Do cooking interventions facilitate behavior change and promote positive family environments? Review of the evidence.

Marla Reicks, PhD, RD Professor and Extension Nutritionist May 18, 2018

Changes in Home Food Preparation 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020

Food Network launched

Cooking intervention systematic reviews coverage

Home Economics college courses mid 1950s

Women’s lib, Home

Econ limitation

Home Ec cut from schools, FACS for few

First Swanson TV dinner

First frozen foods

Women spent 66 min

cooking/day

Meal prep/clean

up 37 min/day

Women spent 113 min

cooking/day

3.9 AFH, 1.8 FF

meals/ wk, cook 5

dinners/wk

AFH - $1.9 billion AFH – $10.5 billion AFH – $79.5 billion AFH - $287 billion AFH - $549 billion

Extension - health/disease not cooking or

recipes

Fast food industry

revenue $6 billion

Fast food industry

revenue $199 billion

Home Econ to schools,

Let’s Move,

Cooking Matters, Culinary medicine

Foodservice delivery ↑

Obesity rate significantly ↑

Microwaves in 20% HHs

Ready meals in stores

Learning from

family member still #1 source

https://www.huffingtonpost.com/2014/09/29/home-ec-classes_n_5882830.html Swanson CNBC.com

Home and away daily energy intake (1965-2008)

0102030405060708090

100

1965-1966 1977-1978 1989-1991 1994-1996 2003-2004 2007-2008

Per

cent

age

Percentage daily energy intake (middle income) US adults by food source

Home Away

Smith et al. Nutr J. 2013;12:45.

Factors contributing to increased spending on food AFH

1940 2 1960 11 1980 80 2000 287 2014 549

Increased dining out

since 1970’s

Larger share women

employed outside home

Higher incomes

Advertising / promotion by foodservice

chains

More affordable / convenient fast food

Smaller size US HHs

More 2-earner HHs

Expenditures on Food Away From Home (AFH): Expenditures for eating and drinking places including tips from 1929-2014 https://www.ers.usda.gov/data-products/food-expenditures.aspx

$ Billion Spent

Year

Food Away from Home (FAFH) – diet and health Diet

• Children/adolescents – 12% calories from fast food (NHANES 2011-2012, Vikraman

et al. 2013)

– Fast food - greater total energy, poorer diet quality, more regular soda consumption (NHANES 2003-2008 Powell et al. 2013)

– Increased sugary drink intake with greater weekly FAFH (Baseline data Project Move, 541 children, Lopez et al. 2012)

• Adults – Greater percentage energy from FAFH - greater

intake fat and cholesterol intake (NHANES 2005-2014 Todd 2017)

– Lower FV intake with greater frequency FAFH (telephone survey, King County, WA 2008-2009 Seguin et al. 2016)

– Fast food/full-service associated with sodium intake, fast food with lower vitamin A, full-service with more fat/lower vitamin D (NHANES 2003-2012 An & Liu 2014)

Health • Adolescents/adults

– Higher % body fat with greater use of fast food, other restaurants, home delivery and takeout (community-based studies 2006-2008 MN, Fulkerson et al. 2011)

• Adults – BMI higher with greater frequency of FAFH (fast

food/sit down) (Health Survey WI 2012-2013, 1418 respondents, Bhutani et al. 2018)

– More frequent AFH/fast food meals – higher BMI, lower HDL-cholesterol; micronutrients declined with increasing frequency AFH meals (NHANES 2005-2010 Kant et al. 2015)

Time spent cooking, US adults (1965-2008)

0

20

40

60

80

100

120

140

160

1965-1966 1975-1976 1985-1986 1992-1995 2003-2004 2007-2008

Min

utes

per

day

Mean time spent cooking, of those cooking (minutes per day)

Women Men

Smith et al. Nutr J. 2013;12:45.

45-year trends US women’s time use

0

5

10

15

20

25

30

1960s 1970s 1980s 1990s 2005+ 2010++

Hou

rs p

er w

eek

Mean hours/week

HH Management Screen Time Leisure Time PA

HH management – time spent preparing food, cleaning, laundry, house maintenance Screen time – non-occupational TV/computer use during free time Leisure time physical activity – sports and exercise Archer et al. 2013 Plos One 8(2): e56620.

Food consumption and spending1

Hours/day preparing, cooking, cleaning up from meals Frequency/wk < 1 hour 1-2 hours > 2 hours p-value2

Fruit (no juice) 6.1 7.1 8.4 <0.001 Green salad 2.8 3.2 3.6 <0.001 Vegetables (no potatoes/salad) 10.6 12.1 13.6 <0.001 Sugar-sweetened beverages 3.3 3.4 3.7 0.369 Sweet snacks 2.9 2.6 2.7 0.309 Spending $/person/wk < 1 hour 1-2 hours > 2 hours p-value Eating out 22.8 16.4 15.1 <0.001 Food at home 43.8 44.6 46.5 0.406 1 Seattle Obesity Study, 2008-2009, 1,319 adults, population-based survey. 2 Means adjusted in GLM with age, sex, race, employment, education, income as covariates.

Monsivais et al. Am J Prev Med. 2014;47:796-802.

• Observational/qualitative studies (n = 38) – Individual level outcomes

• Lower BMI, health improvements • Dietary benefits – indices, nutrient intake, healthier food groups, patterns • Family environment

– Home cooking allowed exploration of food cultures – Perceptions of gender roles and cultural belonging influenced by cooking patterns – Home food preparation - connections with others, increased adolescent independence

• Observational/qualitative studies (n = 38) – home cooking more likely: – Female, confident, passed skills on to children – Perceptions of skills – motivation to cook – Roles of wife, girlfriend, mother – perceived responsibility to provide meals – Interest in learning to cook, personal goals, nutrition, food costs – Time (employment, children’s activities – barriers) – Married, having dependents – Immigrants and Asian-Americans

• Inpatient and community-based cooking interventions (n = 11) – Socialization – group participation, belonging, sharing common interests – Self-esteem – concentration, coordination, confidence, accomplishment – Quality of life – psychological well-being; mediated by healthy food choices – Affect – less anxiety/agitation, positive affect mediated by healthy food choices,

intuitive eating habits

Barriers to home cooking and healthy eating Barriers to home cooking

• Eating away from home provided quality family time, less picky eating and perceived costs

• Early school lunch/after-school sports – Children not hungry or home at the typical dinner hour – Parents did not want to cook after 8pm

• Preparing/eating a meal at home took more time than driving/eating out

• Overestimated cost of home-prepared compared to take-out and frozen meals.

Barriers to healthy eating

– Adults (US/UK) lack of cooking skills/food preparation knowledge

– College students • Non-familiarity with cooking, lack of time, dislike

grocery shopping, kitchen cleanup

– Men lack skills/confidence, constrained by time/expense

– Mothers (low income/overweight) • Reported picky children/food requests, stressful

daily events interfered with cooking

– EU adults lack cooking skills, prefer to eat out, limited cooking facilities

Focus groups, questionnaires, 27 parents who ate dinner AFH ≥ 3 times/week (children 3-10 yrs), Midwest

Robson et al. Appetite 2016;96:147-153. Soliah et al. Am J Lifestyle Med. 2012;96:152-158.

Narrative review of 11 studies, range of countries and populations

Time, taste/pleasing

family, cost

Behavior Change Techniques (BCTs) Applied to Cooking Interventions

59 cooking and food skills interventions • 2 reviews • 1980-2016

40-item CALO-RE taxonomy • BCTs • Coding

Most frequently occurring BCTs • Across and within • Theoretical

underpinnings

Reicks et al. J Nutr Educ Behav. 2014, 2017; Michie et al. Psychol Health. 2011;11:1479-1498; Hollywood et al. Crit Rev Food Sci Nutr 2018.

1980-2011 - 25

2011-2016 - 34

2011-2016

Population adults

Relevant behavioral outcomes

English language

Interventions

After January 1980

If multiple, most

comprehensive Elig

ibili

ty C

riter

ia

Reicks et al. J Nutr Educ Behav. 2014, 2017; Hollywood et al. Crit Rev Food Sci Nutr 2018

Intervention locations

US (31)

UK (6)

Australia (5) Canada (4)

Scandinavia (3) Italy (2)

Participants (n = 21 – 7,422, mean 359)

Target populations • Low-income/vulnerable – 16 • Groups with health needs – 20 • General adult population (including

students) – 14 • Specific cultural groups (e.g.,

Aboriginal adults) – 6 • Families – 3

Sex and Age • Mixed female and male – 40 • Female only – 14 • Male only – 5 • Skewed toward middle-aged/older

adults

Intervention Design

• 24 of 59 – practical cooking sessions to develop cooking skills

• 35 of 59 – wider food skills issues (nutrition knowledge, accessing healthy ingredients, budgeting) 12

12

35

0 5 10 15 20 25 30 35 40

RANDOMIZED CONTROLLED TRIALS

NON-RANDOMIZED CONTROLLED TRIALS

PRE/POST OR POST ONLY

# Interventions

Intervention duration (of 57)

6

13

17

10

0 2 4 6 8 10 12 14 16 18

1 session

2-4 sessions

5-7 sessions

8-10 sessions

Assessment (2011 – 2016) • Dietary outcomes – FFQ, food records/recalls, single/multiple questions

– 7 tested/validated, 6 provided references for use, 10 provided no info on testing • Psychosocial outcomes – confidence, knowledge

– 5 measured confidence (3 tested/validated), 8 measured knowledge (2 tested/validated)

• Health outcomes – body weight, BP, biochemical markers, specific scores – 4 used scores (all tested/validated)

Standardized definitions of behavior change techniques allows for: • Identifies which techniques

contribute to effectiveness (evidence synthesis)

• Accurate description of interventions

• Reliable linking of BCTs to mechanisms of action

40-item CALO-RE Taxonomy Codebook

• Standardization to relate taxonomy to cooking and food skills interventions

• Codebook of definitions developed

Coding

• Interventions coded according to the taxonomy • BCTs mapped where identifiable by 2 coders

• Cooking skills (mechanical process of cooking, chopping, etc.) • Food skills (perceptual planning, acquisition, organizational and

creative skills, those related to nutrition knowledge and food safety)

Clarification/ Consistency

• Coders contacted taxonomy authors for clarification over discrepancies

• Third coder reviewed all interventions and codes to ensure consistency

Behavior change techniques 1. Provide information on consequences of behavior in general (relationship between the behavior and likely consequences usually based on epidemiological data)

Versus 2. Provide information on consequences of behavior to the individual (benefits and costs of action/inaction tailored to relevant group based on individual’s characteristics)

21. Provide instruction on how to perform the behavior (telling the person how to perform verbally or in written form)

Versus 22. Model/demonstrate the behavior (showing the person how to perform through physical or visual demonstrations of performance) 20. Provide information on where and when to perform the behavior (telling the person where and when they might be able to perform the behavior, verbal or written)

26. Prompt practice (prompt the person to rehearse and repeat the behavior once or more than once) Michie et al. Psychol Health. 2011;26:1479-1498.

BCTs identified across interventions

49

24

17

24

45

31

39

15

0 10 20 30 40 50 60

1

2

8

20

21

22

26

29

Frequency of BCT

Info consequences of behavior for individual

Instructions on how to perform the behavior

Demonstrate behavior

Prompt practice/practical cooking

Info where/when to perform behavior

General information on consequences of behavior

Barriers/problem solving

Plan social support

Outcomes 55 of 59 reported positive outcomes after the intervention or short term (3 months) 14 of 59 reported positive outcomes longer term (> 3 months) 1.Health outcomes (e.g., reduced

cholesterol) 2.Dietary outcomes (e.g.,

improved intakes) 3.Psychosocial outcomes (e.g.,

improved nutrition knowledge)

Short-term change (55) • Health - 18 • Dietary - 26 • Psychosocial – 40

Long-term change (14) • Health – 4 • Dietary – 10 • Psychosocial - 8

• Practice – 10/14 • Info how to perform

10/14 • General info - 9/14 • Info when/where -

4/14

Comparison between most commonly used and those used to produce long term behavioral change Behavioral Change Technique Number of

interventions (of all 59) where BCT used

Number of interventions reporting long-term change (of 14) where BCT used

% 1 – Give general information 98 64 2 – Give information specific to the individual

41 21

20 – Where and when to carry out the behavior

0 28

21 – How to carry out the behavior 76 71 22 – Demonstrate the behavior 66 0 26 – Prompt practice/practical cooking 44 71

Theoretical Underpinnings • Theory explicitly cited in 14 of 59 interventions, no report of how theory

informed which BCTs were used or linked theory to content/outcomes • Demonstrate behavior (12 of 14) • Prompt practice (7 of 14) • All 14 indicated primary outcomes were met • 3 of 14 reported long-term positive outcomes

Social Cognitive

Social Learning

Social Ecological

Social Marketing

Experiential Learning

No pattern between using theory and positive long-term outcomes and use of specific BCTs.

Commentary on studies included

1980-2011 • 25 studies • 3 assessed BMI • Small number with clinical outcomes

2011-2016 • 34 studies • 12 assessed BMI • About half assessed clinical

outcomes

→About half in both reviews used measurement instruments tested for reliability and/or validity

→Lack of control group in nonclinical settings, no power calculation →Most participants - convenience samples

• Female, often lower income, middle-aged or older →Wide variety of intervention lengths, co-interventions

Family environment variables

Intervention studies →Food purchasing →Food security →Affordability of home-cooked meals →Changes in the food environment →Cooking attitudes and enjoyment Barriers identified →Family food norms/preferences and resistance to change →Financial constraints (creatively partner with community service

organizations)

Future directions – behavior change & positive family environments

• Standardized cooking and food skills intervention design template • Replication and adoption of effective BCTs in future interventions to

maximize efficacy • Outcomes

– Cooking skills and food skills (meal planning, food acquisition, organization) – Increase home food preparation frequency, decrease FAFH frequency – Self-efficacy for cooking skills and food skills

• Considerations – Time/financial constraints – Mealtime context – routines – Family cooking programs

Thank you!

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