Impact of virtual teaching kitchens on culinary and dietary behaviors of perimenopausal women: A mixed methods analysis

Impact of virtual teaching kitchens on culinary and dietary behaviors of perimenopausal women: A mixed methods analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of virtual teaching kitchens on culinary and dietary behaviors of perimenopausal women: A mixed methods analysis Rhea Dejanira Rasquinha, Andrea Pelletier, Laura Klein, Sarah Sommer, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6181028/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Virtual teaching kitchens have been shown to improve dietary habits, cooking confidence and self-efficacy. This mixed methods study evaluates the quantitative impact of NuCook’s teaching kitchen programs on cooking, eating, and health habits of perimenopausal women. It also assesses which components of the intervention were most beneficial for participants to achieve health behavior changes based on qualitative feedback. Methods: The NuCook program consists of a series of online classes offered synchronously and asynchronously, with 45 minutes of live cooking instruction and 15 minutes of health and nutrition instruction. From September 2020 to May 2024, participants completed pre- and post-intervention surveys which addressed weight, dietary habits, and cooking confidence. Participants answered open-ended questions about their experiences with the program. Normally and non-normally distributed data were analyzed with paired samples t-tests and Wilcoxon signed rank sum tests, respectively. Qualitative analyses were conducted by two independent reviewers who manually charted themes in each participant response. Results: Of 817 unique participants, 537 completed both pre- and post-surveys, and 525 wrote testimonials after attending classes. Participants reported significant decreases in weight (p=0.017), consumption of red (p<0.001), processed meat (p=0.004), white grains (p<0.001), and sugary beverages (p=0.026), and significant increases in consumption of fish (p=0.012), total fruits and vegetables (p<0.001), and beans (p<0.001). Participants also reported significantly improved cooking confidence and dietary habits including following a balanced plate model (p=0.010), replacing salt with spices (p=0.029), and devoting time to physical activity (p=0.014). Participants cited learning and cooking healthy recipes and nutrition education most frequently as beneficial aspects of the courses. Participant testimonials emphasized three positive characteristics of the course: engagement, tools, and change. The easy engagement, and the tools of learning cooking skills and nutrition information were cited as beneficial aspects that supported change of cooking and dietary behaviors. Conclusions: The NuCook virtual teaching kitchen intervention improved dietary habits and cooking confidence among perimenopausal women. Qualitative analysis shows that NuCook courses engaged participants and provided them with tools, such as recipes and health education, to achieve health behavior changes. This demonstrates the potential of virtual teaching kitchen interventions to support lifestyle and behavior changes. Trial Registration: Study obtained IRB exemption. Figures Figure 1 BACKGROUND One in five deaths worldwide can be attributed to suboptimal diet [1], and poor diet is the leading cause of mortality in the U.S. due to diet-related chronic diseases [2]. While popular diets (e.g. low fat, low carbohydrate, Mediterranean, intermittent fasting) have marginal impacts on reducing risk for obesity-related comorbidities, individuals vary in their ability to adhere to different diets, which is the most important factor for successful weight loss [3]. Further complicating individuals’ ability to lose weight and avoid comorbidities is conflicting nutritional information and misinformation. Conflicting nutritional information is frequently present in the media [4-5], and anyone can share nutritional information online, which increases the risk that unreliable and potentially harmful information is disseminated to the public [6]. While three in five U.S. adults viewed conflicting nutritional information as a sign of improved understanding over time with new research, those who are less science-oriented lack trust in nutrition information and find it confusing [7]. In addition, our “diet culture” is filled with conflicting and judgemental opinions for those seeking information about healthy eating [8]. Health interventions aimed at modifying dietary and lifestyle behaviors are currently the first recommended step for treatment of overweight and obese adults [9]. These interventions are also important for women in menopause, a time when type 2 diabetes, cardiovascular disease, obesity, and other diet-related chronic diseases are more prevalent [10]. Interventions focused on health promotion and patients’ control of their own health have been shown to contribute to successful behavior change. These programs focus on health information and education along with the development of life skills and goal setting [11]. One systematic review found that autonomous motivation, self-efficacy, and self-regulation skills were the most promising self-regulation factors for successful behavior change with obesity interventions. A “non-diet” approach promoting a positive body image and flexible eating control were important for long-term weight control [12]. In addition, community engagement is reported to increase the likelihood of success of health interventions with effective community participation and feedback [13-14]. “Food is medicine” is an emerging evidence-based initiative which integrates food and nutrition interventions into patient care, including medically tailored meals, medically tailored groceries, and produce prescriptions [15]. A focus on skill building in addition to access to healthier affordable food has been emphasized in the “food is medicine” movement [16] using a culinary medicine framework. In culinary medicine, teaching kitchens are physical or virtual educational programs which combine nutrition education and culinary skills to improve cooking and dietary habits [17-18]. Following the COVID-19 pandemic, virtual teaching kitchens have become more widely accepted as nutritional interventions [19]. Since these programs only require internet access and do not have space and resource restrictions like in-person teaching kitchens, virtual teaching kitchens can reach underserved populations and potentially increase self-efficacy, as participants source ingredients from their local communities and prepare food at home [20]. Current virtual teaching kitchen interventions have been shown to increase fruit, vegetable, and legume consumption, improve self-efficacy in meal planning, cooking confidence, and attitudes toward cooking [19, 21-23], and enable participants to adjust recipes to make them healthier [24]. These benefits align with updated dietary guidelines, as the Scientific Report of the 2025 Dietary Guidelines Advisory Committee defined a more plant-based diet — including more vegetables, fruits, legumes, nuts, whole grains, and fish/seafood and less red and processed meats, sugary foods and beverages, and refined grains — as a “healthy dietary pattern” [25]. Virtual teaching kitchens can adapt to community needs [26] and be tailored to different literacy levels and language preferences [27]. There is limited literature reporting on the specific aspects of culinary medicine interventions that contribute to behavior changes. However, a review of 14 culinary medicine interventions identified the duration of the intervention, the participation of a chef, and educational components such as hands-on cooking and individual counseling as potential contributing factors to improved health outcomes [28]. Another mixed-methods study of Boston Medical Center’s (BMC’s) Nourishing Our Community Program (NOCP) reported time constraints, busy schedules, and a dislike for vegetables as barriers to cooking at home and following the recommendations of nutrition interventions [29]. Flavor is the largest driver of food choice and intake, and healthy foods are commonly equated to being flavorless or unappealing, so considering flavor can help increase the appeal and efficacy of nutrition interventions. One review found spice, particularly chili powder or capsaicin, to contribute to healthier eating by increasing calorie expenditure, decreasing food intake, and enhancing flavor [30]. Using taste-focused labels also increased vegetable selection and consumption compared to health-focused labels [31]. The NuCook virtual teaching kitchen intervention is a series of online classes offered synchronously which include 45 min of live cooking instruction and 15 min of nutrition education. A preliminary analysis of surveys pre- and post-participation in the NuCook program from September 2020 through December 2021 showed that our intervention improved dietary habits and increased cooking confidence among peri- and post-menopausal women [19]. The purpose of this study was to investigate which components of the courses best supported these behavioral changes using a mixed-methods analysis of survey data of an expanded pool of participants . METHODS This study is a mixed-methods analysis of the impact of NuCook virtual courses with quantitative analysis of dietary patterns and cooking habits and qualitative assessment of participant testimonials regarding how and why the course changed their culinary and dietary choices. The data analyzed in this study includes data analyzed in our previous study [19], and the same virtual teaching kitchen program and recruitment process was used. However, this study includes data from 268 additional participants and was the first to analyze qualitative survey responses. We investigated the impact of participation in NuCook virtual courses using data from pre- and post-intervention surveys. Analyses of quantitative data and content analysis of qualitative data were performed. The institutional review board of Mass General Brigham (MGB) waived the need for ethical approval and informed consent, as this study did not meet the human subject criteria defined by MGB Human Research policies and Health and Human Services regulations in 45 CFR 46. All methods were carried out in accordance with relevant regulations and guidelines of MGB. NuCook virtual teaching kitchen program The NuCook program consists of culinary and nutrition classes designed and taught by a team including a physician, dietitian, health coach, and chef. Classes are offered live over Zoom and free of charge. 31 courses were offered between September 2020 and May 2024. Data was collected on 15 courses with 3-5 virtual classes per course. Classes were offered from 6-7 pm Eastern Standard Time. We previously developed an initial in-person curriculum for a pilot study which used the educational methods of Cooking Matters for Adults [32]. The NuCook course curriculum was developed using this curriculum and other best practices in synchronous, remote education from the Culinary Healthcare Education Fundamentals (CHEF) - Coaching Program [33]. Each class featured at least two healthy recipes, along with nutrition and culinary educational information and designated teaching goals. Several improvements were made to classes and course curriculums throughout the study period based on participant feedback, including ingredient substitutions, increased participant-coach interactions, alterations to class pacing, and the implementation of a platform to make all courses available on demand after the live session. Classes focused on healthy eating with plant-based foods, aligned with the “Harvard Healthy Eating Plate” [34]. This includes additional guidelines on plant oil consumption compared to MyPlate [35]. Each class included up to 75 min of instruction, including 45 min of live cooking instruction with a professional chef, 15 min of health and nutrition instruction by a physician and dietitian, and an optional 15 min for community discussion and other questions. Recipes and instructions were made available to participants before each class, and participants could choose to cook along in real-time or observe the class and have a hands-on cooking experience at another time. Participant recruitment Any participant with working access to Zoom was eligible to participate in NuCook classes. Recruitment efforts focused on women over age 45 living in East Coast metropolitan areas who were interested in healthy cooking, eating, and menopause. All classes were taught in English. Mass General Brigham employees, Fish Women’s Health Center patients, and members of the general public were recruited through hospital health bulletins, EPIC notifications, and social media posts, respectively. Participants were asked to complete the pre- and post-class surveys with timed email reminders. Recipe and class preparation information was sent to all enrolled participants via repeated class reminder emails from NuCook staff. Enrollment was open throughout each course, but the per class capacity was capped at our Zoom capacity of 300 participants. Survey data collection Participants were asked to complete a pre-intervention survey to assess baseline dietary habits, cooking confidence, and health behaviors before beginning the course, along with a voluntary post-intervention survey after course completion. All surveys took approximately 20 minutes to complete and were administered through REDCap. We asked those who participated in one or more courses to complete the post-intervention survey for each course they completed. The National Institutes of Health (NIH) ‘Eating at America’s Table Quick Food Scan’ [36] and the ‘Eating Habits Confidence Survey’ [37] were used to develop survey questions. Questions about the Harvard Healthy Plate [34], whole grain and lean protein consumption, and portion control were also included, along with standard demographic information, height and weight, and class attendance questions. The post-survey included several open-ended questions for qualitative analysis; in particular, participant testimonials in response to the prompt, “We hoped you liked our course, and we're hoping to continue growing! Please write a short testimonial here about what you liked about the class, why you would recommend it, or why somebody else should enroll” were collected for analysis. Survey data analysis A study number was assigned to all participants based on their name and date of birth. For participants who completed more than one course, only the first pre-survey and last-presurvey completed were included for analysis. Quantitative data analysis was conducted using Stata 18.0. Participant-reported height and weight were used to calculate BMI, with the following definitions: Underweight (BMI <18.5), Normal Weight (BMI 18.5-<25), Overweight (BMI 25-30). Servings per day (of food groups of interest) was calculated using the reported frequency of food consumed. We added fruit, raw greens, cooked greens, vegetables as proteins, and other vegetables to calculate total daily servings of fruits and vegetables. Participants self-reported the number of classes taken, and if missing, this data was supplemented by attendance records for each Zoom session. For the purposes of this analysis, we used the number of post-surveys completed as a proxy for the number of classes completed because this ensured the participant completed the class. Continuous, normally distributed data was reported with the mean and standard deviation, and differences pre- and post-intervention were evaluated with a paired samples t-test. Categorical or non-normally distributed data was reported with either the frequency and proportion or median and interquartile range. Differences pre- and post-intervention were evaluated with the Wilcoxon signed rank sum test. Multiple linear regression was used to evaluate the impact of the number of classes taken on changes in outcomes controlling for baseline outcome value. We used paired samples t-tests to separately analyze differences pre- and post-intervention between the lowest quartile for baseline fruit and vegetable consumption and the highest quartile for baseline weight and BMI. Differences between the lowest and highest quartile for baseline fruit and vegetable consumption habits were also analyzed to capture behavior changes of participants with the least healthy dietary habits (i.e., lowest fruit and vegetable consumption) at baseline. Results were considered significant at p <0.05. The qualitative analysis was performed on all subjects who completed a post-survey. Blank and duplicate responses were removed. All testimonials were reviewed by two independent reviewers. The reviewers manually charted themes in each testimonial and established eleven thematic categories based on recurring themes in participant feedback. Responses were then assigned accordingly to one or more categories, and the number of comments for each explicit theme was counted. RESULTS In NuCook courses across 15 total cohorts, there were 817 unique participants who completed pre-course surveys and attended at least one live virtual class. 537 (65.9%) of these 817 participants completed both pre- and post-surveys for inclusion in the quantitative and qualitative analyses. Of the 537 post-surveys with quantitative data, 525 were included for the qualitative analysis. Participants completed between 1 and 12 courses, and the mean number of courses completed (as reported by number of post-surveys completed) was 2.2 (SD=1.9). Demographic data was collected for 383 of the 537 participants (71.3%). The mean age of NuCook participants was 60 years old. Of the 383 records analyzed, 91.6% of participants were White ( n =351), 1.4% were Hispanic or Latino ( n =3), 3.7% were Asian ( n =14), and 1.3% were Black ( n =5). Quantitative analysis The mean self-reported weight at baseline was 169.7 pounds and the mean BMI at baseline was 28.4. At baseline, 0.6% of participants were underweight, 35.5% were normal weight, 29.2% were overweight, and 34.7% were obese based on BMI. Table 1 shows reported changes in weight and dietary habits pre- and post-intervention among the participants who completed pre- and post-surveys ( n =537). There was a decrease in mean self-reported weight from 169.7 pounds at baseline to 168.6 after the intervention ( p =0.017). Further analysis by baseline weight showed a mean 3.1 pound weight loss for those whose self-reported weight was in the highest quartile compared to 0.42 for those below the 75th percentile ( p =0.011). There was no significant decrease in overall mean BMI, along with no significant difference between BMI changes in the highest quartile compared to those below the 75th percentile. Participants reported statistically significant increases in consumption of total fruits and vegetables ( p <0.001), fish ( p =0.012), and beans ( p <0.001) after participation in NuCook courses (Table 1). Participants also consumed significantly less processed meats ( p =0.004), red meats ( p <0.001), white grains ( p <0.001), and sugary beverages ( p =0.026) post-survey compared to baseline. Table 2 shows reported changes in eating and cooking confidence pre- and post-intervention based on a 5-point Likert Scale. Participants reported significantly increased confidence in following the balanced plate model daily ( p =0.010) and devoting time for physical activity ( p =0.014). Participants also reported significantly increased confidence in their cooking skills ( p =0.012), along with improved cooking confidence, specifically that cooking at home is not too time consuming ( p <0.001), frustrating ( p =0.044), or too much work ( p =0.003). Table 3 shows reported changes in eating and cooking confidence pre- and post-intervention when controlling for the number of classes completed. The number of classes completed by participants correlated significantly with change in improved cooking confidence in cooking skills ( p =0.049), confidence that cooking was not too time consuming ( p =0.007), frustrating ( p =0.014) or too much work ( p =0.006). The number of classes attended also correlated with a decreased consumption of red meat ( p =0.028) and sugary beverages ( p =0.026), but did not significantly correlate with changes in weight, BMI, or other food consumption frequencies. We analyzed the mean change in eating behaviors of the fruit and vegetable consumption for those participants in the lowest quartile and highest quartile at baseline and found those in the lowest quartile at baseline had the greatest improvement in consumption of vegetables as protein ( p = <0.01), fruit ( p = 0.018) and raw greens ( p = 0.004). Qualitative analysis of participant testimonials Table 4 shows the 11 thematic categories we identified: Enjoyed cooking and eating healthy recipes; learning new recipes and cooking tips; nutrition and health education; professional support (chef, physician, dietitian); support behavioral changes to improve health; good communication and resources from team; trying new ingredients, flavors, and techniques; community and connecting with others, incorporating new and/or healthy ingredients; supportive of all skill levels; and free courses. Figure 1 shows the 11 thematic categories from respondent testimonials distributed across three features of virtual teaching kitchens (engagement, tools, and change), along with a summary of relevant results from our quantitative analysis. As some testimonials included content aligned with multiple themes, the totals of each category will not sum to 525. The two reviewers additionally identified typical comments to illustrate each thematic category, which are included in Table 4. Of the 525 participant testimonials analyzed, 263 respondents (50.1%) mentioned that they and their families enjoyed the flavor and taste of the healthy recipes provided and/or cooking these recipes along with the live instruction or on their own time. 254 respondents (48.4%) cited culinary education including new recipes and cooking tips, and the nutrition and health information taught in the courses was cited by 211 respondents (40.2%). 95 respondents (18.1%) mentioned that they tried new ingredients, flavors, and techniques based on the different educational resources provided in the courses. 130 (24.8%) respondents mentioned NuCook’s team of professionals, including a physician, chefs, culinary coach, and a registered dietitian. Participants enjoyed having live access to this team and expressed trust in the information and resources provided. 124 respondents (23.6%) cited good communication and/or resources from the NuCook team, including weekly reminders, recipes, live instruction and Q&A, and class recordings. All NuCook courses and resources are available to participants free of charge, which was cited by 5 respondents (1%). 126 respondents (24.0%) mentioned how NuCook courses have helped them make behavioral changes to improve their health, such as greater mindfulness about ingredients when cooking and exercise, which helped some participants achieve weight loss in a sustainable way while eating balanced and fulfilling meals. 68 respondents (13.0%) cited learning how to incorporate new, healthy ingredients into different dishes during classes and making some of these changes in their everyday cooking routines. Although courses were taught fully online, 74 respondents (14.1%) mentioned that participating helped them engage in a bigger community and connect with other participants and people in their lives. 52 respondents (9.9%) mentioned that the courses provided a supportive environment for home cooks of all skill levels, from beginners to seasoned cooks. DISCUSSION This mixed-methods analysis demonstrates that the NuCook virtual teaching kitchen program provides several nutrition and health benefits for perimenopausal women — including significantly decreased weight and significantly improved dietary habits and increased cooking confidence — by engaging participants, supplying tools that supported their success, and encouraging positive changes. Our qualitative analysis provides insight into which components of the courses were most beneficial for participants. In addition, the nutrition and health education provided through the courses was also frequently cited in participant responses, and the distribution of thematic categories demonstrates the importance of both engaging participants and providing them the tools to achieve behavioral change. Our quantitative analysis demonstrated that participation in the NuCook program was associated with significant lifestyle changes including dietary behaviors, cooking confidence, and devoting time to physical activity. These results ( n =537) are consistent with our first publication [19] which analyzed quantitative impacts of NuCook courses on 269 pre- and post-surveys. Our findings regarding improved dietary habits, including increased fruit, vegetable, fish, and bean consumption and decreased red and processed meat, white grains, and sugary drinks consumption (Table 1), are consistent with a preliminary analysis of the efficacy of NuCook virtual teaching kitchen program [19], along with other previous studies on the impact of virtual teaching kitchens [21-23]. These improvements also align with the Dietary Guidelines Advisory Committee’s 2025 Scientific Report, which reports evidence supporting the health benefits of a more plant-based diet with lower red and processed meat, sugary foods and beverages, and white grain consumption [25]. We also report improved cooking confidence and attitudes towards cooking (Table 2), similar to previous studies [22, 38-39]. Participants also reported significant increases in following a balanced plate model, using spices and flavors instead of salt, and devoting time for physical activity post-intervention compared to pre-intervention (Table 2). High salt intake is associated with hypertension [40], which is a risk factor for cardiovascular disease, for which incidence is higher during perimenopause and menopause [41]. In addition, moderate physical activity (e.g., 30 minutes of brisk walking a day) during perimenopause may reduce the risk of late-life dementia [42], and habitual physical activity (e.g., walking 6000+ steps daily) was associated with decreased cardiovascular disease and diabetes risks for premenopausal, perimenopausal, and postmenopausal women [43]. Physical activity has also been reported as a mediator between depressive symptoms and quality of life in perimenopausal women [44] and associated with decreased psychosocial and physical symptoms of menopause [45]. Our preliminary study suggested that perimenopause should be approached as a life transition and suggested the importance of interventions targeting women during this life stage to support sustainable behavioral change [19]. The results presented here similarly support the potential of NuCook programs to help participants realize these changes. Our qualitative analysis looked at what participants identified as factors that they enjoyed and led to their engagement and process of change. In our qualitative analysis, the three most frequently cited thematic categories were: enjoyment of the delicious and healthy recipes provided by the course and cooking these recipes, culinary education with new recipes, and nutrition and health education (Figure 1). The 11 thematic categories were also relatively well distributed across the broader themes of Engagement, Tools, and Change, which is promising in demonstrating the potential of NuCook courses to support different stages of the process of improving health behaviors. NuCook courses are offered online for free and give participants easy access to engage with professionals and class content both in real time and on demand. To optimize engagement and provide personalized support both in and out of class, we employed different pedagogic styles in our classes, asked and answered questions in real time and via email, and provided information which participants could access asynchronously. We encouraged participants to engage with questions from our chef, doctor and dietitian about ingredients, food preferences, health practices, areas of confusion, and more. Following the COVID-19 pandemic, familiarity with video call platforms like Zoom and online learning has increased [46]. Although people have reported experiencing exhaustion from virtual interactions, giving rise to the concept of “Zoom fatigue” [47], online courses continue to allow for increased access to teaching and education [48], particularly for virtual teaching kitchen interventions [19-24, 26-27]. Another benefit of NuCook courses cited by participants was hands-on learning in real time along with lecture-style nutrition education. We provided educational materials tailored to different learning styles and methods of access, including real time talks, nutritional education slides shared live and after class on our website, a library of recipes, and posted videos of classes for asynchronous access. NuCook courses also taught generalizable culinary principles, such as with template recipes, giving multiple examples of how to use a new food or spice when it was introduced, focusing on batch cooking and repurposing leftovers, and providing multiple examples of how to cook a single dish with different flavor profiles reflecting a broader array of cuisines. Studies show that most people learn and retain nutrition and cooking concepts when they can connect the information to actionable steps through experiential or “hands-on” learning [49]. Another study comparing the dietary knowledge, behaviors, and habits of students who participated in either lecture- or experience-based nutritional education programs found that dietary behaviors changed in the experience-based group, while dietary habits changed in the lecture-based group, suggesting that both methods are important for effective nutrition education [50]. Given rising overweight and obesity rates, type 2 diabetes, and cardiovascular disease, which are associated with overnutrition and a sedentary lifestyle, interventions which support dietary and physical behavior change are regarded as important components of treatment [51]. Previous studies report that interventions conducted from a health promotion perspective (i.e., aimed at helping participants gain control over their health through education and the development of skills) contribute to successful health behavior change [52-53]. The Integrated Theory of Health Behavior Change proposes that increasing knowledge, beliefs, self-regulation skills and abilities, and social facilitation can improve health behavior change outcomes [54]. By this theory, interventions which support engagement between participants and the content, along with tools to further education and skills, can contribute to enhanced behavioral change. Participants most frequently cited that the recipes were delicious (Figure 1). 50% of participant testimonials cited the recipes provided as key beneficial aspects of the courses This suggests that the flavor and appeal of NuCook recipes to the participants and their tablemates was a motivator for changes in dietary habits. Flavor is an important factor in food choices and consumption [30-31, 55], and “healthy deliciousness,” the creation and promotion of healthy recipes as delicious, was identified as a key factor for sustainable healthy eating [56]. A qualitative analysis found that the satisfaction and pleasure of eating a meal helps maintain a psychological balance with restrictions limiting food choice, and factors that contributed to this satisfaction included the bright colors and environmental implications of plant-based foods, selecting spices, cooking more and creating your own dishes, and being aware of the attributes of food that contribute to well being [57]. NuCook recipes were vetted by chefs for flavor and by a dietitian and physician for “health” using USDA Healthy Plate guidelines [33-35] and American Heart Association dietary recommendations for menopause [58]. NuCook courses were not presented as specific weight loss programs. Although individualized health analysis and recommendations could not be made in the group format of the courses, guidelines based on age and life stage (i.e. menopause) were utilized to develop and analyze recipes and meal guidelines. Using these guidelines, NuCook courses aimed to demystify the conflicting information present in the media [4-5], and the participant group was self-selected as individuals who were trustful of the NuCook team of experts and their guidance. In our results, the number of classes attended by participants correlated significantly with improved cooking confidence, along with decreased consumption frequency of red meat and sugary beverages (Table 3). However, attending more classes did not correlate with weight or BMI changes or the significant increases in consumption frequency of fish, greens, vegetables, fruits, and beans reported post-intervention compared to pre-intervention. Although participant engagement with health interventions is generally regarded as a contributing factor in their efficacy [59], in our preliminary analysis, the number of classes attended by participants was not significantly associated with changes in weight, eating habits, or cooking confidence [19]. Further analysis is needed to understand how different levels of engagement with virtual teaching kitchen programs impact post-intervention outcomes. One limitation of our study was that the majority (91.6%) of program participants were white women, and the average self-reported weights and BMI of participants were lower than those of the general US female population. Program participants had a mean weight of 169.7 pounds compared to the average weights of 178.1 pounds for women ages 40-49, 173.5 pounds for women ages 50-59, and 172.4 for women 60-69 in the US [60]. In addition, 29.2% of program participants were overweight and 34.7% were obese, while in the general US female population, 27.5% of adult women are overweight and 41.9% are obese [61]. This lack of diversity could be due to the communication style and methods of the courses, where the courses were posted, and the diversity of the teaching team. This limits the generalizability of our results, as we are unable to investigate the impact of different demographic characteristics on program outcomes. Data from the pre- and post-surveys was self-reported, which may limit its accuracy. Additionally although this analysis has a larger sample size ( n =537) than a previous analysis ( n =269), a much larger sample size in future work will help increase generalizability. This study may have self-selected for more health-oriented participants and limited the relevance of teaching kitchens to a more diverse population. CONCLUSIONS Virtual teaching kitchens are a promising intervention to help participants achieve healthy behavior and lifestyle change through culinary and nutrition education. Quantitative analysis showed that participants of the NuCook program reported improved dietary habits and cooking confidence and self-efficacy post-intervention compared to pre-intervention. Qualitative analysis of post-survey participant responses showed that the delicious taste of the recipes that were vetted as healthy and the educational resources provided through the courses were most frequently mentioned as benefits. This suggests that NuCook courses engaged participants and provided them with tools to achieve health behavior changes. 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DECLARATIONS Ethics approval and consent to participate The need for ethical approval and informed consent was waived by the Mass General Brigham (MGB) Institutional Review Board as this was determined to not meet the criteria for human subject research as defined by Mass General Brigham Human Research policies and Health and Human Services regulations set forth in 45 CFR 46. All methods were carried out in accordance with relevant guidelines and regulations of MGB. Consent for publication N/A Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This project was supported by philanthropic donations to Brigham and Women’s Hospital. Authors' contributions RDR contributed to the conception, design, analysis, interpretation, manuscript drafting, and revisions. SS contributed to the conception, design, acquisition, and manuscript revisions. AP contributed to the analysis, interpretation, and the manuscript drafting. EK, AR, LK, PS, SW, and AG contributed to the design and acquisition of data. SCH contributed to the conception, design, acquisition, analysis, interpretation, manuscript drafting, and revisions. All authors approved the submitted version of the manuscript and have agreed to be accountable for their own contributions and have ensured that all questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgements N/A Tables Table 1: Comparison of main outcomes for weight and dietary habits pre- and post-intervention (n=537). Pre-survey Post-survey p value Weight (mean, SD) n=499 169.7 (43.3) 168.6 (42.6) 0.017 BMI (mean, SD) n=496 28.5 (6.8) 28.4 (6.8) 0.074 FREQUENCY (Servings/day) Frequency of processed meats (mean, SD) 0.18 (0.27) 0.14 (0.25) 0.004 Frequency red meat (mean, SD) 0.20 (0.28) 0.15 (0.16) <0.001 Fish (mean, SD) 0.19 (0.18) 0.21 (0.22) 0.012 Vegetables as protein (mean, SD) 0.73 (0.89) 0.75 (0.83) 0.673 Whole grains (mean, SD) 0.51 (0.57) 0.56 (0.57) 0.086 White grains (mean, SD) 0.30 (0.45) 0.24 (0.40) <0.001 Fruit (mean, SD) 1.34 (1.0) 1.42 (1.0) 0.045 Raw greens (mean, SD) 0.78 (0.68) 0.85 (0.68) 0.018 Cooked greens (mean, SD) 0.33 (0.43) 0.43 (0.57) <0.001 Other vegetables (mean, SD) 1.04 (0.83) 1.12 (0.88) 0.032 Fruits and vegetables total 3.49 (2.20) 3.81 (2.34) <0.001 Beans (mean, SD) 0.25 (0.30) 0.30 (0.37) <0.001 Sugar beverages (mean, SD) 0.20 (0.47) 0.16 (0.41) 0.026 Fruit juice (mean, SD) 0.11 (0.28) 0.09 (0.23) 0.150 Table 2: Changes in eating and cooking confidence pre- and post-intervention based on a 5-point Likert Scale ( n =537). Pre-survey result Mean Post-survey result Mean p value* Following balanced plate 4.05 (0.98) 4.17 (0.97) 0.010 Eating whole grains 4.56 (0.88) 4.58 (0.88) 0.637 5 servings fruits/vegetables 4.22 (0.98) 4.21 (1.01) 0.755 Less sugar 4.63 (0.88) 4.67 (0.90) 0.396 Lean meats 4.63 (0.74) 4.70 (0.71) 0.053 Use of spices and flavors instead salt 4.48 (0.88) 4.57 (0.85) 0.029 Portion control 3.87 (1.04) 3.90 (1.02) 0.499 Staying physically active during life changes 4.11 (1.05) 4.10 (1.12) 0.751 Devote time for physical activity 3.89 (1.05) 4.00 (1.06) 0.014 Views about cooking (Likert Scale 1-5) Cooking skills (mean, SD) 2.97 (0.70) 3.02 (0.60) 0.012 Cooking time (mean, SD) 2.89 (1.07) 2.71 (1.07) <0.001 Cooking frustration (mean, SD) 2.29 (1.0) 2.22 (0.96) 0.044 Cooking too much work (mean, SD) 2.57 (1.07) 2.45 (1.02) 0.003 Table 3 : Changes in eating and cooking confidence pre- and post-intervention when controlling for the number of classes completed ( n =537). Linear Regression # classes predicting mean change Mean change Beta p value* Weight -1.12 (10.42) 0.22 0.340 BMI -0.10 (1.22) 0.02 0.397 FREQUENCY (Scale 0-10) Frequency of processed meats -0.04 (0.28) -0.01 0.195 Frequency red meat -0.05 (0.25) -0.01 0.028 Fish as protein 0.02 (0.20) 0.004 0.342 Vegetables as protein 0.02 (0.92) 0.02 0.135 Whole grains 0.04 (0.56) 0.01 0.231 White grains -0.07 (0.35) -0.01 0.103 Fruit 0.08 (0.87) 0.03 0.054 Raw greens 0.07 (0.67) -0.002 0.899 Cooked greens 0.10 (0.54) 0.01 0.262 Other vegetables 0.08 (0.85) 0.03 0.101 Fruits and Vegetables total 0.33 (2.0) 0.07 0.098 Beans 0.05 (0.36) 0.004 0.623 Sugar beverages -0.05 (0.47) -0.02 0.026 Fruit juice -0.01 (0.22) 0.004 0.326 Views about cooking (Likert 1-5) Cooking skills 0.05 (0.46) 0.02 0.049 Cooking time -0.18 (0.95) -0.05 0.007 Cooking frustration -0.07 (0.86) -0.04 0.014 Cooking too much work -0.12 (0.90) -0.05 0.006 Table 4 : 11 thematic categories determined from participant testimonials after charting by two independent reviewers and corresponding specific examples of participant responses. Thematic Category Selected Examples Delicious and healthy recipes “I truly enjoyed watching and making these delicious and healthy recipes and learning about a new health related topic with each session.” “I love that the lessons and recipes were tailored to women going through my phase of life. The recipes were so delicious and incorporated healthy ingredients new to me. I also loved learning new tips and tricks that make cooking easier! Highly recommend this course!” Learning new recipes/cooking tips “The NuCook classes have taught me a lot; they have helped to expand my food prep knowledge which has helped with everyday cooking.” “I love the classes because I learned to use so many new ingredients for me, the Chefs are fantastic, I love learning about the best tools and tricks in the kitchen for prep and I love all the medical and dietary information that we learn weekly. Thanks so much! Love the classes!” Nutrition and health education “This is more than a cooking class. These women address current issues in nutrition and how to live your best life by eating well and getting enough exercise. It is my weekly reminder to take care of myself and my family. Thank you.” “I love the healthy recipes, love the break to talk about bone health, menopause and other important issues. I have referred friends and family to your classes.” Professional support: chef, physician, dietician “NuCook classes are extremely well done and having a professional team (vs. "bloggers") is reassuring that the information is high quality and accurate!” “I looked forward to my weekly hour and a half each week with these wonderful professionals: a chef, medical doctor, very experienced lifestyle coach and dietician. They answered every question with good humor. I became more confident about trying new ingredients and spices and learned how good they are for my body as I enter the afternoon of life. Definitely would recommend every woman to join in.” Support behavioral changes to improve health “I have lost and kept off 32 pounds since I started NuCook in January of 2021. At that time, I cooked along with Chef Eva and learned about new spices and new recipes. I had made a commitment to eat healthier and I was able to because of NuCook. I liked cooking to start and then learning about how to set your plate and exercising every day, as well as cholesterol, salt intake, etc. Since these concepts were enforced weekly, I was able to meet my goals.” “I've spent the last year working hard to lose weight, increase activity, and improve my overall health. This class helped to spark new ideas, fresh flavors and combinations and break up the boredom that can come with trying to get healthier. Thanks for a fun way to cook and prep differently!” Good communication/resources from team “I think the NuCook classes are great. I love the balanced focus of the MD and dietitian approved recipes, the professional chef expertise, the fact that all questions are answered, recordings and recipes are shared..I have already recommended it to several friends.” “The weekly reinforcement and updates on healthy eating for my age group were invaluable. Each weekly topic was informative and presented in a fun lively format. The ongoing group chat for questions was great too. Highly recommend.” Trying new ingredients, flavors, techniques “I really enjoyed cooking with new spices and ingredients that I'd never used before. It expanded my repertoire of healthy meal preparation ideas.” “These were not your run-of-the-mill recipes! They were exciting! I learned how to cook with flavors I would never have considered buying and would not have known what to do with. The food was delicious, and the dedication of the experts to teaching participants how to support a healthy lifestyle through food choices was really wonderful.” Community and connecting with others “I loved cooking alongside an experienced and encouraging chef, and feeling like I was joining a broader community of people in my same life stage, from my home kitchen. This course helped me be even more confident in my cooking skills and encouraged me to make healthier choices. I looked forward to it every week!” “This has been the highlight of my year. The community of women… has felt so empowering. I cannot believe how much I have learned. I have a new appreciation for cooking, spices, and exercise. I also have a better understanding of what I am going through and that maybe I am more normal than I thought. I am certainly a work in progress. I am going to miss this community and I am eagerly awaiting the next series. Thank you so very much!!!” Incorporating new/healthy ingredients “I really enjoyed the pace of the class, the demonstrations and tips from Chef Eva, the recipes that incorporated spices and vegetables (i.e. parsnips, collard greens, kale, Swiss chard, turmeric and harissa paste) that I had never cooked with before or I was afraid to try them!” “Liked getting new ideas from Chef Eva how to include healthy ingredients to make a delicious and not so time consuming meal” Supportive of all skill levels “These courses introduced me to new foods and demonstrated new ways to cook all foods. A very supportive environment with realistic goals and information.” “NuCook classes were informative and easy to follow whether you are new to cooking or just looking for new ideas to get nutritionally balanced, easy meals to round out your repertoire.” Free courses “I would highly encourage anyone interested in learning or in further improving their cooking skills to take these classes for several reasons: they are very well prepared, they are easy to access, easy to follow and there is plenty of room to clarify any questions and concerns from highly qualified professionals. Plus, and this is a huge plus, these high-quality classes are free and are not time consuming. Thank you very much NuCook for making this possible!” “This class was so much fun! I love to cook and am constantly striving to learn new things. Having access to a chef, nutritionists and doctors for free was invaluable.” Additional Declarations Competing interest reported. I am a medical advisor to POMHealth which is a start up providing dietitian counseling to medical practices. Supplementary Files Tables14withhighlighting.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 02 Oct, 2025 Reviews received at journal 29 May, 2025 Reviewers agreed at journal 19 May, 2025 Reviews received at journal 06 May, 2025 Reviewers agreed at journal 03 May, 2025 Reviewers invited by journal 02 May, 2025 Editor assigned by journal 25 Apr, 2025 Editor invited by journal 18 Mar, 2025 Submission checks completed at journal 15 Mar, 2025 First submitted to journal 15 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6181028","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448127508,"identity":"d52e8a01-6981-4ff7-9c08-160eaa05943a","order_by":0,"name":"Rhea Dejanira Rasquinha","email":"","orcid":"","institution":"Brown University","correspondingAuthor":false,"prefix":"","firstName":"Rhea","middleName":"Dejanira","lastName":"Rasquinha","suffix":""},{"id":448127509,"identity":"85395935-4b2e-4192-b541-87f096cdefd7","order_by":1,"name":"Andrea Pelletier","email":"","orcid":"","institution":"Harvard Medical School, Brigham and Women’s 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Hellerstein","email":"data:image/png;base64,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","orcid":"","institution":"Harvard Medical School, Brigham and Women’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Susan","middleName":"Celia","lastName":"Hellerstein","suffix":""}],"badges":[],"createdAt":"2025-03-07 22:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6181028/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6181028/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92679373,"identity":"fab2c5a4-3251-4228-95fc-b3d8ca0522ac","added_by":"auto","created_at":"2025-10-03 00:59:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":445924,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of 11 thematic categories obtained from qualitative analysis of participant responses across Engagement, Tools, and Change.\u003c/p\u003e","description":"","filename":"Screenshot20251001at2.17.58PM.png","url":"https://assets-eu.researchsquare.com/files/rs-6181028/v1/8dc6d0a34caec0a09723e0d1.png"},{"id":92680866,"identity":"7203ac71-0769-47ee-91bf-69b652e0b5de","added_by":"auto","created_at":"2025-10-03 01:07:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1269319,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6181028/v1/3ef1a023-1997-4efe-b143-cd921fb7bcf7.pdf"},{"id":92680842,"identity":"f5c079f6-c7b0-4c20-a551-102f3d7e1a32","added_by":"auto","created_at":"2025-10-03 01:07:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2752816,"visible":true,"origin":"","legend":"","description":"","filename":"Tables14withhighlighting.docx","url":"https://assets-eu.researchsquare.com/files/rs-6181028/v1/1ee69656c3374df40a87a52c.docx"}],"financialInterests":"Competing interest reported. I am a medical advisor to POMHealth which is a start up providing dietitian counseling to medical practices.","formattedTitle":"Impact of virtual teaching kitchens on culinary and dietary behaviors of perimenopausal women: A mixed methods analysis","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; One in five deaths worldwide can be attributed to suboptimal diet [1], and poor diet is the leading cause of mortality in the U.S. due to diet-related chronic diseases [2]. While popular diets (e.g. low fat, low carbohydrate, Mediterranean, intermittent fasting) have marginal impacts on reducing risk for obesity-related comorbidities, individuals vary in their ability to adhere to different diets, which is the most important factor for successful weight loss [3].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurther complicating individuals’ ability to lose weight and avoid comorbidities is conflicting nutritional information and misinformation. Conflicting nutritional information is frequently present in the media [4-5], and anyone can share nutritional information online, which increases the risk that unreliable and potentially harmful information is disseminated to the public [6]. While three in five U.S. adults viewed conflicting nutritional information as a sign of improved understanding over time with new research, those who are less science-oriented lack trust in nutrition information and find it confusing [7]. In addition, our “diet culture” is filled with conflicting and judgemental opinions for those seeking information about healthy eating [8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Health interventions aimed at modifying dietary and lifestyle behaviors are currently the first recommended step for treatment of overweight and obese adults [9]. These interventions are also important for women in menopause, a time when type 2 diabetes, cardiovascular disease, obesity, and other diet-related chronic diseases are more prevalent [10]. Interventions focused on health promotion and patients’ control of their own health have been shown to contribute to successful behavior change. These programs focus on health information and education along with the development of life skills and goal setting [11]. One systematic review found that autonomous motivation, self-efficacy, and self-regulation skills were the most promising self-regulation factors for successful behavior change with obesity interventions. A “non-diet” approach promoting a positive body image and flexible eating control were important for long-term weight control [12]. In addition, community engagement is reported to increase the likelihood of success of health interventions with effective community participation and feedback [13-14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“Food is medicine” is an emerging evidence-based initiative which integrates food and nutrition interventions into patient care, including medically tailored meals, medically tailored groceries, and produce prescriptions [15]. A focus on skill building in addition to access to healthier affordable food has been emphasized in the “food is medicine” movement [16] using a culinary medicine framework.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn culinary medicine, teaching kitchens are physical or virtual educational programs which combine nutrition education and culinary skills to improve cooking and dietary habits [17-18]. Following the COVID-19 pandemic, virtual teaching kitchens have become more widely accepted as nutritional interventions [19]. Since these programs only require internet access and do not have space and resource restrictions like in-person teaching kitchens, virtual teaching kitchens can reach underserved populations and potentially increase self-efficacy, as participants source ingredients from their local communities and prepare food at home [20]. Current virtual teaching kitchen interventions have been shown to increase fruit, vegetable, and legume consumption, improve self-efficacy in meal planning, cooking confidence, and attitudes toward cooking [19, 21-23], and enable participants to adjust recipes to make them healthier [24]. These benefits align with updated dietary guidelines, as the \u003cem\u003eScientific Report of the 2025 Dietary Guidelines Advisory Committee\u0026nbsp;\u003c/em\u003edefined a more plant-based diet — including more vegetables, fruits, legumes, nuts, whole grains, and fish/seafood and less red and processed meats, sugary foods and beverages, and refined grains — as a “healthy dietary pattern” [25]. Virtual teaching kitchens can adapt to community needs [26] and be tailored to different literacy levels and language preferences [27].\u003c/p\u003e\n\u003cp\u003eThere is limited literature reporting on the specific aspects of culinary medicine interventions that contribute to behavior changes. However, a review of 14 culinary medicine interventions identified the duration of the intervention, the participation of a chef, and educational components such as hands-on cooking and individual counseling as potential contributing factors to improved health outcomes [28]. Another mixed-methods study of Boston Medical Center’s (BMC’s) Nourishing Our Community Program (NOCP) reported time constraints, busy schedules, and a dislike for vegetables as barriers to cooking at home and following the recommendations of nutrition interventions [29]. Flavor is the largest driver of food choice and intake, and healthy foods are commonly equated to being flavorless or unappealing, so considering flavor can help increase the appeal and efficacy of nutrition interventions. One review found spice, particularly chili powder or capsaicin, to contribute to healthier eating by increasing calorie expenditure, decreasing food intake, and enhancing flavor [30]. Using taste-focused labels also increased vegetable selection and consumption compared to health-focused labels [31].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe NuCook virtual teaching kitchen intervention is a series of online classes offered synchronously which include 45 min of live cooking instruction and 15 min of nutrition education. A preliminary analysis of surveys pre- and post-participation in the NuCook program from September 2020 through December 2021 showed that our intervention improved dietary habits and increased cooking confidence among peri- and post-menopausal women [19].\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe purpose of this study was to investigate which components of the courses best supported these behavioral changes using a mixed-methods analysis of survey data of an expanded pool of participants\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\n\n\n\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\n\n\n\n\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\n\n\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\n\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\n\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eThis study is a mixed-methods analysis of the impact of NuCook virtual courses with quantitative analysis of dietary patterns and cooking habits and qualitative assessment of participant testimonials regarding how and why the course changed their culinary and dietary choices. The data analyzed in this study includes data analyzed in our previous study [19], and the same virtual teaching kitchen program and recruitment process was used. However, this study includes data from 268 additional participants and was the first to analyze qualitative survey responses.\u0026nbsp;\u003c/p\u003e\u003cp\u003eWe investigated the impact of participation in NuCook virtual courses using data from pre- and post-intervention surveys. Analyses of quantitative data and content analysis of qualitative data were performed. The institutional review board of Mass General Brigham (MGB) waived the need for ethical approval and informed consent, as this study did not meet the human subject criteria defined by MGB Human Research policies and Health and Human Services regulations in 45 CFR 46. All methods were carried out in accordance with relevant regulations and guidelines of MGB.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNuCook virtual teaching kitchen program\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe NuCook program consists of culinary and nutrition classes designed and taught by a team including a physician, dietitian, health coach, and chef. Classes are offered live over Zoom and free of charge. 31 courses were offered between September 2020 and May 2024. Data was collected on 15 courses with 3-5 virtual classes per course. Classes were offered from 6-7 pm Eastern Standard Time.\u0026nbsp;\u003c/p\u003e\u003cp\u003eWe previously developed an initial in-person curriculum for a pilot study which used the educational methods of Cooking Matters for Adults [32]. The NuCook course curriculum was developed using this curriculum and other best practices in synchronous, remote education from the Culinary Healthcare Education Fundamentals (CHEF) - Coaching Program [33]. Each class featured at least two healthy recipes, along with nutrition and culinary educational information and designated teaching goals. Several improvements were made to classes and course curriculums throughout the study period based on participant feedback, including ingredient substitutions, increased participant-coach interactions, alterations to class pacing, and the implementation of a platform to make all courses available on demand after the live session.\u003c/p\u003e\u003cp\u003eClasses focused on healthy eating with plant-based foods, aligned with the “Harvard Healthy Eating Plate” [34]. This includes additional guidelines on plant oil consumption compared to MyPlate [35]. Each class included up to 75 min of instruction, including 45 min of live cooking instruction with a professional chef, 15 min of health and nutrition instruction by a physician and dietitian, and an optional 15 min for community discussion and other questions. Recipes and instructions were made available to participants before each class, and participants could choose to cook along in real-time or observe the class and have a hands-on cooking experience at another time.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipant recruitment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAny participant with working access to Zoom was eligible to participate in NuCook classes. Recruitment efforts focused on women over age 45 living in East Coast metropolitan areas who were interested in healthy cooking, eating, and menopause. All classes were taught in English. Mass General Brigham employees, Fish Women’s Health Center patients, and members of the general public were recruited through hospital health bulletins, EPIC notifications, and social media posts, respectively. Participants were asked to complete the pre- and post-class surveys with timed email reminders. Recipe and class preparation information was sent to all enrolled participants via repeated class reminder emails from NuCook staff. Enrollment was open throughout each course, but the per class capacity was capped at our Zoom capacity of 300 participants.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurvey data collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants were asked to complete a pre-intervention survey to assess baseline dietary habits, cooking confidence, and health behaviors before beginning the course, along with a voluntary post-intervention survey after course completion. All surveys took approximately 20 minutes to complete and were administered through REDCap. We asked those who participated in one or more courses to complete the post-intervention survey for each course they completed. The National Institutes of Health (NIH) ‘Eating at America’s Table Quick Food Scan’ [36] and the ‘Eating Habits Confidence Survey’ [37] were used to develop survey questions. Questions about the Harvard Healthy Plate [34], whole grain and lean protein consumption, and portion control were also included, along with standard demographic information, height and weight, and class attendance questions. The post-survey included several open-ended questions for qualitative analysis; in particular, participant testimonials in response to the prompt, “We hoped you liked our course, and we're hoping to continue growing! Please write a short testimonial here about what you liked about the class, why you would recommend it, or why somebody else should enroll” were collected for analysis.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurvey data analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA study number was assigned to all participants based on their name and date of birth. For participants who completed more than one course, only the first pre-survey and last-presurvey completed were included for analysis. Quantitative data analysis was conducted using Stata 18.0. Participant-reported height and weight were used to calculate BMI, with the following definitions: Underweight (BMI \u0026lt;18.5), Normal Weight (BMI 18.5-\u0026lt;25), Overweight (BMI 25-\u0026lt;30), and Obese (BMI \u0026gt;30). Servings per day (of food groups of interest) was calculated using the reported frequency of food consumed. We added fruit, raw greens, cooked greens, vegetables as proteins, and other vegetables to calculate total daily servings of fruits and vegetables. Participants self-reported the number of classes taken, and if missing, this data was supplemented by attendance records for each Zoom session. For the purposes of this analysis, we used the number of post-surveys completed as a proxy for the number of classes completed because this ensured the participant completed the class.\u003c/p\u003e\u003cp\u003eContinuous, normally distributed data was reported with the mean and standard deviation, and differences pre- and post-intervention were evaluated with a paired samples t-test. Categorical or non-normally distributed data was reported with either the frequency and proportion or median and interquartile range. Differences pre- and post-intervention were evaluated with the Wilcoxon signed rank sum test. Multiple linear regression was used to evaluate the impact of the number of classes taken on changes in outcomes controlling for baseline outcome value. We used paired samples t-tests to separately analyze differences pre- and post-intervention between the lowest quartile for baseline fruit and vegetable consumption and the highest quartile for baseline weight and BMI. Differences between the lowest and highest quartile for baseline fruit and vegetable consumption habits were also analyzed to capture behavior changes of participants with the least healthy dietary habits (i.e., lowest fruit and vegetable consumption) at baseline. Results were considered significant at \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05.\u0026nbsp;\u003c/p\u003e\u003cp\u003eThe qualitative analysis was performed on all subjects who completed a post-survey. Blank and duplicate responses were removed. All testimonials were reviewed by two independent reviewers. The reviewers manually charted themes in each testimonial and established eleven thematic categories based on recurring themes in participant feedback. Responses were then assigned accordingly to one or more categories, and the number of comments for each explicit theme was counted.\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eIn NuCook courses across 15 total cohorts, there were 817 unique participants who completed pre-course surveys and attended at least one live virtual class. 537 (65.9%) of these 817 participants completed both pre- and post-surveys for inclusion in the quantitative and qualitative analyses. Of the 537 post-surveys with quantitative data, 525 were included for the qualitative analysis. Participants completed between 1 and 12 courses, and the mean number of courses completed (as reported by number of post-surveys completed) was 2.2 (SD=1.9).\u003c/p\u003e\u003cp\u003eDemographic data was collected for 383 of the 537 participants (71.3%). The mean age of NuCook participants was 60 years old. Of the 383 records analyzed, 91.6% of participants were White (\u003cem\u003en\u003c/em\u003e=351), 1.4% were Hispanic or Latino (\u003cem\u003en\u003c/em\u003e=3), 3.7% were Asian (\u003cem\u003en\u003c/em\u003e=14), and 1.3% were Black (\u003cem\u003en\u003c/em\u003e=5).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuantitative analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe mean self-reported weight at baseline was 169.7 pounds and the mean BMI at baseline was 28.4. At baseline, 0.6% of participants were underweight, 35.5% were normal weight, 29.2% were overweight, and 34.7% were obese based on BMI.\u0026nbsp;\u003c/p\u003e\u003cp\u003eTable 1 shows reported changes in weight and dietary habits pre- and post-intervention among the participants who completed pre- and post-surveys (\u003cem\u003en\u003c/em\u003e=537). There was a decrease in mean self-reported weight from 169.7 pounds at baseline to 168.6 after the intervention (\u003cem\u003ep\u003c/em\u003e=0.017). Further analysis by baseline weight showed a mean 3.1 pound weight loss for those whose self-reported weight was in the highest quartile compared to 0.42 for those below the 75th percentile (\u003cem\u003ep\u003c/em\u003e=0.011). There was no significant decrease in overall mean BMI, along with no significant difference between BMI changes in the highest quartile compared to those below the 75th percentile.\u0026nbsp;\u003c/p\u003e\u003cp\u003eParticipants reported statistically significant increases in consumption of total fruits and vegetables (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), fish (\u003cem\u003ep\u003c/em\u003e=0.012), and beans (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) after participation in NuCook courses (Table 1). Participants also consumed significantly less processed meats (\u003cem\u003ep\u003c/em\u003e=0.004), red meats (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), white grains (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), and sugary beverages (\u003cem\u003ep\u003c/em\u003e=0.026) post-survey compared to baseline.\u003c/p\u003e\u003cp\u003eTable 2 shows reported changes in eating and cooking confidence pre- and post-intervention based on a 5-point Likert Scale. Participants reported significantly increased confidence in following the balanced plate model daily (\u003cem\u003ep\u003c/em\u003e=0.010) and devoting time for physical activity (\u003cem\u003ep\u003c/em\u003e=0.014). Participants also reported significantly increased confidence in their cooking skills (\u003cem\u003ep\u003c/em\u003e=0.012), along with improved cooking confidence, specifically that cooking at home is not too time consuming (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), frustrating (\u003cem\u003ep\u003c/em\u003e=0.044), or too much work (\u003cem\u003ep\u003c/em\u003e=0.003).\u0026nbsp;\u003c/p\u003e\u003cp\u003eTable 3 shows reported changes in eating and cooking confidence pre- and post-intervention when controlling for the number of classes completed. The number of classes completed by participants correlated significantly with change in improved cooking confidence in cooking skills (\u003cem\u003ep\u003c/em\u003e=0.049), confidence that cooking was not too time consuming (\u003cem\u003ep\u003c/em\u003e=0.007), frustrating (\u003cem\u003ep\u003c/em\u003e=0.014) or too much work (\u003cem\u003ep\u003c/em\u003e=0.006). The number of classes attended also correlated with a decreased consumption of red meat (\u003cem\u003ep\u003c/em\u003e=0.028) and sugary beverages (\u003cem\u003ep\u003c/em\u003e=0.026), but did not significantly correlate with changes in weight, BMI, or other food consumption frequencies.\u003c/p\u003e\u003cp\u003eWe analyzed the mean change in eating behaviors of the fruit and vegetable consumption for those participants in the lowest quartile and highest quartile at baseline and found those in the lowest quartile at baseline had the greatest improvement in consumption of vegetables as protein (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= \u0026lt;0.01), fruit (\u003cem\u003ep\u003c/em\u003e = 0.018) and raw greens (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.004).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQualitative analysis of participant testimonials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eTable 4 shows the 11 thematic categories we identified: Enjoyed cooking and eating healthy recipes; learning new recipes and cooking tips; nutrition and health education; professional support (chef, physician, dietitian); support behavioral changes to improve health; good communication and resources from team; trying new ingredients, flavors, and techniques; community and connecting with others, incorporating new and/or healthy ingredients; supportive of all skill levels; and free courses. Figure 1 shows the 11 thematic categories from respondent testimonials distributed across three features of virtual teaching kitchens (engagement, tools, and change), along with a summary of relevant results from our quantitative analysis. As some testimonials included content aligned with multiple themes, the totals of each category will not sum to 525. The two reviewers additionally identified typical comments to illustrate each thematic category, which are included in Table 4.\u003c/p\u003e\u003cp\u003e\u0026nbsp;Of the 525 participant testimonials analyzed, 263 respondents (50.1%) mentioned that they and their families enjoyed the flavor and taste of the healthy recipes provided and/or cooking these recipes along with the live instruction or on their own time. 254 respondents (48.4%) cited culinary education including new recipes and cooking tips, and the nutrition and health information taught in the courses was cited by 211 respondents (40.2%). 95 respondents (18.1%) mentioned that they tried new ingredients, flavors, and techniques based on the different educational resources provided in the courses.\u0026nbsp;\u003c/p\u003e\u003cp\u003e130 (24.8%) respondents mentioned NuCook’s team of professionals, including a physician, chefs, culinary coach, and a registered dietitian. Participants enjoyed having live access to this team and expressed trust in the information and resources provided. 124 respondents (23.6%) cited good communication and/or resources from the NuCook team, including weekly reminders, recipes, live instruction and Q\u0026amp;A, and class recordings. All NuCook courses and resources are available to participants free of charge, which was cited by 5 respondents (1%).\u0026nbsp;\u003c/p\u003e\u003cp\u003e126 respondents (24.0%) mentioned how NuCook courses have helped them make behavioral changes to improve their health, such as greater mindfulness about ingredients when cooking and exercise, which helped some participants achieve weight loss in a sustainable way while eating balanced and fulfilling meals. 68 respondents (13.0%) cited learning how to incorporate new, healthy ingredients into different dishes during classes and making some of these changes in their everyday cooking routines.\u0026nbsp;\u003c/p\u003e\u003cp\u003eAlthough courses were taught fully online, 74 respondents (14.1%) mentioned that participating helped them engage in a bigger community and connect with other participants and people in their lives. 52 respondents (9.9%) mentioned that the courses provided a supportive environment for home cooks of all skill levels, from beginners to seasoned cooks.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; This mixed-methods analysis demonstrates that the NuCook virtual teaching kitchen program provides several nutrition and health benefits for perimenopausal women — including significantly decreased weight and significantly improved dietary habits and increased cooking confidence — by engaging participants, supplying tools that supported their success, and encouraging positive changes. Our qualitative analysis provides insight into which components of the courses were most beneficial for participants. In addition, the nutrition and health education provided through the courses was also frequently cited in participant responses, and the distribution of thematic categories demonstrates the importance of both engaging participants and providing them the tools to achieve behavioral change.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Our quantitative analysis demonstrated that participation in the NuCook program was associated with significant lifestyle changes including dietary behaviors, cooking confidence, and devoting time to physical activity. These results (\u003cem\u003en\u003c/em\u003e=537) are consistent with our first publication [19] which analyzed quantitative impacts of NuCook courses on 269 pre- and post-surveys. Our findings regarding improved dietary habits, including increased fruit, vegetable, fish, and bean consumption and decreased red and processed meat, white grains, and sugary drinks consumption (Table 1), are consistent with a preliminary analysis of the efficacy of NuCook virtual teaching kitchen program [19], along with other previous studies on the impact of virtual teaching kitchens [21-23]. These improvements also align with the Dietary Guidelines Advisory Committee’s 2025 Scientific Report, which reports evidence supporting the health benefits of a more plant-based diet with lower red and processed meat, sugary foods and beverages, and white grain consumption [25]. We also report improved cooking confidence and attitudes towards cooking (Table 2), similar to previous studies [22, 38-39].\u0026nbsp;\u003c/p\u003e\u003cp\u003eParticipants also reported significant increases in following a balanced plate model, using spices and flavors instead of salt, and devoting time for physical activity post-intervention compared to pre-intervention (Table 2). High salt intake is associated with hypertension [40], which is a risk factor for cardiovascular disease, for which incidence is higher during perimenopause and menopause [41]. In addition, moderate physical activity (e.g., 30 minutes of brisk walking a day) during perimenopause may reduce the risk of late-life dementia [42], and habitual physical activity (e.g., walking 6000+ steps daily) was associated with decreased cardiovascular disease and diabetes risks for premenopausal, perimenopausal, and postmenopausal women [43]. Physical activity has also been reported as a mediator between depressive symptoms and quality of life in perimenopausal women [44] and associated with decreased psychosocial and physical symptoms of menopause [45]. Our preliminary study suggested that perimenopause should be approached as a life transition and suggested the importance of interventions targeting women during this life stage to support sustainable behavioral change [19]. The results presented here similarly support the potential of NuCook programs to help participants realize these changes.\u0026nbsp;\u003c/p\u003e\u003cp\u003eOur qualitative analysis looked at what participants identified as factors that they enjoyed and led to their engagement and process of change. In our qualitative analysis, the three most frequently cited thematic categories were: enjoyment of the delicious and healthy recipes provided by the course and cooking these recipes, culinary education with new recipes, and nutrition and health education (Figure 1). The 11 thematic categories were also relatively well distributed across the broader themes of Engagement, Tools, and Change, which is promising in demonstrating the potential of NuCook courses to support different stages of the process of improving health behaviors.\u0026nbsp;\u003c/p\u003e\u003cp\u003eNuCook courses are offered online for free and give participants easy access to engage with professionals and class content both in real time and on demand. To optimize engagement and provide personalized support both in and out of class, we employed different pedagogic styles in our classes, asked and answered questions in real time and via email, and provided information which participants could access asynchronously. We encouraged participants to engage with questions from our chef, doctor and dietitian about ingredients, food preferences, health practices, areas of confusion, and more. Following the COVID-19 pandemic, familiarity with video call platforms like Zoom and online learning has increased [46]. Although people have reported experiencing exhaustion from virtual interactions, giving rise to the concept of “Zoom fatigue” [47], online courses continue to allow for increased access to teaching and education [48], particularly for virtual teaching kitchen interventions [19-24, 26-27].\u0026nbsp;\u003c/p\u003e\u003cp\u003eAnother benefit of NuCook courses cited by participants was hands-on learning in real time along with lecture-style nutrition education. We provided educational materials tailored to different learning styles and methods of access, including real time talks, nutritional education slides shared live and after class on our website, a library of recipes, and posted videos of classes for asynchronous access. NuCook courses also taught generalizable culinary principles, such as with template recipes, giving multiple examples of how to use a new food or spice when it was introduced, focusing on batch cooking and repurposing leftovers, and providing multiple examples of how to cook a single dish with different flavor profiles reflecting a broader array of cuisines. Studies show that most people learn and retain nutrition and cooking concepts when they can connect the information to actionable steps through experiential or “hands-on” learning [49]. Another study comparing the dietary knowledge, behaviors, and habits of students who participated in either lecture- or experience-based nutritional education programs found that dietary behaviors changed in the experience-based group, while dietary habits changed in the lecture-based group, suggesting that both methods are important for effective nutrition education [50].\u0026nbsp;\u003c/p\u003e\u003cp\u003eGiven rising overweight and obesity rates, type 2 diabetes, and cardiovascular disease, which are associated with overnutrition and a sedentary lifestyle, interventions which support dietary and physical behavior change are regarded as important components of treatment [51]. Previous studies report that interventions conducted from a health promotion perspective (i.e., aimed at helping participants gain control over their health through education and the development of skills) contribute to successful health behavior change [52-53]. The Integrated Theory of Health Behavior Change proposes that increasing knowledge, beliefs, self-regulation skills and abilities, and social facilitation can improve health behavior change outcomes [54]. By this theory, interventions which support engagement between participants and the content, along with tools to further education and skills, can contribute to enhanced behavioral change.\u003c/p\u003e\u003cp\u003eParticipants most frequently cited that the recipes were delicious (Figure 1). 50% of participant testimonials cited the recipes provided as key beneficial aspects of the courses This suggests that the flavor and appeal of NuCook recipes to the participants and their tablemates was a motivator for changes in dietary habits. Flavor is an important factor in food choices and consumption [30-31, 55], and “healthy deliciousness,” the creation and promotion of healthy recipes as delicious, was identified as a key factor for sustainable healthy eating [56]. A qualitative analysis found that the satisfaction and pleasure of eating a meal helps maintain a psychological balance with restrictions limiting food choice, and factors that contributed to this satisfaction included the bright colors and environmental implications of plant-based foods, selecting spices, cooking more and creating your own dishes, and being aware of the attributes of food that contribute to well being [57].\u0026nbsp;\u003c/p\u003e\u003cp\u003eNuCook recipes were vetted by chefs for flavor and by a dietitian and physician for “health” using USDA Healthy Plate guidelines [33-35] and American Heart Association dietary recommendations for menopause [58]. NuCook courses were not presented as specific weight loss programs. Although individualized health analysis and recommendations could not be made in the group format of the courses, guidelines based on age and life stage (i.e. menopause) were utilized to develop and analyze recipes and meal guidelines. Using these guidelines, NuCook courses aimed to demystify the conflicting information present in the media [4-5], and the participant group was self-selected as individuals who were trustful of the NuCook team of experts and their guidance.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; In our results, the number of classes attended by participants correlated significantly with improved cooking confidence, along with decreased consumption frequency of red meat and sugary beverages (Table 3). However, attending more classes did not correlate with weight or BMI changes or the significant increases in consumption frequency of fish, greens, vegetables, fruits, and beans reported post-intervention compared to pre-intervention. Although participant engagement with health interventions is generally regarded as a contributing factor in their efficacy [59], in our preliminary analysis, the number of classes attended by participants was not significantly associated with changes in weight, eating habits, or cooking confidence [19]. Further analysis is needed to understand how different levels of engagement with virtual teaching kitchen programs impact post-intervention outcomes.\u0026nbsp;\u003c/p\u003e\u003cp\u003eOne limitation of our study was that the majority (91.6%) of program participants were white women, and the average self-reported weights and BMI of participants were lower than those of the general US female population. Program participants had a mean weight of 169.7 pounds compared to the average weights of 178.1 pounds for women ages 40-49, 173.5 pounds for women ages 50-59, and 172.4 for women 60-69 in the US [60]. In addition, 29.2% of program participants were overweight and 34.7% were obese, while in the general US female population, 27.5% of adult women are overweight and 41.9% are obese [61]. This lack of diversity could be due to the communication style and methods of the courses, where the courses were posted, and the diversity of the teaching team. This limits the generalizability of our results, as we are unable to investigate the impact of different demographic characteristics on program outcomes.\u0026nbsp;\u003c/p\u003e\u003cp\u003eData from the pre- and post-surveys was self-reported, which may limit its accuracy. Additionally although this analysis has a larger sample size (\u003cem\u003en\u003c/em\u003e=537) than a previous analysis (\u003cem\u003en\u003c/em\u003e=269), a much larger sample size in future work will help increase generalizability. This study may have self-selected for more health-oriented participants and limited the relevance of teaching kitchens to a more diverse population.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Virtual teaching kitchens are a promising intervention to help participants achieve healthy behavior and lifestyle change through culinary and nutrition education. Quantitative analysis showed that participants of the NuCook program reported improved dietary habits and cooking confidence and self-efficacy post-intervention compared to pre-intervention. Qualitative analysis of post-survey participant responses showed that the delicious taste of the recipes that were vetted as healthy and the educational resources provided through the courses were most frequently mentioned as benefits. This suggests that NuCook courses engaged participants and provided them with tools to achieve health behavior changes. This analysis adds to growing research on the efficacy of virtual teaching kitchen interventions while highlighting which components of the NuCook program best supported behavioral change.\u0026nbsp;\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003eBMC – Boston Medical Center\u003c/p\u003e\u003cp\u003eNOCP – Nourishing Our Community Program\u003c/p\u003e\u003cp\u003eMGB – Mass General Brigham\u003c/p\u003e\u003cp\u003eCHEF – Culinary Healthcare Education Fundamentals\u003c/p\u003e\u003cp\u003eNIH – National Institutes of Health\u003c/p\u003e\u003cp\u003eBMI – Body Mass Index\u003c/p\u003e"},{"header":"REFERENCES","content":"\u003cp\u003e[1] Afshin A, Sur PJ, Fay KA, Cornaby L, Ferrara G, Salama JS, Mullany EC, Abate KH, Abbafati C, Abebe Z, Afarideh M. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. 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A comparison of two differential methods for nutrition education in elementary school: lecture-and experience-based learning program. Nutrition research and practice. 2015 Feb 1;9(1):87-91. doi: 10.4162/nrp.2015.9.1.87.\u003c/p\u003e\u003cp\u003e[51] Pearson ES. Goal setting as a health behavior change strategy in overweight and obese adults: a systematic literature review examining intervention components. Patient education and counseling. 2012 Apr 1;87(1):32-42. doi: 10.1016/j.pec.2011.07.018.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[52] World Health Organization. Ottawa Charter for health promotion, an international conference on health promotion. The Move Towards a New Public Health. 1986 Nov.\u003c/p\u003e\u003cp\u003e[53] Irwin JD, Morrow D. Health promotion theory in practice: an analysis of co-active coaching. International Journal of Evidence Based Coaching and Mentoring. 2005;3(1):29-38.\u003c/p\u003e\u003cp\u003e[54] Ryan P. Integrated theory of health behavior change: background and intervention development. Clinical Nurse Specialist. 2009 May 1;23(3):161-70. doi: 10.1097/NUR.0b013e3181a42373.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[55] Pérez-Rodrigo C, Aranceta-Bartrina J. Role of gastronomy and new technologies in shaping healthy diets. InGastronomy and food science 2021 Jan 1 (pp. 19-34). Academic Press. doi: 10.1016/B978-0-12-820057-5.00002-9.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[56] Ariyasriwatana W. “Healthy Deliciousness”: A Key to Sustainable, Healthy Eating Extracted from Yelp Reviews. Food Studies. 2022;12(1):19. doi: 10.18848/2160-1933/CGP/v12i01/19-51.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[57] Atta-Delgado MX, Lozano SP, Torres JA. A survey on the prevalence of sustainable diets and the eating experience satisfaction. Innovative Food Science \u0026amp; Emerging Technologies. 2023 Mar 1;84:103305. doi: 10.1016/j.ifset.2023.103305.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[58] El Khoudary SR, Aggarwal B, Beckie TM, Hodis HN, Johnson AE, Langer RD, Limacher MC, Manson JE, Stefanick ML, Allison MA, American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020 Dec 22;142(25):e506-32. doi: 10.1161/CIR.0000000000000912.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[59] Yardley L, Spring BJ, Riper H, Morrison LG, Crane DH, Curtis K, Merchant GC, Naughton F, Blandford A. Understanding and promoting effective engagement with digital behavior change interventions. American journal of preventive medicine. 2016 Nov 1;51(5):833-42. doi: 10.1016/j.amepre.2016.06.015.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[60] Fryar CD, Carroll MD, Gu Q, Afful J, Ogden CL. Anthropometric reference data for children and adults: United States, 2015-2018.\u0026nbsp;\u003c/p\u003e\u003cp\u003e[61] Overweight \u0026amp; Obesity Statistics. In: Health Statistics. National Institute of Diabetes and Digestive and Kidney Diseases. 2021. https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity. Accessed 02 Feb 2025.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DECLARATIONS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe need for ethical approval and informed consent was waived by the Mass General Brigham (MGB) Institutional Review Board as this was determined to not meet the criteria for human subject research as defined by Mass General Brigham Human Research policies and Health and Human Services regulations set forth in 45 CFR 46. All methods were carried out in accordance with relevant guidelines and regulations of MGB.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eN/A\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis project was supported by philanthropic donations to Brigham and Women’s Hospital.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eRDR contributed to the conception, design, analysis, interpretation, manuscript drafting, and revisions.\u003c/p\u003e\u003cp\u003eSS contributed to the conception, design, acquisition, and manuscript revisions.\u003c/p\u003e\u003cp\u003eAP contributed to the analysis, interpretation, and the manuscript drafting.\u003c/p\u003e\u003cp\u003eEK, AR, LK, PS, SW, and AG contributed to the design and acquisition of data.\u003c/p\u003e\u003cp\u003eSCH contributed to the conception, design, acquisition, analysis, interpretation, manuscript drafting, and revisions.\u003c/p\u003e\u003cp\u003eAll authors approved the submitted version of the manuscript and have agreed to be accountable for their own contributions and have ensured that all questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eN/A\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Comparison of main outcomes for weight and dietary habits pre- and post-intervention (n=537).\u003c/p\u003e\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"628\"\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-survey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-survey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eWeight (mean, SD) n=499\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e169.7 (43.3)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e168.6 (42.6)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eBMI (mean, SD) n=496\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e28.5 (6.8)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e28.4 (6.8)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFREQUENCY (Servings/day)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eFrequency of processed meats (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.18 (0.27)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.14 (0.25)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eFrequency red meat (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.20 (0.28)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.15 (0.16)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eFish (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.19 (0.18)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.21 (0.22)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eVegetables as protein (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.73 (0.89)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.75 (0.83)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.673\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eWhole grains (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.51 (0.57)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.56 (0.57)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eWhite grains (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.30 (0.45)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.24 (0.40)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eFruit (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e1.34 (1.0)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e1.42 (1.0)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eRaw greens (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.78 (0.68)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.85 (0.68)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eCooked greens (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.33 (0.43)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.43 (0.57)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eOther vegetables (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e1.04 (0.83)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e1.12 (0.88)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eFruits and vegetables total\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e3.49 (2.20)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e3.81 (2.34)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eBeans (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.25 (0.30)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.30 (0.37)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eSugar beverages (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.20 (0.47)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.16 (0.41)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 44.586%;\"\u003e\n \u003cp\u003eFruit juice (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0637%;\"\u003e\n \u003cp\u003e0.11 (0.28)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.1083%;\"\u003e\n \u003cp\u003e0.09 (0.23)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.242%;\"\u003e\n \u003cp\u003e0.150\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003cp\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Changes in eating and cooking confidence pre- and post-intervention based on a 5-point Likert Scale (\u003cem\u003en\u003c/em\u003e=537).\u003c/p\u003e\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-survey result\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-survey result\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eFollowing balanced plate\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.05 (0.98)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.17 (0.97)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eEating whole grains\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.56 (0.88)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.58 (0.88)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.637\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003e5 servings fruits/vegetables\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.22 (0.98)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.21 (1.01)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.755\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eLess sugar\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.63 (0.88)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.67 (0.90)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.396\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eLean meats\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.63 (0.74)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.70 (0.71)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eUse of spices and flavors instead salt\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.48 (0.88)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.57 (0.85)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003ePortion control\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.87 (1.04)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.90 (1.02)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.499\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eStaying physically active during life changes\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.11 (1.05)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.10 (1.12)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.751\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eDevote time for physical activity\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.89 (1.05)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4.00 (1.06)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eViews about cooking (Likert Scale 1-5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eCooking skills (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.97 (0.70)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.02 (0.60)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eCooking time (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.89 (1.07)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.71 (1.07)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eCooking frustration (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.29 (1.0)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.22 (0.96)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 45.1923%;\"\u003e\n \u003cp\u003eCooking too much work (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.57 (1.07)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.45 (1.02)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003cp\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e: Changes in eating and cooking confidence pre- and post-intervention when controlling for the number of classes completed (\u003cem\u003en\u003c/em\u003e=537).\u003c/p\u003e\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd colspan=\"2\" valign=\"top\" style=\"width: 37.0192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLinear Regression # classes predicting mean change\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean change\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeta\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eWeight\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-1.12 (10.42)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.340\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.10 (1.22)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.397\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFREQUENCY (Scale 0-10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eFrequency of processed meats\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.04 (0.28)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.195\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eFrequency red meat\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.05 (0.25)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eFish as protein\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.02 (0.20)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eVegetables as protein\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.02 (0.92)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eWhole grains\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.04 (0.56)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eWhite grains\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.07 (0.35)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eFruit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.08 (0.87)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eRaw greens\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.07 (0.67)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.002\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eCooked greens\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.10 (0.54)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eOther vegetables\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.08 (0.85)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eFruits and Vegetables total\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.33 (2.0)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eBeans\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.05 (0.36)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.623\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eSugar beverages\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.05 (0.47)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eFruit juice\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.01 (0.22)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eViews about cooking (Likert 1-5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eCooking skills\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.05 (0.46)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eCooking time\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.18 (0.95)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eCooking frustration\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.07 (0.86)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 43.2692%;\"\u003e\n \u003cp\u003eCooking too much work\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e-0.12 (0.90)\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 20.0321%;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 16.9872%;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003cp\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e: 11 thematic categories determined from participant testimonials after charting by two independent reviewers and corresponding specific examples of participant responses.\u003c/p\u003e\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThematic Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelected Examples\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eDelicious and healthy recipes\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I truly enjoyed watching and making these delicious and healthy recipes and learning about a new health related topic with each session.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I love that the lessons and recipes were tailored to women going through my phase of life. The recipes were so delicious and incorporated healthy ingredients new to me. I also loved learning new tips and tricks that make cooking easier! Highly recommend this course!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eLearning new recipes/cooking tips\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“The NuCook classes have taught me a lot; they have helped to expand my food prep knowledge which has helped with everyday cooking.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I love the classes because I learned to use so many new ingredients for me, the Chefs are fantastic, I love learning about the best tools and tricks in the kitchen for prep and I love all the medical and dietary information that we learn weekly. Thanks so much! Love the classes!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eNutrition and health education\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“This is more than a cooking class. These women address current issues in nutrition and how to live your best life by eating well and getting enough exercise. It is my weekly reminder to take care of myself and my family. Thank you.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I love the healthy recipes, love the break to talk about bone health, menopause and other important issues. I have referred friends and family to your classes.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eProfessional support: chef, physician, dietician\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“NuCook classes are extremely well done and having a professional team (vs. \"bloggers\") is reassuring that the information is high quality and accurate!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I looked forward to my weekly hour and a half each week with these wonderful professionals: a chef, medical doctor, very experienced lifestyle coach and dietician. They answered every question with good humor. I became more confident about trying new ingredients and spices and learned how good they are for my body as I enter the afternoon of life. Definitely would recommend every woman to join in.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eSupport behavioral changes to improve health\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I have lost and kept off 32 pounds since I started NuCook in January of 2021. At that time, I cooked along with Chef Eva and learned about new spices and new recipes. I had made a commitment to eat healthier and I was able to because of NuCook. I liked cooking to start and then learning about how to set your plate and exercising every day, as well as cholesterol, salt intake, etc. Since these concepts were enforced weekly, I was able to meet my goals.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I've spent the last year working hard to lose weight, increase activity, and improve my overall health. This class helped to spark new ideas, fresh flavors and combinations and break up the boredom that can come with trying to get healthier. Thanks for a fun way to cook and prep differently!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eGood communication/resources from team\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I think the NuCook classes are great. I love the balanced focus of the MD and dietitian approved recipes, the professional chef expertise, the fact that all questions are answered, recordings and recipes are shared..I have already recommended it to several friends.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“The weekly reinforcement and updates on healthy eating for my age group were invaluable. Each weekly topic was informative and presented in a fun lively format. The ongoing group chat for questions was great too. Highly recommend.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eTrying new ingredients, flavors, techniques\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I really enjoyed cooking with new spices and ingredients that I'd never used before. It expanded my repertoire of healthy meal preparation ideas.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“These were not your run-of-the-mill recipes! They were exciting! I learned how to cook with flavors I would never have considered buying and would not have known what to do with. The food was delicious, and the dedication of the experts to teaching participants how to support a healthy lifestyle through food choices was really wonderful.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCommunity and connecting with others\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I loved cooking alongside an experienced and encouraging chef, and feeling like I was joining a broader community of people in my same life stage, from my home kitchen. This course helped me be even more confident in my cooking skills and encouraged me to make healthier choices. I looked forward to it every week!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“This has been the highlight of my year. The community of women… has felt so empowering. I cannot believe how much I have learned. I have a new appreciation for cooking, spices, and exercise. I also have a better understanding of what I am going through and that maybe I am more normal than I thought. I am certainly a work in progress. I am going to miss this community and I am eagerly awaiting the next series. Thank you so very much!!!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eIncorporating new/healthy ingredients\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I really enjoyed the pace of the class, the demonstrations and tips from Chef Eva, the recipes that incorporated spices and vegetables (i.e. parsnips, collard greens, kale, Swiss chard, turmeric and harissa paste) that I had never cooked with before or I was afraid to try them!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“Liked getting new ideas from Chef Eva how to include healthy ingredients to make a delicious and not so time consuming meal”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eSupportive of all skill levels\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“These courses introduced me to new foods and demonstrated new ways to cook all foods. A very supportive environment with realistic goals and information.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“NuCook classes were informative and easy to follow whether you are new to cooking or just looking for new ideas to get nutritionally balanced, easy meals to round out your repertoire.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd rowspan=\"2\" style=\"width: 188px;\"\u003e\n \u003cp\u003eFree courses\u003c/p\u003e\n \u003c/td\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“I would highly encourage anyone interested in learning or in further improving their cooking skills to take these classes for several reasons: they are very well prepared, they are easy to access, easy to follow and there is plenty of room to clarify any questions and concerns from highly qualified professionals. Plus, and this is a huge plus, these high-quality classes are free and are not time consuming. Thank you very much NuCook for making this possible!”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd valign=\"top\" style=\"width: 436px;\"\u003e\n \u003cp\u003e“This class was so much fun! I love to cook and am constantly striving to learn new things. Having access to a chef, nutritionists and doctors for free was invaluable.”\u003c/p\u003e\n \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6181028/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6181028/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background: Virtual teaching kitchens have been shown to improve dietary habits, cooking confidence and self-efficacy. This mixed methods study evaluates the quantitative impact of NuCook’s teaching kitchen programs on cooking, eating, and health habits of perimenopausal women. It also assesses which components of the intervention were most beneficial for participants to achieve health behavior changes based on qualitative feedback.\nMethods: The NuCook program consists of a series of online classes offered synchronously and asynchronously, with 45 minutes of live cooking instruction and 15 minutes of health and nutrition instruction. From September 2020 to May 2024, participants completed pre- and post-intervention surveys which addressed weight, dietary habits, and cooking confidence. Participants answered open-ended questions about their experiences with the program. Normally and non-normally distributed data were analyzed with paired samples t-tests and Wilcoxon signed rank sum tests, respectively. Qualitative analyses were conducted by two independent reviewers who manually charted themes in each participant response.\nResults: Of 817 unique participants, 537 completed both pre- and post-surveys, and 525 wrote testimonials after attending classes. Participants reported significant decreases in weight (p=0.017), consumption of red (p\u003c0.001), processed meat (p=0.004), white grains (p\u003c0.001), and sugary beverages (p=0.026), and significant increases in consumption of fish (p=0.012), total fruits and vegetables (p\u003c0.001), and beans (p\u003c0.001). Participants also reported significantly improved cooking confidence and dietary habits including following a balanced plate model (p=0.010), replacing salt with spices (p=0.029), and devoting time to physical activity (p=0.014). Participants cited learning and cooking healthy recipes and nutrition education most frequently as beneficial aspects of the courses. Participant testimonials emphasized three positive characteristics of the course: engagement, tools, and change. The easy engagement, and the tools of learning cooking skills and nutrition information were cited as beneficial aspects that supported change of cooking and dietary behaviors.\nConclusions: The NuCook virtual teaching kitchen intervention improved dietary habits and cooking confidence among perimenopausal women. Qualitative analysis shows that NuCook courses engaged participants and provided them with tools, such as recipes and health education, to achieve health behavior changes. This demonstrates the potential of virtual teaching kitchen interventions to support lifestyle and behavior changes. Trial Registration: Study obtained IRB exemption.","manuscriptTitle":"Impact of virtual teaching kitchens on culinary and dietary behaviors of perimenopausal women: A mixed methods analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 00:59:11","doi":"10.21203/rs.3.rs-6181028/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-02T13:21:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T10:44:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54484139794066895130439268193391525715","date":"2025-05-19T12:04:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-07T03:04:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30442318361773309784501423125653429027","date":"2025-05-03T13:28:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-02T11:44:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-25T16:31:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-18T09:55:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-15T15:24:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-15T15:23:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73136144-ac98-4e13-8964-b6dc34dfd9d2","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T18:38:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-03 00:59:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6181028","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6181028","identity":"rs-6181028","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}