Abstract
Purpose:
Diet is crucial for improving outcomes among pregnant people with diabetes. We present lessons learned from developing and piloting a program, Diabetes Prevention Program Cooks in Pregnancy (DPP Cooks in Pregnancy), tailored to address unique barriers to healthy eating among this population.
Methods:
Participants (n = 23) attended at least one cooking class and completed a post-survey. We used descriptive statistics to summarize findings.
Results:
DPP Cooks in Pregnancy was well received by participants, with higher enrollment and attendance for virtual classes compared with in-person classes.
Conclusion:
Lessons learned from DPP Cooks in Pregnancy can inform the development and implementation of future cooking skills interventions.
Introduction
In the United States, 6.9% of births are affected by diabetes during pregnancy, 1 with Black, Hispanic, and low-income individuals experiencing a disproportionate burden of diabetes and poorer outcomes. 2 Diabetes during pregnancy, including pre-existing and gestational diabetes, can severely impact both parent and child in the short- and long-term. During pregnancy, diabetes increases risk of pregnancy loss, preeclampsia, birth defects, and fetal growth abnormalities. 3 One-third of people with gestational diabetes will develop type 2 diabetes within 15 years of giving birth, 4 and children exposed to diabetes in utero have an increased risk of obesity and poor cardiometabolic health later in life.5–7
Diet and lifestyle modifications are integral to diabetes management. 8 Mounting evidence suggests that home cooking is associated with higher dietary quality,9,10 and lifestyle interventions increasingly incorporate food and cooking skills education to support behavior change. 11 Interventions to build food and cooking skills may be especially impactful during pregnancy, when individuals could have higher motivation to make lifestyle changes. 12 However, few food and cooking skills interventions have specifically recruited pregnant individuals, and a paucity of studies have been tailored to pregnant people with diabetes. 13 This is notable, as people with diabetes in pregnancy face unique challenges to preparing meals at home and achieving a healthy diet. 14 Therefore, food and cooking skills interventions designed for pregnant people with diabetes are needed to test impacts on dietary quality, long-term behavior change, and diabetes-related complications.
To fill this gap, we adapted an existing food and cooking skills curriculum to meet the needs of pregnant individuals with diabetes. The aim of this adapted curriculum, the Diabetes Prevention Program Cooks in Pregnancy (DPP Cooks in Pregnancy), is to help participants build food agency and cooking skills that support healthy dietary patterns and prevent diabetes progression.
Materials and Methods
The original DPP Cooks curriculum is a 6-week food agency-based cooking intervention designed to supplement the Diabetes Prevention Program (DPP), which has been described in depth elsewhere. 15 While the DPP does not include a cooking component, prior studies have demonstrated that DPP participants are interested in and could benefit from cooking skills education.16–18 Thus, DPP Cooks seeks to meet this need. DPP Cooks is grounded in a “food agency” approach, which emphasizes developing skills to navigate structural barriers to healthy food procurement and preparation.14,19,20 To adapt the DPP Cooks curriculum for pregnant people with diabetes, we leveraged prior formative work 11 to understand the specific challenges, needs, and facilitating factors to cooking and making dietary changes during pregnancy. Additionally, we recruited pregnant individuals at the medical clinic with whom we partnered to complete a survey (N = 32) and an in-depth interview (N = 5). This formative work aimed to understand cooking class needs and preferences as well as specific challenges and existing skills, knowledge, perceptions, and attitudes related to healthy home cooking.
The final DPP Cooks in Pregnancy curriculum consisted of five 90-min hands-on classes. Ingredients for the classes were provided free to participants. Those participating virtually received food via a home grocery delivery service. All participants were provided with a DPP Cooks in Pregnancy cookbook containing recipes from the five lessons, bonus recipes from the original DPP Cooks curriculum, and additional food and cooking skills resources. Figure SA1 includes an excerpt from the participant workbook. Virtual classes were led by a professional chef who had previously led the DPP Cooks classes and in-person cooking classes were hosted by the American Heart Association’s Simple Cooking with Heart Kitchen teaching kitchen.
The curriculum was tailored to the needs of individuals with diabetes in pregnancy, regardless of cultural background, (e.g., dietary, financial, physical, and scheduling considerations) and was not further tailored to specific demographic or cultural groups. Table 1 presents cross-cutting curriculum strategies to increase food agency and address barriers to participation identified through formative research with pregnant individuals with diabetes (Part A). During formative work, participants highlighted the importance of offering both in-person and virtual classes at varying times to accommodate more individuals’ schedules. Participants in formative interviews also expressed that they faced barriers to participating in sequential classes, including timing with their due date, concern about going into labor early, and scheduling conflicts due to work or childcare. For this reason, participants were not required to attend a minimum number of sessions, and lessons were designed to be complementary but not necessarily sequential.
Cross-Cutting Curriculum Strategies and Class Content for the Diabetes Prevention Program Cooks in Pregnancy Food Agency Pilot Study
Each recipe provided four servings.
Additionally, participants in formative work expressed difficulty adhering to diabetes-specific dietary recommendations to reduce serving sizes of grains and starchy vegetables (e.g., pasta, potatoes), describing how they found reduced portion sizes unsatiating. Therefore, we chose recipes that emphasized high fiber foods that could be eaten in higher volumes (e.g., non-starchy vegetables) to promote fullness. Participants also expressed interest in learning about new flavors and healthy preparation techniques rather than healthier versions of more familiar recipes. In response, we included recipes with a variety of flavor profiles and ingredients while also balancing local availability, cost, and time to prepare meals.
Table 1 also includes class-specific topics, objectives, and recipes (Part B). All classes included recipe sequencing and organization, food preparation, eating together, and discussion. Recipe sequencing and organization teach participants how to plan out cooking steps to reduce time and effort for meal preparation. Afterward, the chef begins cooking, while participants cook along in their own kitchens (virtual classes) or at their own station (in-person classes). The chef narrates her steps, provides tips, and fields questions. Finally, participants eat together, while the chef facilitates a guided discussion about the meal’s sensory characteristics.
Participants were recruited for the cooking classes from a high-risk obstetrics clinic affiliated with a state-funded, university hospital providing specialized care to pregnant people with diabetes. Flyers in the clinic, MyChart messages, and verbal promotion of the classes from providers during office visits were used to recruit individuals. For the purpose of this feasibility study, individuals were eligible if they were 18 years of or older, spoke English, and met one of the following criteria: (1) current patient at the diabetes in pregnancy clinic, (2) a patient at the diabetes in pregnancy clinic within the last year, or (3) a spouse/partner to someone meeting the first or second criteria. Patients with gestational diabetes or pre-existing type 1 or type 2 diabetes were considered eligible for this study. To participate in virtual classes, participants were also required to have a physical address eligible for grocery delivery via an online delivery service. All participants provided oral consent for this study.
At the end of each class, participants completed an anonymous post-class survey. The survey included questions about class acceptability with answer choices: strongly agree, somewhat agree, neither agree or disagree, somewhat disagree, and strongly disagree. Virtual participants completed an online Qualtrics survey. In-person participants completed a paper copy. Participants received a gift card for each class attended. This study underwent full review and was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB).
Results
Twenty-three individuals attended at least one class, nine attending two or more classes (mean no. of class sessions attended = 1.4). Attendance and results from the survey are presented in Table 2. Attendance for virtual classes was 85%. Attendance for in-person classes was 25%. Only one person attended the last class. Of note, the final class was held on a day with a particularly bad storm, which prompted numerous same-day cancellations. Among those who attended an in-person class, only one person agreed that it was easy to attend.
Attendance and Post-Survey Responses of Participants in the Diabetes Prevention Program Cooks in Pregnancy Food Agency Pilot Study
Percentage from the number of people enrolled.
Percentage from the number of people who attended the class.
Percentage from the number of completed surveys for each class.
Overall feedback from the classes was positive. All participants agreed that they enjoyed the class and learned skills that would help them prepare healthy meals at home. Nearly all planned to apply the skills they learned to prepare other healthy meals at home (virtual: 97%; in-person: 100%). While less than half of participants agreed that the recipes from class were similar to things they already cooked (virtual: 41%; in-person: 0%), nearly all agreed that they liked the food prepared in class (virtual: 97%; in-person: 100%), and that their family would enjoy the recipes (virtual: 94%; in-person: 100%).
Via open-ended questions, we also asked participants to share what they liked most about the class, what they found most helpful, and suggestions for improving the class. Key quotes are highlighted in Table 3.
Key Open-Ended Survey Responses from Participants in the Diabetes Prevention Program Cooks in Pregnancy Food Agency Pilot Study
Discussion
While the DPP Cooks in Pregnancy curriculum was well received, we also identified considerations for implementation that have implications for other food and cooking skills programs. First, enrollment and attendance for in-person classes were lower than for virtual classes, despite requests for both formats during formative work. Reasons for not attending in-person classes included lack of transportation, lack of childcare, work schedule, pregnancy symptoms, and bad weather. In contrast, enrollment and attendance for virtual classes were higher, indicating greater demand and practicality for participants. While virtual classes can present challenges for engagement, participants in the virtual classes noted that they were engaging and easy to follow, suggesting that the virtual format was an acceptable mode of delivery.
Though virtual cooking classes are increasingly used in low-resource settings, there are costs and resource requirements unique to virtual classes. For example, the cost of delivering participants’ cookbooks and groceries was higher than the cost of providing class materials in person. The feasibility and cost-effectiveness of using grocery home-delivery services for class ingredients need to be determined for larger, longer-term programs. Additionally, our classes were carried out in the kitchen of a professional chef with extensive experience in filming cooking classes. As cooking classes are increasingly incorporated into “food as medicine” and “nutrition security” interventions, it is critical to consider the qualifications and experience of those leading such programs. Skills and knowledge pertaining to both nutrition and culinary methods are needed for successful chef instructors.
In this study, we demonstrated that recruiting people with diabetes in pregnancy from a specialized care clinic for a food agency-based cooking intervention was feasible. However, a randomized controlled trial is needed to robustly evaluate DPP Cooks in Pregnancy. It will also be critical to understand the “dose” required to achieve desired outcomes. Only attending a few classes is unlikely to impact diet quality, behavior change, diabetes indicators, or long-term health outcomes. This is an important area to understand as many other “food as medicine” and culinary interventions are gaining popularity. Additionally, it will be important for future intervention studies to understand and address barriers that individuals at different stages in their pregnancy, postpartum former patients, and partners might face in participating. Finally, given the success of the virtual sessions led by a trained, professional chef with strong nutrition expertise, and resource considerations for scalability, it is worth investigating whether pre-recorded videos may also be effective, particularly if paired with additional supports such as sessions with a dietitian or cohort-based support groups (similar to the DPP).
It is important to note some limitations of this study. First, to protect participant privacy, we did not collect demographic information about participants (for the formative work and the intervention). Therefore, we did not distinguish between participants on pregnancy status, diabetes type (gestational diabetes or pre-existing type 1 or 2 diabetes), or partner status. Future research should investigate differences in participant motivation based on pregnancy or partner status, and a larger randomized trial should test whether there are differences in acceptability or effectiveness across diabetes types. Last, as with many opt-in interventions, selection bias may be an issue, as people most interested in the intervention may be more likely to participate.
Conclusions
Food agency-based cooking skills interventions fill an important need for patients who have been instructed by health care providers to change their diets to address health conditions. The lessons learned from the DPP Cooks in Pregnancy can be helpful for others seeking to implement similar interventions.
Footnotes
Authors’ Contributions
A.C.T.: Project administration and writing—original draft. A.D., K.M., K.N., K.S., and J.H.: Resources and writing—review and editing. J.A.W.: Conceptualization, funding acquisition, and writing—review and editing.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Disclosure Statement
The authors of this study have no conflicts of interest to disclose.
Funding Information
Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award number U54MD000214. A.C.T. was supported by Grant Number T32 HL007024 from the National Heart, Lung, and Blood Institute, National Institutes of Health.
Abbreviations Used
References
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