Research Highlights

1. Group meal preparation training builds knowledge, skills, and social support.
2. This enhances confidence in diabetes management and leads to eating behavior change.
3. Family engagement and support may amplify the effects.

Introduction

The past two decades have witnessed a marked increase in the ‘outsourcing’ of food preparation. [1]–[4] Dining out and consuming prepackaged convenience foods are frequently perceived to be more labour and time-efficient. Eating out may also be an opportunity for socialization. Unfortunately, such outsourcing generally results in a dietary intake that is high in fat, starch, sugar, and overall energy intake. [5], [6] This has contributed to a rise in prevalence overweight and obesity [7], [8] and the co-epidemic of type 2 diabetes [9], [10].

A condition characterized by high blood sugar (glucose) values, type 2 diabetes results from an increase in resistance to the action of the hormone insulin. Insulin normally facilitates the entry of glucose into the cells of the body. With insulin resistance, glucose cannot gain efficient entry to function as a fuel. This causes accumulation of glucose in the blood, exacerbated further by an insulin resistance-induced stimulation of the liver to increase glucose production. Insulin resistance results from a combination of excess weight, physical inactivity, and genetic predisposition. It leads to blood vessel damage not only through direct effects of high blood glucose levels but also higher levels of blood pressure and serum lipids and other factors. Type 2 diabetes more than doubles the risk of vascular disease such as heart attack and stroke. [11], [12] Attention to eating habits may not only prevent type 2 diabetes but may also reduce the risk of its vascular complications. [13]–[15] Net weight losses of as little as 2 to 5% in persons with type 2 diabetes have been associated with improvements in both blood pressure and glucose control. [16] Achieving even such a modest weight loss, however, is challenging in an environment that promotes and facilitates the outsourcing of food preparation. [17], [18] With this in mind, we have been developing a strategy designed to promote and facilitate home-based preparation of food, emphasizing taste and time efficiency [19].

The strategy was pilot tested [19] in adults with type 2 diabetes. It consisted of 15 in-person group sessions over 24 weeks, held at the kitchen workshops of two Montreal grocery stores. Each 3-hour session involved the hands-on preparation of a healthy, balanced meal under the supervision of a chef, with concurrent education and counseling from a registered dietitian. Participants were also provided with a book of recipes endorsed by the Canadian Diabetes Association, and encouraged to prepare meals at home using this tool. They received a step counter (pedometer) to track their physical activity levels (i.e., steps per day) and encouraged to increase their daily step count progressively to 10,000 steps per day or more. Completion of an average of 10,000 steps/day is consistent with being ‘active’. [20] A previous systematic review demonstrates that pedometer-based programs lead to higher daily step counts and lower blood pressure levels in several clinical populations, particularly when a specific target is provided (e.g., 10,000 steps/day) [21].

Among the roughly three quarters of participants who completed final assessments, there were improvements in eating control (11.2 point Weight Efficacy Lifestyle Questionnaire score change, 95% CI 4.7 to 17.8) and small but conclusive reductions in weight (mean weight change –2.2%; 95% CI –3.6 to –0.8) linked to clinically- important improvement in blood glucose control (mean A1C change –0.3%, 95% CI –0.6 to –0.1), as well as a strong suggestion of improvement in systolic blood pressure (mean change –3.5 mm Hg, 95% CI –7.8 to 0.9) [19].

In this paper, we endeavour to delineate the program elements that may have led to these improvements and to identify approaches that could increase effectiveness. We report herein the results of focus group discussion analyses conducted among participants following the program. The discussions were held to better understand the participants’ impressions and experiences regarding the program’s structure and its potential effects on their long- term eating habits. Interestingly, in recent years, a number of studies have demonstrated that healthy pre-prepared meals and meal substitutes are effective weight loss tools, both in general and in type 2 diabetes [22], suggesting that ‘healthier outsourcing’ is a potential option. Notwithstanding this evidence, meal replacements and healthier prepared meals are expensive, potentially monotonous, and socially-isolating choices. It is therefore important to develop behavioural change alternatives, and to gather evidence that demonstrates effectiveness. We believe that this qualitative study provides important information regarding a novel strategy that aims to reduce vascular disease risk in type 2 diabetes.

Methods

Focus Group Sessions

Each discussion lasted 120 minutes and was led by a moderator and an assistant, using questions (Table 1) developed by the research team. The questions addressed the decision to take part in the program, the actual experience of program participation, and participants’ impressions of impact on their lives. All discussions were audiotaped and transcribed (3 English, 1 French). The moderators held doctoral degrees in anthropology. Neither was involved in the original intervention study.

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Table 1. Focus Group Interview Questions.

https://doi.org/10.1371/journal.pone.0114620.t001

Results

Discussion

Glucose control is a central focus of type 2 diabetes management. Changes in eating and physical activity behaviours can importantly facilitate blood glucose lowering, reducing reliance on medication and concurrently improving other vascular risk factors such as elevated blood pressure. In a previous analysis, [19] we demonstrated that a group-based program with hands-on meal preparation training and pedometer-based self-monitoring could importantly lower glucose levels in adults with type 2 diabetes, even without marked reductions in weight. In the present qualitative analysis, we have delineated the program elements that the participants perceived as leading to this improvement (Fig. 1). These included the hands-on, interactive learning approach to meal preparation, the grocery store tour, pedometer-based self-monitoring, and peer support. During the program, they were able to ‘live’ the connection between improvements in eating and physical activity behaviours and improvements in blood glucose control. While they had been informed of this link in the past, the regular interactions with the chef, dietitian, and peers motivated them to adopt behavior changes, and they then witnessed the impact of these behaviours.

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Figure 1. Schematic summary of focus group themes and their possible inter-relationships.

The program tested included group-based hands-on meal preparation training under the supervision of a dietitian and chef, a grocery store tour, and pedometer-based self-monitoring. Focus group analyses indicate that the program led to a perception of peer and professional support, greater skills in meal preparation, more knowledge of healthy food choices and combinations, and greater awareness of step counts through pedometer-based self-monitoring. These stimulated changes in eating and physical activity behaviours and witnessing of impact on glucose levels. This enhanced self-efficacy in terms of diabetes management. In many cases, program participation stimulated health-related discussion at home; family interest and engagement enhanced the program’s effects. Lack of such engagement from family or friends, however, posed a barrier to improvement for some.

https://doi.org/10.1371/journal.pone.0114620.g001

The specific changes that participants reported included more regularity in meal consumption, such as not skipping breakfast, greater intake of vegetables and fish, reflection on food choices when shopping and eating out, and higher levels of walking. While the impact on weight was variable, participants more consistently observed reductions in their glucose levels and/or in doses of glucose-lowering medications. Family members were identified as both barriers and facilitators to program participation and adoption of healthy nutritional habits. Specifically, family-related responsibilities and taste preferences could pose challenges to changing eating habits, but some family members provided encouragement and support. Improvements in the dietary and physical activity habits of other family members were also motivating.

Social support emerged as a critical element to effectiveness of the strategy, consistent with the findings of a recent systemic review which identified social support as a key component associated with increased change in diet and/or physical activity in individuals at risk of type 2 diabetes. [15] The peer group reduced a sense of isolation in managing type 2 diabetes. The patience and availability of the chef and dietitian were greatly appreciated, perhaps in contrast to the brevity of many clinical encounters. Thus the shared activity of preparing and consuming a balanced meal had a motivating influence. Home-based social support, in the form of encouragement from family members, was also highly valued and motivating, particularly when family members also altered their eating and activity habits. Correspondingly, resistance of other family members to changes in meals was a potential barrier to change. This suggests that other family members may need to be more explicitly engaged in the behavioural change process, perhaps through participation in some sessions.

The nutritional information and culinary skills- building were also important elements. These led to greater consciousness of eating habits and consciousness of eating patterns. This in turn resulted in improved glucose control and/or weight change, further reinforcing the changes in habits. This is consistent with the Common Sense Model of Self- Regulation [24], which suggests that adherence to healthy behavior recommendations is facilitated by personal experience of positive change. This is also in line with the construct of testability in diffusion of innovations theory [25].

Interestingly, participants voiced a need for higher levels of tracking and monitoring, although they were tracking step counts with a pedometer (step counter) and each session commenced with a weigh-in. They appeared to desire a more personalized approach to goal- setting and accountability. This is consistent with our own work examining experiences during and following a supervised exercise program. [26] There is some evidence that self- monitoring of intake improves adherence to nutritional education, and digital technology may facilitate such monitoring [27]–[29] Review of such records, however, may be more challenging in a group-based context, and suggests a need to couple a group-based program with individualized review of self-monitoring records, perhaps during routine medical follow-up. While medical follow-up visits may not lend themselves to comprehensive behavioural change interventions, they may prove to be useful as sources of accountability and monitoring. Another alternative is feedback and support delivered through Internet-based sites linked with web-based logs. There is an emerging body of evidence suggesting promising results for Internet based features (i.e., on-line progress charts, journals) and social support (i.e., web chats) in terms of impact on weight loss and maintenance following program completion [30].

Participants expressed that the intervention increased their self- confidence (self-efficacy) in their ability to improve nutritional intake and manage diabetes. Self-efficacy, a construct from Social Cognitive theory that refers to one’s confidence to perform a given behaviour, [31] has previously been shown to be a key element in effective behaviour change diabetes prevention programs. [32] This finding lends support to the importance of including theory- driven behaviour change techniques to maximize the effectiveness of diabetes prevention programs [15], [32].

The focus group discussants included only those who had persisted with the program, not those who had been unable to continue. We acknowledge this as a limitation; the views of those who did not persist with the program may have differed. It is clear, for example, that on average focus group participants had more favourable outcomes in terms of weight loss, glycemic control, and blood pressure (S1 Information). Nonetheless, our qualitative findings, as identified through focus group discussion analyses, provide supporting evidence for the role that the intervention played in improving glycemic control and reducing body weight, as well as increasing step counts; that is, the themes that emerged from the focus group discussions indicate that the pre/post intervention improvements that we measured (i.e., weight reduction, step count increase, improved eating behavior control, hemoglobin A1c reduction, blood pressure improvements) [19] were indeed attributable to key components of the intervention itself, through its effects on knowledge, skills, and behavior.

Improving dietary and physical activity habits is a challenge for a large proportion of the population in the 21^st century. Adults with type 2 diabetes constitute a group of individuals who have not only developed their condition as a result of suboptimal eating and physical activity habits but are also at high risk of vascular disease-related complications, particularly if these health behaviours are not optimized. Conversely, small changes may result in important effects. The words and perspectives of our participants indicate that important elements to achieving behavioural change include not only knowledge, but also social support, skills-building, practice, and monitoring. The development and availability of programs aiming to provide this may be critical in stemming the tide of vascular disease complications that may be linked to the obesity and diabetes co-epidemics.

Supporting Information

Acknowledgments

Robbyn Sellar and Pierre Minn were our focus group moderators, with co-moderation by Christopher Mill. Debbie Chan played a key role in all aspects of project management, with invaluable assistance from Amanda Wilkins and Rita Motchula. Registered dietitians involved in the intervention included Gilda Bastasi, along with Lisa Kaouk, Marissa Ranallo, Laura Dytynyshyn, Stephanie Shabat, Geraldine St. Jules, Mary Hendrickson- Nelson, and Ani Tchakrian. The chefs who co- led the intervention sessions included Nicolina Servello, Philip Chang, Martin Patenaude, and Dahlia Gold. Paul Shubin and Martin Patenaude were the community liaisons/events coordinators at the grocery stores (Loblaws) where the sessions were held, providing critical logistic support. Jennifer Brennan provided important support in the preparation of this manuscript.