Prediabetes and diabetes affect 96 million and 37 million Americans, respectively,(1) and disproportionately impacts Black, Hispanic and low-income Americans(Reference Gaskin, Thorpe and McGinty2). Fortunately, type 2 diabetes is preventable, and the National Diabetes Prevention Program (DPP) is an evidence-based 12-month lifestyle change programme that can reduce the risk of diabetes(3,4) . The DPP focuses on weight loss, healthy nutrition with caloric restriction and increased physical activity(1,5) . However, the DPP curriculum incorporates little discussion of food and cooking skills (FACS)(Reference Wolfson, Lahne and Raj6,Reference Lavelle, McGowan and Hollywood7) and does not include any hands-on cooking skills education(8). Thus, changes to cooking practices during the DPP may be more limited than other weight loss strategies such as portion control or counting calories.
To our knowledge, no studies have examined FACS and strategies among DPP participants prior to or after DPP participation. FACS are important for shaping food choices and diet quality(Reference Wolfson, Lahne and Raj6,Reference Lavelle, McGowan and Spence9,Reference McGowan, Pot and Stephen10) , including use of scratch v. pre-prepared or processed foods, and higher cooking frequency is associated with improved diet quality and increased consumption of fruits and vegetables(Reference Wolfson, Leung and Richardson11,Reference Mills, Brown and Wrieden12) . Some studies of community cooking initiatives have demonstrated that cooking skills interventions can be effective in facilitating behaviour changes that can prevent diabetes(Reference Garcia, Reardon and McDonald13–Reference Archuleta, Vanleeuwen and Halderson16).Yet, the extent to which the DPP helps participants develop healthy cooking skills is less established.
The objective of this study was to describe FACS and strategies among recent DPP participants and the ways the DPP influenced their current food behaviours. The primary goal was to understand what FACS and strategies the DPP currently promotes and assess potential gaps in knowledge and behaviours that could inform a future FACS intervention to supplement the DPP.
Methods
This qualitative study used photo-elicitation interviews to explore FACS and strategies among former DPP participants in Baltimore City, MD(Reference Harper17,Reference Mills, White and Wrieden18) . The study team partnered with the [Blinded for Review], which provides the DPP in collaboration with community-based organisations, to identify recent DPP participants eligible for this study. The study team utilised the consolidated criteria for reporting qualitative research (COREQ) checklist(Reference Tong, Sainsbury and Craig19) to guide reporting. The [Blinded for Review] Institutional Review Board approved this study.
Recruitment and selection of participants
The team recruited participants from April to July, 2021 using a database of recent (last several years) Baltimore City DPP participants maintained by the [Blinded for Review]. First, letters describing the study were sent to recent DPP participants (n 93); individuals had 3 weeks to opt out of further contact (n 14 opted out). Next, potential participants were contacted by phone and email to provide more detail and enroll and consent interested individuals. Oral consent was obtained over the phone and at the start of interviews. The goal of the study was described to participants as an opportunity ‘to learn about cooking practices among DPP participants’ and ‘to help us develop a cooking class as part of the DPP.’
Inclusion criteria required that individuals were past participants in a DPP administered by the [Blinded for Review] in Baltimore City, ≥ 18 years old, and willing and able to take photographs of their kitchen and food with a mobile device and send them to the study team. Exclusion criteria included having already been diagnosed with type 1 or type 2 diabetes, and simultaneous participation in another study. All participants who expressed a desire to participate met the eligibility criteria. Sixteen individuals enrolled in the study, three withdrew due to health issues or insufficient time for data collection, resulting in a total sample of 13 individuals with complete data.
Data collection
Due to the COVID-19 pandemic, all data collection was conducted virtually. First, participants submitted photos of their kitchens, inside of their refrigerators and cupboards, and several typical meals they prepared over the course of a week. Then, in-depth interviews over Zoom and phone were conducted using the photographs to guide discussion. The interview guides were influenced by existing literature(Reference Lavelle, McGowan and Spence9,Reference Mills, White and Wrieden18,Reference Wolfson, Bleich and Smith20) and covered food shopping practices, food preparation techniques and barriers and facilitators to cooking healthy meals. All interviews (11 via Zoom and 2 via phone) were conducted by JAW, a white woman, and an experienced qualitative researcher; JT, an Asian woman Master’s student with qualitative training, also participated in the interviews as a notetaker. At the conclusion of the study, participants received a $60 Amazon e-gift card as compensation.
Analysis
Interview audio recordings were professionally transcribed verbatim. One research team member (LER, a white woman Master’s student studying qualitative methods) independently analysed interview transcripts using a grounded theory approach. Coding (by hand) used an inductive and iterative approach(Reference Charmaz21). Preliminary codes were created through line-by-line coding of each transcript; transcripts were revisited as new codes arose. The codes were then categorised into broad themes and key insights. Code memos were written to correspond with each transcript during the data analysis process. Code memos, themes and key insights were discussed with JAW throughout the analysis process. LER also used reflective memos during analysis to track similarities and differences between participants, and her own assumptions, positionality and biases that may influence interpretation(Reference Birks, Chapman and Francis22).
Results
Sample characteristics
The sample included thirteen Black women who formerly participated in the DPP in Baltimore City (Table 1). The mean age was 61 years. A majority (61·5 %) of the participants were college graduates and more than half were married or partnered. Approximately half (54 %) were employed. Nearly 62 % of participants reported an annual household income of ≥ $60 000.
Socio-demographic characteristics of study participants
* Median household income between 2017 and 2021 in 2021 dollars was $54 124 in Baltimore City, Maryland and $81 845 in Baltimore County, Maryland(32).
DPP participants discussed numerous benefits of the DPP including building community with fellow participants and feeling more empowered and in control of one’s own health decisions and outcomes. Though some members of the sample attended cooking classes as part of their DPP experience, most had not. However, a key insight from participants focussed on the use of new cooking strategies and methods to promote more efficient and healthier eating practices after the DPP. Participants cited the DPP as the reason for focussing more on consuming fruits and vegetables and avoiding foods high in carbohydrates, fats, sugars and Na. Participants also reported feeling that they cook differently than many members of their community, including family, often citing new meal preparation and cooking techniques learned during the DPP. Participants said they would have found additional cooking instruction useful during the DPP.
Participants reported specific strategies for cooking more healthfully while still making flavourful meals and being mindful of time and cost constraints. Table 2 presents exemplar quotations chosen to illustrate key findings across participant characteristics and common strategies that individuals used after the DPP. Salads were a commonly consumed meal or meal component and ways to modify salad dressings came up in multiple interviews. The DPP raised awareness of calorie and fat content of salad dressings and participants used different strategies to address that including supplementing a portion of packaged salad dressing with citrus juice or vinegar. Participants also credited the DPP with helping them enhance flavours while reducing Na consumption, often by using herbs, seasonings like garlic powder or acids such as lemon juice. Using appliances such as air fryers and Instant Pots was another common cooking strategy. Participants owned numerous kitchen tools and appliances and found them useful for saving time and reducing the amount of fat in their diets while still being able to prepare familiar foods. Additionally, participants emphasised avoiding canned fruits and vegetables and focusing on frozen and fresh products to avoid Na and other preservatives used in canned items. Participants who had cooking classes as part of their DPP noted preparing all ingredients prior to beginning to cook as a new strategy to facilitate more timely and less stressful meal preparation. DPP participants also shared that they were more attentive to reading labels and packaging and considering the quality of ingredients during their shopping process than they were before the DPP, the latter of which resulted in many participants shopping at multiple grocery stores for routine items. Finally, the DPP encouraged participants to shop around the ‘perimeter’ of the store, where stores tend to stock produce, fish, meats and dairy.
Key insights describing participants cooking practices after DPP
Discussion
In this qualitative photo-elicitation interview study to understand FACS and strategies among former DPP participants, we learned that participants employed numerous cooking techniques to achieve their diet and weight loss goals. After the DPP, participants were more mindful of their food choices and described increased awareness of fruit and vegetable intake, and heightened concern about limiting consumption of fats, carbohydrates, sugars and Na. Participants also described how the DPP made them more aware of strategies for air-frying and baking foods rather than frying, which was the technique many participants learned from family cooking practices. Even without an explicit focus on cooking in the DPP curriculum, findings reveal that participants modified their cooking practices during and after the DPP.
Our findings demonstrate that participants made changes to food preparation and procurement techniques based on ‘food literacy’(Reference Vidgen and Gallegos23) discussions highlighting meal planning, food shopping and nutrition techniques(Reference Williams, Shrodes and Radabaugh24,Reference McGowan, Caraher and Raats25) already included in the existing DPP curriculum. In our results, those who already participated in a cooking class discussed using different strategies related to organising all their ingredients at the start of their meal preparation, which helped them save time and cook more efficiently. Given participants’ enthusiasm for more cooking-related content, which has also been noted in other studies(Reference Srebnik, Chwastiak and Russo26,Reference Realmuto, Kamler and Weiss27) , greater incorporation of cooking skills into the DPP could be beneficial for programme engagement and sustained behaviour change(Reference Polak, Tirosh and Livingston15,Reference Archuleta, Vanleeuwen and Halderson16,Reference Zong, Eisenberg and Hu28) . A recent evaluation of Cooking Matters for Diabetes, a cooking intervention for diabetes management, found high acceptability of the intervention and improvements in self-efficacy, diabetes self-management activities and health outcomes(Reference Williams, Shrodes and Radabaugh24,Reference Shrodes, Williams and Nolan29) .
We found that DPP participants developed new cooking knowledge and strategies that informed modification of their pre-DPP cooking practices. This suggests co-development of cooking interventions between community members and practitioners can leverage existing community-based knowledge and practices and create an opportunity to design an intervention that is tailored to local needs. Given that our findings were from a self-selected sample of participants, some of whom had participated in cooking classes as part of the DPP, it is possible that the embedded knowledge of cooking skills and techniques may differ in a broader sample of DPP participants. Future research should assess the effect of adding FACS to what is already being learned in the DPP. It will also be important that those developing hands-on cooking skills interventions assess knowledge and practices of participants, using a model such as Cook-EdTM(Reference Asher, Jakstas and Wolfson30), before developing an intervention.
Findings demonstrate that cost concerns influence food procurement practices. This is consistent with existing research in which people identified cost as a major barrier to aligning their dietary practices with type 2 diabetes prevention and management recommendations(Reference Byrne, Kurmas and Burant31). Thus, FACS classes should incorporate programming about economical ways to grocery shop and prepare meals as part of prediabetes and diabetes management. Further, though the DPP already encourages participants to shop around the store’s perimeter and read nutritional labels, the curriculum could also focus on ingredients to minimise meal preparation time and strategies for affordable grocery shopping for efficient, healthy meals.
Limitations
All participants in this study identified as Black women living in Baltimore City or Baltimore County, which may limit generalisability to other racial and ethnic groups, socio-economic groups, and more rural areas. Relatedly, participants in this study were self-selected and may have been interested in helping shape a hands-on cooking skills intervention. The goal of qualitative research is not generalisability, but rather to understand a practice or phenomenon based on the lived experience of those with firsthand knowledge or exposure to the topic, so findings are still applicable to DPP providers and other community-based FACS interventions. Further, self-reported benefits of the DPP and positive changes to cooking-related behaviours could have been influenced by social desirability bias.
Conclusions
This qualitative study described FACS in a sample of former DPP participants in Baltimore City, MD. Though not explicitly the focus of the DPP, participants changed their cooking practices from pre- to post-DPP participation and adopted several key strategies to facilitate healthier eating. Incorporating a greater focus on FACS in the DPP may be beneficial for helping participants achieve sustained behaviour change to manage prediabetes and prevent development of type 2 diabetes.
Acknowledgements
Acknowledgements: The authors thank the individuals who participated in the study. Financial support: This research reported in this publication was supported by the National Institutes of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (Award #K01DK119166). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Authorship: J.A.W. designed the study with input from C.R.R. and A.T. J.A.W. led the data collection with contribution from J.T., and L.E.R. led the analyses and interpretation of results. L.E.R. wrote the first draft of the manuscript with input from J.A.W., and all authors critically reviewed the manuscript and approved the manuscript as submitted. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Johns Hopkins University Institutional Review Board. Verbal informed consent was obtained from all subjects/patients. Verbal consent was witnessed and formally recorded.
Conflict of interest:
There are no conflicts of interest.
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