Supplement-CHEF Clinic Culinary and Lifestyle Training for Treatment of Obesity and Obesity-Related Conditions: Report of a Pilot Study and a Practice-Based Intervention
By John La Puma, MD and Jennifer Becker
Abstract
Background: Sixty-three percent of men and 55% of women are overweight; 21% of men and 27% of women are clinically obese. Treatment of obesity is notoriously unsuccessful, and pharmacological treatment in particular has been hazardous for patients.
Methods: Two sets of methods: prospective controlled pilot research study, with 60 hours of hands-on culinary, shopping, eating out, mind-body, and fitness programming over 21 weeks; pre-post practice-based clinical program with an average of 19.5 hours of hands-on programming over an average of 10 weeks.
Subjects: Two sets of subjects: 21 Midwestern sedentary obese subjects; 23 Midwestern overweight patients.
Results: Two sets of results: In the pilot, participants' triglyceride levels dropped an average of 56 mg/dL while controls' levels increased 25 mg/dL; participants lost 10% of their body fat while controls gained 6%; participants' average body mass index (BMI) dropped from 34.5 kg/m2 to 32.2 kg/m2. Participants reported cooking with fresh vegetables and grains, and cooking and eating both grains and fresh fruits significantly more often than controls. In the clinical study, participants' average BMI dropped from 33.58 kg/m2 to 31.79 kg/m2; they lost 11% of their body fat; their average waist measurement decreased from 40 in to 37.8 in; and their average hip measurement decreased from 46.9 in to 45 in. Average blood pressures dropped from 133/80 mm Hg to 127/76 mm Hg; average LDL levels dropped from 148.5 mg/dL to 116 mg/dL; triglycerides dropped from 199 mg/dL to 174.5 mg/dL. Participants increased their average main meal daily cooking time from 24.1 min to 33.2 min, and increased the number of whole fresh vegetables consumed from 1.6 to 3.5 whole vegetables daily.
Conclusion: Teaching new hands-on lifestyle skills to motivated patients can have beneficial, desired effects on BMI, blood pressure, lipid levels, and eating and cooking habits, and result in the consumption of more fresh vegetables.
In 1986, former surgeon general c. everett koop said, "when i left office, 26% of americans were more than 20% overweight. It has now shot up to 33%. That would be my new smoking."1
Successful long-term treatment of obesity is rare. Targeting individual behavior is now thought to be so ineffective that experts advocate environmental change as primary prevention.2 Although good research in this area is lacking, only 5% of people who have lost 30 lbs or more keep it off for five or more years.3
Few clinical programs offer skills training for habit change. CHEF Clinic (Cooking, Healthy Eating and Fitness) aimed to assess the effect of hands-on cooking, shopping, eating out, fitness, and mind-body skills training on sedentary, obese, middle-class, otherwise healthy Midwestern participants in a research pilot. CHEF Clinic also aimed to assess a condensed, practice-based clinical Mini Program. Here, we report preliminary results, propose clinical strategies, and identify future research objectives.
Methods
CHEF Clinic Research Pilot
Hypothesis: Obese patients who create new foods and flavors, accept personal fitness coaching and available mind-body techniques, and retain a change in their eating habits and patterns can avoid obesity-related disease.
Assessment: At both pre- and post-intervention, participants completed validated, pre-tested cooking, eating, quality-of-life, satisfaction, diet-readiness, and well-being questionnaires,4 and three-day food records. BMI, waist-hip ratio, body fat percentage, complete fasting plasma lipid profile, fasting serum glucose, and resting blood pressures were also measured. Qualitative evaluations, including structured focus groups, were completed post-intervention.
Study Methods: Participants were referred from other physicians and also recruited directly. Potential participants on any regular medication or with any cardiac, renal, hepatic, or pulmonary medical problems were excluded. Eligible persons ages 35-65 years, with BMI > 27 kg/m2 < 40 kg/m2 were screened with a diet-readiness instrument for clinical eating disorders; and if still eligible, underwent screening laboratory exams; and if still eligible, underwent modified Bruce treadmill exams. Ineligible patients were referred back to their primary physicians with the above findings.
Curricular Content: Participants were offered 60 hours of programming over 21 weeks, taught by a physican chef, an exercise physiologist, a registered dietitian, and a holistic health registered nurse. Specific culinary, fitness, and behavioral tools were provided. Cooking and shopping classes adapted professional culinary techniques and shopping skills for home use. Plant-based recipes focused on seasonal, high-flavor, low-fat whole foods. No food was considered off limits. Eating out classes were held in local restaurants, and participants were taught how to make good choices. Mind-body skills included breathing techniques, guided visual imagery, music therapy, and group-building activities. Patients were discouraged from weighing themselves or counting calories. Fitness classes were held both individually with a progress assessment, and as a group.
Data Analysis: Statistical analysis was accomplished using SPSS and Food Processor software; statistical comparisons of group means used Wilcoxon's signed rank test; the chi squared statistic was used to test differences in categorical variables.
Informed Consent: Written and verbal consent to participate in the study was obtained from all participants. The study was approved by the Alexian Brothers Medical Center Institutional Review Board. Confidentiality of data collection was assured.
Financing: Unrestricted grant: Alexian Brothers Medical Center.
| Table 1-CHEF Clinic SAMPLE Clinical Strategies for Weight Loss | ||||
| Surround. If it's not in the house, it can't be eaten. | ||||
| Adapt. Adapt professional culinary techniques. | ||||
| Model. Modeling good behavior carries credibility. | ||||
| Plan. People do not fail. Plans do. | ||||
| Log. Successful patients count and record something other than pounds. | ||||
| Enjoy. Create options that people like. | ||||
| Table 2-Research to Practice in Obesity | ||||
| Top Five Suggestions | ||||
| 1. Include spouses, partners, and significant others in the initial basic data gathering. | ||||
| 2. Offer the program directly to participants and do not depend on referrals for enrollment. | ||||
| 3. Do not expect obesity to be on any managed care organization's radar screen any time soon. | ||||
| 4. Make it fun! And easy! | ||||
| 5. Emphasize planning skills: Self-confidence and personal choice are within most people's grasp. | ||||
CHEF Clinic Mini Program
Hypothesis: Patients who learn specific culinary and eating out skills, and accept personal fitness coaching and mind-body skill practice in a group setting will achieve a desired medical goal (such as weight loss or blood pressure control) and a non-medical goal (such as controlling urges to eat or a desire to eat that is not hunger).
Assessment: As above, without post-intervention three-day dietary food records or mandatory post-intervention laboratory examination.
Inclusion Criteria: BMI > 25 kg/m2. Between two and four visits were conducted with a board certified general internist to determine eating patterns and habits and to assess goals and reasons for eating other than hunger. Each patient also had at least one visit with an exercise physiologist/physician assistant who wrote an exercise prescription. Entry to the program was conditional on completion of these visits.
Enrollment: Participants were referred by physicians and contacted the clinic directly. Eligible persons were screened with a diet-readiness instrument, underwent screening laboratory exams, and if clinically indicated, underwent modified Bruce treadmill exams. Persons on blood pressure and lipid medications continued to take them.
Curricular Content: As above, except that participants were offered 18-21 hours (mean 19.5 hours) of programming over seven or 13 weeks (mean 10 weeks).
Data Analysis: Statistical analysis was accomplished using Excel.
Informed Consent: Verbal consent to participate in the study was obtained from all participants. Confidentiality of data collection was assured.
Financing: CHEF Clinic (Cooking, Healthy Eating and Fitness).
Results
Research Pilot: Twenty-one participants were enrolled in the pilot study (11 participants [average age 43.6 years], 10 controls). All participants attended more than 95% of classes offered. Eight (5 women, 3 men) of the 11 participants completed the 21-week program.
Physiological Health Effects: Participants' triglyceride levels dropped an average of 56 mg/dL while controls' triglyceride levels increased 25 mg/dL; participants lost 10% of their body fat, compared to a 6% increase in body fat in the control group (P < 0.05 and P < 0.03, respectively).
Measures of Weight and Fitness: Five of eight participants lost weight, with the group losing an average of nearly 11.5 lbs overall; these results compare with weight loss of only 2.8 lbs among controls (P = 0.07). Among those who lost weight, the loss averaged 24.4 lbs; BMIs fell from 34.1 kg/m2 to 30.0 kg/m2 (P < 0.05). Participants showed significant reductions in waist size (P < 0.02) and waist-hip ratios (P < 0.03) compared with controls. Participants also reduced their mean BMI from 34.5 kg/m2 to 32.2 kg/m2, while controls showed a reduction of only 0.8 kg/m2 (P = 0.07).
Attitudinal Measures of Palate Change and Changes in Cooking and Eating Habits: At post-test, participants reported cooking with fresh vegetables and grains significantly more often than controls (P < 0.03 and P < 0.01, respectively), and within the participant group, subjects cooked and ate more grains and fresh fruits (P < 0.03 in both). Similarly, participants reported a reduction in use of pre-packaged dinners (P < 0.02) and a concomitant increase in number of dinners cooked (P < 0.05) from the pre-test to the post-test. Participants also reported fewer hours of eating while watching TV compared with controls at post-test (P = 0.06).
Behavioral Measures of Eating and Exercise: Participants significantly decreased their use of fat and saturated fat over time (both P < 0.02). Participants also were significantly more likely to exercise than were controls at post-test (P < 0.001), and increased the duration of exercise over time (P < 0.0002). These results were largely maintained at six months.
Mini Program: Twenty (15 women, 5 men, non-Hispanic whites, average age 51.7 years) of the 23 participants completed the program. No follow-up data were available from the three dropouts; all three attended all but one of the scheduled sessions. Initial BMIs ranged widely: 25-29.9 kg/m2 = 7 (4 female, 3 male); 30-34.9 kg/m2 = 8 (6 female, 2 male); 35-39.9 kg/m2 = 0; 40+ kg/m2 = 5 (5 female); mean 33.58 kg/m2.
| Table 3-CHEF Clinic Recommended Kitchen Essentials | ||||
| Pantry | Refrigerator | |||
| Canned or dried beans: pinto, black, cannellini, kidney, garbanzo | Light silken tofu | |||
| Whole wheat pasta, couscous, and bread | Skim milk | |||
| Brown rice | Soy milk and soybeans | |||
| White, yellow, and red onions | Feta cheese | |||
| Garlic | Parmigiano-Reggiano | |||
| Canned tomatoes | Nonfat sour cream | |||
| Reduced-sodium, reduced-fat stocks or broths | Nonfat plain yogurt | |||
| Dried spices and herbs: bay, oregano, dill, black peppercorns, | Salsa | |||
| cumin seeds, aniseed, rosemary, coriander, curry, cinnamon | Seasonal fruits | |||
| Nuts: walnuts, Brazil nuts, almonds | Seasonal vegetables | |||
| Dried fruit: figs, apricots, cherries, raisins | Fresh herbs: cilantro, parsley, mint, thyme, basil | |||
| Vinegars: balsamic, Chinese black, herb, fruit-flavored, wine | Pizza shells | |||
| Extra virgin olive oil | Mustards: spicy brown, dijon, whole grain, other gourmet | |||
| Sea salt | flavors | |||
Physiological Health Effects: Eight of the 20 participants were on medication for hyperlipidemia. Total cholesterol levels dropped an average of 45 mg/dL from 241.4 mg/dL +/-40.5 to 196 mg/dL +/-16.7; HDLs rose from 51.3 mg/dL +/-18.9 to 54.5 mg/dL +/-15.6; LDLs dropped from 148.5 mg/dL +/-35.6 to 113.6 mg/dL +/-75.9; triglycerides dropped from 199 mg/dL +/-86.5 to 174.5 mg/dL +/-127.5. Average blood pressure fell from 133/80 mm Hg to 127/76 mm Hg. Two patients were able to avoid blood pressure medication altogether (150/84 mm Hg to 126/78 mm Hg; 170/108 mm Hg to 124/80 mm Hg). Body fat percentage dropped 11% overall, averaging 35.0% (range 16-53%) initially, dropping to 31.2% (range 15-44%).
Measures of Weight and Fitness: Nineteen of 20 CHEF Clinic participants lost weight, with the group losing an average of 12.2 +/-6.2 pounds, from an average of 206.4 lbs (range 142-332 lbs) to 194.2 lbs (range 141-292 lbs); one person gained 2 lbs, from 145 lbs to 147 lbs, and reduced her body fat from 42% to 26%. Mean BMIs fell from 33.58 kg/m2 to 31.79 kg/m2 (P < 0.05). CHEF Clinic participants also showed significant reductions in waist size (from 40 in to 37.8 in), hip size (from 46.9 in to 45 in), and waist-hip ratios (from 0.86 to 0.84).
Attitudinal Measures of Palate Change and Changes in Cooking and Eating Habits: At post-test, participants reported doubling the number of fresh vegetables eaten, consuming 3.5 +/-1.6 fresh whole vegetables daily (range 1.5-7.5), vs. 1.6 +/-1.0 (range 0-3) initially. Time spent cooking daily also rose from an average of 24.1 min +/-17 (range 0-60 min) to 33.2 min +/-17 (range 10-75 min). Most commonly snacked on foods changed from fruit, cookies, chips, candy, crackers, and ice cream to fruit, vegetables, yogurt, pretzels, and popcorn.
Behavioral Measures of Eating and Exercise: Participants averaged 48.6 min of largely aerobic exercise 4.6 times weekly at the conclusion of the program.
Comment
Our results show the short-term success of a skills-based lifestyle modification program in a controlled prospective research pilot and in a practice-based clinical study. In the research pilot and in practice, outcomes of reduced weight and waist and hip measurements, and significant increases in the number of whole fresh vegetables consumed were noted. Marked reductions in serum lipid levels were observed, and several patients were able to avoid blood pressure and lipid medication altogether.
Comprehensive weight management programs often focus on behavioral and educational strategies. Teaching practical cooking, shopping, and eating skills within such programs—and practicing those skills with specialists—has not been reported.
Sitting with a patient in an exam room with Family Café's menu, for example, is one thing. Sitting with that patient in a restaurant and watching her pour 4 oz of dressing (without tasting it) on her salad because it's "low fat" is another. Telling a patient how to select and roast a butternut squash is one thing; actually choosing and preparing it is another. Telling a patient not to eat because she's stressed is one thing; sticking a post-it on the fridge that says "It's not in here" or "Are you really hungry?" is another.
Our participants formed important bonds with other participants. Differentiating feelings of anxiety, frustration, loneliness, and boredom from hunger was an initial and necessary step for many. Learning to ask others for help—even for those people inclined to keep private things to themselves—was important for many people to build self-confidence.
Specific strategies were identified as helpful in transitioning from research to practice. (See Tables 1-3 and "Recommended Top High-Flavor, Healthful Cookbooks.)
More than half of Americans are considered overweight; the most recent NHANES study found that 63% of men and 55% of women had a BMI of 25 kg/m2 or greater.5 The prevalence of self-reported obesity (defined as a BMI > 30 kg/m2) has increased in the 1990s in every state, across all age groups and educational levels, and in both genders.6
Despite its substantial negative physical, emotional, medical, and economic effects,7 few physicians think of obesity as a rapidly spreading chronic disease in need of treatment, and fewer still can advise about diet or exercise. Physicians find that they have too little time, too little knowledge, too few good materials, and little or no reimbursement for counseling about weight management.8 Barely two of five overweight people are medically advised to lose weight, but those who do are nearly three times as likely to report making an effort as those who never receive advice.9
The strengths of the current data include their prospective nature; excellent community support and sponsorship; keen public interest in the study; its potential application within medical practice; its credible, professional, licensed staff; and its creative, fun, do-something approach to problems. All participants in the pre-study were eligible for the post-study. The changes appear to be substantial, unique, and directly the result of the intervention.
Weaknesses include a personal and professional tendency to focus on weight as a primary outcome instead of fitness. The relative efficacy of each of the component interventions cannot be ascertained. Participants were not randomized, and were motivated to change and to learn from each other. The clinical program is ambitious and comprehensive, requiring attention to detail, excellent organizational and coordinating skills, and careful follow-up.
Future research questions include testing a food-centered skills-based program to identify which components confer greatest benefit, and effective ways to teach and train others in this work. Similarly integrated approaches, such as that of the Ornish program, have now been funded on a trial basis by Medicare.
Conclusion
A multidisciplinary, skills-based, food-centered educational program offers a credible, novel departure from previous treatments for obesity, and effective treatment for elevated blood pressure and lipid levels. Practical strategies for helping patients eat in a more healthful way can be offered and implemented within a medical practice using a systematic, food-centered approach.
Dr. La Puma is Director, CHEF Clinic (Cooking, Healthy Eating and Fitness) at Alexian Brothers Medical Center, 800 Biesterfield Road, Elk Grove Village, Illinois, 60007; www.CHEFClinic.com. Ms. Becker is an Associate for Research at CHEF Clinic, and a senior student at Purdue University in West Lafayette, Indiana. For correspondence: [email protected]; 847-956-6433 (voice); 847-956-6629 (fax).
References
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3. Rosenbaum M, et al. Obesity. N Engl J Med 1997;337:396-407.
4. Committee to develop criteria for evaluating the outcomes of approaches to prevent and treat obesity. Thomas PR, ed. Weighing the Options: Criteria for Evaluating Weight Management Programs. Washington, D.C.: National Academy Press; 1995.
5. Must A, et al. The disease burden associated with overweight and obesity. JAMA 1999;282:1523-1529.
6. Mokdad AH, et al. The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282:1519-1522.
7. Thompson D, et al. Lifetime health and economic consequences of obesity. Arch Intern Med 1999;159:2177-2183.
8. Kushner R. Barriers to providing nutrition counseling by physicians: A survey of primary care practitioners. Prev Med 1995;24:546-552.
9. Galuska DA, et al. Are health care professionals advising obese patients to lose weight? JAMA 1999;282:1576-1578.
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