Scoping Review of Available Culinary Nutrition Interventions for People with Neurological Conditions

People with neurological conditions may face barriers to meal preparation. Culinary nutrition interventions aim to facilitate the building of knowledge and skills for meal preparation. This scoping review aims to map the available evidence for culinary nutrition interventions for people with neurological conditions and evaluate the quality of these interventions based on program design, delivery and evaluation. After a systematic search of online databases (MEDLINE, CINAHL, Embase, Scopus and Proquest) and reference lists, a total of ten publications describing nine interventions were included. Most interventions were designed for people with stroke and/or Transient Ischemic Attack (n = 3) and Multiple Sclerosis (n = 3); others were for traumatic brain injury (n = 1), mild dementia (n = 1) and Parkinson’s Disease (n = 1). Overall, the included culinary nutrition interventions had good program delivery (inclusion of motivational experiences, delivered by appropriate health providers) but needed improvements in program design (lack of consumer engagement and neurological symptom accommodations) and evaluation (lack of complete process, outcome and impact evaluations). In conclusion, the evidence base for culinary nutrition interventions for people with neurological conditions remains sparse. To bridge the gap between theory and practice, it is important to consider the following aspects in culinary nutrition intervention planning/improvement: (I) the involvement of consumers; (II) the accommodation/tailoring for post-condition effects; and (III) the coverage of all disease-specific culinary nutrition aspects.


Introduction
Living with a neurological condition (its post-condition effects, disease progression and drug-food interactions) can significantly impact an individual's nutrition and nutritional state [1].Neurological conditions are chronic conditions that affect the nervous system, including the brain and spinal cord, and the nerves that connect them [2].It is an umbrella term for more than 600 diseases such as stroke, Multiple Sclerosis (MS), Parkinson's Disease (PD), Alzheimer's Disease, epilepsy and Traumatic Brain Injuries (TBI) [2].
Current scientific evidence suggests that dietary intake plays an important role in managing neurological conditions (e.g., preventing malnutrition and managing disease Nutrients 2024, 16, 462 2 of 18 side effects).The European Society for Clinical Nutrition and Metabolism (ESPEN) clinical guidelines recommend people with neurological conditions engage with disease-specific dietary strategies tailored to their condition [1].For instance, ESPEN recommends people with MS consume adequate omega-6 fatty acids to potentially decrease the number and severity of MS relapses (strong consensus with 100% agreement from the evidence base) [1].People with PD are recommended to closely monitor their nutritional status (particularly vitamins D, B12 and folate) because these nutrient levels can be influenced by PD medications [1].Recent research findings also aligned with ESPEN guidelines, suggesting that disease-specific dietary strategies are beneficial for optimal management of neurological conditions [3][4][5].A recent review and a large-scale cohort study (60,000 participants) both confirmed that adherence to a Mediterranean diet was associated with improved cognitive performance and reduced risk of cognitive decline for people with Alzheimer's and Parkinson's Disease [3,5].Furthermore, reducing dietary saturated fats may decrease the risk of dementia progression [3].A recent systematic review (English et al.) also found that modifying certain dietary patterns is linked to reduced secondary stroke risk factors [4].These include higher adherence to a Mediterranean-style diet (or at least increased intake of fruits, vegetables and fibres) and avoiding excessive salt intake [4].
Although research has suggested various dietary strategies to manage neurological conditions, people with these conditions struggle to implement these due to the lack of well-designed nutrition education programs that adequately accommodate for clinical symptoms and outcomes.This was reported in a recent scoping review by Russell et al. (2022), which found that there was limited evidence of nutrition education programs for people with neurological diseases [6].Many published nutrition education programs also did not meet best-practice principles (i.e., not delivered by trained professionals, lack of appropriate evaluation processes) [6].Eating well for neurological conditions means consuming nutritionally appropriate meals tailored to an individual's condition.To eat well, people not only need nutrition knowledge, but also need to acquire the skills for performing various culinary nutrition tasks.Culinary nutrition tasks include planning meals, sourcing ingredients and cooking, compiling and storing meals.However, the effects of neurological conditions can make acquisition of these skills challenging.
Culinary nutrition is the application of nutrition knowledge combined with hands-on cooking skills to create nutritious and fulfilling meals [7].Culinary nutrition programs have so far been used for a limited number of varied population groups.For example, 'Cooking for Vitality' is a culinary nutrition intervention program that has been shown to significantly improve cancer-related fatigue (among cancer survivors) within two sessions of intervention [8].There is also evidence that culinary nutrition intervention programs have been effective for people with diabetes [9], the general healthy population [10] and Indigenous communities living in Australia [11].However, there is limited evidence for people with neurological conditions.
Hence, this scoping review aimed to map the available culinary nutrition interventions for people with neurological conditions, and to evaluate the quality of these interventions based on program design, delivery and evaluation.

Methodological Framework
This scoping review was conducted using the methodological framework for scoping reviews proposed by Arksey and O'Malley (2005) and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist [12,13].

Eligibility Criteria
Studies were included if they: 1. Included participants with neurological conditions (nervous system diseases, stroke, brain injuries, Multiple Sclerosis, Parkinson's Disease and Alzheimer's Disease etc.); 2. Met our criteria for a 'culinary nutrition intervention'.To qualify as a 'culinary nutrition intervention', the main goal of the intervention needed to be to develop participants' culinary nutrition literacy.Culinary nutrition literacy can be defined according to four areas (adopted from Vidgen et al., 2014): 'Plan & manage', 'Select', 'Prepare' and 'Eat ' [14].'Plan & manage' includes the ability to prioritise money and time for food, to plan and ensure regular accessibility to food intake and to make feasible food decisions that balance food needs with available resources [14].'Select' is the ability to determine the advantages, disadvantages, ingredients, origin, storage, usage and quality of food products [14].'Prepare' is the ability to have sufficient skills in making meals from available resources (food products and culinary equipment) while applying basic safe food handling and hygiene principles [14].'Eat' is the ability to understand the impact of meals on personal well-being, to demonstrate self-awareness of the necessity of having a balanced meal intake, and to join and eat socially [14].In addition, the culinary nutrition intervention needs to facilitate the development of cooking skills (cooking method and food preparation techniques) and/or food skills (meal planning, shopping, budgeting, resourcefulness and label reading) (adopted from Lavelle et al., 2017) [15].Cooking skills are the physical or mechanical skills used to produce a meal (e.g., boiling water and peeling vegetables), as well as the conceptual and perceptual skills (e.g., understanding the transformation food undergoes when heat is applied, i.e., knowing that food is fully cooked from its colour, etc.) [15].Food skills are the knowledge and skills to be able to prepare nutritionally and personally satisfying meals with the available resources [15].
We included all types of interventions (e.g., education, rehabilitation, nutrition therapy) unless they were not designed to support neurological condition survivors in a long-term home setting.For example, interventions designed for a hospital setting were excluded.
Additional exclusion criteria were as follows: all participants <18 years old; grey literature; review papers; and non-English-language articles.

Information Sources and Search
Comprehensive literature searches for potentially relevant articles were conducted in the following five online databases: MEDLINE, CINAHL, Embase, Scopus and Proquest during May 2023.Search strategies from each online database are included in Supplementary Table S1.Researchers developed the initial search strategy in MEDLINE (Supplementary Table S1).Similar search strategies were used to search the other identified databases.The final search results were exported into EndNote 20.2.1 referencing software [16].After removing duplicates, the results were uploaded into the online systematic review management system Covidence [17] for article screening purposes.Reviewers also hand-searched the reference lists of the final included studies for additional publications (August 2023).

Selection of Sources of Evidence
After the removal of duplicates from EndNote 20.2.1 [16] and Covidence [17], two authors (CTC and AP) double screened the first 20 records independently, discussed the results and resolved conflicts with a third author (LMW).Following this process, the inclusion/exclusion criteria were clarified and revised.This was to ensure consistency in the following screening process.Three authors single screened (CTC, AP or CE) the remaining records by their title and abstract.Potential full-text articles were double screened by two authors (CTC and AP), with conflicts resolved with LMW.Articles that met all inclusion criteria were included in this review.

Data-Charting Process and Data Items
A standardised data-charting form (a customised spreadsheet) was designed by CTC to chart data extracted from eligible publications (copy available from senior author on request).The included variables in the data-charting form were study characteristics (authors, year, country of study, journal, study design), study population (type of neurological condition, participants number and characteristics), characteristics of culinary nutrition intervention (name, aim of intervention, type of intervention, setting, group size, caregivers involvement, delivery personnel, duration, inclusion of behavioural change techniques, tailoring of the intervention), research outcome (evaluation tools, comparator, intervention outcome) and targeted culinary nutrition components (culinary nutrition content within the intervention, embedded knowledge provision/skills training, embedded food skills/cooking skills content, targeted culinary nutrition areas).These variables were included to map the culinary nutrition interventions and to analyse the program design (i.e., tailoring to disease-specific content, evidence-based, inclusion of culinary nutrition content), program delivery (i.e., inclusion of motivational experiences, educator characteristics) and program evaluation (i.e., inclusion of process, outcome and impact evaluations related to culinary nutrition knowledge and skills).
The culinary nutrition content of each intervention was analysed based on the culinary nutrition literacy components (Vidgen et al., 2014) [14], culinary nutrition skills (Lavelle et al., 2017) [15] and behavioural change motivational experiences (Fredericks et al., 2020).Fredericks et al., 2020, identified ten motivational experiences that can motivate sustainable behaviour change in culinary nutrition interventions [18].They determined that if these ten motivational experiences (Challenge, Celebration, Collaboration, Home Environment, Palate Development, Peer Support, Recipe Concept, Skill Building, Skill Reinforcement and Success) were experienced by participants during the intervention, it would effectively motivate them to develop the intended culinary nutrition-related skills [18].The definition of each motivational experience is detailed in Table 1.

Synthesis of Results
Results were synthesised narratively and are presented in Tables 2-4, and summarised in Table 5.We assessed the quality of the culinary nutrition content of the interventions based on the following criteria: (1) Program design (i.e., tailoring to disease-specific content, evidence-based, inclusion of culinary nutrition content).
(3) Program evaluation (i.e., inclusion of process, outcome and impact evaluations related to culinary nutrition knowledge and skills).

Included Studies
A total of 12,675 articles were retrieved using the search strategy (Supplementary Table S1).Once duplicates were removed, 8675 articles were single screened by title and abstract in Covidence [17] (CTC, AP, CE).The eligible 38 full-text articles were double screened (CTC, AP).We excluded 28 full-text articles due to them being: not an aim of interest (n = 12), not a study design of interest (n = 10), not a population of interest (n = 5) and not a setting of interest (n = 1).A total of ten eligible studies had data extracted for this scoping review [19][20][21][22][23][24][25][26][27][28], which included a total of nine culinary nutrition interventions (as one intervention was published across two articles [20,21]).The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flowchart (Figure 1) reports the flow of records into the review (Figure 1).

Synthesis of Results
Results were synthesised narratively and are presented in Tables 2-4, and summarised in Table 5.We assessed the quality of the culinary nutrition content of the interventions based on the following criteria: (1) Program design (i.e., tailoring to disease-specific content, evidence-based, inclusion of culinary nutrition content).
(3) Program evaluation (i.e., inclusion of process, outcome and impact evaluations related to culinary nutrition knowledge and skills).

Included Studies
A total of 12,675 articles were retrieved using the search strategy (Supplementary Table S1).Once duplicates were removed, 8675 articles were single screened by title and abstract in Covidence [17] (CTC, AP, CE).The eligible 38 full-text articles were double screened (CTC, AP).We excluded 28 full-text articles due to them being: not an aim of interest (n = 12), not a study design of interest (n = 10), not a population of interest (n = 5) and not a setting of interest (n = 1).A total of ten eligible studies had data extracted for this scoping review [19][20][21][22][23][24][25][26][27][28], which included a total of nine culinary nutrition interventions (as one intervention was published across two articles [20,21]).The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flowchart (Figure 1) reports the flow of records into the review (Figure 1).

Discussion
While developing culinary nutrition skills and knowledge are important following diagnosis with or rehabilitation for a neurological condition, few interventions were located for this scoping review.Our findings are similar to a recent scoping review on nutrition education programs, which also concluded that culinary nutrition interventions are lacking [6].There were only ten publications, divided among stroke, MS, mild dementia, PD and TBI.Similar to Russell et al.'s (2022) scoping review, we found no culinary nutrition interventions for people with epilepsy, Huntington's Disease or motor neuron disease, where all these patient groups could benefit from tailored culinary nutrition programs [30][31][32][33].
This scoping review found ten articles (reporting nine interventions) that had implemented culinary nutrition interventions for adults with neurological conditions.Overall, it was found that the delivery of these programs could be considered good but that improvements were needed in the design and evaluation of the interventions.
In terms of program delivery, it was positive to observe that most culinary nutrition interventions were delivered by appropriate health professionals (dietitians and occupational therapists), which was different from the findings of the Russell et al. 2022 review [6] on nutrition education for neurological diseases.The incorporation of motivational experiences that facilitate behavioural change was also evident in all interventions.These might have contributed to the successes (i.e., improved dietary quality and/or general well-being, improved QoL and better side effect management) seen for the included interventions.Although most programs were delivered in groups, there was a lack of guided peer support or collaborative activities in the included interventions.These activities were found to be encouraging for participants during the rehabilitation process for people with TBI, stroke, PD or MS [34].Future programs should, therefore, consider the addition of these experiences for better outcomes.The optimal duration and frequency for a culinary nutrition intervention was inconclusive as the included interventions were either embedded within other health programs, were self-paced or did not report these data.
In terms of program design, all included culinary nutrition interventions had tailored their programs to align with evidence-based recommendations from recent clinical guidelines and research [1,3,5].However, only a few interventions [19,23,28] addressed the accommodation of neurological side effects (dysphagia, fatigue, gut health, inflammation), which may be a barrier to good nutrition [35].The included culinary nutrition interventions were generally not personalised enough to be adequately tailored for the participants' individualised recovery journey.Most interventions were delivered via scheduled sessions, resulting in limited flexibility for participants to attend and engage regularly, especially considering the additional barriers from neurological side effects.People from culturally and linguistically diverse backgrounds are at increased risk of poor nutrition due to additional multifactorial barriers (socioeconomic, healthcare systems and providers) in accessing healthcare and healthier food choices [36][37][38].However, there were only two stroke programs [20][21][22] that included culturally and linguistically diverse (Spanish-speaking, African American) participants in the United States, showing that more work needs to be carried out in these areas.The importance of consumer engagement and co-design in healthcare interventions has increasingly been recognised in recent years [29].Consumer engagement and co-design have shown potential in aligning health services with consumer needs, and improving engagement and uptake with healthcare [29].Consumers include the people who receive the care, people with lived experience, people who provide care or decision makers [29].Within the current evidence base, there was only one MS online learning intervention [25] that utilised a co-design approach, meaning 90% of the culinary nutrition interventions were not co-designed with any consumer partners, and were solely planned by researchers.
Research shows that completing all stages of evaluation (process, impact and outcome) can result in a more engaging health-related behavioural change intervention [39].Most studies only completed either one or two stages of evaluation, with appropriate culinary nutrition-related measures.For instance, quality of intervention and participant engage-ment were measured in process evaluation; dietary and biomedical measures were utilised in impact evaluation; and quality of life and meal preparation attitudes were evaluated in outcome evaluation.Among all the included studies, only one study considered the sustainability of behaviour change [26].As culinary nutrition skills can be improved by sustained behavioural change, future studies should consider evaluating their outcome sustainability and provide future directions in this area.
Among the limited publications, all the included culinary nutrition interventions were delivered by appropriate health professionals using evidence-based content.More work needs to be carried out in peer support activity planning, the accommodation of side effects and cultural barriers, consumer engagement and evaluating outcome sustainability.
There were a few limitations in this scoping review, with the small number of eligible studies being the main one.Due to the small number of eligible studies, this scoping review included diverse study designs and methodologies, leading to heterogeneity in the data.Due to the limited data, the critical appraisal of study quality was omitted, which may limit the depth of our findings.Additionally, all included interventions had short study periods (less than a year) and small sample sizes (n = 4 to 100), which are barriers to analysing the outcomes of culinary nutrition interventions.Publication bias is another possible limitation given the small number of studies found and the mostly positive reported outcomes.As evidenced by the fact that included studies were mostly recent publications, research in the area of culinary nutrition programs is growing rapidly.Hence, this scoping review may need to be repeated in the near future and should include a search of registered trials to capture the full breadth and scope of the research activity.All the above limitations may limit the generalisability of our findings.
Despite these limitations, this was a thorough scoping review and mapped all the available culinary nutrition interventions for multiple types of neurological conditions at this time.Substantial work was undertaken to evaluate each of the interventions in relation to the program design, delivery and evaluation.

Conclusions
Culinary nutrition interventions for neurological conditions are a complicated area of development due to the complexity, variety and individuality of diagnoses and disease progression.The availability of evidence-based culinary nutrition programs is lacking in many neurological conditions with only limited numbers in stroke, MS, PD, dementia and TBI.It is promising, however, to observe the increased number of studies in recent years, with more focused on living well with the neurological conditions.To bridge the gap between theory and practice, it is important to consider these aspects in culinary nutrition intervention planning/improvement: (I) the involvement of consumers; (II) the accommodation/tailoring of post-condition side effects; (III) and the coverage of all diseasespecific culinary nutrition aspects (culinary nutrition literacy components (Vidgen et al., 2014), culinary nutrition skills (Lavelle et al., 2017) and behavioural change motivational experiences (Fredericks et al., 2020)).More research is needed in the areas of stroke, MS, TBI, mild dementia and PD.In addition, there are many neurological conditions without any current evidence base, including but not limited to Epilepsy, Alzheimer's Disease and Huntington's Disease.

Figure 1 .
Figure 1.The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flowchart.

3. 5 .
Summary of Program Design, Delivery and Evaluation for Included Interventions (Table

Table 2 .
Study characteristics of included studies.

Table 3 .
Characteristics of included interventions.

Table 4 .
The culinary nutrition components and intervention outcome from included articles.