With growing awareness of the burden of food-related disease in the United States and globally, medical educators must equip future health professionals to address these challenges through effective and sustainable educational innovations. 1,2 While inconsistent adoption and heterogeneity of nutrition education has long been a challenge, reports have revealed discouraging trends toward less emphasis on this foundational discipline despite greater need. 3–6 Various initiatives that sought to enhance educational programming focused on nutrition curricula at medical schools, including the Nutrition Academic Award, 7 have struggled to gain widespread momentum. In contrast, the educational approach of culinary medicine, which employs practical, interprofessional nutrition training, 8 has garnered international media attention and achieved widespread adoption. 9–11 Culinary medicine provides a unique combination of culinary arts, and evidence-based medical nutrition therapy teaches nutrition principles relevant to patient care in a practical, collaborative, and relatable style; simultaneously, it equips the learner with self-efficacy for personal dietary wellness. This unique model of hands-on cooking appears well received by both educators and learners. 8,12–24
While established curricular programming in culinary medicine exists through licensure, 25 the literature reveals many institutions have launched independent culinary medicine programs. 12 As the culinary medicine field advances a lifestyle-focused approach to improve wellness and potentially population health, it is essential to identify the core programmatic aspects with demonstrated success. Identifying these common elements of success, including the ideal team of educators, level of learners, key resources, and necessary curricular exposure dose, will shape continued growth and inform standardized approaches. To support this endeavor, we conducted a scoping review of culinary medicine programs at U.S. medical schools. Our review aimed to synthesize programmatic approaches in medical education and assess the outcomes of hands-on culinary medicine programs on students’ preparedness to provide patients with nutrition counseling.
Method
Due to the broad nature of our research question and the relative novelty of the culinary medicine field, we determined that the scoping review methodology was the most suitable for our analysis. This review protocol was not registered, but it was carried out in accordance with all applicable Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard critical appraisal guidelines. 26 Our scoping review aimed to answer the following research question: “How are novel culinary medicine programs for U.S. medical students being structured, and how do they assess student knowledge and attitudes regarding nutrition counseling for patients?”
Search strategy
An initial literature search was performed between June 1 and August 1, 2020. The search was limited to published papers written in the English language between January 1, 2012, and August 1, 2020. This time range was chosen because the first medical school–based teaching kitchen for medical students was implemented in 2012 at Tulane University. 27 Studies were not limited to full journal articles as newer programs published curricular information and preliminary data in other formats. However, we did not include programs with only abstracts available when all other methods of gaining access to the full text were exhausted. A combination of database searching, hand searching, and snowball searching strategies were used. PubMed, Ovid MEDLINE, and MedEdPORTAL databases were included in the search. On October 15, 2021, the same search strategies with the addition of the search term “teaching kitchen” were used to capture any applicable studies that had been published since August 1, 2020.
Medical subject headings were used to search the PubMed and Ovid MEDLINE databases. Several medical librarians provided consultation regarding search terms and database inclusion. Terms including “nutrition education”, “nutritional sciences”, “nutrition”, “nutrition counseling”, “diet therapy”, “diet”, “food”, “culinary skills”, “cooking”, “teaching kitchen,” and “culinary medicine” were used to capture as many papers involving culinary medicine programs as possible since the nomenclature varies greatly between programs. Given their similar definition and impact, the terms “teaching kitchen” and “culinary medicine” are used interchangeably throughout this review. Terms such as “medical education”, “undergraduate medical education”, “medical school”, “medical students”, and “physician training” were used to encapsulate programs that catered mainly to medical students. Google Scholar was used to perform hand searches to capture any articles not identified in database searches. The references of papers that were included in the study as well as articles deemed as “similar articles” in the databases were examined to crosscheck that no important articles had been left out of the database searches. An example of the final PubMed search strategy and final OVID search strategy used appear in Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B313.
Inclusion criteria and selection process
Inclusion criteria for the scoping review encompassed the following: the learner participant population was majority medical students, an explanation of the culinary medicine course curriculum, a hands-on cooking component, and an element of reflective discussion or linking of nutritional knowledge to patient counseling. Using the inclusion criteria, the first researcher (C.N.) screened the titles and abstracts of the 239 papers identified by previously mentioned search strategies. Full-text manuscripts were gathered for the remaining 25 papers for which the abstracts looked promising or that lacked enough information to include or exclude. One paper could not be retrieved. 28 The institutional medical librarian exhausted all possible resources, but no library could supply the article; ultimately, the author responded and confirmed that the work was limited to abstract form. Two authors (C.N. and J.Y.) independently evaluated the remaining texts with the inclusion criteria in mind. A third author (J.A.) was available to settle disagreements on any evaluation measure for inclusion in the review. The reasoning for exclusion of texts 12,28–39 is detailed in Figure 1.
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Figure 1: Flowchart of the literature search and study selection process in a scoping review of culinary medicine programs for medical students, January 2012–October 2021.
Data collection, extraction, and charting
All initially identified references were downloaded to EndNote (Philadelphia, Pennsylvania, www.endnote.com). One author (C.N.) removed duplicate references before initial screening and extracted data from studies that met the inclusion criteria. Two authors (J.Y. and J.A.) corroborated all data extraction using the descriptive-analytical method 40,41 by independently reviewing and assessing all included studies. In an iterative process, 40–42 themes and pertinent categories for inclusion in data charting were discussed among the authors and evolved throughout analysis.
To capture programs lacking published results in the scholarly literature, we also reviewed publicly available, online databases to identify and summarize existing teaching kitchens delivering culinary medicine education to medical students. These databases comprised the publicly accessible online maps on the Teaching Kitchen Collaborative 43 and Health meets Food 11 websites.
The Teaching Kitchen Collaborative hosts The Food Is Medicine Map, 43 a listing of international teaching kitchen programs provided on a map showing their location. Inclusion on the map necessitates a brief application form but is free, and the online database includes information about each cited teaching kitchen program across many domains in academic medicine, health systems, and the community. There are currently 6 teaching kitchen programs catalogued on The Food Is Medicine Map with dedicated curriculum for medical students.
Similarly, the Health meets Food website hosts a Culinary Medicine Curriculum map, 10 a listing of programs using the Health meets Food curriculum provided on a map showing their location. The curriculum was developed by a team of physicians, registered dietitians, and chefs and integrates food and cooking into discussions about health through hands-on teaching kitchen experience. Medical schools, nursing schools, dietetics programs, health systems, and other groups can license the curriculum. In 2021, 30 medical schools were licensing the curriculum, including 2 programs also listed on the Teaching Kitchen Collaborative’s Food Is Medicine Map.
One author (J.A.) compiled the data from both maps, corroborated with individual medical school websites based on available information, and 2 authors (J.Y. and C.N.) reviewed the list for accuracy. The collection of details of each program’s implementation strategy and determination of active status was limited by the data that the Teaching Kitchen Collaborative and Health meets Food organizations received from programs and then included in their websites; we also sought additional information on the program websites at the individual medical schools.
Data analysis
Statistical analysis was not possible due to a lack of consistency in reporting quantitative outcomes across programs. Instead, descriptive analysis was used to illustrate statistical significance of outcomes within individual programs.
Results
Literature database searches identified 251 records, of which screening excluded 226 and full-text review excluded 13, leaving 12 studies that met full eligibility criteria. 13–24Figure 1 shows the flowchart of the literature search and study selection process. Searches of the 2 websites identified 34 medical schools indexed by the Teaching Kitchen Collaborative 43 and/or Health meets Food 11 organizations. Some of the programs cited in the included studies overlapped with those cataloged on the websites.
Breadth of programs
Table 1 shows a broad list of all 34 identified medical student programs and available details on these programs based on our search of the Teaching Kitchen Collaborative Food Is Medicine Map 43 and Health meets Food Culinary Medicine Curriculum map. 11 In reviewing the findings from our search of the 2 online maps, we identified information on culinary medicine programs being offered at U.S. medical schools, including participating institutions, types of facilitators, launch year, and funding sources. All programs that provided a launch date listed it between 2012 and 2020. Facilitators included physicians, dietitians, chefs, and other faculty in public health, nutrition, biochemistry, and physician assistant studies. Some programs partnered with community organizations, including use of teaching kitchens at local culinary and hospitality programs, and other programs used campus-based facilities or virtual delivery. Many programs trained interprofessional learners alongside medical students in various years of training, and implementation approaches ranged from elective courses to curricular integration. Funding sources varied, but the most cited sources were medical schools, dean’s offices, philanthropy, and various grants, demonstrating a combination of institutional and external support.
List of 34 Culinary Medicine Programs Offered at U.S. Medical Schools Identified Using the Maps on the Health meets Food
11 and Teaching Kitchen Collaborative
43 Websites, October 2021
Overview of published programs
The experiences reported in the 12 included articles from 12 different medical schools revealed that most of the culinary medicine curricula described in these articles were designed internally at the implementing institutions, but the curriculum launched at Tulane University’s Goldring Center for Culinary Medicine was eventually licensed as the Health meets Food curriculum and has now been used at other institutions as well. 10,21,24 Most of the programs that published their experiences with education in culinary medicine reported provision of primarily voluntary experiences, 13–21,23,24 often in the form of an elective course, but 1 program introduced culinary medicine as a required addition to the medical school’s main curriculum. 22Table 2 summarizes each program’s approach to instructors, learners, and curriculum.
Table 2: Curricular Details From Included Studies on Culinary Education Programs at 12 U.S. Medical Schools, 2012–2021
Program instructors
Instructors typically included an interprofessional team of physicians, dietitians, and chefs, with occasional involvement of medical students as peer educators. 14 The specialties of physician instructors varied and included endocrinology 18 and medicine-pediatrics, 19,21 and 2 physician instructors in one program were dually trained as chefs. 13 In another program, a senior medical student who previously attended culinary school served as the sole director. 23 Local dietetic students served as the main instructors for another program. 22
Program learners
Most program participants had exclusively medical student learners, with 1 program having a cohort of both preclinical medical students and physician assistant students. 13 The training year of medical students participating varied between programs; 3 programs had cohorts that were exclusively first years, 21–23 1 was exclusively second years, 16 1 was exclusively fourth years, 18 5 had a mix of first and second years, 13–15,17,24 and 2 included medical students from every year. 19,20 Medical students were directly involved in the curricular development for 5 of the programs. 14–16,18,23
Program course format
Cohorts of 10 to 20 students attended multiple 2- to 3-hour sessions spanning the course of several months, with the longest-lasting 2 semesters 21 and the shortest-lasting 1 day with only 1 session. 22 Most programs reported graduating more than 1 cohort of students but often only described preliminary data on 1 or 2 cohorts. The number of students analyzed in each study varied greatly, with sample sizes ranging from 10 to 90. One program’s sample size fell well outside this range and included 627 students. 24 Culinary medicine sessions mainly used preexisting or new food science laboratories associated with the medical school or undergraduate university of the same name, 14,21,23,24 or clinic or community teaching kitchens. 15,16,18,19 Only 1 program required rental of a kitchen. 13 Three programs did not describe the location or affiliation of the kitchen spaced used for classes. 17,20,22
Courses sessions followed a general format of:
- A 10- to 30-minute didactic session involving videos, research articles, culinary theories, and other lectures.
- A 60- to 90-minute hands-on cooking session.
- A 30-minute nutritional/cultural discussion while eating, including patient care application strategies.
Curricular content and application opportunities
Curriculum lessons explored nutritional management of common chronic diseases influenced by lifestyle, with some programs covering the role of nutrition for disease prevention and national website resources such as the U.S. Department of Agriculture’s MyPlate guidelines. Some programs explicitly stated objectives to include a cultural competency component. 14,15,17,18 Some programs also provided other culinary medicine opportunities outside of the sessions, typically focused on service learning. Students from these programs led community cooking classes, 16,24 taught nutrition to children in a public school, 17 and worked with a high school to modify recipes to accommodate certain diseases. 18 One program had a particular focus on practicing cooking skills while demonstrating recipe preparation to community members in a farmers’ market setting. 20 Tulane University’s program described culinary medicine opportunities outside of the initial elective with the service-learning component including disease-specific interdisciplinary seminars for third-year medical students and a 4-week away rotation for fourth-year medical students at Rhode Island Hospital and Johnson & Wales University. 24
Program evaluations
All programs used some variation of pre- and postprogram surveys. However, outcome measures varied greatly between programs. Table 3 summarizes outcomes from the included studies of medical school culinary education programs. Some programs 15,17 used validated assessments, such as the Nutrition in Patient Care Survey 44 and the Automated Self-Administered 24-Hour Diet Recall. 45 Other programs used adopted versions of novel intervention assessments or institution-specific surveys using various forms of the Likert scale. 14,18–24 Many programs also included open-ended, qualitative questions in their surveys for student feedback and to gauge how their curriculum was received. 13,14,17,18,20–22 These responses often served as the basis for changes in subsequent iterations of the programs.
Table 3: Participant Details and Outcomes From 12 Included Studies of Culinary Education Programs at U.S. Medical Schools, 2012–2021
Program outcomes and limitations
Outcomes mainly revealed dramatic improvement in student knowledge of healthy cooking strategies, meal planning, and culinary skills, with 1 study specifically incorporating knowledge of biochemical mechanisms into the context of making food. 22 Two studies 13,20 did not measure statistical outcomes but qualitatively assessed student experiences in culinary medicine. Of the remaining 10 papers, 5 showed statistically significant increases in student confidence in discussing dietary interventions with patients. 16–18,21,23 Student confidence in their cooking abilities improved significantly in 5 studies. 14,15,17,21,23 Finally, 2 studies 19,24 demonstrated increased scores measuring nutritional competencies while 2 other studies 17,18 showed application of nutrition knowledge to personal diet, as measured by significant increases in fruit consumption. Limitations across programs included absence of control groups in analyses, 14–17,19–23 retrospective student self-reporting, 13–24 lack of validated assessment use, 13,14,16,18–24 small sample size, 13,14,16–20,23 limited time scope, 14,15,20,22,23 and lack of longitudinal follow-up. 13–22
Program funding
Funding remains a critical issue for medical school culinary education programs. Of the 12 published papers reviewed, only 3 articles mentioned specific sources of funding. One program received funding from the American Academy of Pediatrics Section on Integrative Medicine. 19 Another program was sponsored by the school’s Food as Medicine student organization in its first year and was fully funded by the school’s alumni association in subsequent years. 23 A third program acknowledged an initial small, internal educational grant with no mention of an ongoing funding source. 21 One program explicitly described inconsistent funding, 13 while 3 programs mentioned community program partnerships without elaborating on the nature of these partnerships. 16–18
Discussion
Culinary medicine programs have emerged as a solution to nutrition education in an era of unprecedented lifestyle-related disease. This review presents information on existing culinary medicine programs dedicated to training medical students. While programs vary in resources and implementation strategies, they share goals to equip students for personal and patient wellness. Programs provide improved knowledge and attitudes regarding the role of nutrition in health and patient counseling and are consistently well received by students. Amid the broad success and impact, this review also unveils the wide variety of programmatic methods in format, content, and assessment strategy. Medical schools should seek to align curricula to define best practices in hands-on nutrition education through culinary medicine approaches, emphasizing the role that lifestyle plays in population health and equipping future leaders to deliver value in an era of accountable care organizations and capitated care. 46
Nutrition education challenges
Previous research demonstrated that nutrition education for medical students and practicing physicians improves patient engagement and health professional counseling for dietary change. However, current nutrition education for students is limited in scope and quality, resulting in residents who lack the confidence and knowledge to provide effective nutrition support to their patients. 47 While some efforts have increased the number of nutrition fellowships, advanced training opportunities will be limited until the American Board of Medical Specialties acknowledges nutrition with specialty board certification and until other specialty boards include nutrition content among core topics. 8,48,49 The overwhelming cost and resource burden of chronic disease has reached a tipping point that necessitates further emphasis on nutrition in medical education to address investment of health care dollars in prevention instead of treatment. In fact, leaders in the field suggest legislative mandates, links to funding and accreditation, and inclusion on qualifying exams as essential strategies to ensure widespread nutrition training for health care professionals and equitable access for patients. 50
The time is ripe
The need for well-equipped health professionals skilled in lifestyle change promotion has never been greater. With suboptimal diet well established as a top risk factor for most preventable chronic disease and premature mortality, 51 approaches to prevention and mitigation of chronic disease should be a top priority for medical school curricula. In addition to the well-known impact of diet as a driving force in the related morbidity of obesity, cardiovascular disease, and type 2 diabetes, 52–56 the COVID-19 pandemic revealed the relevance of metabolic health for communicable disease severity. 57 In particular, food-insecure communities suffer higher rates of metabolic disease at baseline, accelerating the pandemic’s disproportionate impact on them via chronic nutrient deficiencies. 58–63 This understanding of the impact of diet further highlights the universal relevance of a lifestyle that promotes lower risk of disease complications. The possibilities to transform patient care are promising and widely adaptable. 64–67
Leaders in the field of culinary medicine present teaching kitchens as innovative research and education laboratories. 68 Due to their universal relevance and ability to teach an adaptable skill set, teaching kitchens empower multilayered solutions. Rooted in a foundation of personal wellness, an increasingly relevant component of medical training and burnout prevention, culinary medicine programs equip learners with practical knowledge of food’s role in disease prevention and mitigation while also training in vital skills of shared decision making and coaching for behavior change.
Culinary medicine as a practical approach
Culinary medicine programs give medical students the experience necessary to translate nutrition knowledge learned in typical medical school curricula into practical advice. 8,49 Culinary experiences allow medical students to provide their patients with individualized food and nutrition ideas that are easier to translate into actionable changes than the typical generalities of healthy eating imparted during many patient visits. Culinary medicine training also provides an environment for medical students to practice motivational interviewing technique, a skill that may not be formally addressed in medical school curricula.
Community engagement
Culinary medicine equips learners to promote access to nourishing food and to advocate for patients through service learning, enhancing the intersection of health care delivery and food. Many culinary medicine programs have partnerships with community-based courses that empower trained medical students to act as instructors in the community environment, 16,17,69 and through these partnerships, students learn to discuss dietary change in culturally sensitive ways. Service learning thus allows students to apply emerging knowledge and skills in actual patient interactions, a higher level of Miller’s pyramid of competence. 70
A growing movement
The Teaching Kitchen Collaborative 43 and Health meets Food 10 organizations are leaders in promotion of widespread culinary medicine education. Their websites both contain maps which chart the breadth of programs across the United States. The complex nature of developing and sustaining these programs merits increased collaboration between teaching kitchens to share resources and lessons learned, especially as national media coverage inspires medical students to seek schools that offer culinary medicine education. 71,72
A foundation of personal wellness
Culinary medicine experience brings mindfulness and an emphasis on lifestyle habits vital to a medical student’s own dietary health and well-being. 49 When physicians practice healthy behaviors, they are also more likely to provide behavior change counseling for their patients. 73 Furthermore, cooking and sharing food fosters a sense of community and shared culture among students and instructors. As trainees and physicians emerge from the collective trauma of the pandemic, strategies such as culinary medicine that advance well-being can expand beyond education to include innovative patient care, community engagement, and practical wellness promotion.
Virtual adaptation
Many culinary medicine courses were modified for virtual delivery during the COVID-19 pandemic. Teaching kitchens across the country have adapted their programs to include virtual and hybrid models, 74 demonstrating scalability with fewer resources. This adaptation may offer solutions for overcoming other potential barriers to culinary medicine programs. Online delivery eliminates the need for access to a teaching kitchen. 75,76 By cooking in their home environment, participants learn techniques and recipes that fit the tools and ingredients to which they already have access. 75 Online delivery also enhances accessibility for participants with family responsibilities and commute concerns. Similarly, participants can ask questions in real time about ingredient modifications that fit their own financial and cultural needs.
Culinary medicine funding within medical education
While virtual innovation expands feasibility in resource-limited settings, advancing culinary medicine necessitates flexibility in educational approach and inclusion of virtual, hybrid, and in-person models. Sustainable funding continues to be a vital issue given the infrastructure, curricula, and personnel required for culinary medicine, and sustainability of culinary medicine programs require stable funding for instructors and teaching kitchen spaces. Medical school sourcing and allocation of funds rely upon highly variable factors, including tuition, endowments, and support from parent universities and state governments. 77 Although many culinary medicine programs lack funding data, medical education as a broader field faces similar issues, with the majority of medical education research being unfunded or insufficiently funded. 78 A Stanford study investigating the outcomes of funding medical student electives in research found that funded work motivated 75% of student researchers to pursue further research and 60% to seek full-time academic careers. 79 Similarly, medical schools could consider dedicated funding 77 for culinary medicine training and study the impact of this support on both short-term student scholarship and career choice and long-term patient outcomes.
Limitations
This review has limitations related to methodology and data interpretation. Only 1 author performed the initial screening of article titles and abstracts, introducing the possibility of error in exclusion. However, 2 authors independently reviewed all 25 full texts, and all 3 authors reviewed the 12 included papers. All data extracted for the 3 summary tables were independently reviewed by the 3 reviewers. Similarly, only 1 reviewer (J.A.) compiled the data from the Health meets Food and Teaching Kitchen Collaborative website maps, and the nature of manually searching numerous websites increases the possibility of error. The other authors reviewed the final data included from these sites.
This review has limited data interpretation due to the heterogeneous format of data collection across studies. Since several programs were in their infancy, some analyses only included qualitative interpretations of raw data as opposed to quantitative statistical tests. 13,20 This limited ability to organize data and make meaningful, thematic conclusions.
Advancing culinary medicine for medical students
This review intentionally focuses on interventions dedicated to medical student nutrition training with reported outcomes. As such, medical student–led community–based intervention programs were excluded because student education details were absent. 29,32,64 Similarly, physician-led patient intervention programs were excluded. 69,80 Other pivotal culinary medicine programs, such as the interdisciplinary conference “Healthy Kitchens, Healthy Lives” organized by Harvard’s School of Public Health and the Culinary Institute of America, 30 as well as lesser-known programs, were excluded from the review due to a different target audience and lack of curricular information. 29
Other reviews have critically appraised nutrition education strategies in medical schools 81 and gathered information about culinary medicine programs aimed at mixed audiences, 12 but no prior review, to our knowledge, has solely focused on medical student-oriented programs. The confusion and widespread nature of non-evidence-based nutrition media makes it paramount for health professionals to disperse evidence-based information. Educators must own the responsibility for equipping the next generation to deliver accurate, consistent messaging. While funding and medical school real estate continue to be significant challenges, student demand for this engaging curricular approach has rapidly grown. 71,72 We thus hope this review serves as a resource for launching or expanding medical school-based teaching kitchens. Faculty and student champions can engage leaders, making the case to join a movement that has tremendous potential to transform not only medical education and wellness but also community engagement, patient care, and population health research.
Future directions
Areas for future research include investigation of the longitudinal effects of culinary medicine on physician practice patterns, especially in comparison to traditional forms of nutrition education. To demonstrate practical and applied skill in a medical student context, assessment must go beyond student knowledge and attitudes to measure how this training may impact encounters with standardized or real patients. Educators need shared assessment tools to measure outcomes across programs.
We identified only 1 paper 21 that detailed extra-institutional medical student outcomes, based on implementation of the Health meets Food culinary medicine curricula; all other published programmatic data focused exclusively on unique, internal curricular development and results. In addition to quantifying the ideal curricular exposure dose, additional studies demonstrating consistent impact across institutions using Health meets Food and other established curricula (such as from the American College of Lifestyle Medicine) 82,83 will help determine a standard of curricular delivery. Finally, since most of the culinary medicine programs in this review were delivered in an elective format, they are skewed toward motivated, self-selecting students. Future studies of integrated courses will inform outcomes for learners that might not have elected additional nutrition training.
Conclusions
Nutrition education remains inadequate and underprioritized, failing to meet the need for health care professionals to address diet-related disease. The hands-on, interprofessional approach of culinary medicine shows unique potential through rapid spread to academic and community training programs. This review illustrates common themes in the teaching kitchen approach and calls on the culinary medicine community to define core competencies and standardize assessment strategies, empowering the impact of food as an evidence-based intervention.
Acknowledgments:
The authors wish to thank Helen Mayo, MLS, Elizabeth Barksdale, MS, and Cathy Nakashima, MLS, MBA, of the University of Texas Southwestern Health Sciences Digital Library and Learning Center for guidance regarding the scoping review process and assistance with EndNote.
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