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• Published: 26 June 2020

Cooking skills related to potential benefits for dietary behaviors and weight status among older Japanese men and women: a cross-sectional study from the JAGES

• Yukako Tani   ORCID: orcid.org/0000-0001-5533-2844 1 ,
• Takeo Fujiwara 1 &
• Katsunori Kondo 2 , 3  

International Journal of Behavioral Nutrition and Physical Activity volume  17 , Article number:  82 ( 2020 ) Cite this article

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Poor cooking skills have been linked to unhealthy diets. However, limited research has examined associations of cooking skills with older adults’ health outcomes. We examined whether cooking skills were associated with dietary behaviors and body weight among older people in Japan.

We used cross-sectional data from the 2016 Japan Gerontological Evaluation Study, a self-report, population-based questionnaire study of men ( n  = 9143) and women ( n  = 10,595) aged ≥65 years. The cooking skills scale, which comprises seven items with good reliability, was modified for use in Japan. We calculated adjusted relative risk ratios of unhealthy dietary behaviors (low frequency of home cooking, vegetable/fruit intake; high frequency of eating outside the home) using logistic or Poisson regression, and relative risk ratios of obesity and underweight using multinomial logistic regression.

Women had higher levels of cooking skills, compared with men. Women with a moderate to low level of cooking skills were 3.35 (95% confidence interval [CI]: 2.87–3.92) times more likely to have a lower frequency of home cooking and 1.61 (95% CI: 1.36–1.91) times more likely to have a lower frequency of vegetable/fruit intake, compared with women with a high level of cooking skills. Men with a low level of cooking skills were 2.56 (95% CI: 2.36–2.77) times more likely to have a lower frequency of home cooking and 1.43 (95% CI: 1.06–1.92) times more likely to be underweight, compared with men with a high level of cooking skills. Among men in charge of meals, those with a low level of cooking skills were 7.85 (95% CI: 6.04–10.21) times more likely to have a lower frequency of home cooking, 2.28 (95% CI: 1.36–3.82) times more likely to have a higher frequency of eating outside the home, and 2.79 (95% CI: 1.45–5.36) times more likely to be underweight, compared with men with a high level of cooking skills. Cooking skills were unassociated with obesity.

Conclusions

A low level of cooking skills was associated with unhealthy dietary behaviors and underweight, especially among men in charge of meals. Research on improving cooking skills among older adults is needed.

There are increasing calls to return to home cooking to prevent poor diets and chronic diet-related diseases [ 1 ]. A systematic review has reported the dietary benefits of eating home-cooked meals, including greater consumption of fruits and vegetables, enhanced nutrient intake, and higher diet quality [ 2 ]. A recent cross-sectional study showed that eating home-cooked dinners was associated with greater dietary guideline compliance, without significantly increasing food expenditures [ 3 ]. Although studies related to the effects of home cooking on health outcomes are limited, a recent large population-based study in the United Kingdom showed that more frequent consumption of home-cooked meals was associated with a greater likelihood of having normal weight and body fat status [ 4 ]. Furthermore, a cohort study targeting older people in Taiwan demonstrated that older adults who cooked more than five times per week had approximately 40% lower risk of death, compared with those who did not cook [ 5 ]. The study also showed a dose–response relationship, meaning that the risk of death decreased as the frequency of home cooking increased. Despite the benefits of home cooking, the consumption of home-cooked meals has declined and the consumption of out-of-home foods, such as fast food and convenience food, has increased in recent decades in developed countries [ 6 , 7 ].

Cooking skills are one important modifiable factor that can encourage people to cook [ 2 ]. In addition to increasing the frequency of home cooking, strengthening people’s cooking skills can improve their diet quality. For example, cross-sectional studies have shown an association between high levels of cooking skills and lower consumption of ready meals, convenience food, and ultra-processed food among adults [ 8 , 9 , 10 ]. Intervention studies have also shown improving cooking skills to increase cooking confidence and consumption of vegetables and fruits [ 11 , 12 ]. Most existing studies have focused on dietary benefits among adults, and limited work has examined the associations between cooking skills and health outcomes among older adults.

Population aging is increasing dramatically, and the percentage of the world’s population aged over 60 years is projected to nearly double from 12% in 2015 to 22% in 2050 [ 13 ]. Overall, older adults do not meet the recommendations for a healthy diet [ 14 ]. Physiological, social, economic, and psychological factors affect older people’s food choices. Physiological factors, such as age-related decline in taste and smell, can lead to decreased appetite and poor dietary habits [ 15 ]. Social factors, including lower social engagement and living alone, are also associated with poor diet quality [ 15 , 16 ]. Economic factors such as low income and retirement can negate older people’s ability to meet their nutritional needs [ 17 , 18 ]. Finally, psychological factors including wellbeing and depression are also associated with eating behaviors [ 16 ]. However, although cooking skills are a fundamental factor in preparing meals, the effects of cooking skills on dietary behaviors do not seem to have been evaluated among older adults. A systematic review demonstrated associations between culinary interventions and improved dietary factors, including attitudes, self-efficacy, and healthy dietary intake among adults [ 19 ]. Focusing on cooking skills as a modifiable factor among older adults is an innovative approach.

The rationales described above indicate that having sufficient cooking skills may be important for healthy aging. More older adults live alone, compared with other age groups: In 43 developing countries, only 1.6% of people were found to live alone overall, compared with 8.8% of older adults [ 20 ]. In Japan, most older people live alone or with their spouses [ 21 ]. Thus, older adults are faced with the task of preparing own meals. Because of changes in living arrangements or spouses becoming unable to cook, the person responsible for cooking at home may change in older age. For example, a widowed man may be in charge of cooking for the first time. Because it is mainly women who are in charge of preparing meals, men have been found to be less confident in their cooking and to have lower levels of cooking skills [ 9 , 22 ]. Therefore, men, especially widowed men or men whose spouses are unable to cook, may be at risk of diet-related problems because of their poor cooking skills. To our knowledge, no study has examined the associations between cooking skills and health outcomes among older people who are in charge of meals.

One reason for the limited evidence relating to cooking skills may be the difficulty of assessing cooking skills. Cooking skills have been defined as a set of mechanical or physical skills used in meal preparation, such as chopping, mixing, and heating basic ingredients, as well as conceptual skills related to understanding how food will react when cooked [ 23 ]. In addition to the various aspects of cooking skills, the cooking skills required vary depending on culture: For example, cooking methods (e.g., grilling, steaming, stewing, and stir-frying) differ by culture. Several methods have been used to measure cooking skills, but there are few validated and reliable measures of cooking skills [ 23 ]. Hartmann et al. conducted a test-retest analysis and designed a reliable cooking skills scale comprising seven items related to the ability to prepare different foods that is applicable to most European cultures [ 9 ]. Because this scale rates the ability to prepare general food groups (e.g., bread), it is more versatile than scales that rate the ability to prepare specific meals (e.g., spaghetti Bolognese). Therefore, for the present study, we modified this scale for application in a Japanese population. The first aim of our study was to assess the reliability of this scale in a large-scale Japanese population-based study. The second aim was to examine the associations of cooking skills with the frequency of home cooking, the frequency of eating outside the home, the frequency of vegetable/fruit consumption, and body weight status.

Study design and participants

The Japan Gerontological Evaluation Study (JAGES), a large nation-wide research project on aging, was established in 2010 to evaluate the social determinants of healthy aging among older people in Japan [ 24 , 25 ]. We used data from the 2016 JAGES, which covered 39 municipalities across Japan and was administered to community-dwelling older adults who were physically and cognitively independent (i.e., without functional disabilities, defined as not being certified as eligible to receive long-term public care insurance system services [ 26 ]). From October 2016 to January 2017, self-report questionnaires were mailed to 279,661 older adults aged ≥65 years. The survey was conducted using random sampling in 22 large municipalities and was administered to all eligible residents in 17 small municipalities. A total of 196,438 participants returned the questionnaire (response rate: 70.2%). In some municipalities, recipients receiving long-term public care insurance benefits were included in the survey by request of the local government, so the target sample was 180,021 older adults, after excluding those who received these benefits. One-eighth of the sample ( N  = 22,219) were randomly selected to receive a survey module on cooking skills. The present analysis was carried out using data for 19,738 participants (9143 men and 10,595 women), after the following exclusions: participants with missing information on gender ( N  = 2); participants who did not complete the questions related to height and weight ( N  = 660) or dietary behaviors (frequency of home cooking, eating outside the home, and vegetable/fruit intake) ( N  = 1475); participants with missing data on the cooking skills scale ( N  = 145); and participants who were included in this study accidentally who reported limitations in activities of daily living ( N  = 199) to ensure that the sample was actually physically and cognitively independent. Limitations in activities of daily living were assessed with the Independence in Activities of Daily Living index [ 27 ] using the following questionnaire item: “Do you need any nursing care or assistance from someone in your daily life?” We excluded participants who answered “I need and receive nursing care or assistance.” Participants were informed that participation in the study was voluntary and that completing and returning the questionnaire indicated their consent to participate in the study. The JAGES protocol was approved by the Ethics Committee in Research of Human Subjects at the National Center for Geriatrics and Gerontology (No. 992) and Chiba University Faculty of Medicine (No. 2493).

Body weight status and dietary behaviors

Participants reported their height in centimeters and weight in kilograms. Body mass index (BMI) was calculated as weight divided by the square of height (kg/m 2 ). We defined underweight as having a BMI < 18.5 kg/m 2 and obesity as having a BMI ≥ 27.5 kg/m 2 , following the suggested cutoff points for Asians [ 28 ]. The evaluated dietary behaviors were the frequency of home cooking, eating outside the home, and vegetable/fruit intake. The frequency of home cooking was assessed using the question “How often do you cook by yourself? Do not include ready-to-eat food” (responses: more than five times a week , three to five times a week , one to two times a week , less than once a week , and never ). Respondents who cooked less than two times a week were categorized as having a low cooking frequency for women because more than three times a week has been shown to predict survival among older women [ 5 ]. For men, respondents who never cooked were categorized as having a low cooking frequency because more than half of the men indicated that they never cooked (Table  1 ). The frequency of eating outside the home was assessed using the question “How often do you eat outside the home?” The responses for this item were the same as those for the frequency of home cooking. Respondents who ate outside the home more than three times a week were categorized as having a high frequency of eating outside the home because eating outside the home more than three times a week has been shown to be related to higher BMI and lower serum concentrations of nutrients [ 29 ]. The frequency of vegetable and fruit intake was assessed using the question “How often did you eat vegetables and fruits over the past month?” (responses: not at all , less than once a week , once a week , two to three times a week , four to six times a week , once a day , and at least twice a day ) [ 30 , 31 ]. Respondents who ate vegetables and fruits less than once a day were categorized as having a low frequency of vegetable and fruit intake. This cutoff point was defined by prevalence to be under 25% of subjects included (Table 1 ) because being in the lowest quartile for vegetable and fruit intake has been shown to be associated with poor health outcomes [ 32 , 33 , 34 ].

Cooking skills

As mentioned above, based on the cooking skills scale for European cultural regions [ 9 ], we adapted Hartmann’s a cooking skills scale for use in Japanese populations. In Japan, a typical meal—known as ichi-ju san-sai —consists of a staple food (such as rice), a soup (usually miso), and three dishes (one main dish and two side dishes) [ 35 ]. The basic Japanese cooking methods— Gohou (five methods)—are raw food, boiling, grilling, steaming, and frying [ 36 ]. We adopted stewing instead of steaming to reflect contemporary cooking practices [ 37 ]. Therefore, we included these elements and designed the following seven items for the Japanese version of the cooking skills scale: “How do you assess your overall cooking skills?”; “Can you peel fruits and vegetables?”; “Can you boil eggs and vegetables?”; “Can you grill fish?”; “Can you make stir-fried meat and vegetables?”; “Can you make miso soup?”; and “Can you make stewed dishes?” Participants were asked to evaluate their own cooking skills on a six-point scale (ranging from 1 for unable to 6 for very well ). Cronbach’s α for these seven items was 0.96. Cronbach’s α was calculated using an unstandardized approach for respondents answering five or more of the seven items. The mean of the seven items was calculated for each respondent to reflect their overall cooking skills; the midpoint was 3.5, and a high score meant that the respondent had high confidence in their cooking skills (Table 2 ). The mean cooking skills score was divided into three categories—high (> 4.0), middle (2.1–4.0), and low (≤ 2.0)—to examine the associations of cooking skills with body weight status and dietary behaviors. For women, because the distribution of the cooking skills score was skewed to the left (leaning towards higher scores), the middle and low groups were merged into one category. Therefore, women were classified into two cooking skills categories: high (> 4.0) and middle/low (≤ 4.0).

Person in charge of meal selection

Participants were asked “In what way are your daily meals mainly prepared?” The responses to this item were as follows: cook by myself , a family member cooks , buy packaged lunches or cooked meals , use catering or home-delivery services , and other . Participants except for those who reported that a family member did the cooking were defined as being in charge of preparing or selecting meals.

Covariates were assessed using the self-report questionnaire. Age was divided into four categories (65–69, 70–74, 75–79, and ≥ 80 years). The duration of education was divided into three categories (≤ 9 years, 10–12 years, and ≥ 13 years). Annual household income was adjusted for household size, dividing the household income by the square root of the number of people in the household. This variable was then divided into three categories (< 2.00, 2.00–3.99, and ≥ 4.00 million yen). Marital status was divided into five categories (married, widowed, divorced, single, and other). To assess comorbidity, the participants were asked whether they were currently under medical treatment for any of the following conditions (multiple responses were allowed): cancer, heart disease, stroke, hypertension, diabetes mellitus, and hyperlipidemia. Covariates with missing data were categorized as “missing.”

Statistical analysis

The analyses were stratified by gender because a previous study reported different associations between cooking skills and dietary behaviors by gender and distinct patterns of potential confounders for men and women [ 9 ]. First, participants were stratified by cooking skill level, and differences between groups were tested using Pearson’s chi-squared tests. Second, multiple comparisons for the cooking skills scale were analyzed using the mixed linear model procedure to examine which cooking skills participants rated as difficult. The model adjusted for age, education, annual normalized household income, marital status, and medical treatment (cancer, heart disease, stroke, diabetes mellitus, hypertension, and hyperlipidemia), and peeling was used as the reference category. Participant identification code was included as a random effect. Third, we calculated adjusted odds ratios with 95% confidence intervals (CIs) of high frequency of eating outside the home using logistic regression. For low frequency of home cooking and vegetable/fruit intake, we calculated adjusted prevalence ratios (APRs) with 95% CIs using Poisson regression because participants with low frequencies of home cooking and vegetable/fruit intake were not uncommon, so the odds ratios derived from logistic regression would have been unable to approximate the prevalence ratio [ 38 , 39 ]. For the association with weight status, we calculated adjusted relative risk ratios (ARRRs) with 95% CIs of underweight and obesity using multinomial logistic regression, with the body weight category of BMI of 18.5–27.4 kg/m 2 as the reference category. The models were adjusted for the following potential confounding factors: age, education, annual normalized household income, and medical treatment for cancer, heart disease, stroke, hypertension, diabetes mellitus, and hyperlipidemia. Participants with missing data on the covariates were included in the analysis. All analyses were conducted using Stata, Version 14 (Stata Statistical Software: Release 14. College Station, TX: StataCorp LP).

The participants’ characteristics are summarized in Table 1 . A total of 46% of the participants were men, about 20% were aged over 80 years, 30% had under 9 years of education, and 40% had annual incomes below two million yen. Of the male respondents, about 10% were widowed or divorced. When cognitive function was assessed with three items from the Kihon Checklist–Cognitive Function scale, for which predictive validity for dementia incidence has previously been confirmed [ 40 ], only 0.9% of participants had three cognitive complaints. The majority of women (94.1%) were classified as having a high level of cooking skills (Table 1 ). For men, the level of cooking skills was classified as high for 52.0%, middle for 35.8%, and low for 12.3%. For women, 8.9% cooked less than two times a week, 3.5% ate out more than three times a week, 14.6% ate vegetables/fruits less than once a day, 9.3% were underweight, and 7.3% were obese. For men, 53.8% never cooked, 7.7% ate out more than three times a week, 27.5% ate vegetables/fruits less than once a day, 4.7% were underweight, and 7.3% were obese. Women with middle/low-level cooking skills tended to be older, have a low level of education, have low income, not be married, and list a family member as the main meal preparer (Table 1 ). For men, in addition to being older, having a low level of education, and having a family member as the main meal preparer, men who were married tended to have a low level of cooking skills (Table 1 ).

The mean cooking skills score was higher for women (5.6 points) than for men (4.1 points) (t (19736) = − 99.6, p  < 0.001) (Table  2 ). For psychometric testing, one factor with an eigenvalue over 1 was found, and this accounted for 80.5% of the variance. All factor loadings were 0.8 or higher. Men rated stewing and stir-frying as more difficult than peeling. Although women had statistically significant differences between the assessed cooking skills, in terms of substantive significance, they rated all the methods assessed on the cooking skills scale as being of similar difficulty (Table 2 ).

There were gender differences in the associations of cooking skills with unhealthy dietary behaviors and body weight status (Table  3 ). Women with a middle/low level of cooking skills were 3.35 times (95% CI: 2.87–3.92) more likely to have a lower frequency of home cooking and 1.61 (95% CI: 1.36–1.91) times more likely to have a lower frequency of vegetable/fruit intake, compared with women with a high level of cooking skills. As for weight status, women with a middle/low level of cooking skills were 1.29 (95% CI: 0.99–1.67) times more likely to be underweight, compared with women with a high level of cooking skills. For men, compared with those with a high level of cooking skills, men with a middle or low level of skill were 1.98 (95% CI: 1.86–2.11) times more likely and 2.56 (95% CI: 2.36–2.77) times more likely, respectively, to have a lower frequency of home cooking. Regarding eating outside the home, compared with men with a high level of cooking skills, men with a low level of cooking skills were 1.30 (95% CI: 1.01–1.67) times more likely to have a higher frequency of eating outside the home. There was a significant association with a low frequency of vegetable/fruit intake only among men with a middle level of cooking skills (APR: 1.15, 95% CI: 1.06–1.26). As for weight status, compared with men with a high level of cooking skills, men with middle or low skill levels were 1.29 (95% CI: 1.04–1.60) times more likely and 1.43 (95% CI: 1.06–1.92) times more likely, respectively, to be underweight. There was no significant association between cooking skills and obesity for either men ( p  = 0.33) or women ( p  = 0.40). Using the cutoff point of BMI ≥ 23.0 kg/m 2 as overweight, we found that a low level of cooking skills was not associated with an increased risk of overweight (Supplementary Table 1 ).

Next, we focused on men in charge of meals. Over 90% of women ( n  = 9618) but only 26% of men ( n  = 2358) were in charge of daily meals. In contrast to men not in charge of preparing meals, most men in charge of meals rated their cooking skills as high (Supplementary Table 2 ). Men in charge of meals tended to have low levels of education and low income and to be unmarried (e.g., widowed or divorced) (Supplementary Table 2 ). When the associations with unhealthy dietary behaviors and weight status were examined for men in charge of meals, the effect size increased (Table  4 ). Compared with men with a high level of cooking skills, men with middle- or low-level cooking skills were 4.22 (95% CI: 3.42–5.21) times more likely and 7.85 (95% CI: 6.04–10.21) times more likely, respectively, to have a lower frequency of home cooking (Table 4 ). Regarding eating outside the home, compared with men with a high level of cooking skills, men with a low level of cooking skills were 2.28 (95% CI: 1.36–3.82) times more likely to have a higher frequency of eating outside the home. In relation to low frequency of vegetable/fruit intake, the APR for men with a middle level of cooking skills was 1.32 (95% CI: 1.15–1.53). Furthermore, compared with men with a high level of cooking skills, men with middle or low skill levels were 1.59 (95% CI: 1.04–2.45) times more likely and 2.79 (95% CI: 1.45–5.36) times more likely, respectively, to be underweight.

To the best of our knowledge, this is the first study to examine the associations of cooking skills with unhealthy dietary behaviors and weight status by gender and meal preparer status among older adults. Using an adapted version of an existing cooking scale for use in Japanese populations, we confirmed that women had higher levels of cooking skills than did men and that the associations of cooking skills with dietary behaviors and weight status differed by gender. For both men and women, a low or middle/low level of cooking skills was associated with a low frequency of home cooking. Having low- or middle/low-level cooking skills was found to be significantly associated with high frequency of eating outside the home and with being underweight for men but not for women. The association between low or middle/low level of cooking skills and low frequency of vegetable/fruit intake was found for both men and women, but among men there was no dose–response relationship. The associations of low level of cooking skills with unhealthy dietary behaviors and underweight status were especially pronounced among men in charge of meals. Cooking skills were unassociated with obesity among both women and men.

In this study, a cooking skills scale for use in Japanese populations was designed with consideration of basic Japanese cooking methods and typical meals. Although we did not confirm the validity of this newly designed cooking skills scale by objective assessment, we were able to obtain plausible results, with the same trends observed with the original cooking skills scale for European populations [ 9 ]. Our cooking skills scale had appropriate internal consistency (Cronbach’s α = 0.96) and showed higher values for women and those with higher education levels, which is consistent with previous findings [ 9 , 41 ]. This result also supports previous findings of a gender difference in confidence in cooking skills indicating that women are more confident in their cooking skills than are men [ 9 , 22 , 42 ]. The differences in cooking skills by gender and educational attainment among Japanese older adults may be explained by opportunities to learn cooking skills in school. In Japan, cooking education in schools was conducted exclusively for women until 1989; therefore, the men in this study (born before 1958) had less opportunity to learn cooking in school [ 43 ]. Another factor is that older age is associated with a stronger belief in the gender role ideology holding that men should work outside the home and women should do housework inside the home. In earlier years, there was even a cultural idea that men should not so much as enter the kitchen. This idea is reflected in the saying “ Danshi-chubo-ni-hairazu ” (“A man would be ashamed to be found in the kitchen”) [ 44 ]. However, men’s mean (SD) cooking skills score of 4.1 (1.42) was higher than the midpoint of 3.5, indicating that older Japanese men have above-average confidence in their cooking skills. In line with previous studies on adults showing that levels of cooking skills tend to be high in multiple-person households [ 8 , 9 ], we found that women’s cooking skills were higher when they were married than when they were not. However, in contrast, men’s cooking skills were higher when they were not married (e.g., widowed or divorced). This result is intuitive because unmarried men do not have a spouse who is responsible for the cooking. We speculate that unmarried women have a moderate level of cooking skills because they were taught to cook in home economics classes and by their mothers, but their cooking skills may not have continued to improve because there was no need to cook for another person. Interventions earlier in the life course, such as at retirement, may be effective because men have a high risk of unhealthy eating behavior caused by their poor cooking skills if they are later widowed or divorced.

We included five basic cooking methods in the cooking skills scale, finding that men rated stewing and stir-frying as more difficult, compared with peeling and boiling. A previous study that examined eight cooking methods in the United Kingdom showed that men were more confident about boiling, compared with stewing or stir-frying [ 42 ]. This result is plausible because stewing and stir-frying require adjusting the level of heat and adding seasoning to prepare the dish properly. In interventions targeting men, it might be most beneficial to focus on simple cooking methods using stewing and stir-frying.

As expected, having a low or middle/low level of cooking skills was significantly associated with having a low frequency of home cooking for both men and women. People with high levels of cooking skills may enjoy cooking and feel self-confident regarding their cooking, leading to a high frequency of home cooking [ 9 , 42 ]. However, a significant association between a low level of cooking skills and high frequency of eating outside the home was found only among men. This result may reflect the gender difference in the prevalence of eating outside the home. The percentage of respondents who ate out at least once a week was 15.5% for women and 23.6% for men (Table 2 ). A previous nationally representative survey in Japan reported that this gender difference exists across all age groups in the country, suggesting that men tend to prefer eating outside the home [ 45 ]. The same national survey also reported that the percentage of people who consume packaged lunches or cooked meals is the same for both men and women [ 45 ]. Therefore, women may consume these meals rather than eating outside the home, even if they have a low level of cooking skills. Another possible reason for the gender difference in eating outside the home is that there is a fundamental difference in cooking ability between men and women. In other words, the men who were categorized as having a low level of cooking skills cannot prepare any kind of meal, but the women who were categorized as having a middle/low level of cooking skills may be able to make basic meals. In our study, 79% of the women categorized as having a middle/low level of cooking skills were originally in the middle-level cooking skills category (Table 1 ). Therefore, women may not have to rely on eating outside the home even if they have a middle/low level of cooking skills.

Unlike home cooking and eating outside the home, no dose–response relationship between cooking skills and low vegetable/fruit intake was observed among men. In a previous study using the original cooking skills scale in Switzerland, favorable associations between cooking skills and various food groups including vegetables and fruits were evident for women, but these associations were weak or nonexistent for men [ 9 ]. This gender difference may be explained by nutritional knowledge [ 22 , 46 ]: Men may not have sufficient nutritional knowledge regarding healthy food choice, even if they have a high level of cooking skills. Additionally, men may be more likely to choose foods because of their sensory appeal rather than for health reasons [ 47 ]. Future work should investigate food skills, including meal planning, food safety, and nutrition knowledge [ 23 ].

A low level of cooking skills was associated with underweight but not with obesity. Although a low level of cooking skills was associated with a high frequency of eating outside the home among men, which is generally associated with obesity, the majority of older Japanese people participating in this study did not rely on eating outside the home. The percentage of people who ate out more than three times a week was only 5% for the study participants, compared with 35% for older Americans aged 60 years or older [ 29 ]. In our sample, more than 90% of the participants reported that their daily meals were mainly cooked by themselves or a family member (Table 1 ). Therefore, for older Japanese people, a low cooking frequency because of a low level of cooking skills may mean that they skip meals or eat simple meals or meals with poor nutritional value instead of eating outside the home. This would be more likely to lead to underweight than to obesity. A study examining the amount of rice served at local and chain restaurants in Japan found that most restaurants set the rice potion at an appropriate quantity for middle-aged and older people (> 160 g and < 200 g) [ 48 ]. Therefore, those eating outside the home in Japan may be unlikely to consume a high number of calories. When we additionally included frequency of home cooking and vegetable/fruit intake as potential mediators in our model, the ARRR of underweight decreased and became statistically non-significant among men, although it remained significant among men in charge of meals (Supplementary Table 3 , Model 2). Another possible explanation for the association between cooking skills and underweight is that cooking skills may be a surrogate indicator of physical capacity in daily living. To examine this hypothesis, we included limitations in instrumental activities of daily living status [ 49 , 50 ] in our model as a confounding factor, confirming that the ARRR of underweight remained significant (Supplementary Table 3 , Model 3). Contrary to expectations, a low level of cooking skills was associated with underweight but not with obesity among older adults. For Asian people, underweight is a consistent risk factor for death, and this risk is higher than that associated with obesity [ 51 ]. Underweight has also been reported to be associated with frailty [ 52 ], fracture, and bone loss [ 53 ], which are critical obstacles to maintaining quality of life among older people [ 54 , 55 ]. Therefore, it may be important for health policy makers to identify people with poor cooking skills and organize programs to enhance cooking skills to prevent underweight.

The association between cooking skills and underweight was especially prominent among men in charge of meals, and this association remained significant in this group even after accounting for limitations in instrumental activities of daily living, frequency of home cooking, and vegetable/fruit intake (Supplementary Table 3 , Model 4). This finding is plausible because many men have family members—often their wives—who prepare meals for them. Among the men in our study sample, 74% reported that a family member prepared their daily meals (Table 1 ). Considering that many men in charge of meals are widowed or divorced (Supplementary Table 2 ), these men may have difficulty preparing meals because they had few opportunities to prepare meals before losing their spouse. These men may thus be less motivated to cook and to eat, which can lead to a lower appetite [ 56 ]. Additionally, appetite decreases with age, and poor appetite has been shown to be related to, for example, lower intake of energy, protein, and vegetables/fruits; lower dietary diversity [ 57 , 58 ]; and higher risks of malnutrition [ 59 ] and mortality [ 58 ]. Further studies are needed to examine the potential mechanisms of the risk of underweight caused by low levels of cooking skills for men. About half of older Japanese men who cook at home started cooking when they were over 50 years old [ 60 ]. Considering that cooking classes for men have increased over the past few decades in Japan, intervening at an older age may be feasible and acceptable.

This study had several limitations. First, we used self-reported weight and height to calculate BMI, which may have led to an under- or over-estimate of BMI [ 61 ]. A previous study demonstrated that, when calculated from self-reported weight and height, the BMI of older Japanese people was underestimated, compared with objective measures of weight and height; however, the same study showed that the BMI of underweight men and women was overestimated by 0.7 and 0.3, respectively, because these groups tended to over-report their weight [ 62 ]. Therefore, we may have underestimated the association of cooking skills with underweight. Second, we defined home cooking simply, excluding only the preparation of ready-to-eat food. Therefore, people who cooked low-quality meals or used some prepared foods in their cooking may have been included in the high frequency of home cooking category. This may have led to an underestimate of the association of cooking skills with low frequency of home cooking. Third, frequency of vegetable/fruit intake was assessed using a single, simple item. Future studies should use more detailed questions to assess which food groups are associated cooking skills. Fourth, we observed a ceiling effect for women’s cooking skills, as has been reported in a previous study using the original cooking scale [ 9 ]. Considering the reduction in the available time for cooking in recent years, it may be beneficial to investigate cooking skills not only in terms of methods (e.g., boiling and stewing), but also in terms of the ability to prepare a variety of meals in a short time. Moreover, a thorough psychometric assessment of the modified cooking scale should be performed if it continues to be used. More comprehensive, validated measures for assessing food and cooking skill confidence are now available [ 63 ]. Therefore, it is possible to use these measurement methods in the future. Fifth, we could only evaluate a limited number of eating behaviors. Future work should examine associations between cooking skills and other aspects of diet, such as dietary pattern, food components, and portion size, to understand the mechanisms of the relationship between cooking skills and weight status. Sixth, because the municipalities that participated in the JAGES survey were not randomly selected, the generalizability of our findings to other populations in Japan is limited. Finally, because this study was cross-sectional, we could not assess causality: Reverse causation is possible, and unmeasured factors such as personality may confound the examined associations. For example, underweight may be accompanied by frailty or low muscle strength, which may make it difficult to cook some foods or to cook for a long time while standing, resulting in low confidence in one’s cooking skills. However, more than half of the adult respondents in a previous study said that they had learned most of their cooking skills when they were teenagers and that they had learned these cooking skills mainly from their mothers [ 64 ]. Future randomized controlled trials comparing cooking, eating behaviors, and weight status among older adults with and without cooking skills interventions would clarify the causal association.

Using a large-scale cross-sectional study, we confirmed that women had higher levels of cooking skills than did men and that the associations of cooking skills with dietary behaviors and weight status differed by gender. Moreover, the associations of cooking skills with unhealthy dietary behaviors and weight status were especially pronounced among men who were in charge of meals. Considering the possibility that the person in charge of meals may change in older age, research on support to improve cooking skills among older people is needed.

Availability of data and materials

The datasets used and analyzed in the current study are from the JAGES study. All enquiries are to be addressed to the JAGES data management committee via e-mail: [email protected] . All JAGES datasets have ethical or legal restrictions for public deposition because of the inclusion of sensitive information from the human participants.

Abbreviations

confidence interval

body mass index

Japan Gerontological Evaluation Study

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Acknowledgments

We are particularly grateful to the staff members in each study area and in the central office for conducting the survey.

This study used data from the JAGES, which was supported by a Japan Society for the Promotion of Science KAKENHI Grant (JP15H01972, 20H00557 and 19 K14029), a Health Labour Sciences Research Grant (H28-Choju-Ippan-002, H30-Junkanki-Ippan-004, 19FA1012 and 19FA2001), grants from the Japan Agency for Medical Research and Development (JP18dk0110027, JP18ls0110002, JP18le0110009, JP19dk0110034 and JP20dk0110034), Research Funding for Longevity Sciences from National Center for Geriatrics and Gerontology (29–42), and a JST-OPERA program grant (JPMJOP1831).

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YT conceived the design, analyzed the data, reviewed the literature, and wrote the first draft of the article. KK collected the data. TF revised the first draft. KK edited the manuscript. All authors approved the final version of the manuscript.

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Additional file 1: table s1..

Adjusted relative risk ratios of underweight and overweight according to the cooking skills of older Japanese men ( n =9,143) and women ( n =10,595). Table S2. Characteristics of older Japanese men by cooking responsibility status ( n = 9,203). Table S3. Adjusted relative risk ratios of underweight by cooking skill among older Japanese men.

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Tani, Y., Fujiwara, T. & Kondo, K. Cooking skills related to potential benefits for dietary behaviors and weight status among older Japanese men and women: a cross-sectional study from the JAGES. Int J Behav Nutr Phys Act 17 , 82 (2020). https://doi.org/10.1186/s12966-020-00986-9

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Impact of cooking and home food preparation interventions among adults: outcomes and implications for future programs

Marla reicks.

Department of Food Science and Nutrition, University of Minnesota

Amanda C. Trofholz

Division of Epidemiology and Community Health, University of Minnesota

Jamie S Stang

Division of Epidemiology & Community Health, University of Minnesota School of Public Health

Melissa N. Laska

Cooking programs are growing in popularity; however an extensive review has not examined overall impact. Therefore, this study reviewed previous research on cooking/home food preparation interventions and diet and health-related outcomes among adults and identified implications for practice and research.

Literature review and descriptive summative method.

Main outcome measures

Dietary intake, knowledge/skills, cooking attitudes and self-efficacy/confidence, health outcomes.

Articles evaluating effectiveness of interventions that included cooking/home food preparation as the primary aim (January 1980 through December 2011) were identified via OVID MEDLINE, Agricola and Web of Science databases. Studies grouped according to design and outcomes were reviewed for validity using an established coding system. Results were summarized for several outcome categories.

Of 28 studies identified, 12 included a control group with six as non-randomized and six as randomized controlled trials. Evaluation was done post-intervention for five studies, pre- and post-intervention for 23 and beyond post-intervention for 15. Qualitative and quantitative measures suggested a positive influence on main outcomes. However, non-rigorous study designs, varying study populations, and use of non-validated assessment tools limited stronger conclusions.

Conclusions and Implications

Well-designed studies are needed that rigorously evaluate long-term impact on cooking behavior, dietary intake, obesity and other health outcomes.

INTRODUCTION

The importance of away-from-home meals and convenience foods in the American diet may relate to a lack of time to plan and prepare meals at home. 1 A recent review also implicates a lack of cooking skills and food preparation knowledge as barriers to preparing home-cooked meals. 2 The percentage of total household food dollars spent on food eaten away from home is now higher compared to 30 years ago (33% in 1970 to 47% in 2010). 3

Consumption of fast food and food from away-from-home locations is associated with lower diet quality and obesity among adults. 4 – 8 National dietary intake data from 1994–1996 and 2003–2004 shows that each meal away from home is related to an increase in calories by 130 per day and a reduction in diet quality by two points on the Healthy Eating Index scale. 9 Food prepared at home provides fewer calories per eating occasion, and on a per-calorie basis, provides less total and saturated fat, cholesterol and sodium, and more fiber, calcium and iron compared to food prepared away from home. 10 Among low-income women, increased frequency of consuming foods prepared from scratch over a three-day period is associated with an increase in fruit and vegetable, protein, vitamin C, iron, zinc and magnesium intakes. 11

Furthermore, time usage data shows that time spent in food preparation and cleanup is less for the average household compared to 30 years ago. In 1995 time spent on food preparation and clean-up is about half (41 minutes/day) that spent in 1965 (85 minutes/day) by working women in the U.S. 12 – 13 More recent time usage data (2003–2004) also shows that time spent in food preparation decreases as time spent working outside the home increases, 14 with a greater number of women in the U.S. workforce (an increase of 44% from 1984 to 2009). 15 This rise in working women, an amplified perception of time scarcity 1 and increased availability of convenience foods based on technological advances and societal demands contributes to the decline in cooking and home food preparation. An observational study of 64 home cooked dinner meals shows that most meals contain processed, commercial foods possibly because of limited cooking skills. 16

Several cross-sectional, observational studies show a relationship between food preparation skills among adults and associated outcomes. Among mothers of school-aged children, confidence in the ability to prepare a healthy meal is positively associated with healthfulness of the meal. 17 A survey of German adults indicates that readymeal consumption (i.e., consumption of complete, main-course meals prepared externally) is inversely associated with cooking skills. 18 A high perceived value of food preparation is associated with greater intakes of fruits and vegetables among women in Australia, 19 and when the main home cook is confident in preparing vegetables, households buy a greater variety of vegetables. 20

Given the potential positive outcomes related to cooking skills, nutritionists and public health professionals are promoting cooking interventions as a way to improve health. For example, one large-scale cooking initiative known as Cooking Matters is underway in at least 35 states. Through the program, local chefs partner with community organizations to teach cooking skills. 21 Even though the programs are becoming more popular and well-established, an extensive review of the literature that examines the short and long-term impact of cooking interventions for adult populations is not available. A review of this type can provide information to improve the effectiveness of current programs and inform the development of new programs. The purpose of this study is to review previous research on cooking/home food preparation interventions and diet and health-related outcomes among adults. Relevant studies include interventions that focus primarily on home food preparation/cooking as the primary aim. Studies are also reviewed to identify implications for practice and future research.

Relevant research studies published between January 1980 and December 2011 were identified via searches of OVID MEDLINE, Agricola, and Web of Science databases. The following keywords were used in various combinations to perform searches: intervention, demonstration, health promotion, education or class; and food preparation, home food preparation, cooking or cookery; and food habits, food intake, eating patterns, diet, dietary intake, dietary outcomes or skills. The search was limited to those studies published in the English language and those involving adults (i.e., primarily 18 years of age or older), including college students.

A total of 373 journal articles and 85 educational materials were retrieved. Educational materials included mostly books as well as visual aids (slide sets, filmstrips, videos, transparencies), teaching kits and government publications. Of the 373 journal articles, 54 were repeated in two or three databases, leaving 319 for further review. Abstracts for all articles were reviewed and studies were excluded if they were not intervention studies (n=209, those having a cross sectional design with qualitative and quantitative methods such as dietary assessment, attitude and behavioral surveys; focus group and individual interviews; case studies). Articles were not included if they reported on studies that involved children as the target group, were reports or commentaries on recommendations or resources, or review articles. Articles were also not included if they were intervention studies that did not have cooking or food preparation as the primary aim, or if only formative development of programs that involved cooking or food preparation was described without evaluation measures. After these exclusions (n=306), thirteen applicable studies that had cooking or home food preparation as their primary aim were included for further review. Other potentially relevant studies were identified from bibliographies of these applicable studies. This study was exempt from Institutional Review Board review because it involved a review of previously completed, published studies.

Twenty-eight studies meeting the inclusion criteria were identified through this search strategy. 22 – 49 Intervention studies included cooking or home food preparation through cooking assignments, 22 – 23 cooking classes/demonstrations in community or clinical settings, 24 – 44 , 46 – 49 and viewing a cooking TV show. 45 Studies were grouped according to design (intervention without control groups, non-randomized control trials (RCT) and RCTs) and intended outcomes. One author extracted information from studies into a standardized table ( Table 1 ) structured to provide objective information about the population, intervention duration, measures and measurement tools and outcomes. Information extraction was checked independently by a second author to ensure that consistent detailed information was included for each study.

Study characteristics, intervention methods, evaluation measures and summary of outcomes regarding diet and health

FV = fruit and vegetable, FFQ = food frequency questionnaire, NCI=National Cancer Institute, NDSR=Nutrient Data System for Research, WHEL=Women’s Healthy Eating and Living, RCT=randomized controlled trial

The validity questions from a quality criteria checklist were used to critically appraise the validity of each study included in this review with respect to research design and implementation. The checklist was available as part of the Evidence Analysis process of the Academy of Nutrition and Dietetics Evidence Analysis Library (EAL) and allowed for rating of primary research studies as positive (“clearly addressed issues of inclusion/exclusion, bias, generalizability, data collection and analysis”), negative (“these issues have not been adequately addressed”) or neutral (“neither exceptionally strong nor exceptionally weak”). 50 The process to appraise study validity involved several steps where an external reviewer first used the checklist to generate responses to all the validity questions for 26 of the 28 studies (two based on primarily qualitative evaluation methods were not included in this process 24 , 38 ). Next, authors generated responses to all validity questions for two to six studies each for a total of 13 of the 26 studies. Lastly, one author reviewed responses to the validity questions for all papers reviewed by the external reviewer and other authors and generated an overall rating of positive, negative or neutral for each study. Inter-rater reliability was determined for ratings of the 13 papers by the external reviewer and multiple authors based on a simple Kappa coefficient (0.71) and percentage agreement of 84.6%.

Table 2 presents information about the evaluation tools used to measure quantitative outcomes, literature sources and pilot testing. A wide variety of outcomes (either qualitative or quantitative dietary outcomes and health outcomes such as weight or blood lipids) across studies was reported based on a variety of evaluation measures.

Description of the evaluation tools used to measure quantitative outcomes regarding dietary intake, cooking behaviors, knowledge and attitudes; literature sources and pilot testing information

To better describe the type of cooking/food preparation studies conducted from 1980–2011, the number of studies was quantified based on study design (inclusion of a control group and randomization of participants), and the type and timing of evaluation to assess effectiveness (post-assessment only, pre- and post-assessment, and whether follow-up was completed after post-assessment). Outcomes based on study objectives were summarized based on several categories including dietary change, knowledge/cooking skills, self-efficacy and intentions, and changes in health outcomes such as metabolic biomarkers or weight. Overall findings were highlighted and examples were provided to further illustrate the type of studies and participants used to generate the findings for each outcome category.

Study Type and Outcome Measures

Of the 28 studies, 16 did not include a control group. Of these, four utilized post-assessment measures only, 22 – 24 , 34 while 12 had pre and post-intervention assessments. 25 – 33 , 35 – 37 Of the 12 studies including a control group, six did not randomize group assignment 38 – 43 and six did. 44 – 49 The total number of sessions in each intervention varied widely, from three, 35 four, 33 – 44 six, 26 – 28 , 30 eight, 31 – 32 , 36 12–13 29 , 37 to 38 sessions. 25 Some studies also contained additional components, such as refresher sessions six months after intervention completion. 37 Across all 28 studies identified in this review, 15 assessed potential impacts of the intervention beyond the immediate post-intervention assessment, including five that did not include a control group 25 – 27 , 33 – 34 and 10 that did. 39 – 43 , 45 – 49 These follow-up assessments ranged from one to 48 months after the intervention concluded.

Studies varied with respect to type of participant, intervention activities and duration, and expected outcomes. Most studies involved adults, however several targeted parents because of the role they play in promoting healthful diets and prevention of chronic disease among children. 42 , 44 The majority of the 28 studies focused on changing outcomes that could be measured quantitatively. Table 2 presents information about quantitative tools used to assess dietary outcomes and outcomes related to nutrition or cooking knowledge, attitudes and practices. Diet-related assessment tools ranged from questionnaires regarding frequency of dietary behaviors (e.g., eating fruits and vegetables, drinking low-fat milk) to standard dietary intake data collection methods (e.g., 24-hour dietary recalls). For some studies, little or no information was provided about the source of some evaluation tools or whether they had been validated. 25 , 32 , 34 Other studies described a process whereby content validity, internal consistency and/or test-retest reliability were assessed. 26 , 39 , 45 – 46 Still other studies referenced previous research from which tools were drawn directly, with or without modification, 29 – 30 , 43 or research from which tools had been adapted for use in the intervention. 35 – 36 , 39 , 45 Some studies used qualitative interviews alone or in conjunction with other measures to assess outcomes 22 – 24 , 34 , 38 or physical and laboratory measures for outcomes, such as change in blood pressure or serum cholesterol. 36 – 37 Only 4 studies examined effects on body weight. 36 , 37 , 43 , 49

Process Evaluation

Process measures were not reported for some studies and varied widely for studies that included this type of evaluation. Most studies reported the number of participants recruited and the number in the final sample, but few discussed the differences in these samples brought about by attrition. Some studies reported attendance at intervention sessions or completion of intervention activities, 25 – 27 , 29 , 33 , 37 differences in outcomes according to attendance, 27 and preferences for follow-up methods. 26 Other studies explored opinions and feedback about programs and participant experiences. 28 , 32 – 34 , 38 , 44 – 45 Reasons for not completing intervention sessions were presented in several studies, 39 , 47 – 49 and only a few studies provided information about program cost. 43 , 46

Evidence Analysis Library Process of Validity Ratings

Based on the EAL validity questions, a positive rating was assigned to 11 studies, a neutral rating to one study, and a negative rating to 13 studies. A “no” response to more than six validity questions resulted in a negative rating. Most often these questions were related to specification of inclusion/exclusion criteria, handling of withdrawals, use of standard, valid and reliable data collection instruments, and adequate description of statistical analysis. Not applicable responses to questions were not considered in the rating. Most often these questions were related to comparability of study groups and blinding for studies without a control group.

Outcome Evaluation: Dietary Intake

Nineteen of the 28 studies evaluated the impact of a cooking intervention on dietary intake, assessed in various ways. Despite varying study designs and measurement tools, 16 studies reported a positive impact on food intake. Ten of these were interventions without a control group; all showed beneficial changes in intake of various nutrients, food groups, and specific foods following the intervention, each using different measurement tools. 24 – 27 , 29 – 31 , 33 , 35 – 36 Using dietary questionnaires, one of which was a previously tested Eating Styles Questionnaire, 30 an intervention aimed at members of a South Asian community in the United Kingdom 25 and an intervention aimed at African American faith community members 30 resulted in reported improvements rather than significant improvements in intakes of dietary sources of fat, fiber, sugar or sodium. 25 , 30 The intervention arm of the Women’s Healthy Eating and Living (WHEL) Study included 12 monthly cooking lessons for women previously treated for breast cancer. 29 Increased cooking class attendance was significantly associated with improvement in participants’ WHEL Adherence Score, an index measuring achievement of dietary targets, such as fruit, vegetable and fiber intakes and percentage of energy from fat.

Of the interventions including a control group (n=12), five showed that intervention participants’ dietary intakes improved to a greater degree than those of the control group. 39 , 41 , 43 , 47 , 49 For example, a multiple-pass, 24-hour recall was used to assess outcomes of a healthy eating class for men with prostate cancer versus a control group receiving usual treatment. 49 A significant reduction in the consumption of saturated fat and animal proteins and increased vegetable protein consumption was observed for the intervention group compared to the control group.

Two of the non-randomized trials showed mixed results for the intervention group compared to the control group, as measured by Food Frequency Questionnaire (FFQ) or food diaries. 39 , 41 Cooking class intervention participants significantly increased consumption of grains compared to the control group that received no intervention, but their intakes of dairy, fruits and meats were not significantly different. 41 Adults living in areas of social deprivation in Scotland who were exposed to a nutrition education and cooking class intervention significantly increased their intake of fruit pre- to post-intervention, but this was not maintained at the six-month follow-up. 39

Outcome Evaluation: Knowledge/Skills

Using qualitative measurements/tools, three cooking class interventions assessed cooking knowledge/skills. 24 , 32 , 38 Participants of all three interventions reported an improved understanding of healthy food preparation and healthier cooking strategies. Four studies reported effects on nutrition and fruit and vegetable knowledge. 35 , 38 , 40 , 45 For example, using theory-based knowledge questions adapted from a questionnaire used in an existing program, a diabetes education and cooking demonstration intervention resulted in an increase in nutrition knowledge pre- to post-intervention. 35

Outcome Evaluation: Cooking Self-Efficacy/Confidence, Intention/Behavior, and Attitudes

Three cooking class interventions, 32 , 34 , 39 two aimed specifically at men, resulted in an increase in cooking confidence. Two of these studies also showed an increase in cooking activity at post-intervention 32 and at four or six week follow-up. 34 A third study found a significant increase in confidence in following a recipe between baseline and six-month follow-up, as measured by an untested cooking skills questionnaire. 39 Two cooking class interventions reported positive results with respect to participants’ cooking attitudes and enjoyment, 32 , 41 although the findings were either not significant or significance was not reported. Attitudes were determined by various surveys, one of which had been evaluated for test-retest reliability 41 and another by key informant interviews. 32

Outcome Evaluation: Health Outcomes

Four studies reported positive health outcomes, 36 – 37 , 43 , 48 and two of these involved positive changes in serum cholesterol. 36 – 37 Other studies addressed improvement in parameters associated with conditions/diseases. For example, patients with rheumatoid arthritis significantly improved a variety of rheumatoid arthritis measures when compared to the control group, which received only healthy eating information. 43 More patients with chronic kidney disease improved in parameters such as urinary protein, urinary sodium, and blood pressure in an experimental group receiving cooking and exercise classes compared to a standard care control group. 48 Men with biopsy-confirmed prostate cancer who completed a cooking class intervention showed a significant increase in quality of life compared to the control group but no impact on body weight was observed. 49 Similarly, BMI did not change from pre to post intervention among hypercholesterolemic individuals. 36 , 37

This review indicates that interventions involving home food preparation and/or cooking may result in favorable dietary outcomes, food choices, and other health-related outcomes among adults. However, the results should be interpreted with caution based on weaknesses in study design, varying study populations and lack of rigorous assessment.

Findings related to changes in dietary intake and health outcomes

Dietary behavior change for an individual may be based on a progression of tasks involving food selection/acquisition, preparation and consumption. Given this progression, food preparation knowledge and skills are critical components that can facilitate dietary change. As expected, the majority of interventions in the current study that targeted changes in food preparation knowledge and skills produced positive effects on dietary intake. Previous cross-sectional studies have suggested a relationship between food preparation knowledge or skills and consumption of particular foods. 51 – 52 For example, among adult WIC participants, the likelihood of consuming fruits and vegetables was strongly related to knowing how to prepare most fruits and vegetables 51 and barriers to long term intake of whole grain foods was related to cooking skills among adults in the UK. 52 Several calls have been made recently for culinary skills education programs for children, 53 – 54 based on the likelihood that these skills would persist into adulthood. However if adults lack these skills and the confidence that might accompany their development as observed in several studies reviewed, 32 , 34 , 39 programs to educate adults with respect to food preparation knowledge and skills are also important.

Several studies in this review identified barriers to dietary changes based on implementing practices encouraged by the cooking intervention. 24 , 40 Primary barriers were family food norms/preferences and resistance to change, as well as financial constraints. Cooking programs have the unique ability to help parents address resistance to dietary change by including family members in the instruction or by providing information about ways to make dietary change more palatable and acceptable. Studies included in this review expanded the intervention’s breadth in such ways as providing professional support and including budgeting sessions alongside cooking instruction. It may not be practical to target all cooking barriers (e.g., a deficit of cooking skills, nutrition knowledge, cooking facilities, and food accessibility) in a single intervention. Furthermore, if these barriers were addressed through an intervention, it is unlikely long-term positive outcomes would result unless the removal of barriers was sustained. Multiple cooking barriers are an opportunity for researchers to creatively partner with organizations working on such issues as food access. Interventions that target multiple cooking barriers are also an opportunity to demonstrate the need for comprehensive community responses to food environment issues.

Certain promising strategies emerged from intervention studies designed for community programs interested in implementing cooking programs. Several studies used peer leaders to guide cooking, nutrition and budgeting sessions, and demonstrated positive outcomes. 25 , 33 In addition to positive outcomes for the participants, peer advisors of one intervention indicated positive dietary intake changes four years after the completion of the intervention. 33 Four additional studies were successful in tailoring healthy cooking interventions to populations with specific health concerns, specifically hypercholesterolemia, 37 rheumatoid arthritis, 43 prostate cancer, 49 and myocardial infarction. 47 In addition to having a significantly positive impact on dietary intake, these interventions positively affected rheumatoid arthritis measurements and blood pressure, 43 serum cholesterol, 37 and quality of life for men with prostate cancer. 49

Interpretation of results based on study design

Study design differences make it challenging to draw conclusions about the potential benefits of interventions. More than half of the studies included in the review (16 of 28) did not include a control group and of the 12 studies that did include a concurrent control group(s) only six involved randomization of group assignment. The limited number of studies with longer-term follow-up assessments (15 of 28) imposes further restrictions on the ability to draw conclusions about effectiveness. While some exceptions exist, the majority of longer-term follow-up assessments demonstrated maintenance of positive dietary and health outcomes. However, the length of time between post-intervention and follow-up assessment varied widely. Although the measured outcomes for most interventions were primarily positive, little consistency existed among the intervention programs with respect to method of delivery (i.e., cooking class, cooking show, etc.), number of participants, type of participant (i.e., men, college students, low-income women), or the time passed between post-intervention and the final assessment.

Community programs almost certainly suffer from selection bias, where participants interested in cooking are naturally drawn to a cooking intervention, resulting in a higher likelihood that positive outcomes will be found. Selection bias can be moderated by conducting interventions among preformed groups (e.g., senior housing complexes) where there is a wider range of interest in cooking because participants do not self-select to participate. Small sample sizes and a small number of intervention sessions also yield concerns about representativeness, generalizability, and intervention dose in many intervention studies.

Interpretation of results based on evaluation/outcome assessment

A wide assortment of measurement tools were used to evaluate effectiveness of the cooking/home food preparation interventions, many of which were neither validated nor well-established measures of dietary intake, such as the 24-hour dietary recall. The wide range of non-validated, unique surveys and questionnaires makes it difficult to compare results across studies. Few validated instruments exist for measurement of cooking intervention outcomes including cooking knowledge, self-efficacy and skills. For example, only recently has the validation/testing of several measures of cooking self-efficacy been reported. 55 – 56

For many studies reviewed, consistent process evaluation was absent. While several studies addressed participant withdrawals, discussion of program implementation and expected output is noticeably absent from most studies. Process evaluation measures are particularly important as cooking programs are being implemented more widely. Process evaluation is important in measuring the degree to which interventions are implemented as planned. 57 Without these measures, it is difficult to assess the efficiency of a cooking program or how well the program is being implemented.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Regardless of the lack of definitive evidence to support a relationship between cooking instruction and long-term cooking behavior or health outcomes, public health professionals have aggressively moved forward with cooking initiatives. Many programs exist at the national, state and community levels that promote cooking as a necessary and appropriate response to overweight/obesity and food insecurity, such as the Cooking Matters program. 21 To enhance the impact of these types of popular programs, additional research is needed regarding the needs of non-cooking individuals and the most effective methods of delivering and evaluating cooking interventions. The most pertinent and essential recommendation for future studies is the necessity for stronger study designs, such as those utilizing control groups. Recruitment strategies and sampling biases should also be considered. The use of standard, valid and reliable data collection instruments and adequate description of statistical analysis is necessary to move this research area forward with rigor. Additional validated evaluation tools may become available as more studies are published with respect to cooking intervention outcomes. Research teams should also incorporate process evaluation measures to report recruitment and retention of study participants, exposure to the intervention, and fidelity of program implementation to the study design. Reporting inclusion/exclusion criteria and handling of withdrawals has become more common in recent studies, but should be a priority to address validity of studies in the future.

Despite imperfections, public excitement over cooking programs is an opportunity for public health professionals to harness this energy and discover the most beneficial approaches to affecting long-term dietary changes and subsequent health outcomes. What is essential is the continued conversation about the direction of cooking initiatives, and the implementation of these initiatives alongside inter-related measures such as increasing food accessibility and affordability. Given the current rates of overweight and obesity in the United States, strong public enthusiasm for cooking classes provide a rare public health opportunity to engage the community while working to affect dietary outcomes, overweight and obesity and related health conditions.

Acknowledgements

Salary support was provided in part by Award Number K07CA126837 from the National Cancer Institute. The content of the present manuscript is solely the responsibility of the authors and does not necessarily represent the official views of NCI. NCI did not play a role in designing the study, collecting the data or analyzing/interpreting the results. Lori Roth-Yousey, PhD, MPH, RD, Postdoctoral Research Associate, University of Minnesota served as the external reviewer for the Evidence Analysis process to rate the validity of studies included in this review.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributor Information

Marla Reicks, Department of Food Science and Nutrition, University of Minnesota.

Amanda C. Trofholz, Division of Epidemiology and Community Health, University of Minnesota.

Jamie S Stang, Division of Epidemiology & Community Health, University of Minnesota School of Public Health.

Melissa N. Laska, Division of Epidemiology and Community Health, University of Minnesota.

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Title: achieving human level competitive robot table tennis.

Abstract: Achieving human-level speed and performance on real world tasks is a north star for the robotics research community. This work takes a step towards that goal and presents the first learned robot agent that reaches amateur human-level performance in competitive table tennis. Table tennis is a physically demanding sport which requires human players to undergo years of training to achieve an advanced level of proficiency. In this paper, we contribute (1) a hierarchical and modular policy architecture consisting of (i) low level controllers with their detailed skill descriptors which model the agent's capabilities and help to bridge the sim-to-real gap and (ii) a high level controller that chooses the low level skills, (2) techniques for enabling zero-shot sim-to-real including an iterative approach to defining the task distribution that is grounded in the real-world and defines an automatic curriculum, and (3) real time adaptation to unseen opponents. Policy performance was assessed through 29 robot vs. human matches of which the robot won 45% (13/29). All humans were unseen players and their skill level varied from beginner to tournament level. Whilst the robot lost all matches vs. the most advanced players it won 100% matches vs. beginners and 55% matches vs. intermediate players, demonstrating solidly amateur human-level performance. Videos of the matches can be viewed at this https URL

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