Breaking Bread,Breaking Barriers: Qualitative Insights into Support and Challenges in Culinary Medicine and Medical Nutrition Therapy Delivery for Diabetes Management

Abstract

Purpose

This study explores patient experience in dietary behavior change after nutrition and culinary medicine interventions.

Design

The qualitative study uses in-depth, semi-structured interviews and thematic analysis.

Setting

Researchers collected participant feedback after nutrition interventions in an urban, safety-net health clinic.

Subjects

Twenty-six adults with uncontrolled type 2 diabetes participated in nutrition or culinary medicine interventions and follow-up interviews.

Method

Study team members completed phone interviews focused on understanding support, challenges, and barriers during nutrition interventions for dietary change. Interviews were recorded, transcribed, and coded using NVivo software. Data analysis based on size and distribution of code applications led to thematic content and patterns of experience.

Results

Two key lessons emerged: (1) Participants valued practical nutrition, culinary, and technical support from the nutrition and research team members. Participants appreciated how team members alleviated doubts and filled knowledge gaps through non-judgmental listening and motivation that emphasized flexibility. (2) Participants valued personalized support to overcome barriers and challenges engaging in nutrition education and dietary change. Barriers included food costs, childcare, technology, and competing health demands, and some of these could be overcome with tailored support.

Conclusion

Integrating medical nutrition therapy and culinary medicine alongside food access resources may address upstream determinants of diet-sensitive disease. Programs that emphasize social connection and support, cultural relevance, and flexibility may be especially effective in safety-net settings.

Keywords

nutrition education medical nutrition therapy culinary medicine diabetes care

Purpose

The driving force of dietary patterns on health outcomes has garnered national attention and inspired innovative food as medicine strategies across the United States and abroad.^1–3 However, practical implementation of food as medicine³ strategies that deliver accessible nutrition education and support needs significant further study. While core tenets of nourishing and health-promoting dietary patterns are well-established, successful implementation of long-term dietary health behavior change remains more challenging, particularly in the context of complex social, economic, and cultural factors.^2,4–7

The Integrated Behavioral Model can help underpin the factors leading to the successful, long-term implementation of food as medicine strategies. The Integrated Behavioral Model builds upon the Theory of Reasoned Action (TRA) and the Theory of Planned Behavior (TPB), two theories developed to help explain an individual’s likelihood of implementing a behavior.⁸ The TRA considers intention as the best predictor of engaging in a behavior. According to this theory, intentions are predicted by an individual’s attitudes and subjective norms.⁹ The TPB adds to this by including perceived behavioral control as another predictor of implementing a behavior.¹⁰ The Integrated Behavioral Model expands on the two theories by including four additional constructs to help explain the sustainability of behavior implementation: knowledge and skills needed to perform a behavior, environmental constraints, salience of the behavior, and repeated experiences of engaging in the behavior (ie, building a behavioral habit).⁸ Nutrition support through traditional medical nutrition therapy (MNT) with registered dietitian nutritionists (RDNs) offers individual or group guidance for dietary change, typically offering knowledge and support for behavior change. However, most interventions lack opportunity for repeated experiences engaging in new behaviors, a gap that may be key to development of sustainable dietary changes.

Culinary medicine (CM),¹¹ a rapidly expanding field integrating interprofessional nutrition knowledge, culinary literacy, and health impact, similarly offers group-based education, typically by building skills needed for implementation of MNT recommendations through hands-on food preparation.^5,12,13 While both methods have demonstrated impact by improving dietary quality, culinary literacy, and biometric outcomes,^5,6,14–22 CM uniquely weaves hands-on experience and skills-building into the approach. The recent consensus statement on CM across settings and professions highlights its application in healthcare settings as “a multifaceted field that bridges the gap between the most up-to-date, evidence-based nutrition science and culinary tradition,” rooted in food is medicine principles and support for disease prevention.¹¹ However, in low-resource settings where individuals and families face food insecurity and other non-medical drivers of adverse health,²³ patients’ capacity for sustained healthy habits can be limited. As such, the development of novel strategies to support dietary change must include a deeper understanding of the barriers and challenges a community of patients faces alongside their strengths and support structures. These domains are typically not the focus of traditional medical management approaches, but their exclusion may be a core, underappreciated contributor to poor dietary patterns and associated chronic diseases.

Design

This qualitative evaluation aimed to explore participant experiences with medical nutrition therapy and culinary medicine education as part of a larger, mixed-methods pragmatic randomized controlled trial (RCT). Trial design and methods have been previously published.²⁴ In brief, participants were randomized to one of two models of nutrition care. MNT participants were offered six, one-hour education sessions in individual or group settings, via phone, WebEx, or in-person; CM participants were offered six, two-hour hands-on education sessions in a virtual, group setting. The MNT arm sessions were based on the American Diabetes Association (ADA) recommended Medical Nutrition guidelines for diabetes education, and the CM arm sessions were based on the Diabetes and Carbohydrate module and others from the Health meets Food community courseware.²⁵ The MNT and CM interventions were facilitated by a bilingual (English and Spanish) RDN or culinary RDN, respectively.

In this paper, we utilize qualitative data from the larger trial to understand the experiences of patients engaging in both the MNT and the CM interventions (together referred to as nutrition education classes). Semi-structured interviews with program participants were used to obtain experiential narratives. The semi-structured interview guide explored and assessed participant experiences regardless of study arm, identified barriers, challenges, and motives for participation and engagement, and aimed to discover what things they enjoyed and/or learned in the classes.

The trial was approved by the Institutional Review Board.

Setting

The larger trial was conducted among patients with uncontrolled type 2 diabetes within a safety net health system serving primarily underinsured and uninsured residents of an urban county in Dallas, Texas. Participants were recruited from a single primary care clinic, with MNT delivered by health system RDNs and the CM intervention delivered virtually by the study team. Further details of the larger trial’s setting, study design, and recruitment have been previously published²⁴ and notably include an understanding of the social needs of this specific community, a local construct which is key to offering the right “menu” of flexible nutrition and culinary support models. Qualitative interviews were conducted via phone.

Participants

Participants for qualitative interviews were recruited from the pragmatic clinical trial. All interview participants met trial eligibility criteria including having a duration of type 2 diabetes >12 months and an HbA1c ≥ 7.0% in the previous 3 months.²⁴ The main trial participants were eligible to participate in qualitative interviews if they attended at least 3 sessions from either intervention arm (MNT or CM), and all eligible participants were invited.

Method (Data Collection and Analysis Strategies)

A total of 26 interviews (16 MNT, 10 CM) were conducted via phone after completing their nutrition intervention (average time of interviews was 2 months after completion) to assess participant experiences. Interviews were performed by a skilled qualitative, bilingual researcher following an Interview Guide designed by the trial PI (MEB) and expert qualitative researchers in the trial team (CSM, PC, and MM),²⁴ based on knowledge of the relevant literature and trial goals. The interviews were recorded, transcribed, translated as necessary, and coded using NVivo software and following a codebook of 22 defined codes. Two independent raters (MP or GIP with CSM) coded each transcript and then discussed each code application to consensus. Post hoc axial coding was performed when necessary to better organize large code sets. The coded data set contained a total of 2114 unique code applications across the 26 transcripts. Overall, thematic content was identified through analysis of the size and distribution of code applications, the importance of narrative content with respect to the research purpose, and patterns which had bearing on relevant gaps in the literature regarding the patient experience of nutrition care and barriers to behavior change. Thematic results were determined through an iterative process of code summary analysis with the entire study team, with further refinements made during manuscript production. Due to the large size of the data set, we focus this discussion on a limited portion of code sets and thematic data as described below.

The research and author team reflects varied positionalities, including professional positions in academic medicine and public health. Some authors identify as members of the communities served by the intervention and have experience with food insecurity. Several authors occupy institutional roles that may confer power. All authors participated in one or more of the following: study design, implementation, data collection, data analysis, and/or manuscript writing. Reflexivity was maintained through ongoing team discussions, documentation of analytic decisions, and inclusion of community perspectives, including study engagement with a community advisory panel.

Results

The full qualitative results and associated 22 codes from analysis of participant interviews are described separately. The current discussion focuses on the “Support” and “Barriers” code sets which conveyed distinctive patterns relevant to CM and MNT programming and provided insight for nutrition teams to design tailored support strategies addressing common barriers. These specific codes inform two key lessons for implementing dietary health behavior change programs and focus on learnings applicable to nutrition teams. Here, the key lessons emphasized are rooted in the Integrated Behavioral Model’s constructs for behavior change (knowledge and skills, environmental constraints, salience of the behavior, and repeated experiences engaging) and prior findings in the literature. The lessons are supported by code counts and illustrative quotes from this study’s participants.

The first key lesson revealed the role of practical support, guidance, and education from the nutrition team members (RDNs, culinary RDN, and research team members). The second key lesson demonstrated the value participants placed on tailoring and personalization of nutrition support to their situation, particularly as it relates to overcoming challenges and barriers. These lessons are described as unifying themes relevant to designing impactful nutrition programs that integrate with the health goals and life circumstances of participants, rooting in the Integrated Behavioral Model’s constructs.

Theme 1: Participants Valued Practical Nutrition, Culinary, and Technical Support From the RDN, Culinary RDN, and Research Team Members

The code “Support” marked participants’ unprompted narratives of the support they received from others during and after the class. Participants were not asked explicitly about support that may have impacted their experience in the trial, yet the code was applied 75 times across 26 interviews, indicating that support was mentioned multiple times by participants independent of direct prompts by research staff. Sources of support named by participants included family, friends, and nutrition team members. The support code was applied to passages naming research team members 3 times in 3 interviews, to the RDNs 25 times in 8 interviews, and to passages about the culinary RDN 13 times in 4 interviews. The RDNs had the highest number of mentions, likely related to the fact that the MNT study arm had the most participants (n = 43) and subsequent interviewees (n = 16); the CM study arm had fewer participants overall (n = 36), but interviewees (n = 10) still mentioned the support of the culinary RDN and research team members without prompting.

Selected participant quotes reflecting the support codes demonstrate the breadth of impact of the key lesson. Participants appreciated that the nutrition team members alleviated doubts, addressed incorrect beliefs, answered questions, and helped fill knowledge gaps, which motivated behavior change.

“I gotta say one thing that is weird, every one of my questions were answered. Whether I asked him or whether he mentioned it, that made me feel a lot more comfortable… Then at dinner it was really good. -CM Participant

“I learned mostly by going to the classes to learn about this. And more, right? Because you know it, as I said, but you don't apply it because it's easy to continue the same way. But if you attend, for example, these classes. And pay attention to what they tell you, how they explain it to you, well, little by little you start understanding that it's true.”-MNT participant

“And she helped us a lot to get rid of many doubts we had about food. -MNT Participant

“Just enlightenment on a lot of things that I was thinking was wrong, but it was actually something I could eat. So it was very beneficial. -MNT Participant

Participants valued the listening, patience, and energy of nutrition team members which supported motivation for behavior change, built confidence in the kitchen, and left participants feeling that they could recreate healthy dishes they enjoyed on their own. Participants noted the importance of feeling that they were not judged, which they often experienced through the team members’ listening well and emphasizing the flexibility of dietary change without rigidity.

“The chef [culinary RDN] told us, right? That everything should be in small portions. And to eat it, to put it on the plate, he showed us how we should plate it. -CM Participant

“She listened to what I was doing, and I get a suggestion like, well, you could do this and this. I really think that that helped a lot and at the end of the day it was part of the success I was having, just being comfortable with it and her being so helpful and all the information she was giving me too. -MNT Participant

“So, motivation plays a big role. He transmitted a lot of positivity during the classes, and the coordinator also encouraged us a lot. -CM Participant

“So once she kept on track, that kept my mind focused on the goal. Sometimes a person needs that. They get the extra boost because you don’t have that, you just go back to your old way because it’s easy to slip back into that habit.” -MNT Participant

“Well, he was very patient with us. Yes, he was very patient, very calm. A really good chef [culinary RDN]. Because, if we forgot something we could ask him, and he would say it again. And...like that, he showed patience. -CM Participant

The group context proved valuable as a low-risk way to support new knowledge about nutrition and cooking. By reducing traditional power dynamics in the healthcare context, a group class naturally creates an environment where participants outnumber facilitators but foster a sense of accountability. During group sessions, a practical and exploratory environment normalizes common experiences across participants, allows practical skill demonstration, and promotes learning from one another. The group context also allows potentially fewer “touchpoints” of support directly from the nutrition team members as everyone learns simultaneously.

“…she would check in with us and so that made me accountable to somebody. Hey, let me try to change this about the way I eat. Let me introduce this to the kids so it could be a constant thing that we add to our menu. -MNT Participant

“Well, with demonstrations. Because he [the culinary RDN] also cooked. He'd also cook and show us. He showed us how to put the food on the plate. Ah ha. We add a portion of rice. Then we add a portion of beans or if you're going to put rice then you don't put beans there. Or a portion of salad. And from there, what we were going to add for fish or meat. I tell you, he was the one who taught us how to do it.” -CM Participant

Theme 2: Participants Valued Personalized Support to Overcome Barriers and Challenges Engaging in Nutrition Education and Dietary Change

Within the larger qualitative codebook described in a separate manuscript, the code “Barriers” was designed to mark narratives about barriers participants experienced trying to join the nutrition (MNT or CM) classes. The code was applied 27 times across 10 interviews, and these findings contributed to the second theme. Participants addressed a variety of barriers, and sometimes reported no barriers, associated with either joining classes or applying lessons from the classes. We address these two sets of barriers in turn below.

Barriers to Joining or Attending Classes

Problems in transportation were mentioned 2 times in 1 interview, cost of food/access to food was named 4 times in 2 interviews, childcare was named 2 times in 2 interviews, technological issues were named 9 times in 5 interviews, class expectations were named 5 times in 3 interviews, and no barriers were reported 5 times in 4 interviews.

Participants shared experiences revealing the role of work schedules, transportation, childcare needs, and costs of food in their ability to engage and continue participation in nutrition education classes. Food insecurity clearly impacted many participants, and they shared about their experiences with the cost of food and picking up the provided food.

“Food is always needed. -MNT Participant

“If I didn't go to the food pantry, I don't know where I will be right now. You know, it's hard.” -MNT Participant

“I would arrive just on time, but I did make it. Only for the last class the bus didn't come, and I was stranded.” -MNT Participant

“Well, I do have work some of the days but the nutritionist helped me with the timetable. So that I could get my daughter to school and also participate on a day when I wasn't working.” -MNT Participant

Technological challenges, such as using devices for virtual classes, served as a common barrier, but most participants overcame this with support and technical assistance; some even found the virtual approach convenient with their work schedules.

“Well, at first, it was very difficult for me. I thought, how will I do that with the phone? I don't even know how to use it. And well, it wasn't complicated. And then I told my daughter, tell me how to use this, because I'm having a class.” -CM Participant

“I'm not very familiar with phones like that, but later, later, my children taught me how to use it, how to put it on, how to get into the class, how to join, and everything was very clear.” -CM Participant

Participants also described anxious emotions about class expectations, including uncertainty about their cooking skills and schedule. For the class experience specific to the CM arm, participants occasionally struggled with interaction in the virtual setting. They shared comments suggesting their culinary literacy may impact comfort interacting in a group setting.

“I thought I was gonna have to show off my cooking skills. -CM Participant

“I was a little bit nervous at first because I'm not a cook and I don't know anything about cooking. And so I kind of thought I was awkward at first, but once I got to do it, I found out it was so much easier than I thought it would be.” -CM Participant

Barriers to Applying New Knowledge in Their Lives

In addition to overcoming the barriers related to attending classes, participants shared key insights about the challenges they faced applying the new knowledge learned to their lives. The code “Challenges” within the larger and separately published codebook is similar to “Barriers” but was used to capture interview narratives about challenges that participants faced in engaging and applying new knowledge from the classes into their everyday lives. The code was applied 108 times across 25 interviews.

Narratives in this code fell into the following categories: comorbidities/competing health issues (named 19 times in 8 interviews), competing demands such as life and family circumstances (mentioned 26 times in 9 interviews), cost of and access to food (named 12 times in 7 interviews), fatigue/low motivation (mentioned 9 times in 5 interviews), and cravings (mentioned 21 times in 12 interviews). Notably, the absence of challenges in some domains was noted 21 times across 12 interviews.

Participants faced a wide variety of challenges with both their own competing health issues as well as other competing demands unrelated to health.

“I am having some problems with my sight. The girl asked me last week if I see the quantities when I go the shop and I tell her I don't because I don't see very well.” -MNT Participant

“I was in poor health. That time, yes, that's the truth, I did not connect, is that the right word? I didn't log in because I was in very poor health.” -CM Participant

“Trying to get everybody on one accord to eat the same thing. Like tonight, I wanted to have fish and I put it back, I'm like, the kids don't like fish, so I put it back in the fridge.” -MNT Participant

“But during the course of me taking the classes, I kind of had a little trauma in my life, so I kind of got unfocused. -MNT Participant

Participants also shared challenges with motivation, cravings, and food preferences with respect to impact on making and sustaining dietary changes.

“I love tortillas. I love rice. I love pasta. I love bread. The most difficult. Yes. Yes. And that sometimes I already have it in my mouth, and I say, ‘Oh, I have fallen again.’” -MNT Participant

“What challenges did I face in making all these changes? Well, I had to... How do you say it? Motivate myself to eat nutritiously. -MNT Participant

“Well, everything that is unhealthy tastes good. But whenever you're eating healthier, sometimes you like, man, ‘I wish I were eating that instead of this or I wish I were having more of this instead of more vegetables.’ Well, that's where willpower comes in. You really have to stick to your guts if you want to try to make a change. -MNT Participant

“I had to call the person that called me for the class tell them that I don't incorporate no vegetables in nothing that I eat, but now I’m learning to like vegetables.” -CM Participant

Discussion

Dynamic, adaptable support to help patients address the challenges of dietary behavior change is vital. Delivery of this personalized support, particularly in vulnerable populations, requires significant flexibility, creativity, and willingness to offer multiple strategies that allow participants to overcome common barriers and challenges. MNT, a standard of care in type 2 diabetes, provides essential support, particularly in addressing gaps in nutrition knowledge. However, many patients have a co-existing gap in culinary literacy, and this has rarely been historically addressed in clinical practice settings, in part due to a lack of culinary literacy in clinicians as well but also related to complex clinical environments that often lack the structure and resources for hands-on experiences.^17,25,26 This dynamic highlights the potential of CM training for dietitians and other health professionals, particularly with its emphasis on intersecting expertise across nutrition, clinical care, and culinary arts.^5,12 CM thus offers an additional, complementary strategy for promoting dietary behavior change with personalized support.

The navigation of any major dietary change for health reasons tends to be overwhelming for patients. Nutrition education teams benefit from awareness of the impactful role of each team member as a source of key support, encouragement, and system navigation for patients undertaking dietary change efforts. According to these results, they deeply value individualized support and education during this process of change. In fact, many participants shared a desire to support their family members through their own learnings on the journey, either in their roles as caregivers or to promote healthier habits in children and partners for prevention and management of disease. Participants’ perception of support from the nutrition team members in this study empowered those participants to make changes in their home, carrying forward the impact.

Rooted in the Integrated Behavioral Model⁸ of change, nutrition team members in our study promoted knowledge and skills as well as perceived behavioral control through practical support and education. McManus and colleagues similarly found that culinary education for youth with diabetes and their caregivers increased self-efficacy for sustaining healthy eating behaviors and mealtime preparation.²⁷ In our study, illustrative quotes about the support of each nutrition team member demonstrated the impact of layered, flexible, and practical support to sustain behavioral change. Participants found value in consistent facilitators who held them accountable (repeated experience engaging); taught them new strategies and corrected incorrect beliefs (knowledge and skills); and supported their technical challenges (environmental constraints). Some participants shared stories regarding the lack of support from their families, but the supportive nutrition team members helped them to overcome some of these challenges and recognize the importance of healthy eating for diabetes management (salience of behavior). Rivera and colleagues had similar findings when studying caregiver self-efficacy in management of a specific carbohydrate diet for children with pediatric inflammatory bowel disease, and they described themes of gratitude for guidance, encouragement, and support from the nutrition team.²⁸ Group visit facilitators show participants their support by making them feel at ease and welcome, demonstrating interest in their stories, respect, being approachable, and responding to their questions.^29,30

The practical application of new dietary knowledge to everyday life, the “how” of dietary change, varies by individual experience, relationships with food, health history, and competing demands (environmental constraints). Participants in this study described many common barriers and challenges that influenced their process of change. They also gained an improved understanding of the key lessons that can predict and mitigate some of those challenges. For example, the flexibility of bringing children to class enabled some participants to attend. Others found that a virtual model allowed flexibility to accommodate busy work schedules, transportation barriers, and health reasons preventing in-person participation. Salas-Groves and colleagues³¹ demonstrated the value of virtual cooking models to improve kitchen confidence in older adults, and this study’s participants similarly reported many instances of support from the culinary RDN in the virtual CM arm. Similarly, other studies support virtual culinary and nutrition support models to improve dietary quality^32–34 and biometric outcomes like hemoglobin A1c reduction.^17,35 While not always modifiable, addressing environmental constraints like transportation, food access, and childcare needs are essential to behavior change.⁸

Insights from participants in this study further reinforce the value of listening during nutrition-focused care. The context of each individual’s circumstances offers the opportunity to guide the next steps and shapes the ability to personalize nutrition and culinary education. Ultimately, behavior change requires hope that success is possible, and the strategic support of nutrition team members can enhance knowledge and skills, address some environmental constraints, highlight salience of dietary change, and guide habit formation. Applying these strategies and fostering an intention to change one’s behavior, as outlined in the Integrated Behavior Model, through nutrition education classes may lead to efficient and long-lasting adoption of healthy eating behaviors. The value of employing these strategies at a local level with a vulnerable patient population remains paramount, as each individual and community needs tailored approaches. This study included patients from one large urban area, and the insights presented here may be limited by recall bias since interviews occurred within an average of 2 months after the completion of the nutrition intervention. Additional research should explore the needs and challenges of a variety of populations and allow the findings to iteratively shape nutrition and culinary interventions.

Conclusions

Increased awareness of the role of dietary patterns in health alongside the tremendous suffering associated with chronic disease necessitates effective, feasible strategies for dietary health promotion. Lessons from the lived experience of participants in this study emphasize the immense value of enhanced support, both by nutrition team members imparting knowledge and skills and through personalized guidance to overcome specific barriers and challenges. Even while facing numerous overlapping barriers ranging from competing health demands and food costs to family members resisting dietary change, the direct support from nutrition teams served as a catalyst for success through provision of both education and practical strategy. The real-life human kitchen has many variables that are both individual and shared, messy and rewarding. A pragmatic approach to nutrition interventions must remain sensitive to the many nuances and influences shaping why people eat the specific food on their plates, tailoring the right “dose” of personalized support for each person, family, and community. Future research should explore a deeper understanding of how to best optimize limited resources by tailoring approaches to both disease state and types of barriers. Ultimately, patient outcomes will be influenced by cultural, societal, and economic backgrounds. This reality behooves nutritional health professionals to embrace flexibility and practicality as they meet patients where they eat – literally and figuratively.

So What?

What is already known on this topic?

Food insecurity and poor dietary quality are common among patients with type 2 diabetes, particularly in safety-net settings. Clinical interventions often lack attention to the complexity of engaging in dietary behavior change.

What Does This Article Add?

Both medical nutrition therapy and culinary medicine models for nutrition education deliver valuable support appreciated by patients, with nutrition team member individualized support weaved into their experiences of success. Patients face many practical barriers and complex challenges in engaging and applying nutrition lessons, necessitating flexible strategies to promote dietary behavior change.

What are the Implications for Health Promotion Practice or Research?

Health systems should consider tailored models of support that address participants’ real-life constraints such as childcare, food insecurity, and technology limitations while expanding access to medical nutrition therapy and culinary medicine programs for patients with type 2 diabetes to optimize group support and motivation.

Footnotes

Acknowledgements

The authors would like to express gratitude to the many individuals who engaged in nutrition programming and provided their insightful feedback about the support, challenges, and barriers they faced in making dietary changes.

ORCID iDs

Jaclyn Albin

Guadalupe Isabel Perez

Carolyn Smith-Morris

Ethical Considerations

The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Institutional Review Board of The University of Texas Southwestern Medical Center (STU2020-1244). The trial is registered with NCT#05019274.

Consent to Participate

Informed consent was obtained from all participants involved in the study. All participants completed Verbal consent.

Author Contributions

JA, MAL, MS, and CSM conceptualized the manuscript. JA drafted the manuscript with significant input from MAL and CSM. GIP and MP provided key data analysis and insight alongside CSM. MEB secured funding and oversaw the larger study. All authors reviewed and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the W.W. Caruth Jr. Foundation grant 74-6000203. Research reported in this publication was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under award Number UL1 TR003163, and the Clinical Translational Science Awards NIH Grant UL1-RR024982. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MEB declares research support from Boehringer Ingelheim (unrelated to this work). JA serves on the Advisory Board and is a Committee Chair for The American College of Culinary Medicine focused on the development of educational strategy and tools in graduate medical education (unrelated to this work). The other authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

De-identified data is available upon request.*

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