Welcome to today's webinar. All right, so I'm Ronnie Chatterjee. I'm chair of the ADA's Nutritional Science and Metabolism Interest Group. And I am Dr. Sarah Thomas, an advisor for the Nutrition Science and Metabolism Interest Group. I'm excited to welcome our expert panel to discuss today's webinar, Culinary Medicine and New Ingredient for Diabetes Care. So here is a glance at today's agenda. I'll provide a few announcements and we'll introduce our experts in a few moments. They'll each provide short presentations followed by a Q&A session. The panel will be taking questions from the audience, so please don't wait until the end of the session to send in your questions. Instead, go ahead and type it into the Q&A box that's in your control panel below. Please be sure to use the Q&A box and not the chat function for your questions. We will be using the chat box to send you important links during this announcement segment. Then I wanted to take a moment to thank all the members of the leadership team for their work throughout the year and to provide interest groups such as this one to the interest group members. If you're not a professional member of ADA, join today. ADA professional members can join three interest groups, as well as enjoy member-exclusive webinars and webinar recordings. Additionally, recognition opportunities and volunteer leadership positions are available. Use the link in the chat to learn more about ADA membership. Another benefit of ADA membership is connecting with members of the interest group on the Diabetes Pro Member Forum, and you can see the link in the chat. Here is a preview of the upcoming live webinars hosted by the ADA. To register for upcoming webinars, please visit the link on your screen and in the chat. And then lastly, I wanted to direct you to the ADA nutritional resources for both patients and professionals. Use the link on the screen and in the chat to look around ADA's shop. All right, so finally, I'd like to introduce today's presenters. We're very excited to have, first, Dr. Katherine Rogers-McManus speak. She's a licensed registered dietitian nutritionist and assistant professor and vice chair for education in the nutrition department at Case Western Reserve University in Cleveland, Ohio. Katherine's expertise focuses on type 1 diabetes and culinary lifestyle medicine. She's completed advanced professional culinary training and has developed numerous culinary medicine research interventions, recently earning the Academy of Nutrition and Dietetics 2020 Innovative Culinary Effort Award for her most recent intervention. Dr. McManus' expertise in type 1 diabetes has afforded her the opportunity to hold numerous national leadership roles, including vice chair of the Academy of Nutrition and Dietetics Expert Panel Committee on Pediatric Type 1 Diabetes, member of the Scientific Advisory Board for the Juvenile Diabetes Research Foundation, and she's advisor of our nutrition interest group. We're very lucky to have her. She recently was a recipient of the ADA's Junior Faculty Health Disparities and Diabetes Research Grant to assess the efficacy of an innovative culinary medicine program she developed herself for underserved youth with type 1 diabetes. And then after she presents, we're lucky to have Diana Guevara, who is a community health education specialist for the Nourish Program at the Michael and Susan Dell Center for Healthy Living at the University of Texas Health Science Center at Houston, also called UT Health School of Public Health. After completing her undergraduate degree in nutrition and dietetics from the University of Texas at Austin, she continued to UT Health Houston School of Public Health to complete her master's in public health and dietetic internship. As a registered dietician, Diana started her career in corporate wellness in Lake Buena Vista, Florida. She later returned to serve the Houston community as an outpatient clinical dietitian, where she took part in the first food prescription program to be established in the state of Texas. Following her passion for helping others adopt a healthier lifestyle in an easy and delicious way, she returned to UT Health Houston, where she creates and implements culinary nutrition programming in community settings. Diana has worked extensively with adults with type 2 diabetes and has experience in individual counseling, nutrition education, cooking demonstrations and cooking classes. And additionally, Diana is bilingual in both English and Spanish. So we will start with Dr. McManus's presentation. And thank you all for being here. Thank you, Ronnie and Sarah, for the introduction. I want to apologize. My kiddos brought one of them brought a nasty virus home from daycare. So my entire family has been sick and under the weather. So I apologize for my hoarse voice. I'm just hoping I can. It will last through the end of the webinar. So today I'm going to be starting us off by providing an introduction, an overview on this growing area of culinary medicine and food is medicine. And then we're going to be diving into talking about its specific application to patients with diabetes. But before doing this, here are my disclosures. The only one that I do want to highlight is the last one shown, which is that today I'm presenting not only as a diabetes dietician and researcher, but also as a type one patient myself, as well as a type one mom. So if we take a snapshot of the nutritional health of individuals across the globe, as well as here in the US, we see that globally, one of every five deaths is attributable to suboptimal diet. And we see here in the US that suboptimal dietary intake has just contributed tremendously to the rising prevalence of chronic disease that we've seen over the past two decades. And many of our patients with a chronic disease, we place them on and strongly recommend them to follow a dietary regimen as a part of their disease management treatment plan. However, for a variety of different reasons, such as food insecurity, diet complexity, as well as innate, as well as developed food preferences, we see that less than 50 percent of our patients are actually adhering and following these dietary recommendations that their health care providers are providing them with. And we see that these dietary adherence barriers are really heightened among our underserved populations. So diabetes is one of our chronic diseases where nutrition plays such a critical role in its management. But when we look at individuals with diabetes, we see, unfortunately, that compared to their healthy counterparts, they tend to have a notably poor dietary intake as well as dietary quality, which is really concerning given that we know there is a strong association between suboptimal dietary intake and poor glycemic control, increased risk of diabetes complications and comorbidities, as well as increased health care costs. So given this, there have been many, many interventions and programs that have been developed to try to foster positive dietary behavior change, as well as improve overall health outcomes among individuals with diabetes. What we have really learned from these interventions is that knowledge and education alone is not enough to produce lasting positive behavior change. And please know that I am not minimizing education and knowledge because, of course, it is certainly important. But if we look at the example on this slide, we have our two plates. We have a plate with salad on the right and then a plate with burgers, fries and bacon on the left. The vast majority of Americans, and to be quite honest, even preschoolers at my son's daycare, would be able to tell you that the plate on the right with the salad is healthier, is the healthier option. But does that mean that all of us are going to choose the plate on the right? No, not necessarily, right? So while we do need to provide our patients with knowledge and education, we also need to try to equip them with the necessary skills, the resources, the self-efficacy or confidence, as well as social support they need that really addresses their specific and their unique barriers, needs, as well as preferences. So food is medicine is a new area of medicine that has really gained a lot of interest over the past two to three years as it focuses on this unique intersection of food and health care. And our food is medicine interventions really aim to provide healthy food resources to treat, manage and prevent specific chronic conditions in coordination with the health care sector. And although there are a lot, there's a lot of variability among our food is medicine interventions, we do see that there are two key components that are consistent across all of these interventions. The first is that all of them provide food that supports health. And second is that these interventions really serve as a nexus to our health care system. So there are really three primary types of food is medicine interventions. So we have our medically tailored meals and these are going to be fully prepared, ready to eat meals or snacks that really address a patient's medical diagnosis, their symptoms, as well as their medication side effects. Secondly, we have our medical medically tailored groceries. And these differ in that they are unprepared foods that provide either partial or near complete nutrition. And they are really integrated as part of a medical treatment plan for a patient. And then lastly, we have our produce prescriptions. So these are going to be vouchers or debit cards that provide patients with free or discounted produce that's available to them based on their specific health condition or risk. So culinary medicine is another area of the overall umbrella of food is medicine, but it is unique from our other interventions is in that it really focuses very heavily on the culinary aspect and really focuses in on food preparation and cooking. And through culinary medicine interventions, we have seen health care professionals really try to leverage cooking skills, nutrition knowledge, food education, as well as sociocultural humility in order to really empower positive behavior change among our patients to try to achieve desired health outcomes. So culinary medicine interventions have targeted very, very diverse populations. We have seen health care professionals as well as students actually seeking out culinary medicine training through continuing education, as well as supplementary coursework and degrees. We have also seen that the vast majority of our culinary medicine interventions for patients have really aimed to improve the health outcomes for a specific health condition or disease state. And these have really targeted populations across the entire lifespan, as well as patients of very, very demographic factors. And as culinary medicine has really gained popularity, we have seen that it has become integrated into numerous sectors of health care, including clinical, community, government, as well as academia. And across these sectors, culinary medicine interventions have been implemented in virtual formats, as well as in-person and hybrid formats. And when interventions have included an in-person component, they have been implemented at a variety of different sites, including teaching kitchens, community centers, as well as religious centers. And even though food is medicine and culinary medicine research is still really in its infancy, we have seen that over the past few years, both the rigor as well as the volume of this research has really taken off. We have seen studies assessing process outcomes of these interventions be able to demonstrate that these interventions are feasible, they have high fidelity, they are replicable and scalable, and then they also have very high participant retention, as well as satisfaction. We've also seen studies demonstrate that these interventions are efficacious at producing positive patient outcomes. We have seen improvements in food and nutrition outcomes, as we have seen improvements in food security, improvements in dietary intake, as well as dietary quality. We've also seen improvements in disease-specific clinical outcomes. So specific to our diabetes population, we have seen improvements in A1C, diabetes distress, as well as BMI. And then lastly, we have seen improvements as well in our healthcare outcomes, as we have seen reductions in inpatient hospital admissions and hospital lengths of stay, as well as overall healthcare costs. So now that you hopefully have a general understanding of culinary medicine and food as medicine, we're going to dive into looking at their specific application to patients with diabetes, starting off by talking about patients with type 1 diabetes. So as I'm sure many of you know, prevalence of type 1 has just been steadily rising over the past two decades. And though we have had really significant medical as well as technological advances in type 1 diabetes care, really our primary goal with type 1 remains to be disease management, as we have yet to find a cure for this really lifelong and taxing autoimmune disease. So when we look at disease management across the lifespan, unfortunately, we consistently see our poorest outcomes among our children and adolescent population. And this is despite us having endless interventions that have been specifically developed for this population, which really shows that there is significant room for improvement here. So culinary medicine interventions do show great potential to actually be able to produce and foster positive health outcomes among patients with type 1 diabetes and specifically among youth with type 1 diabetes. And the reason I say that is not only because of the critical role that food and nutrition plays in type 1 diabetes management, but also because very recent culinary medicine interventions that have targeted adults with type 2 diabetes have shown significant improvements in glycemic control, as well as other diabetes management behaviors. We've also seen culinary medicine interventions targeting healthy youth actually have significant improvements in not only dietary intake, but several other behavioral and psychosocial outcomes. So given all of this, though, what's really interesting is that there really has been almost a complete absence of culinary medicine interventions for youth with type 1 diabetes. So this led to the development of DICE, or Diabetes-Inspired Culinary Education, which is a culinary medicine intervention that aims to improve glycemic control among youth with type 1 diabetes. So DICE is a family and community-based culinary medicine intervention that includes 10 90-minute in-person lessons, and these lessons are delivered weekly over the dinner hour. Each of these lessons focuses in on a specific food and nutrition or type 1 diabetes topic that has been identified in the literature as being a really challenging area for diabetes management for youth with type 1 and or for their families. So each of these lessons includes hands-on culinary education, they include interactive tailored diabetes education, a group family meal that is actually prepared by our participating families, as well as behavioral goal setting and family meal planning. So the DICE intervention was piloted back in fall of 2019, and the pilot study demonstrated that this intervention had high program feasibility, acceptability, as well as participant retention. We also saw potential efficacy for the intervention as we saw significant improvements in a variety of our participant outcomes. But what was really most interesting and insightful to us from this pilot study was that both our quantitative as well as our qualitative data demonstrated that the DICE intervention had the greatest impact, and it was needed the most by number one, our underserved families, and number two, by our youth who had the poorest glycemic control. So this really caused us to take a step back and actually modify and really redesign the original DICE intervention so that it specifically addresses the racial, ethnic, as well as the socioeconomic disparities that exist in the treatment and health outcomes of at-risk youth with type 1 diabetes. And we really do this by addressing the unique and those specific barriers and preferences that these families do have. So we hypothesize that this modified DICE intervention will improve vital child health outcomes, our primary outcomes being child A1c, as well as quality of life, both directly as well as mediated through our intervention targets. So this is an outline of our 10 Dice lessons. You can see for our in-person lessons, you can see the lesson topics for each of these lessons. And again, as I mentioned previously, these lesson topics were drawn from the literature because they have been shown to be really challenging areas for youth with type 1 diabetes, as well as their families for really being able to manage that child's type 1 diabetes well. You can also see the family meal that is prepared by our participating families and eaten by our families during each of these lessons. In addition, we have a psychosocial educational component that is led by our team psychologists. And this psychosocial component is delivered completely virtually through a private login for our participants on our Dice website. So each of our in-person lessons follows a consistent format and structure. Each lesson, we start off the lesson by having a separate but simultaneous caregiver and child education. So for our child education, we break up our youth into two separate age groups. And during the child education, each of these age groups learns a new age-appropriate cooking skill each lesson through hands-on cooking and hands-on food preparation. At the same time, the caregivers are in their caregiver education, which is a very, very interactive and discussion and problem-solving based education that really focuses in on type 1 diabetes management, nutrition, as well as culinary topics that these families have reported to be very, very challenging and problematic areas for their child's type 1 diabetes management. We then bring our families together for a family education where we engage the entire family in an interactive educational game or activity that really focuses specifically on the topic of that lesson. During the family education, we also have families plan at least two family meals for the upcoming week. And the reason we do this is that the literature has shown that when children are actually involved in food preparation, as well as food and meal planning, it is much more likely that they are going to actually eat those meals that are served during mealtime. Another reason that we do this family meal planning together as a family during programming is it does build a form of accountability for those caregivers to actually prepare and serve these home cooked meals at home during the upcoming week. And then lastly, we conclude each program by having a group family meal where the recipes and the foods that we served are those that were prepared by the children during the childhood education. The purpose of having this group family meal is to really model positive family mealtime environments to these families because the literature consistently shows that family mealtime is a very, very stressful period of time for families with a child with type one diabetes. And then lastly, at the very end of each lesson, we provide every single family with a take home kitchen equipment. And the reason we do this is we don't want the lack of kitchen equipment at home to be a barrier for these families to be cooking and eating family meals at home together. So the efficacy of our modified DICE intervention will be assessed in an upcoming two group weightless randomized control trial that will be launched in February of 2024. Our participants are 18 to 14 year old youth who are diagnosed with type one for at least a year and they are currently demonstrating poor glycemic control. And we're really prioritizing our underserved youth for our recruitment efforts. We also enroll and collect data on that child's primary caregiver because we know that the caregiver plays a really instrumental role in their child's type one diabetes management. In addition, we invite families to bring up to three additional family members to programming. And the reason we do this is because type one diabetes to be truthful with you, it's really a family affair. So we want that child's entire support system to be present during the programming. So although our primary outcomes are child A1C and quality of life, we will be assessing a variety of other social and behavioral as well as anthropometric outcomes at various levels of assessment, including the child, the caregiver, as well as the family level. And all of these outcomes will be assessed at three time points across the study. So next steps for the DICE intervention is that, as I mentioned, we'll be assessing the efficacy of this modified culturally sensitive DICE intervention in our upcoming waitlist randomized control trial. And we are really hoping to contribute to this growing body of literature on culinary medicine and food as medicine through this intervention. And then really our ultimate goal and hope is to disseminate this DICE packaged curriculum across diverse sites, settings, and populations to really help our type one youth community as well as their families. So I would like to thank you for your time. And now I will turn it over to Diana who will present on culinary medicine and food as medicine among patients with type two diabetes. Thank you so much, Katie. That was really wonderful. It's such important work. So like Katie mentioned, we'll be switching gears and talking about culinary medicine interventions in type two diabetes. So my disclosures are very easy. I really have none other than my position at UT Health Houston. And today I'll be describing some of the work being done in this space by my institution, how we're implementing it in partnership with the local healthcare system, and then just touching on other work to look out for and maybe get inspired by. So nourishing the communities through culinary medicine was our pilot study to test a five session culturally adapted virtual culinary medicine program to improve healthy eating and cooking skills among patients living with type two diabetes. We partnered with Sanitas Medical Center, which has clinics all over the Houston and Dallas area. Most of our participants were referred by their physicians and the clinic also sent out text messages and we had flyers and little slides on the TV monitors. And our criteria was pretty wide, including adults with diagnosis of type two diabetes, ages 18 to 70, A1C over seven, and then insured by Blue Cross Blue Shield, which was our funder for this program. We completed three cohorts in English and three in Spanish of five 90 minute sessions. So the classes were taught virtually, but live. So participants, you can see on the little picture, they logged on in the evening and cooked along with me via Webex. So we wanted to teach those lifelong skills in these classes. So we emphasized the cooking techniques we were using instead of just that one recipe and made sure to create a really safe space for people to share what they liked, but more importantly, what they didn't like to fit their foods and cultural preferences. So on top of just cooking, we also created a virtual culinary medicine toolkit, which I'll dive into now. So our toolkit was created to extend the learning beyond just those five sessions. It included information in the form of handouts and videos to appeal to different learning preferences. We provided printed booklets to make it cooking a little bit easier so they could have their actual printed booklet there. They had the recipes, the shopping lists, and then nutrition handouts that they could actually fill in with their specific goals or blood sugar monitoring. And then handouts on cooking techniques that explain the technique, have little helpful tips. And then they have little QR codes that lead to our cooking technique videos for them to watch on their own time if they wanted to recap or kind of look ahead on what we'll be doing during class. And these were also, everything was in English and Spanish available for both. So in each session, I like to promote a really interactive environment in my classes. I've learned that's the best way to go in a virtual environment. So we start with a welcome and a check-in on how everyone's previous week had gone, if anyone wanted to share a win or something new they tried. They really were able to build community at this point and kind of discuss wins and challenges from the previous week. Typically participants were eating the meal that they cooked with their families after they logged off of the Webex. So they would share how their families liked the meals, which was really fun to hear. We encourage our participants to have their ingredients kind of measured out and ready to go, but we would actually go over knife skills together each time just to really solidify those safe cooking skills. We prepped our vegetables together and then we would go into the cooking process. And during that downtime is when we would watch our animated videos, which you can see a little screen grab there. We had different themes for each class. So some topics included eating with kids, picky eaters, grocery shopping, and high and low blood sugar and diabetes management. In terms of measurements, we had a pre and post surveys asking about fruit and vegetable intake, diabetes self-management, cooking self-efficacy. And we also conducted qualitative analysis. So we held some semi-structured interviews where participants could share their thoughts on the classes, what worked, what didn't. And through our partnership with Sanitas, we were able to pull EMR data on their A1c, BMI, and blood pressure. Our participants that we have both pre and post surveys for were average age 52, plus or minus nine years, mostly female, almost 80%. About half of our participants were Hispanic Latino, which makes sense. Half of our classes were in Spanish. 24% were black. About 50% bilingual and pretty even spread between college graduates, some college, and then a slightly higher amount of high school education or less. We found statistically significant improvements in servings of fruits and vegetables, frequency of healthy food consumption, shopping, cooking, and eating behaviors, diabetes self-management, and cooking self-efficacy. And then we found a decrease in barriers to healthy eating, which is what we would have liked to see. So that was exciting. And then for labs, we saw a decrease in A1c from a mean of almost nine, so 8.94, down to 8.39 after the intervention. And then an even bigger decrease at the six-month mark with a mean A1c now down to 7.85. So we saw some lasting results, which is really exciting. What's also promising is the spread of the standard deviations is also decreasing. So they're getting better as time goes on. To decrease patient burden, we did pull this data from their medical records as part of their routine follow-up care versus drawing labs specifically for this study, which is why we don't have data for everyone. So this is definitely a limitation. During our qualitative interviews, this is kind of my favorite data. We got some really positive and powerful feedback. So I won't read all of the quotes, but I'll highlight some of my favorites. One participant shared, keep the classes coming. It's something that even if some doctor tells us to eat healthy, we have no idea. If you give us these classes, for us, it is everything. So how many of us have told our patients, just follow my plate, eat more vegetables, balance your carbs? Like Katie mentioned, we give out all this knowledge, but knowledge does not equal behavior change. It's not that they don't want to make that change. It's that they don't have the practical skills to actually do it. It's that inability to kind of start cooking at home and really getting it to taste good. So we see that with hands-on cooking, there's an increased self-efficacy for that. Again, something I noticed in my community, my group classes for diabetes just throughout my career is that sense of community that's built. We know that with type two diabetes, it can be really, or type one as well, it can be really isolating for our patients. They feel like they need to eat differently than their families. And that social support is such a huge component of behavior change. So one participant shared, I think it's kind of fun because you get to meet other people. We're talking about the struggles we've had along the way, and that's good. Someone else said, through the program, I get to see other people that are trying to better themselves also. That's encouraging to me, seeing others do it and being part of a group. I don't know, but that's something, something like that makes you want to do it more. So this can be really, really impactful for our patients, especially as we saw through the pandemic that a lot of people lost a lot of social support and this virtual iteration still fostered that community. Some quotes on outcomes. So one participant shared, my A1C at one time was 11. I believe now I'm down to 8.2. Someone else said, now I've noticed that I'll go buy fresh beets, fresh carrots, even asparagus to try to cook them and go out of my comfort zone. And someone simply said, I noticed that I'm not as sickly. I'm feeling more healthy. And one piece of feedback that I actually received in class, it wasn't part of the interviews, but I love to think about it. One of our participants shared that her children had actually begun asking for her to cook instead of asking for takeout or fast food. And so to me, this is huge because not only are we improving the lives and the health of our patients, our participants, but we're also affecting that whole family unit. So they cooked in their own homes. They used their own kitchens. They shared those meals with their families afterwards. And so we're indirectly impacting the long-term health of everyone in that household. The spouses got to eat the food and they ate it and enjoyed it. The children ate it and were asking for more. So this was really special to hear. So limitations, it was an uncontrolled pilot study, very small, simple size. And of course we were able to recruit people who have the technology to join a virtual class. They had wifi at home that's stable. They were able to shop for themselves. So we sent them gift cards to get the ingredients. So there wasn't a cost associated, but they did have to go to the grocery store and shop for themselves, which can be a barrier to some people. Our participants were referred by the clinics. So we had that physician buy-in, which is really, really, really huge. And they contacted us via either website or phone calls. So they were already receiving routine care by their PCP and they were motivated enough to change, to reach out to us. So this might not be representative of all patients as we might know. By considering the limitations, what we can take away is that a brief five session culinary medicine and direction significantly improved healthy eating, cooking behaviors, diabetes self-management and cooking self-efficacy and reduced barriers to healthy eating and A1C levels and continue to improve A1C levels six months post. So they took away these lifelong culinary skills that hopefully they're still using to this day. Our toolkit was able to boost education beyond just those five sessions. So it doesn't have to be a super long intervention. It decreases the burden of having participants commit to those really long interventions. And it being online and delivered virtually can decrease barriers like transportation and childcare, as well as staff burden compared to putting on a full in-person cooking class. It can be really, really staff heavy. So this virtual adaptation is, I think, works really well. So what's next for us? We actually just got funded to run a second round of this with patients from another local clinic. Again, we'll run six cohorts, some in English, some in Spanish. And this time around, we'll be including a control group from a nearby clinic. So this will hopefully contribute to a little bit more robust evidence. Switching gears a little bit. So these are some papers published with our work with a local health system. So Harris Health System is the safety net health system here in Houston. And in an effort to help their under-resourced patients, they have co-located food pharmacies in partnership with the local food bank. So patients who screened positive for food insecurity and have an A1C over seven can be referred to the food pharmacy. They, at this specific program, they received 30 pounds of produce plus other healthy food items like lean proteins or beans or rice, et cetera. Their program includes nutrition education, but they partnered with us to incorporate that culinary component because they knew that it was important. So we trained their dieticians and community health workers to implement an iteration of our program at their food pharmacies. They call it Our Kitchen or Nuestra Cocina. And patients can be referred by pretty much anyone in the healthcare team. And they're enrolled in this five-session program. So typically they're recruiting patients who are already receiving the food pharmacy program. And this is just an additional assistance. These are implemented in person and they aim to align them with the days they're already coming in to reduce their food prescriptions. So it's a little bit less of a burden. Again, transportation here in Texas is a huge burden for our under-resourced populations. It's currently being implemented at four of their clinics and they don't have data to share yet, but definitely look out for that soon. And then going forward, these are programs that I do not have any affiliation with. There's just some great work being done in this space. So one of them is Dining with Diabetes. They're being implemented by several extension programs throughout the country. It consists of four two-hour classes discussing self-care, healthful food choices, physical activity, food samples, and cooking demonstrations. So it's not a full-on hands-on cooking, but they are incorporating culinary demonstrations in their classes. There was a 2018 study out of Penn State with a large sample of 1,783 people, and they saw a decrease in A1C in about 49.7% of their participants. So about half of them improved their A1C. And these were people with diabetes, pre-diabetes, and no diagnosis of diabetes, and it was all self-reported. So we could use more robust evidence there, but they did see an increase in days per week exercising 20 minutes or more, and eating a variety of fruits and vegetables. And then they saw an increase in improved confidence in managing their diabetes. So that looks promising. Fresh Start is a program out of rural North Carolina. So they're also working with adults living with diabetes or pre-diabetes. Their program includes health coaching group classes and produce boxes. They actually had a pilot program that started with just culinary demonstration. They conducted interviews to garner feedback, kind of like Katie did with her program, and they realized their participants shared they wanted more culinary content and more hands-on stuff. So each class now includes hands-on cooking on three different ways to prepare non-starchy vegetables. They saw an improvement in food literacy, fruit and vegetable consumption, and a decrease in mean A1C of 0.79, which was statistically significant for their cohort. It was a very small cohort, but still gaining a little bit more of that research. And then Cooking Matters, just in itself, has been around for many years providing nutrition and culinary resources, but researchers out of Ohio State University decided to combine Cooking Matters curriculum with a DSMES curriculum to create a Cooking Matters for Diabetes. They recruited adults living with type 1 or type 2 diabetes with A1C over 7, and they found improvements in dietary behaviors, physical activity, health-related quality of life, and food care. They did not see statistically significant improvements in A1C, but it was a very small sample. But the cool thing about this program is that they did combine it with the DSMES, so they're able to bill for one hour of that time. A lot of times the pushback on culinary medicine is, well, who's going to pay for it? So we are finding some ways to kind of bill for it, which is exciting. And that's what the Community Teaching Kitchen out of Providence-Milwaukee Hospital in Portland, Oregon, is doing. They're incorporating some of their culinary medicine work into existing DSMES programs, and they're getting reimbursed for that portion. The DOM Center, or the Diabetes Awareness and Wellness Network, was created by the Houston Health Department here in Houston, and they offer free resources to members. So it's typically patients coming out of a nearby hospital who are found to have high A1C. So they offer these four cooking classes on the right, which I thought was really cool. They have a Taste of African Heritage that is put on by Old Ways, Cooking for Health Living, Cooking Demonstrations just in general, and then a Garden and Nutrition Series. So I haven't seen any data from them, but it is encouraging to know that these programs exist. And then just some items on the horizon to look out for. This paper was just published in September of this year on the redesign of recruitment strategies for a virtual culinary medicine intervention. So I'd be looking out for the outcomes of this study fairly soon. It's going to be a randomized controlled trial at a UT Southwestern testing the efficacy of virtual culinary medicine program for adults with type 2 diabetes compared to standard clinic-based MNT. So this will be a really robust study if we can get the data out soon. And then lastly, Cook to Diabetes is an effort funded by the European Union to co-create a culinary nutrition education program for people with diabetes. So they plan to develop, validate, and show proof of concept for a training program, and then create an e-learning platform. So this looks like a really great project coming out of Europe. And that is all I have for you. I kind of ran by that very quickly, but thank you so much for your time, and we can move on to questions. Thank you to both of our speakers today. With our remaining time, I will ask questions from the Q&A box. Please remember to use the Q&A box and not the chat function to ask your questions. So it looks like we've already had a few questions come in. I'll start with the first one. It looks like this is geared towards both Diana and Catherine. The question says, I would love to know if there have been any cost-effective studies related to food is medicine interventions. I don't mind taking that. So that is a really great question because that's often a concern because there is an investment for food, there's an investment for the cooking equipment that is required to implement these studies. Recently, several cost-effectiveness studies have been done, and they have shown that despite these interventions having a relatively higher cost associated with them, that they are quite cost-effective. And I really think that drives on the point that Diana and I have both shared, and that these are really doing a great job at producing positive health outcomes and positive behavior change in our patients to the extent that they are really offsetting the costs that are associated with their implementation. So a great question. And thankfully, like I said, more and more studies have come out recently to show that these are, it is a cost-effective intervention methodology. All right. The next question, I think this is geared towards you, Catherine. What kind of equipment do you provide? I think that's related to your cooking equipment. Yeah, that's a really great question. So we actually did formative research where we went in and interviewed, we went into the homes of our target audience, our target population, to really see what did they have at home, what did they need. And we actually found that a very high percentage of our patients actually did not have a home and a high percentage of our families were using their stove, not at all for cooking. It was never used for cooking, but it was their heat source. So we found that so many of these households did not have even basic cooking equipment, baking sheets, measuring cups, measuring spoons. So we would provide these basic kitchen equipment that these families needed. And then we would also provide some more advanced pieces as well. To help them build their kitchen at home. So we would provide meat thermometers. We provide veggie spiralizers as well. And the way that we distribute the take-home kitchen equipment is we align the kitchen equipment that we're providing with our recipes so that the families are getting a kitchen equipment that actually helps them make the recipe that we serve that day. Wonderful. Okay. And this question came in during Diana's presentation. So I think this is for her. How long did it take you to develop this curriculum and materials? Amazing work. Great question. I was not here when they developed it. It's been a long time coming. So our work with Harris Health actually started when I was a student. So it's been several iterations of this program. It was previously called a Prescription for Healthy Living. We did cooking classes. We refined it a little bit. COVID hit. We made it virtual. We brought it back to in-person. We made it virtual again. So it's been several, at least five years in the making. But for this specific, all the content and whatnot, I would say probably maybe two years. We had a lot of dietetic interns who are wonderful. So we have a lot of help as well. Okay. And then this next question I think is also for you. Do you have any preliminary data for long-term monitoring of cooking behaviors and or clinical outcomes? So we have the six-month post data. I think that's the longest that we've done on our end. And let me see if I can pull that back up. Oh, that was follow-up. No, we don't. We just have the A1C at six months. So we didn't do another round of surveys, but that is a great idea. Okay. Wonderful. And the next question. Thank you, Katie and Diana for intriguing information and great talk. I have a question related to meal plan for type 1 and type 2 diabetes individuals. Considering the variability and gut microbiome between individuals, do individuals with type 1 or type 2 respond to the same in terms of postpartum glucose levels for the same type of food? So I think, do they respond the same for the same type of food in terms of blood glucose levels? If they respond differently, is there any strategy to tailor the personalized meal plans for the type 1, type 2 individual? And how will it affect the family? So a lot of questions in there. So feel free to ask me if you need me to repeat. Do either of you want to tackle that? Diana, do you want to go ahead? I see you starting. So the thing with type 2 is we don't have to, I personally don't get as specific and nitty gritty. Everyone has different food preferences. And really the idea of culinary medicine is to bring the joy of food back into people's lives, especially when we're talking about health care. A lot of times patients hear, don't eat this, don't eat carbs, don't do this, don't do that. So our job, or what I see as my job, is really healing that relationship with food again and really saying, what are your favorite foods and how can we make it work? So it really is that patient-centered and patient-led experience of try it out, see how your blood sugar looks, and then if we need to make adjustments, we will. So it's really working with the patient. It's not giving them a meal plan, unfortunately. Yeah, I completely agree with what Diana is saying. And we see in type 1 specifically, so many challenges with disordered eating and eating disorder rates prevalence being very, very high. Because if you think about it, it is not normal for an 8-year-old child to have to count out how many goldfish crackers they're eating, right? But that's the way they're taught. And that's really the approach we take from a dietitian, nutrition standpoint, is they have to literally micromanage and micro-count out every single piece of carbohydrate that they're putting in their mouth. So as a result of that, a lot of times, just like Diana said, really unhealthy relationships with food develop among this patient population. So culinary medicine is trying to really improve these relationships more from a holistic standpoint, rather than really getting into the weeds on specifics and that personalization piece. I also want to mention, though, too, in that we often see that parents see, and honestly, adults too, often see family meals as something they need to check off their to-do list. But we're trying to reframe that thinking and saying, don't check off that to-do list and then go spend time with your family. Then go play a game. Use that family mealtime as quality family time. So involve your kids from start to finish in every step of the family mealtime process, from planning all the way through cleanup. And then we also teach, at least in our program, during mealtime. You can play games during mealtime. There's mealtime-appropriate games. So really trying to teach the entire family how to use that family meal as a family bonding time. And again, trying to instill this positive relationship with food and family mealtimes. So I hope we answered that question correctly, based on what you were looking for. All right. Thanks for that. The next question, I think, would be for both of you. Are there any grants available to get something like this started? I'm a chiropractor professional chef. And I tried to get something like this going this past summer, but couldn't get funding. So that's a really good question. So actually, the NIH, National Institutes of Health, is putting out this huge push towards food as medicine. But you have to have preliminary data. You have to have pilot study data to even typically be able to apply for these grants. So where do you start is a really good question. So there are a lot of nonprofit organizations that are very supportive of food as medicine and culinary medicine. of food as medicine and culinary medicine interventions that provide funding for not just faculty or researchers at universities, but a lot of individuals who are just doing these efforts out in the community. So I would say really tap into your local groups, your organizations. Truthfully, go to your grocery store, because a lot of them have been very supportive. If they can't provide you with a lump sum of money. I know for our pilot study, they were really great in providing us discounted groceries, providing discounted gift cards so that we could use those to encourage our participants to come to programming. So my recommendation is really be creative in how you can obtain funding and support for doing studies kind of at that at that foundational level. Diana, I don't know if you want to tap on a tag on anything else. Yeah, so the good thing is food as medicine, culinary medicine right now is really, really hot. It's a very interesting topic to a lot of people. So people are getting more interested, like you said, local, local groups. Also, you can consider the I lost the word like insurance companies. So our study was funded by Blue Cross. If you show them our patients who go through this five session program will cost you less. That's very enticing to them. So so finding those those preliminary studies that we've talked about that are seeing that cost benefit analysis that can be really helpful in kind of nudging whoever you need to nudge. Excellent. OK, there's sorry. So I'm going to add on to that and like try to leave my researcher hat aside, but I have to put it back on really quickly. Even if you're doing a small study like collect data, even if it's just asking participants at the end of the study, like, what did you like? What didn't you like? Things like that is what can then help you get more funding. And it can really help to demonstrate that your program was effective, hopefully effective. And if maybe it wasn't effective or it wasn't well received, it helps you learn how can I change my program to improve those outcomes or to be better while received? So we often think of data collection as to be very intense and very, very, very involved in a lot of statistics. But you can just even do really basic data collection that can be really, really informative. Yeah, and I would say also just tacking on to that, consider your local academic institutions, consider a partnership with them. We have the ability to assess the program, manage the data, do all of the things that maybe the health care institution isn't doing. We can do that part. And people are always looking for grants and for projects and publications. So definitely consider if you have a local university or medical school or program, definitely consider that. OK, and then another question, and I'm not sure if either of you answered this or not to tell me if you did, but for programs not covered under insurance, how were products funded? I don't know if part of your research projects, if there were programs not funded under insurance. I'm not sure if I'm articulating the question correctly, but. That's a good question. That's a good question. So for my pilot study that I did for the DICE intervention, we were funded actually not through insurance and we were funded through our local diabetes association. It was called the Greater Cleveland Association, the Greater Diabetes Association of Cleveland. So we got funding through them, but it wasn't it was not a lot of money, to be quite honest. So that's where we try to be very resourceful in what we did. So we went to our local grocery stores and they were very kind in providing discounted food. We actually used a teaching kitchen that was located in a local grocery store and they waived the fees. They waived the costs. We worked with our public transportation system and they provided discounted bus passes for our families because it was a very community based intervention that was targeting underserved populations. So a lot of times, like I said, you have to be really resourceful and creative and pull from different sources. But if you have a kind of a proposal in place, there are a lot of organizations and a lot of companies that tend to be very supportive of these types of studies, because especially if you can justify them by explaining how so many of these studies have shown very, very significant improvements in patient outcomes. And I would say just we've seen a lot of the work that there is that greater impact in the under-resourced populations. And then there are a lot of institutions that are really wanting to pour into the community. So if you work with under-resourced populations and you want to do work in there, that's how you can get those institutions like we have MD Anderson and Methodist. They both have community grants that we've worked under as well. So health care institutions that want to pour into their community, that can also be a great way to look into it. OK, great. This concludes our webinar. We're out of time, but I'd like to thank Catherine and Diana for their insightful presentations and all the great discussions. So thanks for joining today and enjoy the rest of your day.

culinary medicine

diabetes care

food

cooking techniques

health outcomes

DICE intervention

type 1 diabetes

nutrition

A1C levels