Innovation in nutritional counseling: Culinary Medicine Diabetes Day October 2015 Rani Polak, MD, MBA, chef Research fellow in Lifestyle Medicine Institute of Lifestyle Medicine, PM & R Department, Joslin Diabetes Center, Harvard Medical School
Today s topics: Culinary Medicine Background The science Early adopters Joslin experience Culinary Medicine for you - Tools for your clinic - Tools for self-care
Culinary Medicine Background
Eating behaviors In the US, the most important risk factor is unhealthy diet, which is associated with 26% of deaths and 14% of DALYs (e.g. Disability-Adjusted Life-Years) Murray CJ et al. JAMA. 2013 Aug 14;310(6):591-608.
Cooking behaviors Home food preparation US: home food preparation 1965-6: 65%-72% of total energy 2007-8: 54%-57% of total energy Decrease of 23% in 40 years US: eating away from home 1970: 33% of total household food expenses 2010: 47% of total household food expenses Increase of 42% in 40 years Smith et al. Nutrition Journal 2013;12:45 US department of agriculture, economic research service 2011
Cooking behaviors Fast-food Monsivais P. et al. Am J Prev Med. 2014;47(6):796-802
Cooking and health Nutritional quality Monsivais P et al. Am J Prev Med. 2014;47(6):796-802
Cooking and health Mortality Inverse correlation between cooking and mortality Cooking parameters: - Time spent cooking (> 5 times a week) Chen R.C. Public Health Nutr., 2012;15(7)1142-1149
Nutrition education Potential solution (1) Nutritional counseling should augment a primary focus on nutrients with food-oriented education Mozaffarian D, Ludwig DS. JAMA 2010; 304:681-2
Nutrition education Potential solution (2) Nutritional counseling should emphasize skills such as shopping, food storage, and meal planning and preparation. Lichtenstein AH, Ludwig DS. JAMA 2010;303:1857-8
Exercise education
Nutrition education
What if?
Culinary Medicine A new evidence-based field in medicine that blends the art of food and cooking with the science of medicine La Puma J. Popul Health Manag 2015. In press
Culinary Medicine The science
Cooking interventions Overview, research Systematic review - Effectiveness of interventions that included cooking - January, 1980 through December, 2011 - Twenty eight studies were identified Well-designed studies are needed that rigorously evaluate long-term impact on cooking behavior, dietary intake, obesity and other health outcomes. Reicks M. J Nutr Educ Behav. 2014 Jul-Aug;46(4):259-76
Cooking interventions Children with obesity, methods Educational strategies: - Twelve meetings - 45-minute interactive cooking and nutrition education sessions (graduate student) - 45-minute interactive gardening lessons (master gardener) - Location: mobile cooking island & tables in a community garden Educational goals - Increasing fruit and vegetable Davis JN. J Am Diet Assoc 2011;111:1224-30.
Cooking interventions Children with obesity, impact - Intervention: 5 th grade students at an elementary school - Control: all students who were not enrolled in the study - Follow-up: post training Davis JN. J Am Diet Assoc 2011;111:1224-30.
Cooking interventions Patient with diabetes, methods Educational strategies: - Four meetings - Nutrition and hands-on sessions (home economist & health care professional) - Strategies within social cognitive theory such as self-efficacy, cognitive restructuring, social support, and goals setting - Location: teaching kitchen Topics covered - Dietary recommendations for people with T2DM - Recipes & culinary tools which address T2DM s dietary recommendations Archuleta M. Et al. J Nutr Educ Behav 2012;44:319-25
Cooking interventions Healthy children, impact - Intervention: 117 individuals with T2DM - Control: NA - Follow-up: post training Archuleta M. Et al. J Nutr Educ Behav 2012;44:319-25.
Cooking interventions Public health nurses, methods Educational strategies: - Lifestyle medicine training - 3 nutrition sessions & 2 culinary sessions - 45-minute nutrition classes (RD) - 2.5-hour hands-on sessions (Chef ) - Mixed behavioral change strategies - Location: teaching kitchen Topics covered - Dietary recommendations for healthy nutrition - Easy-to-make, affordable recipes and menus Polak R. et al. J Ambul Care Manage. 2015 Apr-Jun;38(2):164-77
Cooking interventions Public health Nurses, impact Intervention: 104 public health nurses Control: NA Follow-up: 18 months 45% of the nurse report on culinary counseling Hasson R. Manuscript under review
Culinary Medicine Early adopters Polak R. et all. Global Health Advanced Medicine, invited paper
Culinary Medicine programs Early adopters A summary of representative educational programs - Survey of 10 Culinary Medicine program s directors Results - All ten culinary programs deliver medical education curricula educating 2,150 health professions/ year - Six programs deliver curricula for both healthy individuals and patients with chronic diseases, educating 3,800 individuals/ year Polak R. et al. Glob Adv Health Med. Invited paper
Culinary Medicine programs Early adopters, There is currently no consensus about: Definitions Learning objectives Curricular components Staffing and facility requirements Thus far there has been very little research to explore whether, how and to what extent any of these culinary curricula affect behaviors and health outcomes. Shared strategy is needed whereby these challenges can be collectively overcome Polak R. et al. Glob Adv Health Med. Invited paper
http://www.healthykitchens.org/
Healthy kitchens healthy lives Health professionals, methods Educational strategies: - Full weekend - 45-minute nutritional talks (faculty) - Other health behavior talks - 30-60 minutes hands-on sessions (Chef ) - Location: teaching kitchen Topics covered - Dietary recommendations for healthy nutrition - Easy-to-make, affordable recipes and menus Eisenberg DM, Burgess JD. Acad Med. 2015
Cooking interventions Health professionals, impact 215 providers; 3-day CME program Eisenberg DM. et al. JAMA Intern Med. 2013;173(6):470-2
Cooking interventions Health professionals, impact Eisenberg DM. et al. JAMA Intern Med. 2013;173(6):470-2
http://tmedweb.tulane.edu/mu/teachingkitchen
Golding center for Culinary Medicine Medical school education, methods Educational strategies: - Eight 4-hour hands on culinary modules - Location: teaching kitchen - Licensing the program to 12 medical schools - Location: teaching kitchen in the community Topics covered - Mediterranean cooking - Nutrition and health Polak R. et al. Glob Adv Health Med. Invited paper
Golding Center for Culinary Medicine Medical education, impact Intervention: 18 individuals with T2DM Control: 9 individuals with T2DM (nutritionist led classes) Follow-up: 6 month post training Polak R. et al. Glob Adv Health Med. Invited paper
http://www.bmc.org/nutritionresourcecenter
Nutrition Resources Center Patient education Educational strategies: - Two-hour cooking demonstration for patients with diabetes/ cardiac disease/ cancer/ obesity / failure to thrive/ allergies - Two-hour community cooking demonstration for elders/ teens Topics covered - Easy-to-make, affordable culinary techniques and recipes Polak R. et al. Glob Adv Health Med. Invited paper
Culinary Medicine Our experience Polak R. et all. Global Health Advanced Medicine, invited paper
The Chef Coaching Main principles - Coaching-based culinary intervention - Hands-off culinary education Polak R. et al. Eating behaviors 2015.19:65-9
Chef Coaching: 12 weekly one-on-one 30-minute coaching sessions via Skype: Identify culinary goals & review progress Practical culinary skills are taught when requested No "hands on" / cooking demonstrations Polak R. et al. Glob Adv Health Med. 2014;3(6):42-48
Chef coaching case report: Personal details - 55-year-old white male physician single and living alone - Recently diagnosed with type 2 diabetes - Reports chronic stress, sedentary behavior, and unhealthy eating The process - First five meetings: culinary goals - With his success: goals from other lifestyle domains Polak R. et al. Glob Adv Health Med. 2014;3(6):42-48
Chef coaching case report: Before CCP After CCP BMI 31 31.5 Blood pressure 130/74 130/75 HgA1C 8.8% 6.7% HDL cholesterol 28 25 LDL cholesterol 108 100 Triglyceride 563 320 Diabetic medication Metformin 1,000 mg * 2/day Insulin Glargine 40 unit/day Metformin 1,000 mg * 2/day Liraglutide 1.2 mg * 1/day Polak R. et al. Glob Adv Health Med. 2014;3(6):42-48
Chef coaching case report: "I bought a wide variety of vegetables for the whole week. Now I understand how to store in order to keep them fresh so I will bring some to my office. I bought a multigrain bread and I froze it. I did not know it is possible to freeze bread. Now I have a healthy bread every day without the need to buy it." Polak R. et al. Glob Adv Health Med. 2014;3(6):42-48
Chef coaching service: http://www.instituteoflifestylemedicine.org/services/chef-coaching/
The Chef-Coaching - feasibility
Culinary Medicine Medical education Students should be able to: - Define the relationship between food items and obesity and differentiate it from the single nutrient approach. - Improve their attitude about the importance of their patient s culinary behaviors. - Receive tools for increasing their patients culinary behaviors such as recipes resources, skills, clips, etc. - Have greater confidence and spend more time cooking, thus improving their personal health. Polak R., Butch S. Unpublished data
Culinary Medicine Medical education, example Please see the following healthy recipe video-clips (Tabbouleh salad, fish): https://www.youtube.com/watch?v=l6ne4vg5ni4 Mr. Jo is a 45 year old individual with obesity that hase just started to cook for himself. He saw the video clip and would to make it for dinner. 1. What can Mr. Jo do in order to decrease the energy density of his dinner? - To make a smaller portion of the fish - To add more vegetables to the Tabbouleh salad - To substitute the quinoa with lentils - To substitute the olive oil with Canola oil
Culinary Medicine For you!
Tool 1: Food language Mozaffarian D, Ludwig DS. JAMA 2010; 304:681-2
Food language Example Dietary fiber that occurs naturally in foods may help reduce the risk of cardiovascular disease, obesity, and type 2 diabetes It is unclear if added fiber provides the same health benefits as naturally occurring sources Dietary Guidelines for Americans 2010
Tool 2: Shared medical appointments Delichatsios H. et al. Glob Adv Health Med 2015. In press
Tool 3: Web resources - Culinary clips - Recipes http://www.instituteoflifestylemedicine.org/services/culinary-medicine//
Tool 4: Books
Tool 5: Peer reviewed resources Polak R. et al Clinical Diabetes. 2015. 23(4); 198-205
Culinary Medicine Self-care
Thank you Mentor Edward Phillips Additional teachers Martin Abrahamson Scott Butsch Marie Dacey David Eisenberg Collaborators Rachele Pojednic Sarah Hawkins Mary Kennedy Diana Dill