People with serious mental illness (SMI), such as those with a schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder, are highly susceptible to medical comorbidities. Cardiovascular disease (CVD) is the leading cause of premature death in this population and has been attributed to several factors including obesity, smoking, and lifestyle behaviors [1,2,3,4]. Among them, suboptimal diet is an important and modifiable contributor to poor cardiometabolic health. Culinary medicine and nutritional psychiatry are growing fields that explore the relationship between food and personal and mental health, respectively [5]. As of 2016, more than ten medical schools in the USA have adopted culinary medicine curricula to educate rising physicians about the integration of eating behaviors with the health care goals of patients [6, 7]. Diet modification programs have been shown to improve symptoms of depression [8, 9] and bipolar disorder [10], suggesting the potential mental health benefit of such interventions [11].

We present Food4Thought, a virtual nutrition outreach program for community members with SMI and staff that support them at a community mental health agency. The program followed the community participatory model which promotes community-academic collaborations to ensure program content is relevant and meaningful [12, 13]. The goals of our initiative were to evaluate the feasibility and potential benefit of Food4Thought and provide an opportunity for medical trainees to develop a public health intervention program.

Program Development and Evaluation

The Food4Thought program was crafted as an educational collaboration between the Community Intervention Program (CIP) at UMass Chan Medical School and Genesis Club, a non-profit clubhouse that utilizes a person-centered approach to support the recovery of people with mental illness in the Greater Worcester Region of Massachusetts. CIP is a community outreach initiative led by medical students and psychiatry residents and supported by UMass MIND research employees and volunteers. The Healthy Living initiative within CIP aims to promote lifestyle behaviors in the SMI population. In partnership with the Genesis Club kitchen unit, three medical students and one psychiatry resident within the Healthy Living team designed the program under the advisement of an attending psychiatrist and a registered dietitian. Additional medical trainees joined to help prepare materials and lead sessions. For this paper, “participants” refer to Genesis Club members with SMI and staff and “facilitators” refer to individuals from the CIP Healthy Living team. The UMass Chan Medical School IRB determined that the Food4Thought program was not research involving human subjects.

The program was administered through the HIPAA-compliant Zoom platform and advertised via flyers posted within the clubhouse and email through the Genesis Club listserv. A remote format was chosen in response to the shift in virtual care delivery during the COVID-19 pandemic. First, three medical students and a psychiatry resident facilitated a Listening & Informational session open to all clubhouse members and staff to gather their perspectives on lifestyle programming and brainstorm topics of interest. Following this session, participants completed a survey about preferred learning modalities. Enrollment was capped at twelve participants set by Genesis Club based on their ability to fund ingredients. The first program comprised three modules with each module containing an educational session and kitchen skills session. Each session lasted 1 h and was led by a medical student. Educational sessions consisted of 30–40 min of a slide presentation with group discussion. Prior to each kitchen skills session, participants picked up their recipe and ingredient package at Genesis Club. Participants used their own kitchen equipment in their homes. The lead medical student provided recipe instructions while simultaneously preparing the meal. Each module was separated by two weeks to provide time for facilitators to prepare materials. Surveys with 4- or 5-point Likert scales (1 = strongly disagree, 4 or 5 = strongly agree) were delivered after each module to assess thoughts on and motivation for healthy eating. A second Listening & Informational session was held 1 week after the completion of the program to allow participants and facilitators to reflect on the experience. Those who attended at least one module of the program were asked to complete a final survey which included questions for future program improvement.

A second Food4Thought program was again open to all Genesis Club members and staff and closely followed the format of the first program: first Listening & Informational session, four two-part modules, and second Listening & Informational session. Each session was separated by 1 week. Using a hybrid approach, participants with SMI had the option to work together with staff participants at the Genesis Club kitchen to prepare the recipe(s). A survey using 5-point Likert scales was administered following the first and second Listening & Informational sessions to evaluate nutrition knowledge and attitudes toward the effect of food on health. No surveys were provided after each module to reduce respondent fatigue.

The second Listening & Informational session of the first program and the entire second program were recorded with participant consent. The audio was transcribed, and representative quotes were excerpted. Medical trainees who participated in the program and were not involved in the writing of this report were asked to complete a survey including 5-point Likert scales of their experience as program facilitators.

Program Results

Twelve individuals from Genesis Club attended the first Listening & Informational session of the launch program. An overview of the program is described in Table 1. Nutritional Psychiatry, Mindful Eating, and Cooking Healthy on a Budget were chosen by the facilitators and Genesis Club kitchen unit as topics based on feedback. From the survey responses (n = 10), participants preferred materials to be presented as informational videos, PowerPoint presentations, and small-group discussion. Selected recipes were inspired by meals already served at the clubhouse and the module theme. For example, a multi-component meal was chosen for Mindful Eating to allow participants to practice mindful eating principles with foods of various flavors and textures. Module-specific survey response rates of participants who attended either the educational or kitchen skill sessions were 42% (5 respondents/12 participants), 50% (5/10), and 100% (8/8), respectively. Ten of the twelve participants attended at least four of the six total sessions across the three modules. In all post-module surveys, all participants strongly agreed or agreed that “I am confident I can make changes in my everyday diet” and “Nutritious meals can taste good too.” In the second Listening & Informational session, participants (n = 8) discussed lessons learned during the program and challenges to eat healthier including easy access to unhealthy foods. One participant noted that they learned to think about “more than just food groups… [but also] think colors” when choosing foods with different nutrients. In the final survey provided after this session, participants (n = 8) expressed their preference for the virtual format and additional module topics.

Table 1 Objectives of the nutrition outreach program
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The second program incorporated feedback from the first program. Twelve Genesis Club members and staff attended the first Listening & Informational session. The module topics were expanded to Food, Mind, and Body (Module 1), Cooking Healthy on a Budget (Module 2), Mindful Eating (Module 3), and Food as Medicine (Module 4) (Table 1). Module-specific attendance of participants who attended either the educational or kitchen skills sessions was twelve, ten, nine, and nine, respectively. Ten of the twelve participants attended at least five of the eight total sessions. During the second Listening & Informational session, participants (n = 5) discussed their relationships with their SMI and food. One participant stated “My mind interacts with my belly. Since I have schizophrenia, my appetite changes during the meal.” Others commented on the benefits of digital technologies to maintain their social connections and reduce anxiety of meeting in person. Seven participants completed both pre- and post-program surveys. No statistically significant changes in knowledge and attitudes surrounding healthy eating behaviors were observed; however, there was a trend for “The foods I eat can affect my mood” (p = 0.10, paired t test) (Table 2).

Table 2 Summary of pre- and post-program survey results from the second Food4Thought program
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Four medical trainee facilitators (three medical students and one psychiatry resident) completed the post-program survey. One survey respondent commented “while discussing and sharing healthy food habits, I was able to significantly improve my own.” Another facilitator noted the importance of continuing a hybrid model to directly assist participants who may have challenges with cooking during kitchen skills sessions. All medical student respondents “strongly agree” that community-based programs should be part of the medical education curriculum.

Interpretation of Program Findings

The remotely delivered Food4Thought program was well-received by participants. The feasibility of our program can be attributed to the open exchange of ideas between the CIP Healthy Living team and Genesis Club during its development. The first Listening & Informational session was critical in forming an alliance with the community-based partner. The virtual format was feasible and allowed both facilitators and participants to easily sign onto sessions in their own homes or the Genesis Club kitchen, encouraging equitable access to nutrition support. Participants also received teachings from a clinical dietician who helped develop the recipes and materials used in the program.

Several limitations of the program are apparent. The small number of participants and facilitators in the program may not reflect the overall attitudes of individuals with SMI or medical trainees, respectively. No statistical differences were observed in the pre-post program survey in the second program, which may have been impacted by the small sample size of the participants. People with SMI who do not have access to or require education on the use of digital technologies as well as kitchen space will have more difficulty participating in the program [14, 15].

Reflections on Academic-Community Partnerships

Food4Thought used the community participatory model to recognize identities and strengths within the community, build on existing resources, and attain a balance between research and action [16,17,18]. After the program, the Genesis Club kitchen unit changed and expanded their menu to include more culturally varied and vegetarian meals. Printouts of visual aids used during the program were placed in the kitchen and dining area to reinforce information and skills learned in the program. These discernible changes demonstrate how nutrition knowledge can be transported from an academic to community setting supporting individuals with SMI.

Implications for Medical Education

Remote delivery of Food4Thought allowed medical trainees to directly interact with individuals with SMI and better understand their attitudes around and challenges to eating healthier. Medical trainees had the opportunity to engage community partners and develop a public health intervention program to serve one of the most vulnerable populations in our society. We hope our experience encourages more medical trainees to be involved in similar endeavors, which could be an important part of the medical education curriculum.