assistance (gas cards or bus passes) were made available to all participants.

Each Cooking After Cancer class included a nutrition education portion, during which an educator would discuss one of the major food groups (such as grains, fruits, vegetables, protein) and their importance for a balanced diet. Nutrition education was kept general and focused on balanced eating as opposed to fad dieting or weight loss. Lessons cover topics such as switching from refined to whole grains, choosing plant-based protein over animal protein, reading and understanding nutrition fact labels, and increasing fruit and vegetable consumption. Specific dietary needs for cancer survivors were discussed, and cancer-specific resources offered. These included handouts developed by SFC in collaboration with a board of registered dietitians and medical doctors.

Cooking classes took place in a teaching kitchen located at the SFC Headquarters in Austin, Texas. Classes were primarily demonstration, with some hands-on participation by class participants. Ingredients were displayed in their raw form, and educators demonstrated food safety practices including hand washing and produce washing. Ingredients are chopped and measured in front of the class. The educators discussed the recipe seasonality and answered any questions from participants. Participants were given the opportunity to help the educator prepare the dishes, with tasks such as reading the recipe or measuring ingredients. After preparation is complete, all participants are asked to taste the final dish and give feedback. At the end of the sessions, all ingredients except highly perishable items (such as chicken) and staples (such as salt) were given to participants so that they may try the recipe at home. Participants were also given copies of the recipes and any relevant nutritional handouts for the week. Most recipes for the series were sourced from The Happy Kitchen’s cookbook, Fresh, Seasonal Recipes. All recipes in this book are available in English and Spanish, and include nutrition facts, cost per serving, and the season for any fresh ingredients. The average cost per serving is $0.79. Recipes are designed to take 30 minutes or less of active cooking time. Each household receives a free copy of the cookbook at the end of the series. Facilitators may also choose recipes from other approved sources, such as Rebecca Katz’s The Cancer-Fighting Kitchen, if there are particular ingredients or techniques that they want to showcase.

Measures.

The Healthy Cooking Index (HCI) was applied to the recipes making up the Spring 2019 Cooking After Cancer curriculum. The HCI is based on a previously published conceptual model and has been described in depth elsewhere [21,22]. Briefly, the HCI consists of a series of 19 food preparation practices across 5 domains with the potential to impact the nutrition or carcinogen content of meals. Cooking behaviors with the potential to boost the nutrient density or lower the energy density of meals (such as using whole grains or using low fat cooking methods) are assigned +1 point, while behaviors with the potential to increase energy density or carcinogen exposure (such as deep frying or using processed/cured meats) are assigned −1 point. Points are summed to generate an overall cooking quality score.

The Healthy Cooking Questionnaire (HCIQ2) is a self-report tool mapped to the HCI. The HCIQ2 includes items covering general meal habits and cooking frequency as well as individual HCI behaviors. HCI items are phrased as “The last time you prepared a main meal at home did you…”. Responses are then coded and scored using the same process described above (+1 point for healthy cooking behaviors, −1 point for less healthy cooking behaviors). The structure of the HCIQ2 questions were developed based on findings from a pilot study examining self-reported cooking practices among parents of school-aged children (JAND) and subsequent comprehension testing with a diverse group of community volunteers.

SFC class facilitators administered the written HCI questionnaires on the first and last class of the Cooking After Cancer series. Researchers from the University of Texas MD Anderson Cancer Center analyzed participant responses. Class attendance was collected by SFC class facilitators at each session.

Statistical Considerations/Analysis Plan

Recipes from the Cooking After Cancer curriculum were scored using the HCI coding system described above. Individual items from the HCI were examined, and the proportion of recipes utilizing each item from the index over the total number of included recipes was reported. HCIQ2 responses were analyzed and general cooking frequency and meal habits reported using descriptive statistics. Baseline (first session) self-reported HCI behaviors were examined by individual item and summed to generate the overall HCI score for each participant. Baseline HCI scores were compared to post (final session) scores and changes evaluated using a paired-sample t-test. All analysis was completed with IBM SPSS Version 25.0.

Results / Implementation:

A total of 25 participants attended at least one Cooking After Cancer class over the six-week series. Mean attendance was 3.2 out of a possible 6 classes. Nine participants attended five or more sessions, and seven participants attended only one session. Of the 25 total participants, 20 completed the HCIQ2 survey on at least one occasion.

Cooking After Cancer Curriculum

Six recipes were included in the Cooking After Cancer curriculum and served to reinforce the central nutrition lesson of each class. All included recipes scored over 5 ( +5 to +9) on the HCI scale (possible range −9 to +10) (Table 1).

Table 1:

Cooking After Cancer curriculum topic, recipes, and scores.

Topic	Recipe	Recipe HCI Score
Grains	Creamy Polenta	6
Fruits	Poached Pears	5
Vegetables	Stir-Fried Baby Bok Choy and Mushrooms	6
Protein	No-Mayo Chicken Salad (chickpea	9
	variation)
Fats & Sugars	Parsley Scallion Pesto	7
Toolbox	Kitchari	8

The HCI items demonstrated in the Cooking After Cancer curriculum were consistent, with almost all recipes (>83%) utilizing seven positive HCI practices including measuring fat and oil, using citrus, herbs and spices, low fat cooking methods, olive oil, and adding fruit and vegetables. Only two negative HCI items were present in the curriculum; using processed foods and using animal fat (Figure 1).

Figure 1: Scheme depicting proportion of Healthy Cooking Index behaviors present in curriculum.

Scheme showing proportion of recipes from the CAC curriculum that utilized one of 19 cooking practices from the HCI.

Characteristics of Cooking After Cancer Participants

Of the 20 participants that attended at least one session and completed at least one HCIQ2, 18 completed the baseline survey. The majority (61%) of participants reported dinner as their largest or main meal of the day; one third noted lunch as their main meal. With regard to the last time participants prepared their main meal at home, 66.5% reported cooking within the last two days, and 29.4% reported cooking three or more days ago. The mean summative HCI score for the group based on the HCIQ2 was 4.56 (SD=1.75, range −1 to +9). Individual HCI items were demonstrated consistently in much of the sample (Figure 2), with 94% of participants reporting using low fat cooking methods and adding fruits and vegetables the last time they cooked a main meal. Further, 72% reported using animal fats and 56% reported using processed foods.

Figure 2: Scheme depicting proportion of baseline Healthy Cooking Index behaviors reported by participants.

Bar graph showing baseline HCI practices as reported by participants using the HCIQ2. Bars represent the proportion of participants reporting each individual behavior (n=18).

Changes in Cooking After Cancer Participant Cooking Behavior

Eight participants completed both baseline and final class assessments. There was no significant difference in mean baseline HCI score between those that completed both assessments (n=8, mean (SD) =3.75(2.9)) and those that completed the baseline assessment only (n=10, mean (SD)= 5.2 (2.7)) (F=1.18, p = .29). The mean difference in HCI from pre to post among those that completed both assessments was .375, which was not significant (t = −.704, p = .504). Further, there were few changes with regard to individual HCI behaviors, although positive trends were seen for herbs/spices usage, alliums usage, red meat and processed food usage (Figure 3).

Figure 3: Changes in individual Healthy Cooking Index behaviors reported by participants before and after attending the Cooking After Cancer class series.

Graph showing changes in HCI practices pre and post among participants with full data sets (n=8).

Discussion and Recommendations.

This study examined the curriculum and cooking practices of participants in a community-based cooking program targeting cancer survivors. We demonstrated that the curriculum of the Cooking After Cancer program is in line with extant evidence of nutrition optimizing cooking practices. Participants reported overall high levels of healthy cooking practices at baseline, and no significant changes were observed in cooking practices after the program.

Healthy eating programs for survivors should be tailored to highlight cancer prevention and late-effect specific aspects of diet. One challenge to this is the variability in treatment effects and prevention research across cancer sites. The HCI is an appropriate tool to evaluate programs for cancer survivors as HCI items include practices that both impact general diet quality and practices that impact carcinogen exposure. Cooking red meat at high temperatures or charcoal grilling, for example, have been linked to increased cancer risk and may cause the development of heterocyclic amines and polycyclic aromatic hydrocarbons [23–28], which are probable human carcinogens. Deep fried food consumption has been linked to increased risk for several cancers, including prostate cancer, potentially due to the production of mutagenic compounds that remain on the surface of fried food and are later metabolized into the body [29–31].

With regard to diet quality, the HCI is in line with the American Cancer Society and American Institute of Cancer Research guidelines that promote whole grain, fruit and vegetable consumption and discourage processed food, fast food and processed meat consumption among survivors [8,32]. The HCI analysis of the Cooking After Cancer recipe curriculum revealed the most consistent underlying constructs in the curriculum including natural low-calorie flavoring (alliums, herbs and spices, citrus), nutrition-enhancing additions (olive or canola oil, fruit/vegetables, whole grains) and energy-density reducing techniques (low fat cooking, measuring oil and salt).

Many of the positive HCI items present in the Cooking After Cancer curriculum were already being practiced by class participants at baseline, which may explain the lack of change in cooking practices between the first and final class. The mean HCI score was higher in this small sample than previously studied populations including overweight weight loss intervention participants and US-based MTurk online workers (Unpublished data). This finding suggests that the individuals who choose to attend the Cooking After Cancer class may not be the highest need survivors. One potential way for organizations like the SFC to maximize impact may be to embed existing cooking class infrastructure within other types of survivorship programs. Another option is developing relationships with local oncology practices to facilitate referrals to the Cooking After Cancer course for survivors at high risk of nutrition-related disease. These approaches may reduce participant self-selection and give high-need survivors more extensive support.

Compared to these other groups, Cooking After Cancer participants appeared to cook less consistently, with only 60% reporting cooking a main meal at home within the last 2 days. For comparison, 90% of US-based MTurk workers reported cooking within the last 2 days (unpublished data). Participants in the Cooking After Cancer program may be more knowledgeable about healthy cooking than the general population, but may not be utilizing that knowledge to prepare meals at home. One potential reason for this disconnect may be health issues relating to treatment that limit survivors’ ability to devote time to cooking such as fatigue or reliance on caregivers. Potential future iterations of the Cooking After Cancer series should consider adding modules to target barriers to cooking frequency for this population.

One strength of this communication includes the research partnership between an academic cancer hospital and a community organization targeting cancer survivors, as well as the use of an evidence-based method for quantifying cooking curriculum quality (the HCI). As food preparation education gains popularity in schools, hospitals, and community centers, evidence-based metrics to evaluate program content and impact is essential. Standardized tools for community program evaluation will support consistent messaging throughout the cancer care continuum. Unfortunately, the use of a pre-post questionnaire in this study was limited by the variability in participant attendance. Digital versions of the HCIQ2 that can be completed by participants at home may improve data quality in a community setting. This study is further limited by the small sample, but the findings from this work will inform future evaluations of community-based cooking programs. Future research should consider utilizing the HCI to evaluate cooking curricula targeting cancer prevention, patients, and survivors across settings. Clarification of underlying program constructs will allow for optimization of program delivery in these populations.