Review Reports - Culinary Nutrition Programming for Members of a Community-Based Cancer Program

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study employed a mixed-methods approach to explore the supportive role of the New Jersey State Cancer Cooking Nutrition Program (NJSC), revealing its multiple values in terms of psychosocial support and the promotion of plant-based diets. The inclusion of cancer survivors and their support networks, along with the development of directly applicable nutrition guidelines and recipes, demonstrates both population inclusiveness and practical translational significance. However, several issues need to be further improved:
1. The sample size of this study was 41 individuals (40 interviews), which is relatively small. Although a mixed-methods design was adopted, the multivariate regression model and subgroup analysis in the quantitative analysis might be limited by the sample size, resulting in insufficient statistical power.
2. The study utilized a simplified food frequency questionnaire (FFQ) focusing on protein-rich foods, without assessing the intake of key foods such as fruits and vegetables. However, the qualitative results repeatedly mentioned an increase in participants' fruit and vegetable intake, but lacked quantitative data to support this core dietary change.
3. The paper mentioned that two researchers independently coded the qualitative data, but did not report the results of the consistency test (such as Cohen's kappa coefficient) or explain the mechanism for resolving discrepancies.
4. The results showed a significant correlation between participation duration and nut intake, but did not delve into the relationship between the project's intervention measures and this association (such as the frequency of nut use in the recipes or the emphasis on nuts in nutrition education).
5. The study subjects were 88% female and only 12% male, indicating a significant gender bias. The dietary needs and social preferences of male cancer patients and caregivers may differ from those of females, and the current results are difficult to generalize to the male population.
6. The study developed cancer nutrition guidelines, recipe collections, and other resources for promotion, but did not report the actual usage of these resources.
7. The study was a cross-sectional design and lacked follow-up data, making it impossible to assess the long-term impact of the program on participants' dietary behaviors and health status.
8. Although the discussion section mentioned several similar cooking intervention studies, it did not systematically compare the intervention characteristics and outcome differences among these studies.

Author Response

We thank the Reviewers for their insightful comments. We have addressed all comments, reviewed the manuscript in detail for readability and clarity, and revised the manuscript accordingly. We feel the revisions have improved our manuscript. Our responses to each of the comments are indicated point-by-point in the attached Author Response Letter. We have also shared the responses below.

Reviewer 1

Response: Thank you for recognizing the inclusiveness and practical translational significance of our research on the Not Just Supper Club (NJSC) program. We agree that serval areas could be further improved and have addressed each of your comments point-by-point below.

Comment 1. The sample size of this study was 41 individuals (40 interviews), which is relatively small. Although a mixed-methods design was adopted, the multivariate regression model and subgroup analysis in the quantitative analysis might be limited by the sample size, resulting in insufficient statistical power.

Response 1: We thank the reviewer for pointing this out. We agree that our sample size is a limitation and have further emphasized this within the Limitations section of the manuscript. The section reads:

Discussion (Page 17, Line 565) “Several limitations should also be acknowledged. The small sample size limits statistical power, particularly for multivariable regression and subgroup analyses, and warrants cautious interpretation of quantitative findings. Larger, adequately powered studies are needed to confirm these findings.”

We would like to highlight that compared to other published research on culinary cancer programs, our sample size is average with most studies including 20-50 participants ) (see Johnston et al., 2024, Table S3, link: https://data.mendeley.com/datasets/p893jb9khz/1) with interview-based qualitative analyses studies generally having smaller sample sizes (e.g., O'Callaghan et al., 2022 including 20 participants and Murat-Ringot et al., 2025 included 6 participants). While small, we believe our study contributes to the growing literature on culinary cancer programs and culinary medicine in general.

References:

Johnston EA, Ayre SK, Au-Yeung YT, Goodwin BC. A Scoping Review of Group Nutrition Education and Cooking Programs for People Affected by Cancer. J Acad Nutr Diet. 2024;124(10):1302-27.e1.

O'Callaghan N, Douglas P, Keaver L. A qualitative study into cancer survivors' relationship with nutrition post-cancer treatment. J Hum Nutr Diet. 2023; 36: 406–414. https://doi.org/10.1111/jhn.13094

Murat-Ringot, A., Lan, R., Goetz, E., Basbous, L., Charreyre, M. T., & Carrouel, F. (2025). Peer-led plant-based cooking workshops for post-cancer patients: an observational pilot study on dietary practices. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 33(11), 978. https://doi.org/10.1007/s00520-025-10049-z

Comment 2. The study utilized a simplified food frequency questionnaire (FFQ) focusing on protein-rich foods, without assessing the intake of key foods such as fruits and vegetables. However, the qualitative results repeatedly mentioned an increase in participants' fruit and vegetable intake, but lacked quantitative data to support this core dietary change.

Response 2: We appreciate this important comment. We agree that the simplified FFQ used in this study focused primarily on protein-rich foods and did not comprehensively assess total dietary intake, including fruits and vegetables. This decision was intentional and guided by considerations of participant burden within a community-based cancer support setting. We have revised the discussion to more clearly acknowledge that fruits and vegetables were not quantitatively measured despite emerging as prominent themes in the qualitative findings.

Discussion (Page 15, Line 496): “Participants also reported increasing their intake of fruits and vegetables after attending NJSC. These changes could not be quantitatively evaluated because the abbreviated protein-focused FFQ did not assess fruit and vegetable consumption. Therefore, we are unable to determine whether perceived increases translated into measurable dietary change. However, this perceived dietary change remains notable, as higher fruit and vegetable intake is strongly recommended by cancer nutrition guidelines. Future evaluations should incorporate a more comprehensive dietary assessment to quantify changes in all measures of dietary quality”

Comment 3. The paper mentioned that two researchers independently coded the qualitative data, but did not report the results of the consistency test (such as Cohen's kappa coefficient) or explain the mechanism for resolving discrepancies.
Response 3: We thank the reviewer for highlighting this. We have added the mechanism for resolving discrepancies for coding the interviews.

Methods (Page 5, Line 210): “Discrepancies were resolved by consensus or arbitration by the senior author. Upon reaching consensus on the coding, BJH and JS collaboratively examined the coded transcripts to identify and develop overarching themes.”

Comment 4. The results showed a significant correlation between participation duration and nut intake, but did not delve into the relationship between the project's intervention measures and this association (such as the frequency of nut use in the recipes or the emphasis on nuts in nutrition education).
Response 4: We thank the reviewer for this important comment. We have expanded both the Methods and Discussion to clarify how nuts were incorporated into the NJSC intervention, including their frequency of use in recipes and their emphasis within the nutrition education. We agree these additions help contextualize the observed association between duration of participation and reported nut intake.

Methods (Page 4, Line 159): “Plant protein foods such as nuts, seeds, pulses (beans, chickpeas, lentils, etc.,) and soy foods (tempeh, tofu, edamame, etc.,) were a major focus of the program, as these foods have been associated with health benefits related to cancer [29, 32-34] and other chronic diseases [35-37], and are not commonly consumed by most Canadians [38]. These plant protein foods including nuts, seeds, pulses and soy foods were regularly incorporated into program recipes and were featured in the majority of shared meals and cooking demonstrations. Members were shown plant-based adaptations of familiar dishes, demonstrating how foods to limit, such as red meat can be substituted with options like tempeh or lentils [39].”

Discussion (Page 15, Line 472): “Plant protein foods including nuts, seeds, pulses (beans, chickpeas, lentils, etc.,) and soy foods (tempeh, tofu, edamame, etc.,) were all a major focus of the NJSC program. The reason nuts were positively associated with duration at NJSC, but no associations were observed for other plant protein foods, needs to be further explored. Higher adherence to nuts compared to other plant foods has been observed by others [49], possibly due to nuts requiring less preparation and being highly palatable. Nuts were included in approximately one third of the dishes prepared for members and were emphasized in the nutrition education sessions. These findings are encouraging as nut consumption has been inversely associated with cancer risk [34].”

Comment 5. The study subjects were 88% female and only 12% male, indicating a significant gender bias. The dietary needs and social preferences of male cancer patients and caregivers may differ from those of females, and the current results are difficult to generalize to the male population.

Response 5: We agree that the predominance of female participants is an important limitation and our findings may not be generalizable to males. Recruitment occurred within an active culinary cancer care program, and participation was therefore limited to current attending members. Prior research has demonstrated that women on average are more likely than men to engage in cancer-related psychosocial and support group programs, as well as in health-related help-seeking behaviors more broadly (Hoyt, 2009; Galdas et al., 2005). This may partially explain the sex distribution observed in our study. We have now explicitly acknowledged this limitation in the Discussion. To further explore potential differences, we also conducted sex-stratified analyses to evaluate whether the association between time spent at NJSC (years) and nut intake (servings/day) differed by sex (Table S3). There was no statistical evidence of effect modification by sex (p for interaction = 0.42). However, given the small number of male participants, these analyses should be interpreted cautiously.

Discussion (Page 17, Line 568): “Restriction of our participant population to current NJSC members may have resulted in a predominance of female participants (88%), limiting the generalizability of our findings to male cancer patients and caregivers and to individuals who do not enroll in or remain engaged with culinary cancer care programs.”

References:

Hoyt MA. Gender differences in help-seeking among cancer patients. Cancer Nurs. 2009.
Shows that male cancer patients are significantly less likely to engage in psychosocial and group-based support interventions.

Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. Health Psychol Rev. 2005.

Comment 6. The study developed cancer nutrition guidelines, recipe collections, and other resources for promotion, but did not report the actual usage of these resources.
Response 6: We thank the reviewer for highlighting this important point. The cancer nutrition guidelines, recipe collections, and related materials were developed iteratively alongside the program beginning in 2012 and were integrated into routine program delivery. Recipes and educational materials were continuously refined over time based on participant feedback, preferences, and practical experience within sessions, allowing the program to evolve responsively to the needs of the community. The Community Guide to Cancer Nutrition is essentially all of the handouts from the information sessions created during the program in one concise, edited document.

Formal measurement of individual resource utilization (e.g., frequency of access or independent use outside sessions) was not part of the original evaluation framework. This study focused on evaluating participant characteristics and reported dietary patterns rather than tracking engagement with specific educational materials. However, in the qualitative component we did ask them if the information provided (which includes resources like the handouts and guides) changed their behaviours, but we did not formally ask if they utilized the resources and handouts they were provided AFTER their exposure to our programming. Anecdotally though we hear members discuss how they still use the resources religiously. We agree that future evaluations could incorporate structured assessment of resource utilization to better understand how these materials contribute to dietary behavior change and program impact.

We have included a comment to emphasize the importance of future work on this within the limitations section of the Discussion

Discussion (Page 17, Line 582): “Additionally, this study did not formally measure individual at-home use of the evidence-based resources provided during NJSC programming. Future evaluations should incorporate a structured assessment of resource utilization to better understand its impact on dietary behavior change, cancer nutrition knowledge, and food literacy.”

Comment 7. The study was a cross-sectional design and lacked follow-up data, making it impossible to assess the long-term impact of the program on participants' dietary behaviors and health status.
Response 7: We agree with the reviewer and have clarified this limitation in the Discussion and explicitly noted the need for prospective evaluations with longitudinal follow-up to assess sustainability of dietary changes and potential impacts on clinical and psychosocial outcomes.

Discussion (Page 17, Line 573): “Additionally, this study was cross-sectional and dietary data were collected at a single time point, which precluded direct assessment of sustained changes over time…. Larger, adequately powered longitudinal studies with repeated dietary assessments and clinical measures are needed to evaluate the durability of behavioral changes and potential long-term health impacts of culinary cancer care programs.”

Comment 8. Although the discussion section mentioned several similar cooking intervention studies, it did not systematically compare the intervention characteristics and outcome differences among these studies.
Response 8: We agree and have revised the Discussion to provide a more systematic comparison of intervention characteristics (e.g., study design, duration, delivery format, sample size, and caregiver inclusion, etc.,). We have also incorporated additional recent studies not included in the Johnston et al. scoping review to provide a more comprehensive and up-to-date comparison. In addition to including 2 recent qualitative interview based studies.

Discussion (Page 16, Line 503): “This study is one of the few to examine the experiences of participants in an ongoing culinary cancer care program in Canada. A recent scoping review by Johnston et al. identified 37 group-based nutrition education and cooking programs for people affected by cancer, highlighting growing but still limited evidence in this area [52]. The review noted substantial heterogeneity in study design especially delivery format (in-person vs. virtual) and outcome measures. Most interventions (n=21) were conducted in the US, with only 4 studies in Canada, they were short-term (typically 6–12 weeks), and focused primary on behavioural or psychosocial endpoints rather than dietary patterns.
Several interventions have employed structured, time-limited programs delivered virtually or in-person with quantitative pre–post assessments. Huang et al. conducted a 9-week virtual teaching kitchen intervention focused on plant-based and Mediterranean dietary patterns among 102 breast cancer survivors and reported improvements in mindful eating behaviors in a pre–post design [53]. Likewise, Allen-Winters et al. piloted a 8-week culinary medicine program in a small cohort of children/caregiver dyads (n = 9 dyads) demonstrating improvements in dietary choices and cooking confidence in a pre–post design [13]. Barak-Nahum et al. evaluated a 10-week culinary group intervention within a controlled trial among 109 adult cancer patients and found improvements in dietary behaviors, health related quality of life, and psychological well-being when compared with a control group [54].
More recent work not included in the Johnston review includes Pritlove et al., who conducted a pilot culinary nutrition intervention among gynecologic cancer survivors (n = 53) in Canada treated with pelvic radiotherapy, reporting improvements in digestive symptoms and self-reported dietary practices in a pre–post design [55].
Qualitative work has provided insight into survivors’ lived experiences with food following cancer treatment. O’Callaghan et al. conducted an interview-based qualitative study with 20 cancer survivors and reported that post-treatment nutrition experiences were shaped by evolving beliefs about food, uncertainty, and the desire for practical, trustworthy guidance [56]. Similarly, Murat-Ringot et al. described an observational pilot of peer-led plant-based cooking workshops among six post-cancer participants, highlighting perceived improvements in dietary practices, social connectedness, and empowerment [57]. These qualitative studies emphasize the psychosocial and experiential dimensions of nutrition after cancer, complementing the behavioural outcomes reported in structured interventions.
In contrast to these interventions, NJSC represents an ongoing, real-world community-based culinary cancer care program embedded within a support organization. By including both cancer survivors and their support networks in the same program, our findings represent the lived experiences of all members in the NJSC. While less common, the inclusion of caregivers in culinary cancer care research offers a more holistic approach to support, acknowledging the interconnectedness of the patient’s well-being and the well-being of their support network. In a scoping review of group nutrition education and cooking programs for those affected by cancer, only four of the 37 programs invited caregivers to attend [52]. This limited inclusion represents a notable gap as caregivers may be at a higher risk of poor dietary intake while providing care [21] and often assume primary responsibility for meal preparation [22]. By involving caregivers, programs can enhance the application of the intervention and may encourage sustained long-term healthy eating habits within the household.”

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, I appreciate the opportunity to review your interesting manuscript. After reading it, I would like to offer some comments/suggestions for improvement.

- I find the introduction comprehensive, well-detailed, and well-referenced. Perhaps I would like to see a more detailed explanation of what a plant-based meal program specifically entails. It is not entirely clear what types of foods are included, how frequently, and why other foods, documented in the literature as beneficial for cancer patients, are avoided.

- Regarding the methodology used, you indicate that the data were collected between 2017 and 2019. Why did you wait so long to publish them? The data you present could be outdated. Cancer research, and especially research related to nutrition, has improved and evolved overwhelmingly in recent times. I would appreciate an explanation for this, as you also do not provide a comparative study of that initial data with the current data.

- Almost all the participants were women. Why is this? Many of them had the same type of cancer. Are the dietary recommendations the same for different types of cancer? With the method described, did all patients eat the same types of food, the same amount...?

- They included 13 caregivers in the sample...don't you think the inclusion of these people affects the results? They aren't cancer patients themselves. I'm sorry if I haven't understood correctly.

- Figure 1 is very blurry.

- I think Table 4 (nuts) could be omitted since the results obtained are not representative.

- I liked that they included the testimonials of some participants, and that adds value to the work.

- Another question I have is...is this work the starting point for others?

Thank you very much

Author Response

Reviewer 2

Dear authors, I appreciate the opportunity to review your interesting manuscript. After reading it, I would like to offer some comments/suggestions for improvement.

Comment 1. I find the introduction comprehensive, well-detailed, and well-referenced. Perhaps I would like to see a more detailed explanation of what a plant-based meal program specifically entails. It is not entirely clear what types of foods are included, how frequently, and why other foods, documented in the literature as beneficial for cancer patients, are avoided.
Response 1. Thank you for highlighting our introduction is well written. The meal program provided to NJSC patrons which consisted of a soup, salad, main, pasta and dessert, focused on the most recent cancer nutrition guidelines and took into consideration attendee’s dietary needs, restrictions and allergies. We have added an example of a menu to the supplement (Figure S4). Overall, the meals provided were culturally diverse and the ingredients used focused on fruits, vegetables (particularly leafy greens, cruciferous, red and orange vegetables), nuts, seeds, legumes and other high-quality plant-based proteins such as tofu, tempeh, and edamame. We agree the manuscript could provide a more detailed explanation of what a plant-based meal program specifically entails and have revised the Methods to include a new section 2.3 Plant-based Meal Program describing the program in more detail.

Methods (Page 4, Line 144): “
2.3. Plant-based Meal Program
The meal program provided to NJSC patrons which consisted of a soup, salad, main, pasta and dessert, focused on the most recent cancer nutrition guidelines and took into consideration attendee’s dietary needs, restrictions and allergies (Figure S4). As an observational evaluation of an existing community-based culinary cancer support program, the program did not prescribe individualized meal plans, caloric targets, or weight-related goals; rather, it emphasized whole, minimally processed foods, particularly plant-based protein sources, within a group-based educational setting.
Menus were informed by current cancer nutrition evidence [24-29] and guidelines [30, 31], emphasizing whole plant-based ingredients including fruits, vegetables (particularly leafy greens, cruciferous, red and orange vegetables), whole grains and high-quality plant-based proteins and to minimize sugar-sweetened beverages, processed meats, and red meats. Plant protein foods such as nuts, seeds, pulses (beans, chickpeas, lentils, etc.,) and soy foods (tempeh, tofu, edamame, etc.,) were a major focus of the program, as these foods have been associated with health benefits related to cancer [29, 32-34] and other chronic diseases [35-37], and are not commonly consumed by most Canadians [38]. These plant protein foods including nuts, seeds, pulses, and soy foods were regularly incorporated into program recipes and were featured in a majority of shared meals and cooking demonstrations. Members were shown plant-based adaptations of familiar dishes, demonstrating how foods to limit, such as red meat can be substituted with options like tempeh or lentils [39].”

Comment 2. Regarding the methodology used, you indicate that the data were collected between 2017 and 2019. Why did you wait so long to publish them? The data you present could be outdated. Cancer research, and especially research related to nutrition, has improved and evolved overwhelmingly in recent times. I would appreciate an explanation for this, as you also do not provide a comparative study of that initial data with the current data.
Response 3: We thank the reviewer for this important question. The data collection period (2017–2019) reflects a defined evaluation phase of the ongoing community-based culinary cancer support program. Data analysis and manuscript preparation were subsequently impacted by the COVID-19 pandemic. Importantly, the structure and core principles of the program have remained consistent, and the findings continue to reflect the current model of delivery (i.e. what we provided during those years is the same as what we provide now). The program’s emphasis on whole, minimally processed foods and plant-based protein sources remains aligned with contemporary cancer survivorship and chronic disease prevention guidelines (World Cancer Research Fund; American Cancer Society). We have cited these guidelines within the manuscript to emphasize its relevance. Although cancer nutrition research continues to evolve, the foundational dietary principles examined in this evaluation remain relevant and consistent with current recommendations.

Because this study was designed as an evaluation of a defined participant cohort rather than an ongoing surveillance study, we did not collect additional contemporary comparison data. We agree that future research could examine temporal trends or compare cohorts across different program phases to further strengthen the evidence base. By including recent and relevant publications in the area of culinary nutrition cancer programming (Johnston et al., 2024) and updating our discussion of the current evidence (See our response to Reviewer 1 (Comment #8), we highlight this work is topical and relevant to ongoing community cancer programs.

References

World Cancer Research Fund. Our cancer prevention recommendations. Eat wholegrains, vegetables, fruit and beans. Accessed from: https://www.wcrf.org/research-policy/evidence-for-our-recommendations/wholegrains-veg-fruit-beans/ Accessed on January 2026.

World Cancer Research Fund International/CUP Global. Dietary and Lifestyle Patterns for Cancer Prevention: Evidence and Recommendations from CUP Global. 2025. https://www.wcrf.org/wp-content/uploads/2025/09/DLP_Report_FINAL_updated.pdf Accessed September 10, 2025.

Rock CL, Thomson C, Gansler T, Gapstur SM, McCullough ML, Patel AV, et al. American Cancer Society guideline for diet and physical activity for cancer prevention. CA: A Cancer Journal for Clinicians. 2020;70(4):245-71.

Johnston EA, Ayre SK, Au-Yeung YT, Goodwin BC. A Scoping Review of Group Nutrition Education and Cooking Programs for People Affected by Cancer. J Acad Nutr Diet. 2024;124(10):1302-1327.e1.

Comment 3. Almost all the participants were women. Why is this? Many of them had the same type of cancer. Are the dietary recommendations the same for different types of cancer? With the method described, did all patients eat the same types of food, the same amount...?
Response 3: Recruitment occurred within an active community-based culinary cancer support program, and participation was limited to current participating members. This study was not a dietary intervention trial, but rather an evaluation of an ongoing cancer support program delivered in a real-world setting. As such, participants self-selected into the program and were not recruited based on cancer type, stage, or dietary needs. We believe the predominance of women likely reflects broader patterns of engagement in psychosocial and support-based programming. Prior research has demonstrated that women are more likely than men to participate in cancer-related support groups and to engage in help-seeking behaviors (Hoyt, 2009; Galdas et al., 2005). We have addressed this further in our response to Reviewer 1 (Question #5) and acknowledge this as a limitation in terms of generalizability.

With respect to dietary guidance, the program did not prescribe individualized meal plans, specific caloric targets, or weight-related goals. Instead, participants were encouraged to consume whole, minimally processed foods, with an emphasis on incorporating plant-based protein sources (e.g., legumes, nuts, seeds, soy foods) which align with current cancer survivorship and chronic disease prevention guidelines (World Cancer Research Fund; American Cancer Society) which are not specific to one cancer type. The program was designed to promote food literacy, culinary confidence, and social connection rather than to standardize intake across participants.

We have added a section to clarify these details within the methods:

Methods (Page 4; Line 147): “As an observational evaluation of an existing community-based culinary cancer support program, the program did not prescribe individualized meal plans, caloric targets, or weight-related goals; rather, it emphasized whole, minimally processed foods, particularly plant-based protein sources, within a group-based educational setting.”

Comment 4. They included 13 caregivers in the sample...don't you think the inclusion of these people affects the results? They aren't cancer patients themselves. I'm sorry if I haven't understood correctly.
Response 4: Thank you for the question. Caregivers are an important and often overlooked population (Million et al., 2025; Johnston et al., 2024). They have been found to be at a higher risk of poor dietary intake while providing care (Ezendam et al., 2019) and often assume primary responsibility for meal planning and preparation (Molassiotis et al., 2021). This limited inclusion represents a notable gap with a recent scoping review of group nutrition education and cooking programs for those affected by cancer highlighting that only four of the 37 programs invited caregivers to attend (Johnston et al., 2024).

Part of Gilda’s mantra is that “no one faces cancer alone” and that they support “the whole family the whole time.” By including both cancer survivors and their support networks in the same program, our findings represent the lived experiences of all members in the NJSC. While less common, the inclusion of caregivers in culinary cancer care research offers a more holistic approach to support, acknowledging the interconnectedness of the patient’s well-being and the well-being of their support network. By involving caregivers, programs can enhance the application of the intervention and may encourage sustained long-term healthy eating habits within the household.

To investigate if the inclusion of the caregivers (n=13) may have influenced the observed findings, we have performed a separate sensitivity analyses to address the reviewers concern. We observed that the positive association between time spent at NJSC and total nut intake remained directionally consistent in caregivers but was attenuated and no longer statistically significant after multivariable adjustment (β adj = 0.41 servings/day per year; 95% CI −0.49 to 1.32), whereas among participants with cancer (n=28), the adjusted association was β = 0.57 (95% CI −0.11 to 1.24). These estimates are similar to the primary finding in the full sample (β adj = 0.49; 95% CI 0.02 to 0.96). There was also no statistical evidence of effect modification by caregiver status (p for interaction = 0.78). We have also revised the Introduction and Methods sections to clarify and emphasise the rationale for including caregivers.

Introduction (Page 2, Line 81): “Often overlooked, caregivers may be at higher risk of poor diet quality while providing care. Given that they frequently assume primary responsibility for meal preparation, they also represent an important target for implementation of nutrition strategies.”

Methods (Page 3, Line 115): “Eligible participants were adults (≥18 years) who were members of GT, had attended at least two NJSC events, and were either living with cancer, had a household or family member living with cancer, or had recently experienced the death of a household or family member from cancer. The inclusion of caregivers in the study ensured the findings represent the lived experiences of all members.”

References

Milliron, B. J., Mountain, P., Salman, K., Longo, G., Schlechter, H., Deutsch, J. M., & Jubelirer, T. (2025). Culinary medicine for caregivers: protocol for a mixed-methods feasibility study to improve pediatric cancer patient and caregiver outcomes through nutrition and culinary support. Pilot and feasibility studies, 11(1), 120.

Johnston EA, Ayre SK, Au-Yeung YT, Goodwin BC. A Scoping Review of Group Nutrition Education and Cooking Programs for People Affected by Cancer. J Acad Nutr Diet. 2024;124(10):1302-1327.e1.

Ezendam NPM, Karlsen RV, Christensen J, Tjønneland A, van de Poll-Franse LV, von Heymann-Horan A, et al. Do people improve health behavior after their partner is diagnosed with cancer? A prospective study in the Danish diet, Cancer and Health Cohort. Acta Oncol. 2019;58(5):700-7.

Comment 5. Figure 1 is very blurry.
Response 4: Thank you. We have revised Figure 1 in the manuscript document and also uploaded the png image directly onto the journal site .

Comment 6. I think Table 4 (nuts) could be omitted since the results obtained are not representative.
Response 6. We agree and have revised the manuscript to omit Table 4 from the main manuscript.

Comment 7. I liked that they included the testimonials of some participants, and that adds value to the work.
Response 7. We thank the reviewer for their positive comment. We agree that the quotes from the participant interviews are valuable.

Comment 8. Another question I have is...is this work the starting point for others? Thank you very much
Response 8. We thank the reviewer for this thoughtful question.

We view this work as an important contribution toward encouraging the integration of evidence-based nutrition and food literacy within a social setting in cancer support programming, particularly given the limited research in Canada (Johnston et al., 2024). In the context of widespread online nutrition misinformation and conflicting dietary advice for individuals affected by cancer (Sullivan 2021), community-based programs that provide practical, skill-based education grounded in current evidence may play an important role in supporting evidence-informed food choices.

We hope our findings encourage other cancer care organizations to consider incorporating structured nutrition, culinary education, and social eating into survivorship and support services. And that publication of our findings will inform future, larger-scale evaluations of ongoing culinary-based cancer support programs in diverse populations.

References
Johnston EA, Ayre SK, Au-Yeung YT, Goodwin BC. A Scoping Review of Group Nutrition Education and Cooking Programs for People Affected by Cancer. J Acad Nutr Diet. 2024;124(10):1302-1327.e1.

Sullivan ES, Rice N, Kingston E, Kelly A, Reynolds JV, Feighan J, et al. A national survey of oncology survivors examining nutrition attitudes, problems and behaviours, and access to dietetic care throughout the cancer journey. Clinical Nutrition ESPEN. 2021;41:331-

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

No additional comments.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors, I appreciate your responses to the comments and suggestions I received. I believe you have addressed each comment thoughtfully and comprehensively, and that your additional contributions have improved the manuscript. I congratulate you on your work.