Application of Behavioral Theory in Cooking Interventions Targeting Dietary Intake in Adults: A Systematic Review.

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Published in final edited form as: J Nutr Educ Behav. 2025 Apr 4;57(6):508–521. doi: 10.1016/j.jneb.2025.02.002 Application of Behavioral Theory in Cooking Interventions Targeting Dietary Intake in Adults: A Systematic Review Anna Claire Tucker 1 , Margaret Raber 2 , Alice S Ammerman 3, 4 , Julia A Wolfson 1, 5 Author information Article notes Copyright and License information 1. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. 2. Department of Health Disparities Research, University of Texas MD Anderson Cancer Center, Houston, TX. 3. Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill 4. Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill 5. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. ✉ Corresponding Author: Anna Claire Tucker, 615 N Wolfe St, Baltimore, MD 21205, atucke31@jh.edu Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12146092  NIHMSID: NIHMS2055996  PMID: 40186611 The publisher's version of this article is available at J Nutr Educ Behav Abstract Objective: Studies of cooking interventions often state that behavioral theory was used to inform intervention development. However, to understand why interventions impact behavior change, it is crucial to understand how theory is used in the development, evaluation, and interpretation of interventions. Design: We conducted a systematic review by searching PubMed, Scopus, and CINAHL for articles published between January, 2000-March, 2023. Participants: We considered studies among adults ages ≥ 18 years. Variables Measured: Dietary intake was the primary outcome, and cooking behavior was a secondary outcome. Analysis: We used the Theory Coding Scheme (TCS) to assess theory use. We used descriptive statistics to summarize study characteristics and outcomes of interest. Results: We identified 7,846 unique articles; 31 met inclusion criteria. On average, studies met less than 6 of 17 criteria from the TCS. The majority (65%) of interventions had a positive impact on at least one measure of dietary intake. However, just over half (55%) measured cooking behavior, and only 41% of these reported a positive impact on cooking behavior. Conclusions and Implications: Findings support the need for future studies to link intervention techniques with theoretical constructs, and evaluate whether changes in constructs mediate improvements in dietary intake and cooking behavior. Keywords: Cooking; Psychological Theory; Diet, Food, and Nutrition INTRODUCTION Over the last century, intake of meals prepared at home and time spent cooking have substantially decreased in the United States (US). 1 These changes in meal sourcing and cooking behavior are largely due to changing societal factors, shifts in lifestyles, and increasing workloads, leading to less time for meal preparation and less developed cooking skills among the general US population. 2 – 4 While meals prepared outside the home can provide quick, convenient, and affordable sources of food, these foods tend to have lower dietary quality and higher energy density compared to meals prepared at home. 5 – 8 Conversely, greater cooking frequency and intake of meals prepared at home are associated with higher dietary quality and lower prevalence of obesity. 9 – 11 For this reason, interest in cultivating home cooking skills as a strategy for improving dietary quality and preventing diet-related chronic disease continues to grow, with numerous cooking interventions demonstrating positive impacts on dietary intake. 12 Behavioral theory provides a framework for understanding the myriad factors that influence health behaviors like home cooking. Using theory to inform intervention development allows researchers to identify upstream factors that should be targeted to change the behavior of interest. 13 Additionally, evaluating intervention impacts on targeted theoretical constructs (i.e., self-efficacy) and discussing results in relation to theory is critical for understanding how and why interventions were or were not effective; providing a basis for informing future research. 14 While many studies cite a behavior change theory in intervention development, it is often unclear how theory was used. 15 Prestwich et al described such interventions as, “theory-inspired,” or providing “lip service” to theory. 15 However, it is unclear if these studies actually use theory in the meaningful selection of intervention techniques. 15 These interventions suffer from a lack of transparency and replicability – essential aspects of rigorous, well-conducted research. 16 Explicitly identifying, targeting, measuring, and reporting constructs from established theories of behavior change enables researchers to demonstrate whether changes in the construct lead to changes in the health behavior as theorized. For example, if researchers aimed to increase cooking frequency by improving cooking self-efficacy, then researchers would expect to see concomitant changes in both cooking self-efficacy and frequency. Measuring and reporting such changes can help uncover the mechanisms underpinning behavior change which enables the development or refinement of interventions better equipped to improve the health behavior of interest. While there are many plausible pathways by which cooking interventions may impact dietary intake, these pathways are likely complex, with multiple stages of behavior change required to achieve the desired outcomes. For example, improving cooking skills without increasing healthy eating self-efficacy, attitudes, or intentions might lead to neutral or negative impacts on dietary intake if individuals used cooking skills to prepare unhealthy meals, especially in the presence of barriers (e.g. affordability, access) to accessing healthy ingredients. 10 , 17 , 18 For this reason, it is important to understand how behavioral theory has been used to develop cooking intervention content by selecting theoretical constructs hypothesized to impact behavior. Previous reviews have reported the frequency of behavioral theory use among cooking interventions. 19 , 20 For example, Reicks et al found that theory was generally missing from cooking interventions, 19 while Hollywood et al recorded the type of behavioral theory used in cooking interventions. 20 However, cooking interventions have proliferated since Reicks et al summarized the published literature as of 2016, and neither review examined how theory was used in the development, implementation, and evaluation of these interventions. To fill this gap, we conducted a systematic review to identify cooking interventions informed by behavioral theory. We then used Michie and Prestwick’s Theory Coding Scheme (TCS) to systematically evaluate how theory was used in these interventions. 14 The TCS was developed to provide an objective and systematic method for evaluating theory use in interventions. While interventions often state that they are “theory-based” the TCS allows researchers to evaluate the extent to which this claim is true. This systematic review aimed to answer the following questions: (1) how is behavioral theory used in the development, evaluation, and interpretation of theory-based cooking interventions for adults? and (2) what is the impact of theory-based cooking interventions on dietary intake among adults? METHODS Literature Search This systematic review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Supplementary Table 1 ). We conducted comprehensive searches of PubMed, Scopus, and CINAHL from January 1, 2000 to March 21, 2023. A medical reference librarian assisted in the development of the search strategies and choice of databases. The search strategies used in each database are listed in Table 1 . Table 1. Search Strategies Used to Identify Eligible Articles for a Systematic Review on Cooking Interventions Targeting Dietary Intake in Adults Database Search Strategy Results PubMed (“Cooking”[Mesh] OR culinary[tiab] OR cook*[tiab] OR “food preparation*”[tiab] OR kitchen*[tiab]) AND (“Program Evaluation”[Mesh] OR “Education”[Mesh] OR intervention*[tiab] OR class*[tiab] OR skill*[tiab] OR course*[tiab] OR education[tiab] OR instruction*[tiab] OR program*[tiab] OR curriculum[tiab] OR curricula[tiab] OR workshop*[tiab]) AND (“Feeding Behavior”[Mesh] OR feeding[tiab] OR nutrition[tiab] OR dietary[tiab] OR diet[tiab] OR diets[tiab] OR dieting[tiab] OR “dietary habit*”[tiab] OR “dietary intake*”[tiab] OR “dietary outcome*”[tiab] OR “food habit*”[tiab] OR “food intake*”[tiab] OR “eating pattern*”[tiab] OR “eating”[tiab]) 4026 CINAHL ((MH “Meal Preparation+” OR TI (culinary OR cook* OR “food preparation*” OR kitchen*) OR AB (culinary OR cook* OR “food preparation*” OR kitchen*)) AND (MH “Program Evaluation” OR MH “Education+” OR TI (intervention* OR class* OR skill* OR course* OR education OR instruction* OR program* OR curriculum OR curricula OR workshop*) OR AB (intervention* OR class* OR skill* OR course* OR education OR instruction* OR program* OR curriculum OR curricula OR workshop*)) AND (MH “Eating Behavior+” OR TI (feeding OR nutrition OR dietary OR diet OR diets OR dieting OR “dietary habit*” OR “dietary intake*” OR “dietary outcome*” OR “food habit*” OR “food intake*” OR “eating pattern*” OR eating) OR AB (feeding OR nutrition OR dietary OR diet OR diets OR dieting OR “dietary habit*” OR “dietary intake*” OR “dietary outcome*” OR “food habit*” OR “food intake*” OR “eating pattern*” OR eating)) 3659 Scopus TITLE-ABS((culinary OR cook* OR “food preparation*” OR kitchen*) AND (intervention* OR class* OR skill* OR course* OR education OR instruction* OR program* OR curriculum OR curricula OR workshop*) AND (feeding OR nutrition OR dietary OR diet OR diets OR dieting OR “dietary habit*” OR “dietary intake*” OR “dietary outcome*” OR “food habit*” OR “food intake*” OR “eating pattern*” OR eating)) 5281 Open in a new tab Inclusion and Exclusion Criteria The research team used the PICOS framework in developing research questions and selecting inclusion and exclusion criteria. The PICOS framework includes five elements: Population, Intervention, Comparison, Outcomes, and Study Design. 21 These elements and inclusion and exclusion criteria are presented in Table 2 . Briefly, we considered articles eligible for inclusion if they were intervention studies with an interactive cooking education component and measured dietary intake of adult participants aged 18 years or older. We included both randomized and non-randomized intervention studies with or without a control group. To be eligible for inclusion, articles were required to mention behavioral theory, but were not required to be explicitly based on behavioral theory. Only peer-reviewed full-length articles published in English were considered. Table 2. PICOS Elements with Inclusion and Exclusion Criteria Used to Identify Cooking Interventions Targeting Dietary Intake in Adults a Participants Studies that measured outcomes for adults ages 18 years and older were included in this review. Studies targeting adult-child dyads were included if dietary intake was measured for adults. Interventions Cooking interventions were defined as studies with an interactive cooking education component delivered in-person or in a synchronous virtual format, including sessions delivered hands-on or as demonstrations. Multicomponent studies were included if cooking education was one of the components and there were no more than three components; or if cooking education was part of every session. There were no specifications for the number or duration of sessions or for the qualifications of those delivering the sessions. Studies were also required to mention behavioral theory, although studies were not required to be explicitly based on behavioral theory. Comparison A comparison group was not required for inclusion. Outcomes Dietary intake outcomes had to be measured at least once pre- and post-intervention using quantitative assessment methods such as 24-hour diet recalls, food frequency questionnaires, or food records. Studies using only subjective assessment of dietary intake (ie. participants’ perceived change in dietary quality) were excluded. Study Design Both randomized and non-randomized interventions with or without a control group were considered. Open in a new tab a. To be included, studies were also required to be peer-reviewed full-length articles published in English. Selection of Articles The research team consisted of a full professor, an associate professor, an assistant professor, and a graduate student in nutrition. All four members of the study team have experience designing, implementing, and evaluating cooking interventions, with two members providing extensive expertise in cooking behavior research and one providing expertise in behavior science. One reviewer screened all titles and abstracts and conducted all full-text reviews. Since having a single reviewer can introduce selection bias, we performed quality control by having a second reviewer independently complete title and abstract and full-text reviews on a random 10% subsample of the original citations. Percent agreement between reviewers was 99.8%, and reviewers reached consensus through discussion. During data abstraction the two reviewers met regularly to discuss decisions and any ambiguities about applying the standardized protocol to each included study. Data Extraction A single reviewer used a standardized protocol for data extraction from full text articles. Extracted information included: author, study / program name, research design, program goal (ie. obesity prevention), data collection schedule and duration, participant age group, participant health focus, sample size, income focus, race/ethnicity focus, recruitment method, geographic location, outcomes measured, outcome method of measurement, and strengths and limitations, as determined by reviewer. The reviewer also used the TCS protocol to extract information on how behavioral theory was used in the intervention. Additional extracted information on intervention characteristics included: intervention components, delivery mode, control condition, number and duration of intervention sessions, total program length, qualifications and training of program leaders, and delivery location. Assessment of Risk of Bias The reviewer assessed potential bias in randomized trials using the Cochrane risk-of-bias tool for randomized trials. 22 To assess bias in non-randomized interventions, the reviewer used the Risk of Bias In Non-Randomized Studies of Interventions (ROBINS-I). 23 While the ROBINS-I tool is appropriate for quasi-experimental studies, Mobley et al was a self-described quasi-experimental study that randomized participants to intervention or delayed control. 24 Therefore, we assessed this study for bias using the Cochrane tool. Data Synthesis Dietary intake was the primary outcome of interest for this review. Given the variability in measuring and reporting diet, the reviewer categorized intake based on the 2020–2025 Dietary Guidelines for Americans. 25 Accordingly, food groups and nutrients considered part of a healthy diet included: fruits and vegetables, whole grains, lean protein, dairy, non-tropical plant oils and unsaturated fat, and fiber. We considered increases in the intake of these food groups and nutrients as positive changes. Food groups and nutrients to limit include refined grains, saturated fat, sodium, and added sugar. We also included red and processed meat as a food group to limit, given recommendations from the International Agency for Cancer Research/World Health Organization and World Cancer Research Fund. 26 , 27 We considered decreases in the intake of these foods and nutrients as positive changes. We also reported increases in overall dietary quality if measured quantitatively. There were numerous measures of dietary intake that were highly variable and not able to be categorized, and were therefore not included in our results. We also extracted outcomes related to cooking behavior. Cooking behavior lacks a standardized definition or gold standard measure. 28 However, there are various constructs that are typically measured in efforts to understand the relationship between cooking and dietary intake, including cooking frequency, self-efficacy/confidence, attitudes, skills, and healthfulness. 28 Therefore, for the purpose of this review, we considered outcomes related to these aspects of cooking behavior. We assessed theory use with the TCS. All items from the TCS are reported and discussed here, except participant randomization which was instead reported using the Cochrane risk of bias tool. Each TCS item is listed in Table 4 , and categorized into one of three elements of theory use: theory implementation, theory evaluation, and informing theory. Theory implementation is concerned with how theory was used in the design and implementation of the intervention. Theory evaluation is concerned with how theory constructs were measured and evaluated. Miche and Prestwick propose that this is important because changes in theoretical constructs should mediate changes in behavior. 14 Therefore, behavioral theory is challenged if changes in behavior are observed without concurrent changes in the theoretical constructs hypothesized to impact behavior. Conversely, behavioral theory is supported if changes in theoretical constructs accompany changes in behavior. This is relevant for the third element, Informing Theory , through which Michie and Prestwick suggest authors should contextualize their results and use their findings to refine current understandings of behavioral theories. 14 During data extraction, a single reviewer coded TCS items as “Yes” or “No.” The reviewer extracted details on theory implementation and evaluation from protocol papers only if authors explicitly referenced and cited a protocol paper when describing intervention development. Finally, we summed the total number of items met for each study and calculated the average number of items met across all studies. Studies could score a maximum of 17 items. Table 4. Using the Theory Coding Scheme (TCS) to Evaluate Theory Use among Cooking Interventions Targeting Dietary Intake in Adults (n=31) TCS Category TCS Item Allen-Winters et al, 2020 53 Archuleta et al, 2012 58 Archuleta et al, 2012 59 Baltaci et al, 2022 60 Barnhart et al, 2019 50 Beck et al, 2021 40 Begley et al, 2019 54 Bernhart et al, 2023 36 Buckner et al, 2021 61 Clark et al, 2015 37 Greenlee et al, 2015 43 Greenlee et al, 2016 29 Haynes-Maslow et al, 2020 62 Larose et al, 2022 38 Matias et al, 2021 31 McGorrian et al, 2015 63 McHugh et al, 2016 32 Miller et al, 2016 64 Miller et al, 2020 33 Mobley et al, 2023 24 Moreau et al, 2015 35 Morris et al, 2015 65 Novotny et al, 2023 39 Ohtsuki et al, 2018 66 Orr et al, 2017 67 Peters et al, 2014 34 Reicks et al, 2022 68 Robson et al, 2016 51 Sharma et al, 2018 41 Szczepanski et al, 2022 30 West et al, 2020 42 Total Studies Implementation of Theory 1) Theory/model of behavior mentioned Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y 31 2)Targeted construct(s) described as predictor of behavior N N N Y N Y Y N N N N N Y N N N Y Y Y N Y Y Y N N N N N Y N Y 12 3)Intervention based on single theory N Y Y Y Y N N Y N Y N N Y Y Y N Y N N N N N Y Y N Y N N N N Y 14 4)Theory/predictors used to select recipients for the intervention N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N 0 5)Theory/predictors used to select/develop intervention techniques N Y Y Y N Y Y Y N Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y N Y Y Y 26 6)Theory/predictors used to tailor intervention techniques to recipients N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N 0 7)All intervention techniques are explicitly linked to at least one theory-relevant construct/predictor N N N N N N N N N N N N N N N N N N N N N N N N N N Y N N N N 1 8)At least one, but not all of the intervention technique s are explicitly linked to at least one theory-relevant construct/predictor N Y N N N Y Y Y N N Y Y N Y Y N Y Y N N N Y Y N N N N N N Y Y 14 9)Group of techniques are linked to a group of constructs/predictors N N N Y N N N N N N N N N N N N N N N N Y N N N N N N N Y Y N 4 10)All theory-relevant constructs/predictors are explicitly linked to at least one intervention technique N N N N N N N Y N N N N N N N N N N N N N N N N N N N N N N N 1 11)At least one, but not all, of the theory relevant constructs/predictors are explicitly linked to at least one intervention technique N Y N N N Y Y N N N Y Y N Y Y N Y Y N N N Y Y N N N Y N N Y Y 14 Evaluating Theory 12)At least one theory-relevant constructs/predictors are measured pre and post intervention N N N N N Y N Y N Y Y Y N Y Y N Y N Y Y Y Y Y N N Y N N Y Y Y 17 13)At least one of the measures of theory relevant constructs/predictors had some evidence for their reliability N N N N N N N Y N N N N N Y Y N Y N Y N N N N N N Y N N N Y N 7 14)At least one of the measures of theory relevant constructs/predictors have been previously validated N N N N N N N N N Y N N N N Y N Y N N N N N N N N Y N N N Y N 5 15)Changes in measured theory-relevant constructs/predictor N N N N N N N Y N Y N N N N Y N N N Y Y Y Y N N N N N N Y Y Y 10 16)Mediational analysis of construct/s/predictors N N N N N N N N N N N N N N N N N N N N Y N N N N N N N N N N 1 Informing Theory 17)Results discussed in relation to theory Y Y Y N N Y N Y N N N N N Y Y N Y N Y N Y Y Y Y Y N N N Y Y Y 17 18)Appropriate support for theory N N N N N N N N N N N N N N N N N N N N Y N N N N N N N N N N 1 19)Results used to refine theory N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N 0 Total Items Met 2 6 4 5 2 7 6 9 1 6 5 5 4 8 10 1 10 5 7 4 9 8 8 4 3 6 4 1 7 10 9 Open in a new tab Given the variability in how outcomes were measured, we were unable to conduct a meta-analysis of studies’ impact on dietary intake. Instead, we present results narratively using descriptive statistics. This study was exempt from institutional review, as humans were not involved in this study. The study was not prospectively registered. RESULTS Search Results Figure 1 depicts the flow of studies through the selection process. The search strategy returned 12,966 articles. After removing duplicates, reviewing titles and abstracts, and completing the full-text review, a total of 31 studies representing 29 unique interventions, met the inclusion criteria. Key study characteristics are presented in Table 3 . Most studies were carried out in North America (74%; n=23). The majority were one-group pre-test post-test studies (65%; n=20), with 2 quasi-experimental studies and 9 studies of randomized controlled trials. Studies had a mean sample size of 121.4 (95% CI: 47.6, 195.2), with a range of 4–1092 participants. Studies were conducted in a range of age groups, with 13% (n=4) targeting college students or young adults and 19% (n=6) of studies reaching older adults. Thirty-two percent of studies (n=10) were intended to reach low-income adults, though few were developed specifically for certain cultural, racial, or ethnic groups (16%; n=5). Risk of bias was high. Sixty-eight percent of the non-randomized studies (n=15) had a critical risk of bias due to potential confounding, and the other 32% of non-randomized studies (n=7) had a serious risk of bias. Among randomized studies, 56% had a high risk of bias (n=5), with the remaining studies having moderate (n=2) or low risk of bias (n=2). Figure 1. Open in a new tab Flow Diagram of Study Selection Process Table 3. Summary of Included Studies on Cooking Interventions Targeting Dietary Intake in Adults (n=31) Study and Year Country Study Design Sample Size (N) Focus Population Study Components Delivery Method Number of Sessions Program Duration Session Leader Theory Cited Risk of Bias a Allen-Winters et al, 2020 53 Unite d States One group pre/post 4 Adult patients undergoing head and neck radiotherapy and caregivers Nutrition education and cooking classes In-person; hands-on 3 3 months Professional chef and culinary medicine staff members Social Cognitive Theory Critical Archuleta et al, 2012 58 United States One group pre/post 117 Adults with type 2 diabetes Nutrition education and cooking classes In-person; hands-on 4 4 weeks Registered Nurse with Certified Diabetes Educator training or Registered Dietitian Social Cognitive Theory Critical Archuleta et al, 2012 59 United States One group pre/post 193 Adults with type 2 diabetes Nutrition education and cooking classes In-person; hands-on 4 4 weeks Home economist and healthcare professional (Registered Nurse with Certified Diabetes Educator training or Registered Dietitian) Social Cognitive Theory Serious Baltaci et al, 2022 60 United States Randomized controlled trial 94 Latino father and child dyads Food preparation, nutrition education, physical activity, and parenting skills education In-person; hands-on 8 8 weeks Bilingual Extension educators, community partner staff, or former participants of past Extension parenting classes Social Cognitive Theory Moderate Barnhart et al, 2019 50 United States One group pre/post 15 Adults with developmental disability and direct support professionals Nutrition education and cooking classes In-person; hands-on 6 6 weeks Chef and nutrition educator Social Cognitive Theory Critical Becket al, 2021 40 Denmark One group pre/post 114 Grandparent and grandchild dyads Nutrition education, cooking classes, and intergenerational relations building In-person; hands-on 4 sessions Varied Nutrition educator Social Cognitive Theory, Experiential Learning Theory, and Intergenerational Theory Critical Begley et al, 2019 54 Australia One group pre/post 1092 Adults from low- and middle-income households Nutrition education and cooking classes In-person; hands-on 4 sessions 4 weeks Not specified Health Belief Model and Social Learning Theory Critical Bernhart et al, 2023 36 United States Quasi-experimental 60 Black and African American adults with overweight or obesity Nutrition education, cooking classes, provision of healthy meal vouchers Virtual; demonstrations 12 sessions 12 weeks Community health workers Social Cognitive Theory Serious Buckner et al, 2021 61 India One group pre/post 12 Women from marginalized communities Nutrition education and cooking classes In-person; hands-on 3 sessions Not specified Trained volunteers Social Cognitive Theory Critical Clark et al, 2015 37 United States One group pre/post 18 Adults with severe mental illness Nutrition education and cooking classes In-person; hands-on Not specified 6 weeks Not specified Social Learning Theory Critical Greenlee et al, 2015 43 United States Randomized controlled trial 61 Hispanic breast cancer survivors Nutrition education, cooking classes, and food shopping field trips In-person; hands-on 9 sessions 12 weeks Bilingual, Hispanic registered dietitian and chef Social Cognitive Theory and the Transtheoretical Model Low Greenlee et al, 2016 29 United States Randomized controlled trial 58 Hispanic breast cancer survivors Nutrition education, cooking classes, and food shopping field trips In-person; hands-on 9 sessions 12 weeks Bilingual, Hispanic registered dietitian and chef Social Cognitive Theory and the Transtheoretical Model Low Haynes-Maslow et al, 2020 62 United States One group pre/post 19 Adults with low income Nutrition education and cooking classes In-person; hands-on 6 sessions 6 weeks Trained instructors Social Cognitive Theory Critical Larose et al, 2022 38 United States Random ized controlled trial 23 College football athletes Nutrition education and cooking classes In-person; hands-on 3 sessions 3 weeks Graduate kinesiology student and dietetic technician Theory of Planned Behavior High Matias et al, 2021 31 United States One group pre/post 171 College students Nutrition education and cooking classes In-person; hands-on Not specified; 1 session per week 1 semester Faculty and graduate students Social Cognitive Theory Critical McGorrian et al, 2015 63 Ireland Randomized controlled trial 108 Adult patients with overweight or obesity undergoing cardiac rehabilitation Nutrition education and cooking classes In-person; demonstration 5 sessions 5 weeks Chef, dietitian, and health promotion officer Social Cognitive Theory High McHug h et al, 2016 32 Ireland Randomized controlled trial 100 Older adults at risk for social isolation Nutrition education and cooking classes In-person; hands-on 8 sessions 8 weeks Trained volunteers Social Cognitive Theory Moderate Miller et al, 2016 64 United States One group pre/post 54 Parent and child dyads from low-income households Nutrition education and cooking classes In-person; hands-on 6 sessions 12 weeks Not specified Social Cognitive Theory and Experiential Learning Theory Critical Miller et al, 2020 33 Unite d States Randomized controlled trial 47 Adult survivors of breast cancer Nutrition education and cooking classes In-person; hands-on 8 sessions 9 weeks Registered Dietitian and social worker Social Cognitive Theory and Experiential Learning Theory High Mobley et al, 2023 24 United States Quasi-experimental 45 Father and child dyads from low-income households Nutrition education, cooking classes, and parenting education In-person; hands-on 8 sessions 8 weeks Licensed Clinical Social Work Therapist and graduate student in nutrition Social Cognitive Theory and Family Systems Theory High b Moreau et al, 2015 35 Canada One group pre/post 144 Adults aged 50 years and older Nutrition education and cooking classes In-person; hands-on 8 sessions 8 weeks Registered Dietitian Social Cognitive Theory, Theory of Planned Behavior, and Transtheoretical Model Serious Morris et al, 2015 65 United States One group pre/post 96 Adults from low-income households Nutrition education and cooking classes In-person; hands-on 6 sessions 6 weeks Community nutrition assistants (undergraduate and graduate students) Social Cognitive Theory and Experiential Learning Theory Critical Novotny et al, 2023 39 United States One group pre/post 14 pre; 14 post b Adults Nutrition education, cooking classes, and horticulture activities In-person; hands-on 5 sessions 5 weeks Certified Health Education Specialist Registered Dietitian and undergraduate student Social Cognitive Theory Critical Ohtsuki et al, 2018 66 Japan Randomized controlled trial 98 College students Nutrition education, cooking class, and horticulture activities In-person; hands-on 3 sessions 25 weeks Not specified Social Cognitive Theory High Orr et al, 2017 67 United Kingdom One group pre/post 66 Adults with young families living in under-resourced settings and at risk for cardiovascular disease Nutrition education and cooking classes In-person; hands-on 6 sessions 6 weeks Community food workers Behavior change theory Critical Peters et al, 2014 34 United States Randomized controlled trial 71 Adults who have undergone menopause Nutrition education, cooking classes, and behavior change sessions In-person; hands-on 28 sessions 1 year Not specified Social Cognitive Theory High Reicks et al, 2022 68 United States One group pre/post 586 African American adults Nutrition education and cooking classes In-person; hands-on 6 sessions 6 weeks Registered nurses, registered dietitians, other healthcare professionals, and chefs Social Cognitive Theory and Transtheoretical Model Serious Robson et al, 2016 51 United States One group pre/post 6 Parent and child dyads from low-income households; parents with overweight and obesity Cooking classes and parenting education In-person; hands-on 10 sessions Not specified Doctoral level registered dietitian and psychology student Theory of Experiential Learning Critical Sharma et al, 2018 41 United States One group pre/post 210 Pregnant adults from low-income households Nutrition education, cooking demonstration, physical activity, and food box provision In-person; demonstration 6 sessions 6 weeks Community health workers Social Cognitive Theory and Theory of Planned Behavior Serious Szczepanski et al, 2022 30 United States One group pre/post 46 College students Nutrition education and cooking classes In-person; hands-on 4 sessions 4 weeks Chef and dietitian Social Cognitive Theory Serious West et al, 2020 42 Australia One group pre/post 21 Adults from low-income households Nutrition education and cooking classes In-person; hands-on 6 sessions 6 weeks Nutritionists and dietitians Social Cognitive Theory Critical Open in a new tab a. Bias among randomized trials was assessed using the Cochrane risk-of-bias tool for randomized trials. For non-randomized interventions, bias was assessed using the Risk of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. b. Out of 19 total participants in Novotny et al, 14 completed the pre-intervention survey and 14 completed the post-intervention survey, with nine completing both the pre- and post-intervention survey. Intervention Characteristics Of the 29 unique interventions, nearly all (97%; n=28) included both cooking classes and nutrition education. Ten unique interventions (34%) included an additional component such as: family-focused activities (14%; n=4), providing food (7%; n=2), physical activity (7%; n=2), guided grocery shopping (3%; n=1), horticulture (3%; n=1), and behavior change sessions (3%; n=1). Ninety percent of unique interventions (n=26) implemented hands-on cooking education, with the remaining 10% of interventions (n=3) using synchronous demonstrations conducted in-person or virtually. The program duration ranged from 3 weeks to 1 year, while the number of sessions ranged from 3–28; with an average of 6.8 sessions (95% CI: 4.9, 8.7). Programs leaders included dietitians and nutrition educators (45%; n=13)), chefs (21%; n=6), community health workers and extension educators (14%; n=4), students (10%; n=3), and former participants (7%; n=2). However, 17% of interventions (n=5) did not specify program leader qualifications, and only 45% of interventions (n=13) specified that program leaders received training to carry out the intervention. Theory Implementation Twenty-six (84%) studies mentioned Social Cognitive Theory (SCT) as the basis for the intervention. Other behavioral theories mentioned the Transtheoretical Model (16%; n=5), Experiential Learning Theory (13%; n=4), Theory of Planned Behavior (10%; n=3), and Social Learning Theory (6%; n=2). Table 4 presents results from application of the TCS. Overall, studies met on average 5.7 (95% CI: 4.7, 6.6) out of 17 criteria. Forty-five percent of studies (n=14) were based on a single theory, while only 12 studies (39%) clearly identified theory constructs targeted by the intervention and provided evidence that these constructs influenced behavior. Eighty-four percent of studies (n=26) explicitly based the intervention on theory by using theory to select intervention techniques. However, only one study linked all theory constructs to at least one intervention technique, whereas 45% (n=14) explicitly linked at least 1 theory construct to at least one intervention technique. None of the studies included in this review selected participants based on theory (ie. enrolling only those with low cooking self-efficacy) or tailored the intervention to participants using theory (ie. adapting the intervention based on participants’ cooking self-efficacy). Theory Evaluation and Informing Theory Fifty-five percent of studies (n=17) measured at least 1 theory construct before and after the intervention, with 12 studies providing evidence for the reliability or validity of the measures used. No study measured all theory constructs. Among studies that measured theory constructs, only 59% demonstrated a significant change in these constructs post-intervention (n=10). Additionally, only 1 study conducted a mediational analysis to test whether changes in the theory construct mediated changes in the behavioral outcome of interest (ie. if changes in cooking self-efficacy mediate changes in cooking frequency). Furthermore, only 55% of studies (n=17) mentioned theory in the discussion of results. Only 1 study was able to provide appropriate support for their findings related to theory, as only 1 study had conducted a mediational analysis and discussed this in the results. Lastly, none of the studies attempted to refine theory by describing how findings supported or refuted the theory underlying the study. Dietary Intake Outcomes related to dietary intake are summarized in Table 5 . Overall, 20 (65%) studies demonstrated a positive impact of cooking interventions on at least 1 dietary outcome. Fruits and vegetables, whole grains, and saturated fat were the most commonly reported outcomes. Among the studies that measured fruit and vegetable intake, 64% (n=16) demonstrated significant increases in intake. Forty percent (n=4) and 27% (n=3) of studies reported improvements in participants’ intake of whole grains or decreases in intake of saturated fat, respectively. Table 5. Summary of Dietary Intake Measures and Reported Outcomes among Cooking Interventions Targeting Dietary Intake in Adults (n=30) a Dietary Intake Measures Total Studies Measuring Outcome Studies Reporting Improvement Studies Reporting No Improvement n Study References n Study References n Study References Dietary Quality b 3 36 , 38 , 58 0 3 36 , 38 , 58 Fruit/Vegetables c 24 24 , 39 – 43 , 54 , 58 – 61 29 – 31 , 33 – 35 , 37 , 53 , 62 – 67 16 24 , 29 , 31 , 34 , 35 , 37 , 39 , 41 – 43 , 54 , 59 , 60 , 64 , 65 , 67 9 30 , 33 , 40 , 53 , 58 , 61 – 63 , 66 Whole Grains 10 31 , 33 – 35 , 37 , 39 , 61 , 62 , 64 , 65 4 35 , 39 , 61 , 64 6 31 , 33 , 34 , 37 , 62 , 65 Lean Protein d 7 34 , 40 , 53 , 60 , 61 , 63 , 65 1 34 6 35 , 46 , 53 , 54 , 58 , 60 Dairy 6 34 , 35 , 37 , 40 , 61 , 66 3 34 , 35 , 61 3 34 , 35 , 37 , 40 , 61 , 66 Oils/Unsaturated Fat 3 29 , 43 , 53 0 - 3 29 , 43 , 53 Fiber 6 30 , 37 , 38 , 61 , 66 , 68 1 30 5 37 , 38 , 61 , 66 , 68 Red/Processed Meat 2 33 , 53 1 33 1 33 Refined Grains 2 34 , 61 0 - 2 34 , 61 Saturated Fat e 11 29 , 34 , 43 , 51 , 53 , 61 , 62 , 64 , 66 – 68 3 34 , 64 , 68 8 29 , 43 , 51 , 53 , 61 , 62 , 66 , 67 Sodium 5 37 , 51 , 61 , 68 1 68 4 37 , 51 , 61 , 68 Added Sugar f 10 34 , 37 , 40 – 42 , 53 , 54 , 58 , 62 , 67 4 34 , 42 , 54 , 67 6 36 , 40 , 41 , 53 , 58 , 62 Open in a new tab a. McHugh et al 32 not included in Table 5 , as the only dietary intake outcome was change in energy intake, which was non-significant. b. Assessment of overall dietary quality varied across studies. Barnhart et al 50 and Bernhart et al 36 did not use standardized measures of dietary quality. Larose et al 38 reported Healthy Eating Index (HEI) score. c. Combined fruits and vegetables since several studies reported intake of fruits and vegetables as one score. d. Includes poultry, seafood, eggs, nuts, seeds, and legumes. e. Includes main sources of saturated fat: butter, full-fat dairy, high-fat cuts of meat, high-fat sweets. f. Includes sources of added sugar: sugar-sweetened beverages, desserts, sugary snacks. Cooking Behavior Seventeen (55%) studies reported outcomes for at least 1 aspect of cooking behavior. These results are presented in Table 6 . Overall, fewer than half (42%; n=13) of studies reporting on a cooking behavior outcome demonstrated significant improvements. Cooking confidence/self-efficacy was the most commonly reported outcome (n=10), followed by cooking frequency (n=5). Half of studies that reported on cooking confidence/self-efficacy demonstrated significant improvements (n=5), while only 1 of the 5 studies reporting on cooking frequency or frequency of consuming meals away from home found improvements. Other cooking behaviors reported included cooking attitudes (n=3), skills (n=3), healthfulness (n=3), barriers (n=1), and food literacy (n=1). Table 6. Summary of Cooking Behavior Measures and Reported Outcomes Among Cooking Interventions Targeting Dietary Intake in Adults (n = 17) a Total Studies Measuring Outcome b Total Studies Reporting Improvement c Total Studies Reporting No Improvement d Dietary Intake Measure n Study References n Study References n Study References Cooking confidence/self-efficacy 10 24 , 31 , 33 , 37 , 39 , 41 , 42 , 50 , 51 , 58 5 31 , 33 , 41 , 42 , 58 5 23 , 32 , 34 , 43 , 44 Cooking frequency/meals consumed away from home 5 24 , 44 , 51 , 52 , 59 1 59 4 24 , 44 , 51 , 52 , 59 Cooking attitudes 3 30 , 51 , 58 2 44 , 56 1 30 Cooking skills 3 30 , 33 , 40 2 30 , 33 1 40 Cooking healthfulness 3 42 , 53 , 58 1 58 2 42 , 53 Cooking barriers 1 50 0 – 1 50 Food literacy 1 54 0 – 1 54 Open in a new tab a Only 17 of the 31 included studies reported a cooking behavior outcome; b Count of the total number of studies measuring a given outcome; c Count of the total number of studies documenting a significant improvement in a given outcome; d Count of the total number of studies that measured a given outcome but found no significant improvement. DISCUSSION This review assessed application of behavioral theory across 31 articles reporting on 29 cooking interventions targeting dietary intake. Overall application of theory was poor, with studies meeting less than 6 out of 17 criteria from the TCS on average. Findings suggested that the majority of cooking interventions have a positive impact on at least 1 aspect of dietary intake. However, fewer than half of studies measuring cooking behavior had a positive impact on this outcome. Our results suggest that there are many ways theory application could be improved across intervention development, evaluation, and reporting. First, while the majority of studies in this review stated that theory was used to select intervention techniques, less than half of studies explained how this was done. Therefore, links from theory constructs to specific intervention techniques may require explicit description. While it may be challenging to include all of these details in journal articles due to word limits, studies would benefit from publishing and citing protocol papers or including appendices where these details could be included. For example, Greenlee et al provided a table linking each stage of change from the Transtheoretical Model to a specific intervention session with session goals and tasks. 29 This degree of transparency is important for ensuring that theory was actually incorporated in the earliest stages of intervention development, rather than tagged into the paper post hoc. Detailed reporting of the ways in which theory informs intervention development is also useful to help other researchers and practitioners understand the conceptual framework underpinning the intervention. The majority of studies included in this review reported using SCT, with few studies reporting the use of other theories, such as the Transtheoretical Model, Experiential Learning Theory, Theory of Planned Behavior, or Social Learning Theory. Additionally, these theories were typically used in conjunction with one another, and studies using multiple theories rarely differentiated between how each theory was used in intervention development, making it challenging to identify the unique contributions of each theory. Furthermore, while SCT was the most commonly used theory, it does not necessarily mean that SCT is preferred for developing cooking interventions. However, the lack of studies leveraging other theories limits us from concluding which theories or combination of theories produce the most effective cooking interventions. These findings support the need for cooking interventions based on other theories, such as the Transtheoretical Model or Social Learning Theory, and for research to compare the effectiveness of interventions based on different theories or combinations of theories. Evaluation and discussion of theory was limited across studies. Though over half of studies measured at least 1 theory construct, 24 , 29 – 44 only 1 study conducted the appropriate mediational analyses to test whether changes in theoretical constructs mediated changes in dietary intake. 35 Studies without mediational analyses were unable to draw meaningful conclusions regarding whether theoretical constructs led to changes in desired outcomes. According to the TCS, it may be beneficial to measure all constructs that an intervention is designed to target, using valid and reliable tools, and conduct mediational analyses to link changes in theoretical constructs to changes in behavior. 14 This allows for better supported discussion and refinement of theory, while establishing an evidence base that facilitates the identification of theoretical constructs that have the greatest influence on outcomes of interest, such as dietary intake. Our findings related to dietary intake are consistent with previous systematic reviews which suggest that cooking interventions may have a positive impact on dietary intake but are limited by poor-quality evidence. 12 , 19 Additionally, the high degree of variability in outcomes limited further synthesis. Dietary intake is complex and multifaceted. Accordingly, interventions target many different aspects of diet for improvement. However, current evidence supports emphasizing dietary patterns rather than changing intake of one food group or micronutrient. 25 For example, the Healthy Eating Index, 45 Dietary Approaches to Stop Hypertension, 46 and Mediterranean Diet Score 47 are all measures that can be used to summarize adherence to health-promoting dietary patterns. Despite this, only 1 of the studies in this review measured change in dietary patterns. 38 To better align with current evidence and allow for greater comparability between studies, it may be beneficial for cooking interventions to place greater emphasis on measuring and improving whole dietary patterns. Among included studies, there was a high degree of variability in the measurement of cooking behavior. As with dietary intake, cooking behavior is multifaceted and challenging to measure. 28 , 48 , 49 Cooking frequency and cooking confidence were the most commonly reported cooking behavior outcomes in this review. While several cross-sectional studies have demonstrated associations between greater cooking frequency and higher dietary quality, 9 , 11 the utility of this measure is limited, as the healthfulness of home cooking depends on what and how meals are prepared. Cooking self-efficacy and cooking confidence are similarly limited, as individuals can have high self-efficacy for preparing sweets or other less healthy foods, but limited self-efficacy for preparing vegetables and whole grains. Furthermore, while many studies that measured cooking behavior provided at least some evidence for the validity of the tool used to measure this outcome, 30 , 31 , 37 , 39 , 40 , 42 , 50 – 54 it is unclear how comparable findings from these tools are. Thus, even among studies measuring specific aspects of cooking behavior such as cooking self-efficacy, it is challenging to synthesize these findings due to use of varying measurement tools. While this review was not designed to investigate the impact of cooking interventions on cooking behavior, the small number of studies measuring cooking behavior and the limited impact on cooking behavior among studies measuring this outcome calls for further investigation. Since all interventions in this review implemented a cooking component, an unstated assumption of these studies is that changing cooking behavior is important for changing dietary intake. However, this is not borne out by robust evidence. There are observational studies that have demonstrated associations between greater cooking frequency or cooking skills and higher dietary quality, particularly among households with higher income. 10 , 55 However, it is not known whether cooking interventions are more effective at changing behavior than other behavioral nutrition interventions without cooking components. Additionally, there is a paucity of experimental evidence to demonstrate that changes in cooking behavior mediate improvements in dietary intake in such interventions. For this reason, it is important for cooking interventions targeting dietary intake to also measure cooking behavior using validated and reliable measurement tools. This will help demonstrate whether changes in cooking behavior are relevant for improving dietary intake, identify which aspects of cooking behavior should be targeted to improve dietary intake, and assist in the synthesis of findings in future reviews. It is also important to note that there are additional factors that could explain the limited impact of cooking interventions on cooking behavior. First, selection bias may lead to individuals participating in cooking interventions who already cook frequently or have high cooking self-efficacy, thus leaving limited room for improvement in these measures. Second, participants may reconceptualize a reported behavior, leading to differences in reporting pre- and post-intervention. 56 For example, participants may include preparing ready-to-heat meals as cooking pre-intervention, but, after participation in the study, define cooking as preparing foods from scratch post-intervention. Thus, they might report a decrease in cooking frequency post-intervention, even if cooking from scratch ingredients increases. Third, other factors, such as affordability of ingredients, access to food stores selling healthy food, and lack of time to cook more/differently, could impede changes to cooking behavior even after interventions to improve cooking skills. It is, therefore, important for potential interventions to critically examine the key barriers to healthy eating and how cooking skills fit into the broader structural contexts in which individuals make decisions about whether, what, and how to cook. To address these challenges, studies can more intentionally select participants with lower cooking frequency and self-efficacy for the intervention, and carefully consider different measures of cooking behavior, such as cooking healthfulness, 57 to better reflect the potential impacts of the intervention on cooking behavior. Additionally, further research into the effects of cooking interventions on participants’ conceptualization of cooking pre- and post-intervention could help identify other potential sources of measurement error. Some strengths of this review include the use of the PRISMA framework and TCS tool to provide a detailed, systematic approach for judging the quality of behavioral theory application across diverse studies. However, there are also several limitations to consider. Importantly, this review had a single reviewer complete the title and abstract reviews and full-text reviews for all citations. While a second reviewer completed an independent title and abstract review and full-text review for a random sub-sample of the citations and percent agreement was nearly unanimous (99.8%), this limitation may have introduced selection bias. This high percent agreement between reviewers suggests a lower chance of selection bias as a result of having a single reviewer for all studies and therefore mitigates some of this concern. Furthermore, a single reviewer completed data extraction and compilation, including assessing risk of bias, which may have biased the findings of this review. Findings should be interpreted in light of this limitation. Selection bias may have also occurred as this review was limited to articles published in English in scientific journals. It is also important to acknowledge that this review may have excluded theory-based interventions that did not mention the study’s theoretical basis. The majority of studies in this review took place in high-income Western countries, thus limiting the generalizability of this review. The high potential for bias and the high degree of variability in outcomes limits our ability to draw conclusions regarding the efficacy of theory-based cooking interventions. For example, various tools were used to measure cooking self-efficacy. However, measures of cooking self-efficacy may refer to cooking in general, performing specific tasks (i.e., frying, baking, or using a knife), preparing specific foods (i.e., roasting a chicken, baking a cake, or making a salad), or general skills (i.e., creating a meal from ingredients on hand). Importantly, not all of these behaviors would be expected to lead to improvements in dietary quality– self-efficacy to bake a cake does not necessarily translate to self-efficacy to prepare healthful meals. This variability in how cooking behavior is measured and the small sample size of studies measuring cooking behavior limited our ability to determine whether better application of theory leads to greater improvements in cooking behavior, whether changing cooking behavior leads to improvements in dietary intake, and if so, which cooking behaviors should be targeted. IMPLICATIONS FOR RESEARCH AND PRACTICE Though use of behavioral theory is generally regarded as an important step in the development of behavioral interventions, overall application of theory among the cooking interventions included in this review was poor. Furthermore, high heterogeneity in how dietary intake and cooking behavior were measured prevented us from rigorously testing whether higher TCS scores predicted greater improvements in these outcomes. Poor application of theory and use of numerous unvalidated measures present barriers to identifying mechanisms of behavior change and developing more effective interventions. There is a need for more experimental evidence from randomized controlled trials that incorporate well-documented use of behavioral theory, conduct mediational analyses to determine whether changes in theoretical constructs mediate behavioral improvements, and use consistent, validated measures of dietary intake and cooking behavior. Additionally, by selecting study participants based on existing cooking skills and behaviors, future research could further our understanding of who benefits most from cooking interventions and which cooking skills and behaviors are most important to target. Taken together, improvements in the design, evaluation, and reporting of theory use in cooking interventions will help identify the most critical features of these interventions, ensuring that finite public health resources are directed toward programs with the greatest potential impact on diet and health outcomes. Supplementary Material 1 NIHMS2055996-supplement-1.docx (18.8KB, docx) Acknowledgements: ACT was supported by Grant Number T32 HL007024 from the National Heart, Lung, and Blood Institute, National Institutes of Health. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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