Cooking with the curriculum: a pilot culinary medicine program at the Larner College of Medicine

Abstract

Background

Physicians are highly trusted sources of health advice, yet many feel unprepared to address nutrition with their patients due to a perceived lack of knowledge or confidence. In recent years, there has been increased recognition in medical education of lifestyle factors’ impact on health outcomes in chronic diseases and the value of integrating diet-related interventions into patient care. This integration requires physicians and healthcare professionals to have the knowledge and tools necessary to provide nutrition recommendations and counseling to improve chronic disease management. A growing number of medical schools have begun to incorporate culinary medicine, an evidence-based discipline that offers an experiential learning approach to improve student's education in nutrition and address food-related social determinants of health.

Methods

In the fall of 2023, a culinary medicine pilot program was implemented for first-year medical students at the Larner College of Medicine (LCOM), aimed at increasing their nutrition knowledge and counseling skills. The course was led and developed by two second-year medical students certified in dietetics and integrative health with oversight provided by faculty physicians board-certified in family medicine and lifestyle medicine. The program included five sessions, each focusing on a different chronic disease. Each session consisted of a 45-min didactic lesson followed by a 45-min culinary medicine experiential lesson. The program took place in medical education classrooms utilizing small appliances and low-cost ingredients. The pilot program was evaluated by a post-program survey, which measured perceived knowledge, confidence, and intention to apply learning in clinical practice and personal life.

Results

The program included 26 first year medical students. The post-program survey revealed that 86% of respondents agreed they would use the information learned in the course in their future clinical practice, and 100% agreed they would apply this knowledge in their own lives. Ninety-one percent reported an enhanced understanding of the relationship between diet and disease, and 95% indicated increased confidence in providing nutrition counseling, particularly regarding social determinants of health.

Conclusion

These results demonstrate the benefits of a low-cost educational model of culinary medicine. Its potential to increase future physicians'nutrition knowledge and improve their confidence in providing meaningful, evidence-based dietary guidance is considerable.

Background

In the United States, heart disease, type 2 diabetes, and stroke are leading causes of disability and death [1]. Dietary habits and lifestyle behaviors are well-established modifiable risk factors that can have a crucial impact on managing and preventing chronic diseases [1]. Physicians are uniquely positioned to assist patients in making dietary and lifestyle changes as they are seen as trusted, credible sources of nutrition information [2]. However, many physicians feel ill-prepared to address nutrition with their patients due to a perceived lack of knowledge or confidence [2]. This perception has led to a lower proportion of diet and lifestyle counseling by physicians compared to the high prevalence of these diet-related health conditions [3, 4].

Underserved populations are disproportionately affected by chronic diseases and often grapple with social determinants of health, such as food insecurity, that impact nutritional status and increase disease risk [5]. In 2022, forty-four million Americans lived in food-insecure households, with forty-nine million accessing food assistance programs [6, 7]. Analysis of the National Health and Nutrition Examination Survey (NHANES) data from 2013–2016 found that food-insecure adults faced a higher risk of mental-physical comorbidities [8]. The connection between chronic disease and social determinants of health supports the need for interventions focused on reducing the risk and burden of chronic illness [1, 8].

The deficit in nutrition training within medical school education is well-documented [2, 9]. Only 29% of Liaison Committee on Medical Education (LCME)-accredited medical schools meet the minimum 25 required hours of nutrition education set by the National Academy of Sciences [10]. In 2019, only 49% of schools included nutrition content related to social determinants of health [11]. Culinary medicine is an emerging evidence-based discipline that can help improve these educational deficits while positively impacting patient care and physician wellbeing.

Many studies have supported the efficacy of culinary medicine interventions. Active culinary instruction teaches healthcare professionals and patients how to integrate healthy habits into their lives [12]. In a medical school setting, this integrative approach improves nutrition education through experiential learning, enhances medical trainee self-care, and ultimately boosts the frequency of nutrition counseling with patients [2, 9]. Medical students who participate in culinary medicine programs have been found to be more comfortable discussing healthy eating habits with patients and report healthy eating to be less time consuming and expensive [13].

These courses can improve students’ dietary behaviors and increase the effectiveness of learning through active experiences [14] while benefitting medical trainees who have a high risk of burnout and generally poor nutritional behaviors during medical school and residency [15]. Although it is well established that nutritious food is integral to health, inadequate education and the low frequency of dietary counseling among physicians present an opportunity for culinary medicine to bridge this gap.

This culinary medicine pilot program at LCOM aimed to develop medical students’ aptitude in meal preparation and basic nutrition in addition to increasing their education on social determinants of health and issues of food access. With those tenets in mind, the overarching objectives for the course were to increase student knowledge in foundations of nutrition, promote skills development for patient encounters, including motivational interviewing, and setting specific, measurable, achievable, relevant, and time-bound (SMART) goals, and view diet counseling through the lens of social determinants of health. The curriculum was designed to provide future doctors with the knowledge, skills, and language needed to confidently discuss diet and nutrition with their patients as well as when to make appropriate referrals to subject matter experts such as registered dietitians.

Methods

Participants and study design

The extracurricular culinary medicine pilot program ran from August to December 2023 and engaged 21% (n = 26) of first-year medical students at LCOM. Students signed up for the course through an online platform, where they provided their name and email address for further correspondence. All students who signed up were accepted into this non-credit, 5-part program, which consisted of 90-min monthly sessions. The educational objectives and class materials were created and led by two second-year medical students, one a registered dietitian and the other certified in integrative healthcare (MH). They were supported by a medical doctor faculty advisor. Each session included 45 min of didactic instruction on a chronic condition followed by 45 min of cooking. All classes were conducted in LCOM classrooms. Lecture Topics.

Didactic lessons included a 45-min discussion about pathophysiology and diet related considerations in cardiovascular disease, diabetes mellitus, obesity, cancer, and nutrition through the lifecycle (pediatrics and geriatrics). During the didactic lessons, students examined patient cases, identified social barriers, and brainstormed SMART goals that could be applied to the patient's situation. The lessons also provided resources for individuals with food insecurity in the Burlington, Vermont area that could be offered to those seeking assistance, such as local food pantries, crop shares, and the state supplemental nutrition assistance program.

Experiential learning

Following each didactic lesson, students participated in a hands-on cooking experience focused on simple, plant-based dishes adaptable to low-resource settings. These sessions took place in LCOM medical education classrooms using the “LCOM Mobile Kitchen,” a collection of small appliances, cutting boards, and utensils that require minimal setup and can be easily transported. By selecting inexpensive ingredients and using free classroom space, the course kept costs low — only $23.81 per participant, which was covered by American College of Lifestyle Medicine Taste of Lifestyle Medicine Grants. Students were divided into teams of 3–5, provided with ingredients, cooking tools, and recipes, and collaborated to complete the dish. During the 45 min of cooking, students had the opportunity to ask questions and engage in informal nutrition discussions. At the end of the session, they shared the meal.

Data collection

Evaluation of the program was completed using a post-program survey, developed specifically for appraisal of this program, with questions that assessed student engagement, perceived educational value, confidence in nutritional counseling, understanding of diet-disease relationships, and personal well-being. For data analysis questions were evaluated on a Likert scale. A response of “strongly agree” corresponded to a score of 5, “agree” corresponded to a score of 4, “neutral” a 3, “disagree” a 2, and “strongly disagree” a 1. Additionally, there were several open-ended questions regarding what students found most meaningful in the course, areas for improvement, and additional comments or thoughts they had to share. All survey answers were collected anonymously using Qualtrics software to avoid potential bias. For detailed information on the administered survey, see the supplementary data (Table S1).

Results

We utilized data collected through a prior survey conducted at LCOM of first year medical students after the completion of their nutrition, metabolism, and gastrointestinal course in 2023 intended for course quality improvements to inform the need for Cooking with the Curriculum. This survey found that less than half of respondents felt very or extremely confident in topics such as counseling patients on healthy eating, using evidence-based nutrition guidelines, managing nutrition-related aspects of specific chronic diseases, and referring patients to nutritional professionals (Figure S1) (n = 34).

The program was conducted at the Larner College of Medicine at the University of Vermont in Burlington, Vermont and enrolled n = 26 first-year medical students. Eighty-five percent of participants (n = 22) responded to the post-program survey. Participants were between the ages of 21–40, 50% (n = 11) identified as female, and 41% (n = 9) identified as white. The program had a retention rate of 73% (n = 19), with 77% (n = 20) of respondents attending at least four sessions (Table 1).

Table 1 Student Demographics and Session Attendance

Of the respondents, 86% (n = 19) “agreed” or “strongly agreed” that the course significantly contributed to their medical education, and 100% (n = 22) indicated they would recommend the program to their peers (Fig. 1). Furthermore, 86% (n = 19) “agreed” or “strongly agreed” that they would use the information learned in the course in their future clinical practice, and 100% (n = 22) “agreed” or “strongly agreed” they would apply this knowledge in their own lives (Fig. 1). Ninety-one percent (n = 20) reported an enhanced understanding of the relationship between diet and disease (Fig. 2), and 95% (n = 21) indicated increased confidence in providing nutritional counseling, particularly regarding social determinants of health (Fig. 3). When students were asked how important they thought it was to integrate the information from the course into the core nutrition curriculum, 95% (n = 21) agreed it was “important” or “very important". Ninety-five percent (n = 21) of participants also felt that the course met or exceeded expectations.

Fig. 1

Student perception of overall course applicability. To assess students’ perceptions of the course, they were asked the degree to which they agreed or disagreed with the above statements. 100% of participants strongly agreed or agreed that they would use knowledge learned in their own life (4.77 ± 0.43). 95% strongly agreed or agreed that they would use this knowledge in clinical practice (4.59 ± 0.6). 100% strongly agreed or agreed that others would benefit from taking this program (4.82 ± 0.39), and 86% strongly agreed or agreed that this course significantly contributed to their medical education (4.36 ± 0.73).​

Fig. 2

Student perception of knowledge gained related to diet and chronic disease. To assess how the course impacted student’s knowledge of the role that diet plays in the covered chronic diseases, students were asked the degree to which they agreed or disagreed with the following statement: “Participation in this course improved my understanding of how the following diseases are linked to diet.” Of the 22 participants, 77% strongly agreed or agreed that the course improved their understanding of diet in pediatric and geriatric conditions (Lifecycle) (4.32 ± 0.78), 91% strongly agreed or agreed for cardiovascular disease (4.41 ± 0.67), 91% strongly agreed or agreed for diabetes mellitus (4.6 ± 0.67), 95% strongly agreed or agreed for cancer (4.54 ± 0.60), and 91% strongly agreed or agreed for obesity (4.45 ± 0.67)

Fig. 3

Student perception of knowledge gained related to patient counseling. To assess how the course impacted students’ confidence in patient counseling, students were asked the degree to which they agreed or disagreed with the following statement: “Participation in this course has improved my confidence in counseling patients to overcome the following common barriers to healthy eating.” 95% felt more confident in counseling patients to overcome the perception of insufficient time to eat healthy (4.36 ± 0.58), 95% felt more confident in counseling the belief that eating healthy on a budget is impossible (4.36 ± 0.73), 91% felt more confident on counseling unwillingness to give up unhealthy foods (4.27 ± 0.77), and 91% felt more confident counseling lack of patient confidence to prepare healthy food (4.36 ± 0.66). Additionally, 86% of participants felt more confident in offering nutritional advice to future patients (4.23 ± 0.69), and 77% felt more confident in taking a diet history (4.23 ± 0.81)

In the open-ended section of the survey, students appreciated, “learning different ways to educate patients on how to integrate healthier lifestyle choices” and valued the “actionable ways to improve communication and patient care.”

Discussion

The aims of this program were to develop medical students’ aptitude in meal preparation and basic nutrition in addition to increasing their education on social determinants of health and issues of food access. These aims were informed by the quality improvement survey that was conducted at LCOM in 2023. Cooking with the Curriculum, a pilot culinary medicine program was launched to address identified gaps in LCOM nutrition education. The course’s combination of didactic and active learning was used to enhance medical students’ knowledge and confidence in a fun, hands-on way. The post-program survey demonstrated encouraging results, with high levels of engagement, satisfaction and an increase in perceived nutrition knowledge.

Overall, participants reported increased confidence in taking a diet history and a better understanding of the relationship between diet and disease. Students indicated that they intended to use the information they learned in both clinical practice and their personal lives. Students found a strength of the course was highlighting social determinants of health while providing ways to alleviate those effects on patients. The positive feedback and high levels of student engagement throughout the course suggest this type of program could be a valuable addition to the standard curriculum. Our results extend the existing evidence by supporting culinary medicine as an effective method to teach nutrition education in undergraduate medical education as well as promote wellness among students.

It is important that physicians feel confident in their knowledge of nutrition and ability to make patient-specific recommendations on diet and lifestyle to engage effectively in fundamental dietary counseling. Research has shown that nutrition training in medical schools leads to increased self-confidence in counseling patients on nutritional interventions and higher rates of counseling engagement [2, 9, 16]. The integration of culinary medicine into medical schools can equip future physicians with the skills needed to provide comprehensive nutritional care.

Commonly cited barriers to the implementation of culinary medicine courses in medical schools include high costs, challenges in obtaining curriculum licensing, and difficulty accessing teaching kitchens [17,18,19]. Costs associated with starting a teaching kitchen can range from $10,000 to over $500,000, and licensing a new curriculum is estimated to be $1,200-$3,000 [17, 18]. Some culinary medicine programs have overcome these barriers through the creation of"pop-up"kitchens, virtual classes where students use their own home kitchens or community kitchens [20,21,22]. The LCOM program was unique in its integration of a"mobile kitchen"and a culinary medicine curriculum, which was developed and led by medical students, including a registered dietitian and a certified integrative health professional. This helped minimize costs and allowed for a greater number of students to join the elective. The course's emphasis on small appliances, basic tools, and more affordable foods simulates a low-resource environment many patients may experience, addressing the challenge of cooking on a budget with limited resources. The program demonstrated the feasibility of a low-cost, accessible model of culinary medicine that other medical schools can replicate.

Additionally, this course sought to highlight social determinants of health as they relate to food access and chronic disease. As previously mentioned, underserved populations are disproportionately affected by chronic diseases and often grapple with social determinants of health, such as food insecurity, that impact nutritional status and increase disease risk. Many other culinary medicine courses have chosen to integrate social determinants of health into their curriculums, emphasizing issues of food access or food insecurity [19, 23,24,25]. This type of material has often been taught through lectures or by challenging students to prepare budget-friendly recipes [24, 26].

Like existing programs, the LCOM pilot program incorporated social considerations into its didactics. However, it placed additional emphasis on the importance of addressing social determinants of health when counseling patients. To support this aim, the program incorporated motivational interviewing, encouraging students to consider social determinants while practicing these skills in small group settings. Additionally, the program’s"mobile kitchen"reinforced the focus on social determinants of health by utilizing easily accessible, low-cost culinary materials and featuring simple recipes, simulating a low resource setting to actively demonstrate these principles to students. Specific community organizations and resources were discussed during class to inform students of the local options available to support patients facing food insecurity.

In 2022, the US House of Representatives passed a resolution that called for meaningful nutrition education for medical trainees. The resolution was prompted by the growing prevalence of nutrition-related diseases in the US. In response, a panel of 37 multidisciplinary medical education professionals compiled a consensus statement which was comprised of 36 nutrition competencies for medical professionals, 32 of which apply to undergraduate medical education. There is a significant overlap between the objectives of the LCOM pilot course and the proposed competencies (Table 2). Additionally, 92% of the panelists agreed that surveys of students should be used to assess their competency and confidence in this area, which LCOM participants completed at the end of the program. The article also reiterates that"there is mounting evidence that medical students and physician trainees who receive culinary medicine education change their own cooking and eating behaviors and demonstrate increased confidence in discussing food and nutrition with their patients [27]. These findings were reaffirmed in the LCOM pilot program.

Table 2 Proposed Nutriton Competencies met by Cooking with the Curriculum

Limitations

This study had several limitations. As there was no pre-course survey, the ability to determine changes in participants'confidence and knowledge after completion of the course was limited. Long-term retention of nutritional information and counseling skills was not assessed through follow up surveys, it is unknown if students in the program gained lasting knowledge. Variability was limited in this study as this course was provided at one institution and did not include the entire medical school class. Students elected to participate in the program, which introduced selection bias. Students who joined the program likely already had an interest in nutrition, which may have made them more likely to perceive the course as valuable. Not all students responded to the post-course survey, which may have introduced further selection bias, by overrepresenting the opinions of students who were more engaged. The course curriculum was created and taught for free by a registered dietitian and funded through micro-grants, limiting reproducibility at other institutions that lack similar resources. The course did not have faculty trained in culinary medicine contributing to course design and implementation, potentially limiting the depth and breadth of content.

Conclusion

The findings suggest that the culinary medicine pilot program was well received by participants and can be a meaningful intervention to enhance students'nutrition knowledge and educate them on patient counseling. The successful implementation of the pilot study was encouraging, and the elective program has continued with a curriculum that focuses on social determinants of health, practical counseling tools, and lifestyle medicine tenants. The innovative, experiential approach of culinary medicine can be used to address nutrition education deficits in current medical training effectively.

Future directions

In the Spring of 2024, the program received grant funding through the University of Vermont Teaching Academy Frymoyer Scholars Program. With this funding, the program has begun expanding to include service-learning activities, leadership opportunities for students, and longitudinal engagement opportunities with culinary medicine throughout the pre-clerkship years. Future iterations of the program will aim to incorporate interprofessional collaboration, engage community partners, and evaluate long-term impacts on student knowledge, behavior, and patient care outcomes. Pre and post surveys will be incorporated into future programs to assess subjective knowledge gained, changes in confidence in addressing dietary considerations, and understanding of when to refer to a registered dietitian. Additionally, students will take a multiple-choice assessment at the beginning and end of the program as a quantitative measure of change in knowledge. This assessment will be sent to students again months after completion of the course to assess long term retention. Several new faculty members have joined the project, including a chef educator and a pediatric endocrinologist, each bringing their expertise to curriculum development and course implementation. Improving students'understanding of nutrition, its practical applications to patient care and when to refer to a registered dietitian, will allow students to be more prepared to address the nutritional needs of their future patients. Student feedback from the pilot program indicated that students would have liked to learn more about the costs of ingredients and tips on budgeting. This information will be integrated into future courses.