Meta-analysis and machine learning-augmented mixed effects cohort analysis of improved diets among 5847 medical trainees, providers and patients.

OBJECTIVE: We sought to produce the first meta-analysis (of medical trainee competency improvement in nutrition counseling) informing the first cohort study of patient diet improvement through medical trainees and providers counseling patients on nutrition. DESIGN: (Part A) A systematic review and meta-analysis informing (Part B) the intervention analysed in the world's largest prospective multi-centre cohort study on hands-on cooking and nutrition education for medical trainees, providers and patients. SETTINGS: (A) Medical educational institutions. (B) Teaching kitchens. PARTICIPANTS: (A) Medical trainees. (B) Trainees, providers and patients. RESULTS: (A) Of the 212 citations identified (n 1698 trainees), eleven studies met inclusion criteria. The overall effect size was 9·80 (95 % CI (7·15, 12·45) and 95 % CI (6·87, 13·85); P < 0·001), comparable with the machine learning (ML)-augmented results. The number needed to treat for the top performing high-quality study was 12. (B) The hands-on cooking and nutrition education curriculum from the top performing study were applied for medical trainees and providers who subsequently taught patients in the same curriculum (n 5847). The intervention compared with standard medical care and education alone significantly increased the odds of superior diets (high/medium v. low Mediterranean diet adherence) for residents/fellows most (OR 10·79, 95 % CI (4·94, 23·58); P < 0·001) followed by students (OR 9·62, 95 % CI (5·92, 15·63); P < 0·001), providers (OR 5·19, 95 % CI (3·23, 8·32), P < 0·001) and patients (OR 2·48, 95 % CI (1·38, 4·45); P = 0·002), results consistent with those from ML. CONCLUSIONS: The current study suggests that medical trainees and providers can improve patients' diets with nutrition counseling in a manner that is clinically and cost effective and may simultaneously advance societal equity.

Effect of culinary education curriculum on Mediterranean diet adherence and food cost savings in families: a randomised controlled trial.

OBJECTIVE: Diet-related diseases are the leading cause of morbidity and mortality in the USA. While the critical aspects of a healthy diet are well known, the relationship between community-based, teaching kitchen education and dietary behaviours is unclear. We examined the effect of a novel culinary medicine education programme on Mediterranean diet adherence and food cost savings. DESIGN: Families were randomised to a hands-on, teaching kitchen culinary education class (n = 18) or non-kitchen-based dietary counselling (n = 23) for 6 weeks. The primary outcome was adherence to the validated nine-point Mediterranean diet score, and the secondary outcome was food cost savings per family. SETTING: The Goldring Center for Culinary Medicine, a community teaching kitchen in New Orleans. PARTICIPANTS: Families (n = 41) of at least one child and one parent. RESULTS: Compared with families receiving traditional dietary counselling, those participating in hands-on, kitchen-based nutrition education were nearly three times as likely to follow a Mediterranean dietary pattern (OR 2·93, 95% CI 1·73, 4·95; P  <  0·001), experiencing a 0·43-point increase in Mediterranean diet adherence after 6 weeks (B  =  0·43; P  <  0·001). Kitchen-based nutrition education projects to save families $US 21·70 per week compared with standard dietary counselling by increasing the likelihood of consuming home-prepared v. commercially-prepared meals (OR 1·56, 95% CI 1·08, 2·25; P  =  0·018). CONCLUSIONS: Community-based culinary medicine education improves Mediterranean diet adherence and associates with food cost savings among a diverse sample of families. Hands-on culinary medicine education may be a novel evidence-based tool to teach healthful dietary habits and prevent chronic disease.

Multisite Medical Student-Led Community Culinary Medicine Classes Improve Patients' Diets: Machine Learning-Augmented Propensity Score-Adjusted Fixed Effects Cohort Analysis of 1381 Subjects.

Background. Healthy diet represents one of the largest single modifiable risk factors proven to decrease rates of obesity and associated chronic disease, but practical approaches to improving dietary habits through nutritional intervention are limited. Objective. To evaluate the effectiveness of a medical student-led, 6-week culinary course on participants' dietary knowledge and behaviors, particularly focusing on the tenets of the Mediterranean diet (MedDiet). Design. This study is a prospective multisite cohort study evaluating the effects of a 6-week, hands-on community culinary education course offered at 3 sites. Participants' knowledge of cooking skills, eating habits, and adherence to the MedDiet were evaluated using a survey prior to beginning and 6 weeks after the completion of the course. Analysis was conducted using multivariable regression to assess subjects' diets, associated behaviors, and nutrition beliefs according to the number of classes to which they were exposed (0 to >6). Statistical results were then compared with the machine learning results to check statistical validity after selection of the top-performing algorithm from 43 supervised algorithms using 10-fold cross-validation with performance assessed according to accuracy, root relative square error, and root mean square error. Results. Among the 1381 participants, cooking classes significantly improved patients' overall 9-point MedDiet adherence (ß = 0.62, 95% CI 0.23-1.00, P = .002). Participants were more likely to meet MedDiet point requirements for fruit intake (odds ratio [OR] 2.77, 95% CI 1.46-5.23, P = .002), vegetable intake (OR 4.61, 95% CI 1.85-11.53, P = .001), legume intake (OR 2.48, 95% CI 1.45-4.26, P = .001), and olive oil use (OR 2.87, 95% CI 1.44-5.74, P = .003), and were less likely to believe that cooking takes excessive time (OR 0.31, 95% CI 0.16-0.59, P < .001). Conclusion. Hands-on culinary education courses were associated with increased MedDiet adherence and improved knowledge of healthful eating. Such interventions thus represent a cost-effective option for addressing rates of obesity and obesity-related chronic illness.

Etiological Role of Diet in 30-Day Readmissions for Heart Failure: Implications for Reducing Heart Failure-Associated Costs via Culinary Medicine.

Background. Reducing the under-30-day readmission for heart failure (HF) patients is a modifiable quality-of-care measure, yet the role of diet in HF readmissions and cost-effective HF care remain ill-defined. Methods. Medical chart review was conducted to determine cause(s) for HF treatment failure. Randomized controlled trial-backed machine learning models were employed to assess the relationship of culinary medicine education with HF 30-day readmission rate and cost. Results. Of 1031 HF admissions, 130 occurred within 30 days of discharge (12.61%.) Nearly two-thirds of individuals were male (64.02%), while the mean age and median length of stay were 64.33 ± 14.02 and 2, respectively. Medication noncompliance (34.62%) was the most common etiology for 30-day readmissions, followed by dietary noncompliance (16.92%), comorbidity (16.92%), a combination of dietary and medication noncompliance (10%), HF exacerbation (10%), iatrogenic (10%), and drug abuse (1.54%). Medication noncompliance contributed to the highest gross charge by readmission, costing a total of $1 802 096. Compared with traditional care, culinary medicine education for HF patients would prevent 93 HF readmissions and save $3.9 million in an estimated 4-year period. Conclusion. Though pharmacological treatment remains a focal point of HF management, diet-based approaches may improve tertiary HF prevention and reduce HF-associated health care expenditures.

Regional variations in medical trainee diet and nutrition counseling competencies: Machine learning-augmented propensity score analysis of a prospective multi-site cohort study.

BACKGROUND: Medical professionals and students are inadequately trained to respond to rising global obesity and nutrition-related chronic disease epidemics, primarily focusing on cardiovascular disease. Yet, there are no multi-site studies testing evidence-based nutrition education for medical students in preventive cardiology, let alone establishing student dietary and competency patterns. METHODS: Cooking for Health Optimization with Patients (CHOP; NIH NCT03443635) was the first multi-national cohort study using hands-on cooking and nutrition education as preventive cardiology, monitoring and improving student diets and competencies in patient nutrition education. Propensity-score adjusted multivariable regression was augmented by 43 supervised machine learning algorithms to assess students outcomes from UT Health versus the remaining study sites. RESULTS: 3,248 medical trainees from 20 medical centers and colleges met study criteria from 1 August 2012 to 31 December 2017 with 60 (1.49%) being from UTHealth. Compared to the other study sites, trainees from UTHealth were more likely to consume vegetables daily (OR 1.82, 95%CI 1.04-3.17, p=0.035), strongly agree that nutrition assessment should be routine clinical practice (OR 2.43, 95%CI 1.45-4.05, p=0.001), and that providers can improve patients' health with nutrition education (OR 1.73, 95%CI 1.03-2.91, p=0.038). UTHealth trainees were more likely to have mastered 12 of the 25 competency topics, with the top three being moderate alcohol intake (OR 1.74, 95%CI 0.97-3.11, p=0.062), dietary fats (OR 1.26, 95%CI 0.57-2.80, p=0.568), and calories (OR 1.26, 95%CI 0.70-2.28, p=0.446). CONCLUSION: This machine learning-augmented causal inference analysis provides the first results that compare medical students nationally in their diets and competencies in nutrition education, highlighting the results from UTHealth. Additional studies are required to determine which factors in the hands-on cooking and nutrition curriculum for UTHealth and other sites produce optimal student - and, eventually, preventive cardiology - outcomes when they educate patients in those classes.

Multisite Culinary Medicine Curriculum Is Associated With Cardioprotective Dietary Patterns and Lifestyle Medicine Competencies Among Medical Trainees.

Background. Adherence to Mediterranean dietary patterns reduces the incidence of cardiovascular disease and other major chronic diseases. We aimed to assess the association between participation in kitchen-based nutrition education and Mediterranean diet intake and lifestyle medicine counseling competencies among medical trainees. Methods. The Cooking for Health Optimization with Patients (CHOP) curriculum is a hands-on cooking-based nutrition education program implemented at 32 medical programs (4125 medical trainees) across the United States. Mediterranean diet intake, nutrition attitudes, and lifestyle medicine counseling competencies were assessed via validated surveys. Multivariable-adjusted logistic regression assessed the relationship of CHOP education with Mediterranean diet intake, nutrition attitudes, and lifestyle medicine counseling competencies. Results. Individuals participating in the CHOP program were 82% more likely to follow the Mediterranean diet compared with those receiving traditional nutrition education (OR = 1.82; P < .001). CHOP participants were more likely to satisfy daily intake of fruits (OR = 1.33; P = .019) and vegetables (OR = 2.06; P < .001) and agree that nutrition counseling should be a routine component of clinical care (OR = 2.43; P < .001). Kitchen-based nutrition education versus traditional curricula is associated with a higher likelihood of total counseling competency involving 25 lifestyle medicine categories (OR = 1.67; P < .001). Conclusion. Kitchen-based nutrition education is associated with cardioprotective dietary patterns and lifestyle medicine counseling among medical trainees.

Machine Learning-Augmented Propensity Score-Adjusted Multilevel Mixed Effects Panel Analysis of Hands-On Cooking and Nutrition Education versus Traditional Curriculum for Medical Students as Preventive Cardiology: Multisite Cohort Study of 3,248 Trainees over 5 Years.

BACKGROUND: Cardiovascular disease (CVD) annually claims more lives and costs more dollars than any other disease globally amid widening health disparities, despite the known significant reductions in this burden by low cost dietary changes. The world's first medical school-based teaching kitchen therefore launched CHOP-Medical Students as the largest known multisite cohort study of hands-on cooking and nutrition education versus traditional curriculum for medical students. METHODS: This analysis provides a novel integration of artificial intelligence-based machine learning (ML) with causal inference statistics. 43 ML automated algorithms were tested, with the top performer compared to triply robust propensity score-adjusted multilevel mixed effects regression panel analysis of longitudinal data. Inverse-variance weighted fixed effects meta-analysis pooled the individual estimates for competencies. RESULTS: 3,248 unique medical trainees met study criteria from 20 medical schools nationally from August 1, 2012, to June 26, 2017, generating 4,026 completed validated surveys. ML analysis produced similar results to the causal inference statistics based on root mean squared error and accuracy. Hands-on cooking and nutrition education compared to traditional medical school curriculum significantly improved student competencies (OR 2.14, 95% CI 2.00-2.28, p < 0.001) and MedDiet adherence (OR 1.40, 95% CI 1.07-1.84, p = 0.015), while reducing trainees' soft drink consumption (OR 0.56, 95% CI 0.37-0.85, p = 0.007). Overall improved competencies were demonstrated from the initial study site through the scale-up of the intervention to 10 sites nationally (p < 0.001). DISCUSSION: This study provides the first machine learning-augmented causal inference analysis of a multisite cohort showing hands-on cooking and nutrition education for medical trainees improves their competencies counseling patients on nutrition, while improving students' own diets. This study suggests that the public health and medical sectors can unite population health management and precision medicine for a sustainable model of next-generation health systems providing effective, equitable, accessible care beginning with reversing the CVD epidemic.

Novel Longitudinal and Propensity Score Matched Analysis of Hands-On Cooking and Nutrition Education versus Traditional Clinical Education among 627 Medical Students.

Background. Physicians are inadequately equipped to respond to the global obesity and nutrition-associated chronic disease epidemics. We investigated superiority of simulation-based medical education with deliberate practice (SBME-DP) hands-on cooking and nutrition elective in a medical school-based teaching kitchen versus traditional clinical education for medical students. Materials and Methods. A 59-question panel survey was distributed to an entire medical school twice annually from September 2012 to May 2014. Student diet and attitudes and competencies (DACs) counseling patients on nutrition were compared using conditional multivariate logistic regression, propensity score-weighted, and longitudinal panel analyses. Inverse-variance weighted meta-analysis (IVWM) was used for planned subgroup analysis by year and treatment estimates across the three methods. Results. Of the available 954 students, 65.72% (n = 627) unique students were followed to produce 963 responses. 11.32% (n = 109) of responses were from 84 subjects who participated in the elective. SBME-DP versus traditional education significantly improved fruit and vegetable diet (OR = 1.38, 95% CI: 1.07-1.79, p = 0.013) and attitudes (OR = 1.81, 95% CI: 1.40-2.35, p < 0.001) and competencies (OR = 1.72, 95% CI: 1.54-1.92, p < 0.001). Conclusions. This study reports for the first time superiority longitudinally for SBME-DP style nutrition education for medical students which has since expanded to 13 schools.

Medical school-based teaching kitchen improves HbA1c, blood pressure, and cholesterol for patients with type 2 diabetes: Results from a novel randomized controlled trial.

AIMS: A medical school-based teaching kitchen sought to establish proof-of-principle for its hands-on Mediterranean diet (MD)-based cooking and nutrition curriculum for patients with type 2 diabetes (T2D). METHODS: This pilot randomized controlled trial (RCT) allocated 27 patients with T2D between the control and GCCM arms. Mixed effects linear regression with repeated measures was used to investigate differences from baseline to 6 months. The primary and secondary endpoints were HbA1c -0.3% (-27 mmol/mol) and diastolic blood pressure (DBP) -10 mmHg and a 25% improved responses in dietary habits and attitudes and competencies in healthy nutrition. RESULTS: Compared to the control group, the GCCM group had superior HbA1c reduction (-0.4% vs. -0.3%, p = 0.575) that was not statistically significant. There were significantly greater reductions in the GCCM vs. control group for DBP (-4 vs. 7 mmHg, p=0.037) and total cholesterol (-14 vs. 17 mg/dL, p = 0.044). There was a greater proportion increase though not significant of GCCM subjects compared to controls who mostly believed they could eat correct portions (18% vs. -11%, p = 0.124), and who used nutrition panels to make food choices (34% vs. 0%, p = 0.745). CONCLUSION: This is the first known RCT demonstrating improved biometrics using a novel MD-based hands on cooking and nutrition curriculum for patients with T2D. These results suggest subsequent clinical trials are warranted on the grounds of documented feasibility and clinical efficacy.