A total of 1784 articles were screened by their title and abstract and 32 articles were reviewed as a full-text. Of these articles, 12 met the criteria and were included in the systematic review.
Reasons for excluding articles reviewed as full-text included wrong study design (n=10),11-20 wrong population (n=2),21 a failure to report any outcome measures (n=2),8, 22 wrong intervention (n=3),23-25 and two studies were found to be a duplicate data set.26, 27 Of the 12 included studies, the majority were qualitative studies (n=4)28-31 or cross-sectional studies (n=4);32-35 and the remainder were prospective case series studies (n=2),36, 37 a case study (n=1)38 and a mixed-methods study (n=1).39
All 12 studies were conducted in the United States of America (USA) and ranged from four 28 to 4215 participants.35 Ten studies involved medical students only,28, 30-36, 38, 39 five of which evaluated a single year cohort of students rather than a mixed cohort between years one through four of their medical program.28, 30, 31, 38, 39 Two studies involved medical students and medical registrars,35, 37 and one also included nutrition students.37 All 12 studies had a didactic lecture component to their course and hands on culinary skill lessons and collaborative cooking sessions. A variety of other delivery methods were used amongst the studies including: case-based learning in groups (n=9);28-30, 33-35, 37-39; pre-course preparations in the form of pre-readings, videos, and assignments (n=10);28-30, 32-35, 37-39 pre-session quizzes (n=4);28, 32, 37, 38 and after-class assignments and homework (n=6).28-31, 38, 39
Six studies reported the study population demographics, with participants from varying ethnicities and nutritional backgrounds.32-35, 38, 39 The recruitment process in the studies typically involved an open elective application (n=2), 31, 38 or voluntary enrolment into the course (n=4).28, 29, 33, 36
Most studies had an underpinning objective of using culinary medicine approaches to improve medical students’ nutrition knowledge and counseling in a clinical environment to support chronic disease prevention and management (n=11).28-36, 38, 39 Most studies assessed medical students’ culinary skills (n=2),36, 38 nutrition attitudes (n=6),29, 32, 33, 36, 38, 39 and provision of nutrition counseling to patients (n=5).29, 31, 33, 38, 39 Some studies assessed student collaboration amongst other populations, such as people in the community (n=4)28, 33, 38, 39 and other healthcare professionals, such as dietitians or future physicians (n=7).29-31, 36-39 In many of the studies practical nutrition education in the form of a culinary medicine program was compared against traditional nutritional education in the form of solely didactic teaching(n=7)29, 30, 33-37 and in some studies there was a focus on improving interprofessional and doctor-patient relationships (n=7).28, 30, 34, 35, 37-39
Nine studies reported statistically significant improvements in outcomes and were therefore considered as effective.31-39 Students’ improvement in nutritional attitudes were reported in pre- and post-course surveys, four of which achieved statistically significant improvements;32, 33, 36, 38 two identified statistically significant improvement in culinary skills,36, 38 and five identified changes in competency providing nutritional counseling,29, 31, 33, 38, 39 four of which were statistically significant.31, 33, 38, 39 Pre- and post-course surveys from six of 12 of the included studies identified changes in personal health behaviors8, 32, 33, 36, 38, 39 and two studies reported student improvements in their ability to identify food by visual inspection.36, 39 Five of the 12 studies failed to mention any negative or non-significant outcomes within their results.28, 29, 35-37
Four studies utilised interventions that were adopted by multiple faculties.32-35 The interventions were implemented within a number of different settings. The most common settings were teaching kitchens (n=8)32-39, community kitchens (n=4)28, 33, 38, 39 and off site kitchens (n=6).28-31, 33, 35 Only four studies explicitly stated that the interventions met or exceeded the recommendation that US medical education include 25 hours in nutrition education.32, 34, 35, 37, 40
The curriculum offered to students in each study varied by session layout, duration, type of instructor/instructors, and whether courses were offered as an elective (n=11)28, 29, 31-39 or non-elective course (n=1).30 Half of the interventions were based on an established program, CHOP from Tulane University (n=6)28, 32-35, 37 and others used an original program (n=6).29-31, 36, 38, 39 Four studies reported modifications in their curriculum between cohorts with all changes made to address student feedback.30, 31, 38, 39 Nine studies had chef instructors,28, 29, 31, 34, 36-39 five studies included physicians as instructors;29, 31, 35, 37, 39 six studies included instructors from the school of medicine faculty,28-30, 35, 37, 38 and five studies from the school of nutrition faculty;29, 31, 34, 35, 37 three studies involved instruction from hospital dietitians;36, 37, 39 and two studies included medical students teaching peers.36, 39 Three studies included a service component where medical students taught and/or served members of the community.30, 32, 39 Of all the included papers, only one reported observations from the facilitators on the programs themselves following completion of the course.
None of the included papers explicitly reported the complete cost of running these programs. In only one paper, the cost of cooking materials, in addition to the license for Tulane’s culinary medicine curriculum were reported.28
Quality Appraisal
The mean CASP score was 10.8 out of a possible 20 points for qualitative studies (median = 11, range = 8-13) and 4·7 out of a possible 24 (Median = 4.7, range =0-7) for cohort studies. The most frequent item that was not achieved amongst the cohort studies was that the follow up of subjects was not sufficiently complete (6/7 studies),29, 32, 34, 35, 37 with the most common reasons including unclear reporting or high attrition rates of participants. Many of the cohort studies also lacked an acceptable recruitment method (5/7 studies),29, 32, 34, 36, 37 with the most common reasons including unclear reporting, lack of inclusion/exclusion criteria and the reliance of convenience sampling biased towards students with a ‘voluntary’ or ‘elective’ interest. Most studies failed to report attrition rates (n=8) and only one of these studies reported reasons why the participants failed to complete the course.
The overall poorer quality of the qualitative studies was related to the frequent absence of several CASP items in the studies. The relationship between the researchers and participants was poorly reported in all five qualitative studies, most frequently due to lack of reporting of any such considerations in the methodology.28, 30, 31, 38, 39 In addition, all included papers displayed poor consideration of ethical issues, either due to failure to mention any ethical considerations or having their ethical approval waived by the institution.38 All included papers also had an insufficiently rigorous analysis of data, most commonly due to a lack of data presented and analysis performed. The findings of the CASP quality appraisal, with reasons for negative scoring per criterion, are described in Tables 1 and 2.
Table 1 Qualitative study appraisal
|
Criterion
|
Dreibelbis & George, 2017;
|
Ring et al., 2019;
|
Pang et al., 2019;
|
Hennrikus et al., 2020;
|
Rothman et al., 2020;
|
Was there a clear statement of the aims of the research?
|
Yes
|
Yes
|
Yes
|
Yes
|
No a
|
Is a qualitative methodology appropriate?
|
Can't Tell b
|
No c/d
|
Yes
|
Can't Tell b
|
Yes
|
Worth Continuing?
|
Yes
|
No c/d
|
Yes
|
Yes
|
Yes
|
Was the research design appropriate to address the aims of the research?
|
No a
|
No c/d
|
Yes
|
Yes
|
No e
|
Was the recruitment strategy appropriate to the aims of the research?
|
No a
|
No d
|
No c
|
Yes
|
Yes
|
Was the data collected in a way that addressed the research issue?
|
Can't Tell a/b
|
Yes
|
Yes
|
Can't Tell b
|
No g
|
Has the relationship between researcher and participants been adequately considered?
|
No a/f
|
No a
|
No a
|
No a
|
No a
|
Have ethical issues been taken into consideration?
|
Can't tell a
|
No a
|
No a
|
No a
|
No a
|
Was the data analysis sufficiently rigorous?
|
No a/b/f/g
|
No
|
No b/f
|
No b/f
|
Can't tell g
|
Is there a clear statement of findings?
|
No g
|
Yes
|
No f
|
Yes
|
Yes
|
Uncertainty Score
|
13
|
12
|
10
|
8
|
11
|
Reasons: aNot reported; bSelection bias/Convenience sampling/Elective course; cPoorly designed surveys; dInadequate controlling for multiple confounders; eHigh attrition rate; fNot performed; gPoor overall quality of study; hLow sample size.
|
Table 2 Cohort study appraisal
|
Criterion
|
Monlezun et al., 2015;
|
Jaroudi et al., 2018;
|
Monlezun et al., 2018;
|
Lawrence et al., 2019;
|
Hauser, 2019;
|
Patnaik et al., 2020;
|
Razavi et al., 2020;
|
Did the study address a clearly focused issue?
|
Yes
|
Yes a
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Was the cohort recruited in an acceptable way?
|
Yes
|
Can't Tell b
|
Yes
|
Can't Tell a
|
Can't Tell a
|
Can't Tell b
|
Can't Tell b
|
Worth Continuing?
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Was the exposure accurately measured to minimise bias?
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Can't Tell b
|
Can't Tell b
|
Was the outcome accurately measured to minimise bias?
|
Yes
|
Yes
|
Yes
|
Yes
|
Can't Tell a
|
Can't Tell b
|
Can't Tell c
|
Have the authors identified all important confounding factors?
|
Yes
|
Yes
|
Yes
|
Yes
|
Can't Tell a
|
Yes
|
Yes
|
Have they taken account of the confounding factors in the design and/or analysis?
|
Yes
|
Can't Tell d
|
Yes
|
Can't Tell c/e
|
Can't Tell a
|
Yes
|
Yes
|
Was the follow up of subjects complete enough?
|
Yes
|
No
|
Can't Tell a
|
No
|
Can't Tell a
|
Can't Tell f
|
Can't Tell f
|
Was the follow up of subjects long enough?
|
Yes
|
Can't Tell a
|
Can't Tell a
|
Can't Tell a
|
Yes
|
Can't Tell f
|
Can't Tell f
|
Do you believe the results?
|
Yes
|
Yes
|
Yes
|
Yes
|
Can't Tell g/h
|
Yes
|
Yes
|
Can the results be applied to the local population?
|
Yes
|
No h/g
|
Yes
|
No h/g
|
Can't Tell g/h
|
Yes
|
Yes
|
Do the results of this study fit with other available evidence?
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Uncertainty Score
|
0
|
7
|
2
|
7
|
7
|
5
|
5
|
Reasons: aNot reported; bSelection bias/Convenience sampling/Elective course; cPoorly designed surveys; dInadequate controlling for multiple confounders; eHigh attrition rate; fNot performed; gPoor overall quality of study; hLow sample size.
|