Michelle H. Loy- Department of Medicine and Pediatrics, Weill Cornell Medicine, Cornell University, New York, NY, United States
The field of culinary medicine has gained significant attention for its potential to improve health outcomes through the integration of nutrition and medical practice. However, the cultural dimensions of this interdisciplinary field remain underexplored. Emphasizing the role of sociocultural practices, the paper highlights how culturally appreciative culinary practices can meet the sextuple aim of healthcare system innovation. By examining diverse cultural traditions and their contributions to culinary medicine, this review underscores the importance of culturally attuned approaches in promoting human health. The integration of cultural food wisdom into healthcare practices offers a pathway to more effective and personalized care, stronger patient–provider relationships, diversity/equity/inclusion/belonging, and sustainable food systems.
1 Introduction
There is an urgent call for healthcare systems to address the sextuple aims for health improvement, namely (1) quality and experience of patient care; (2) population health outcomes; (3) healthcare provider satisfaction; (4) cost reduction; (5) diversity, equity, inclusion, and belonging (DEIB); and (6) environmental sustainability (1, 2).
Culinary medicine (CM) offers practical approaches to address each of these aims for improved human health. CM has been associated with patient satisfaction (3), improved population health outcomes (4), healthcare provider satisfaction (5), and cost reduction (4) to health systems. Additionally, it offers promise in addressing the two newest aims: diversity, equity inclusion, and belonging (DEIB) (6) and environmental sustainability (2).
Culinary medicine has a long history and has roots in every culture. Discussing food during healthcare visits and offering culturally responsive personalized nutritional dietary plans provide an opportunity to deliver respectful patient care. It honors the diverse food cultures and dietary practices of our patients. Culturally competent healthcare providers and trainees (7) must acknowledge complexities around food and nutrition within different cultural contexts respecting individual unique needs, experiences, preferences, lifestyle, and general wellbeing goals. By embracing culturally attuned, appreciative, and responsive practices, healthcare providers can offer more effective and personalized care. Harnessing culturally relevant models of healthy eating promotes personal and community wellbeing among diverse populations. This review highlights the ways CM can address all six aims, emphasizing the two newest identified aims (DEI and environmental sustainability).
2 Culinary medicine and the sextuple aim
Patient care experience and satisfaction, the first aim of healthcare system improvement, is supported by personalized care respecting cultural dietary practices and offering culturally responsive dietary plans. Discussing the diverse food cultures and dietary practices of our patients demonstrates respect and value for indigenous knowledge and traditional food practices. This mutual respect provides a strong base for a collaborative and therapeutic provider–patient relationship (8). Many studies support the role of culturally diverse culinary medicine initiatives in attaining the second aim of healthcare system improvement—improved population health outcomes (9). Clinical parameters (10, 11) (weight, blood glucose, lipids, and HgA1C), food purchasing behavior (12), and culturally relevant health education (13) are some documented effects among Sioux, Latinx, and Asian populations. The third aim, healthcare provider work satisfaction, has been demonstrated to increase among providers engaged in culinary medicine. The enhanced provider–patient relationships through cultural competence and satisfaction from providing personalized and effective care have beneficial downstream effects on healthcare providers, including an increased sense of connection to patients (14–16) of different cultures and generations. Healthcare cost-reducing impacts of culinary medicine (the fourth aim) have been projected for produce prescription programs (17) and other hands-on nutrition programs (18). The use of local and minimally processed foods was associated with household food cost savings (19).
The remainder of this briefing will focus on the implementation of culinary medicine through the lens of diversity, equity, inclusion, and belonging (DEIB) and environmental sustainability, the final two newest aims of the healthcare system reform. Health equity (aim #5) can be promoted through culturally tailored nutrition and addressing social determinants of health related to food access. Environmentally sustainable food practices (aim #6) are rooted in traditional diets, with traditional plant-centric diets producing lower greenhouse gas emissions.
3 Cultural diversity in culinary medicine
3.1 Nutritional diversity and health benefits
There are well-documented health benefits of nutritionally diverse cultural foods and flavors within cultural heritage eating patterns. Spices, which play a strong role in cultural heritage, have been associated with a plethora of health benefits (20). The bioactive components, polyphenols, and microbiota within traditional foods offer novel mechanistic insight for metabolism and health promotion (21, 22, 121). Advancing cultural diversity education of nutrition educators (23) can harness the benefits of ethnic “superfoods” to optimize healing. Clients can be free to enjoy choosing cost-effective local seasonal produce from ethnic markets rather than work extra shifts to afford the latest marketed “superfood” supplements. Shop with the Doc (24, 25) culinary grocery tours can bring awareness and joy to choosing nutritious, seasonal, culturally revered produce. Diverse traditional cultural diets rely on locally available, minimally processed, nutritious foods rather than processed and packaged foods, which more frequently contain GMO components (26).
Health benefits of spices from various cultural traditions (e.g., TCM, Ayurvedic, Mediterranean, African, and Latin American) have been associated with star anise (27, 28), ajwain, clove (28), cinnamon (28–31), allspice (28, 29), oregano (28, 29), cumin (29) black cumin (30), coriander (29), garlic (29, 32), ginger (29, 30), turmeric (29), caraway (33), parsley (29), black pepper (29), allium (29, 34–36), paprika (29), chili powder (29), rosemary (29), cilantro (29), thyme (29), bayleaf (29), cardamom (29), sage (29), and dillweed (37).
Benefits include blood pressure (29), glucose metabolism (30, 31), reduction in advanced glycation end products (28), cancer risk reduction (34), gut microbiome modulation (38), and immune health (27). Spices confer selective inhibiting effects on pathogenic organisms (Candida, Clostridium, and Bacteroides) while having no effect on beneficial organisms (Lactobacillus and Bifidobacterium) (33). Culinary amounts (2 tsp. cinnamon daily × 4 weeks had effects on 24-h glucose measured by continuous glucose monitoring) (31).
3.2 Promoting a healthy relationship with food
Enjoying culturally familiar and revered foods can promote a healthy relationship with food (39). The benefits of introducing culturally diverse foods and spices include less picky eating (40), increased acceptance throughout the lifespan (41), intake of vegetables (42–44), positive emotional context, family bonding, connection, flexibility, and enjoyment. Conversely, the risks of restriction include allergy risk (45, 46) and exacerbation of food anxiety in avoidant restrictive food intake disorder (ARFID) (47). Expanding food variety, increasing pleasure around food, and creating positive emotional context surrounding food are particularly beneficial in situations of food anxiety, ARFID, and disordered eating (which has increased with post-COVID-19 mental stress).
3.3 Culturally diverse diets preserving connection, heritage, and health
Elevating and embracing the cultural food wisdom of our patients within the medical visit preserves cultural heritage and supports the idea that there are many “best diets” (48), not just the well-studied Mediterranean Diet. For example, oldways (49) and Blue Zones (50–52) have also been associated with vitality and longevity.
Some foods common in traditional heritage healthy dietary patterns are often less commonly consumed in Western diets. These traditions deserve recognition and support wherever possible. For example, studies suggest that Saccharomyces boulardii may play a role in the prevention and treatment of certain gastrointestinal diseases (53–56). This tropical yeast was first isolated from lychee and mangosteen fruit peel (57) by the French scientist Henry Boulard, who was searching for a yeast strain that could withstand heat for wine production. He discovered this “modern probiotic” during his travels to Southeast Asia in the 1920s, after noticing that the natives who drank tea made from Mangosteen skins and other tropical fruits experienced fewer diarrhea symptoms from cholera.
One practical way to recognize and support traditional dietary patterns during medical visits is to ask patients to share their stories about food. Consider inquiring (58) about familiar tastes and foods while growing up, details around taste, smell, feelings, sensations, mood around the table, and memories of preparers. This may open the way for discussion about special cooking (or fermentation) methods, recipes, ingredients, or cultural food events. Not only do cultural and religious food community events preserve heritage, but some also involve philanthropy, commensality, hospitality, and sharing (59–61), thus contributing to equity.
Many cultural food preparation methods and techniques, such as sprouting (25) or fermentation (25, 62) have known health benefits (63). Examples of fermented foods with health benefits include fermented rice (jiu niang) (64, 65), injera (66), dosa (67), natto (68), tempeh (69, 70), sauerkraut (122), yogurt (71), kefir (72), and kombucha (73).
4 Addressing socioeconomic diversity in food choices
The role of cultural social determinants of health in acquiring and preparing food for populations with socioeconomic diversity cannot be underestimated. Food choices are often affected by biological, cultural, and societal filters (6, 58, 74, 75).
4.1 Special populations
Caregivers within food-insecure household settings face tremendous stress, often working multiple jobs, seeking to avoid wasting food, and may even seek to maximize calories by choosing fast food items with the highest number of calories for the price. Taking into account Satter’s Hierarchy of Food Needs (76), families must first be provided with the resources to meet their immediate needs (77) and then connected to additional resources (78, 79) that allow them to explore a variety of novel foods without the fear of cost burden or waste (74).
These caregivers also include students, many of whom are first-generation parents or caregivers, non-traditional in age, and/or identify as being part of minority groups (80, 81). Sadly, food insecurity among students, including those in postsecondary education, has been on the rise (82–85), with minority and first-generation students facing the highest risk of food insecurity (86, 87). Providing culturally diverse food choices is one way to create a culture at higher institutions supporting food security and health equity.
4.2 Inclusive options
Providing inclusive dietary options for special food needs, including medical restrictions, religious dietary restrictions, and food allergies (vegetarian, vegan, halal, kosher, gluten-free, lactose-free, and allergen-friendly) in schools, hospitals, and communities is a baseline requirement, and a variety in cuisine offerings (88) (Japanese, Italian, and Australian) can increase nutritional quality.
Institutions and communities can consider offering alternative ingredients that are cost-effective or more readily available. Within global cuisine, there are diverse options to build basic flavors. For example, salty taste can be imparted through salt, soy sauce, fish sauce, celery, seaweed, and miso, and sourness can be conveyed through apple cider vinegar, rice wine vinegar, citrus, and tamarind.
4.3 Ethnic grocery stores
Perhaps “food swamps” should be reframed as “food havens” (75), focusing on the role of local ethnic markets (including dollar bins), bodegas, and farms as underestimated treasure troves of food (89). Patients need to be encouraged to enjoy their “ethnic superfoods” (often found locally and in abundance at ethnic grocery stores) rather than focusing time, money, and resources on acquiring costly “trendy superfoods” (90). Such superfoods are often heavily marketed and processed, stripping them of their nutritional and price value (91).
Providing families with resources for access to healthy foods in low-resource environments, such as week on WIC (78) and “Cooking healthily on a penny” (92–94), can have effects on purchasing behavior and consumption of fresh fruits and vegetables.
4.4 Home-cooked meals
The role of rising food costs and inflation have also led to an interest in home-cooked meals. In the Seattle Obesity Study (95), home-cooked dinners were associated with higher Healthy Eating Index scores and reduced per capita food expenditures. In contrast, frequent eating out was associated with higher expenditures and lower dietary quality. Food away from home (FAFH) frequency is associated with adverse weight and cardiovascular outcomes (96) and lower overall Healthy Eating Index scores [fewer servings of greens and beans, total and whole fruits; and a higher intake of saturated fats (97) and added sugars (98)]. A greater amount of time spent on home food preparation was associated with a significantly more frequent intake of vegetables, salads, fruits, and fruit juices. Spending <1 h/day on food preparation was associated with significantly more money spent on FAFH and more frequent use of fast-food restaurants than those who spent more time on food preparation (99). Away food contained less dietary fiber, calcium, and iron on a per-calorie basis (97). One study showed variations in socioeconomic and race/ethnicity differences in home dinner preparation habits, indicating that households with foreign-born reference persons and households with dependents tend to cook more dinners at home (100). Regardless of income level, more frequent cooking at home was associated with better diet quality (101). Providing resources for quick, easy, culturally familiar meals at home can have far-reaching public health benefits.
4.5 Family meal benefits
Family meals are powerful tools for nurturing physical and emotional health. The frequency of family meals has been associated with improved dietary quality (102), rates of chronic disease, mental (103) and emotional wellbeing (104), and overall positive outcomes (105). Connections to families and cultural values have been shown to be powerful buffers in promoting mental health among minority college students facing stressors (106). Family meals centered around cultural favorites can be especially nourishing.
5 Environmental sustainability and culinary medicine
Many traditional cultural diets rely on seasonal (107) locally available, minimally processed, nutritious foods. Many of these foods and preparation methods are plant-centric and low in carbon emissions. These sustainable food practices are relevant not only at the local level (108) but also within the health systems.
5.1 Institutions
The use of plant-forward dishes has been associated with lower greenhouse gas emissions in healthcare systems (109) and campuses (110, 111). Emphasizing the procurement of food for local ecosystem also supports sustainable food practices. The export of quinoa is one tale of caution (112, 113).
5.2 Upcycling
Many cultures have a tradition of “upcycling” foods by using products that would otherwise go to waste in the food supply chain, yet contain valuable bioactive compounds that confer health benefits (114). Examples might include fruit rinds, vegetable pulps, extracted fibers from plants, or corn silk.
6 Clinical applications of culturally responsive culinary medicine
Culturally responsive healthcare through culinary medicine can be applied in a variety of healthcare settings.
6.1 Medical education
In recent years, medical schools have started to include justice and advocacy in their curriculum. For example, in one Justice and Advocacy in Medicine course for first-year medical students, culturally relevant cases using traditional Chinese medicine principles to teach nutrition to older Asian adults from the local area highlight cultural competency and health equity applied to patient care (115). A literature review of DEIB in nutrition education provided a recommended checklist for culturally competent nutrition education (7). All healthcare trainees and providers need to be aware of and responsive to the dietary habits and needs of diverse patient populations, diversifying the foods recommended to their clients. Furthermore, increased diversity among professionals with representation of all backgrounds will allow patients to see their cultures embraced (116).
6.2 History taking and case examples
Integrating ethnographic food questions into patient history (58) is a helpful tool within patient encounters. Past case studies highlighting successful integration of cultural culinary practices in healthcare settings include using cultural foods to support an oncology patient’s nutrition, making healthy pizza together with an adolescent of Mediterranean origin suffering from a metabolic condition, recommending asafetida to a patient struggling with IBS symptoms, incorporating the five flavors of TCM and 6 flavors of Ayurvedic medicine in expectant mothers’ diet (prenatal palate), and making Hungarian sauerkraut with an older Eastern European patient dealing with chronic pain and lack of purpose.
Adding detailed ethnographic food life questions to standard patient history and clinical encounters provides a broader cultural approach beyond standard food intake questions. It delves into the patient’s emotional, cultural, and familial relationship with food and food choices, for example: asking “what food and flavors take you right back home?,” “what are your food rules?” “how are you learning to care more about food in your life?” (58). These questions often lead to rich discussion that ultimately has lasting effects on patient’s sense of self-efficacy and motivation for behavioral change.
6.3 Group visits, community, and employee outreach
Culturally sensitive culinary medicine can be applied to group visits, community outreach, and employee health initiatives. Insurance billable shared medical appointments/group visits (117) extend access to quality care. Group topics may focus on metabolic health, lifestyle change (118, 119), intuitive eating, positive relationships with food, seasonal eating, TCM/ayurvedic dietary patterns (120) healthy detoxification, prenatal health, and oncology (119, 120).
Programs such as Shop with a Doc, farm-to-table events, or cooking demonstrations (121) for employees/staff are other ways to incorporate culturally diverse foods into community outreach education.
7 Conclusion
Culinary medicine that emphasizes culturally relevant, nutritionally diverse whole plant foods offers delicious, healthy, practical, and affordable tools to promote sustainable health and wellbeing for patients and clinicians from diverse cultural and socioeconomic backgrounds.
Culturally responsive culinary medicine meets all six aims of healthcare institution reform, including the two newest aims: DEIB and environmental sustainability. Practical tools for integrating cultural food wisdom into medical education and healthcare practices are shared.
Future directions for research and implementation in health systems should include studies that consider culturally relevant topics in the design and implementation of medical education and nutritional studies (8).
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
ML: Conceptualization, Writing – original draft, Writing – review & editing.
Funding
The author declares that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Nundy, S, Cooper, LA, and Mate, KS. The quintuple aim for health care improvement: a new imperative to advance health equity. JAMA. (2022) 327:521–2. doi: 10.1001/jama.2021.25181
2. Alami, H, Lehoux, P, Miller, FA, Shaw, SE, and Fortin, JP. An urgent call for the environmental sustainability of health systems: a ‘sextuple aim’ to care for patients, costs, providers, population equity and the planet. Int J Health Plann Manag. (2023) 38:289–95. doi: 10.1002/hpm.3616
3. Irl, BH, Evert, A, Fleming, A, Gaudiani, LM, Guggenmos, KJ, Kaufer, DI, et al. Culinary medicine: advancing a framework for healthier eating to improve chronic disease management and prevention. Clin Ther. (2019) 41:2184–98. doi: 10.1016/j.clinthera.2019.08.009
4. Chen, AMH, Draime, JA, Berman, S, Gardner, J, Krauss, Z, and Martinez, J. Food as medicine? Exploring the impact of providing healthy foods on adherence and clinical and economic outcomes. Explor Res Clin Soc Pharm. (2022) 5:100129. doi: 10.1016/j.rcsop.2022.100129
5. Wood, NI, Stone, TA, Siler, M, Goldstein, M, and Albin, JL. Physician-chef-dietitian partnerships for evidence-based dietary approaches to tackling chronic disease: the case for culinary medicine in teaching kitchens. J Healthc Leadersh. (2023) 15:129–37. doi: 10.2147/jhl.S389429
6. Chao, MT, and Adler, SR. Integrative health equity: definition, principles, strategies, and reflections. Glob Adv Integr Med Health. (2024) 13:27536130241231911. doi: 10.1177/27536130241231911
7. Ring, M, Ai, D, Maker-Clark, G, and Sarazen, R. Cooking up change: DEIB principles as key ingredients in nutrition and culinary medicine education. Nutrients. (2023) 15:4257. doi: 10.3390/nu15194257
8. Villalona, S, Ortiz, V, Castillo, WJ, and Garcia, LS. Cultural relevancy of culinary and nutritional medicine interventions: a scoping review. Am J Lifestyle Med. (2022) 16:663–71. doi: 10.1177/15598276211006342
9. Metghalchi, S, Rivera, M, Beeson, L, Firek, A, de Leon, M, Cordero-MacIntyre, ZR, et al. Improved clinical outcomes using a culturally sensitive diabetes education program in a Hispanic population. Diabetes Educ. (2008) 34:698–706. doi: 10.1177/0145721708320913
10. Kattelmann, KK, Conti, K, and Ren, C. The medicine wheel nutrition intervention: a diabetes education study with the Cheyenne River Sioux tribe. J Am Diet Assoc. (2009) 109:1532–9. doi: 10.1016/j.jada.2009.06.362
11. Yeh, MC, Heo, M, Suchday, S, Wong, A, Poon, E, Liu, G, et al. Translation of the diabetes prevention program for diabetes risk reduction in Chinese immigrants in new York City. Diabet Med. (2016) 33:547–51. doi: 10.1111/dme.12848
12. Amaro, H, Cortés, DE, Garcia, S, Duan, L, and Black, DS. Video-based grocery shopping intervention effect on purchasing behaviors among Latina shoppers. Am J Public Health. (2017) 107:800–6. doi: 10.2105/ajph.2017.303725
13. Ho, EY, Acquah, J, Chao, C, Leung, G, Ng, DC, Chao, MT, et al. Heart healthy integrative nutritional counseling (H2INC): creating a Chinese medicine + western medicine patient education curriculum for Chinese Americans. Patient Educ Couns. (2018) 101:2202–8. doi: 10.1016/j.pec.2018.08.011
14. Paetow, G, Scott, N, Panning, A, Hopkins, J, Aden, M, and Hart, D. Culinary cultural immersion: a qualitative analysis of resident knowledge, attitudes, and behavioral changes following a brief Somali cultural immersion experience. AEM Educ Train. (2023) 7:e10844. doi: 10.1002/aet2.10844
15. Dreibelbis, TD, and George, DR. An intergenerational teaching Kitchen: reimagining a senior center as a shared site for medical students and elders enrolled in a culinary medicine course. J Intergenerational Relatsh. (2017) 15:174–80. doi: 10.1080/15350770.2017.1294438
16. Pang, B, Memel, Z, Diamant, C, Clarke, E, Chou, S, and Gregory, H. Culinary medicine and community partnership: hands-on culinary skills training to empower medical students to provide patient-centered nutrition education. Med Educ Online. (2019) 24:1630238. doi: 10.1080/10872981.2019.1630238
17. Wang, L, Lauren, BN, Hager, K, Zhang, FF, Wong, JB, Kim, DD, et al. Health and economic impacts of implementing produce prescription programs for diabetes in the United States: a microsimulation study. J Am Heart Assoc. (2023) 12:e029215. doi: 10.1161/jaha.122.029215
18. Monlezun, DJ, Dart, L, Vanbeber, A, Smith-Barbaro, P, Costilla, V, Samuel, C, et al. Machine learning-augmented propensity score-adjusted multilevel mixed effects panel analysis of hands-on cooking and nutrition education versus traditional curriculum for medical students as preventive cardiology: multisite cohort study of 3,248 trainees over 5 years. Biomed Res Int. (2018) 2018:5051289–10. doi: 10.1155/2018/5051289
19. Razavi, AC, Sapin, A, Monlezun, DJ, McCormack, IG, Latoff, A, Pedroza, K, et al. Effect of culinary education curriculum on Mediterranean diet adherence and food cost savings in families: a randomised controlled trial. Public Health Nutr. (2021) 24:2297–303. doi: 10.1017/s1368980020002256
20. Tapsell, LC, Hemphill, I, Cobiac, L, Sullivan, DR, Fenech, M, Patch, CS, et al. Health benefits of herbs and spices: the past, the present, the future. Med J Aust. (2006) 185:S1–s24. doi: 10.5694/j.1326-5377.2006.tb00548.x
21. Witkamp, RF. Bioactive components in traditional foods aimed at health promotion: a route to novel mechanistic insights and Lead molecules? Annu Rev Food Sci Technol. (2022) 13:315–36. doi: 10.1146/annurev-food-052720-092845
22. Mercado-Mercado, G, Blancas-Benítez, FJ, Zamora-Gasga, VM, and Sáyago-Ayerdi, SG. Mexican traditional plant-foods: polyphenols bioavailability, gut microbiota metabolism and impact human health. Curr Pharm Des. (2019) 25:3434–56. doi: 10.2174/1381612825666191011093753
23. Setiloane, KT. Beyond the melting pot and salad bowl views of cultural diversity: advancing cultural diversity education of nutrition educators. J Nutr Educ Behav. (2016) 48:664–668.e1. doi: 10.1016/j.jneb.2016.05.008
24. York, PPMNY. Shop with the doc: a culinary medicine grocery tour. (2023). https://plantpoweredmetrony.app.neoncrm.com/np/clients/plantpoweredmetrony/event.jsp?event=2860&&secureIdCustomer=1& (Accessed May 28, 2023)
25. Loy, M. Culinary medicine/teaching kitchens for advancing food equity and preventing chronic disease. Int J Dis Rever Prevent. (2024) 6:1–17. doi: 10.22230/ijdrp.2024v6n1a427
26. Abrams, SA, Albin, JL, and Landrigan, PJCommittee on NutritionCouncil on Environmental Health and Climate Change. Use of genetically modified organism (GMO)-containing food products in children. Pediatrics. (2023) 153:e2023064774. doi: 10.1542/peds.2023-064774
27. Patra, JK, das, G, Bose, S, Banerjee, S, Vishnuprasad, CN, del Pilar Rodriguez-Torres, M, et al. Star anise (Illicium verum): chemical compounds, antiviral properties, and clinical relevance. Phytother Res. (2020) 34:1248–67. doi: 10.1002/ptr.6614
28. Starowicz, M, and Zieliński, H. Inhibition of advanced glycation end-product formation by high antioxidant-leveled spices commonly used in European cuisine. Antioxidants. (2019) 8:100. doi: 10.3390/antiox8040100
29. Petersen, KS, Davis, KM, Rogers, CJ, Proctor, DN, West, SG, and Kris-Etherton, PM. Herbs and spices at a relatively high culinary dosage improves 24-hour ambulatory blood pressure in adults at risk of cardiometabolic diseases: a randomized, crossover, controlled-feeding study. Am J Clin Nutr. (2021) 114:1936–48. doi: 10.1093/ajcn/nqab291
30. Garza, MC, Pérez-Calahorra, S, Rodrigo-Carbó, C, Sánchez-Calavera, MA, Jarauta, E, Mateo-Gallego, R, et al. Effect of aromatic herbs and spices present in the Mediterranean diet on the glycemic profile in type 2 diabetes subjects: a systematic review and Meta-analysis. Nutrients. (2024) 16:756. doi: 10.3390/nu16060756
31. Zelicha, H, Yang, J, Henning, SM, Huang, J, Lee, RP, Thames, G, et al. Effect of cinnamon spice on continuously monitored glycemic response in adults with prediabetes: a 4-week randomized controlled crossover trial. Am J Clin Nutr. (2024) 119:649–57. doi: 10.1016/j.ajcnut.2024.01.008
32. Loy, MH, and Rivlin, RS. Garlic and cardiovascular disease. Nutr Clin Care. (2000) 3:145–52. doi: 10.1046/j.1523-5408.2000.00043.x
33. Hawrelak, JA, Cattley, T, and Myers, SP. Essential oils in the treatment of intestinal dysbiosis: a preliminary in vitro study. Altern Med Rev. (2009) 14:380–4.
34. Desai, G, Schelske-Santos, M, Nazario, CM, Rosario-Rosado, RV, Mansilla-Rivera, I, Ramírez-Marrero, F, et al. Onion and garlic intake and breast Cancer, a case-control study in Puerto Rico. Nutr Cancer. (2020) 72:791–800. doi: 10.1080/01635581.2019.1651349
35. Zhang, J, and Yang, J. Allium vegetables intake and risk of breast cancer: a meta-analysis. Iran J Public Health. (2022) 51:746–57. doi: 10.18502/ijph.v51i4.9235
36. Jiang, Z, Chen, H, Li, M, Wang, W, Long, F, and Fan, C. Garlic consumption and colorectal cancer risk in US adults: a large prospective cohort study. Front Nutr. (2023) 10:1300330. doi: 10.3389/fnut.2023.1300330
37. Hamner, HC, Dooyema, CA, Blanck, HM, Flores-Ayala, R, Jones, JR, Ghandour, RM, et al. Fruit, vegetable, and sugar-sweetened beverage intake among young children, by state – United States, 2021. MMWR Morb Mortal Wkly Rep. (2023) 72:165–70. doi: 10.15585/mmwr.mm7207a1
38. Dahl, SM, Rolfe, V, Walton, GE, and Gibson, GR. Gut microbial modulation by culinary herbs and spices. Food Chem. (2023) 409:135286. doi: 10.1016/j.foodchem.2022.135286
40. Fredericks, L, Koch, PA, Liu, AA, Galitzdorfer, L, Costa, A, and Utter, J. Experiential features of culinary nutrition education that drive behavior change: frameworks for research and practice. Health Promot Pract. (2020) 21:331–5. doi: 10.1177/1524839919896787
41. Borowitz, SM. First bites-why, when, and what solid foods to feed infants. Front Pediatr. (2021) 9:654171. doi: 10.3389/fped.2021.654171
42. Savage, JS, Peterson, J, Marini, M, Bordi, PL Jr, and Birch, LL. The addition of a plain or herb-flavored reduced-fat dip is associated with improved preschoolers' intake of vegetables. J Acad Nutr Diet. (2013) 113:1090–5. doi: 10.1016/j.jand.2013.03.013
43. Carney, EM, Stein, WM, Reigh, NA, Gater, FM, Bakke, AJ, Hayes, JE, et al. Increasing flavor variety with herbs and spices improves relative vegetable intake in children who are propylthiouracil (PROP) tasters relative to non-tasters. Physiol Behav. (2018) 188:48–57. doi: 10.1016/j.physbeh.2018.01.021
44. Fritts, JR, Bermudez, MA, Hargrove, RL, Alla, L, Fort, C, Liang, Q, et al. Using herbs and spices to increase vegetable intake among rural adolescents. J Nutr Educ Behav. (2019) 51:806–816.e1. doi: 10.1016/j.jneb.2019.04.016
45. Hicke-Roberts, A, Wennergren, G, and Hesselmar, B. Late introduction of solids into infants' diets may increase the risk of food allergy development. BMC Pediatr. (2020) 20:273. doi: 10.1186/s12887-020-02158-x
46. Tran, MM, Lefebvre, DL, Dai, D, Dharma, C, Subbarao, P, Lou, W, et al. Timing of food introduction and development of food sensitization in a prospective birth cohort. Pediatr Allergy Immunol. (2017) 28:471–7. doi: 10.1111/pai.12739
47. Kim, YK, di Martino, JM, Nicholas, J, Rivera-Cancel, A, Wildes, JE, Marcus, MD, et al. Parent strategies for expanding food variety: reflections of 19,239 adults with symptoms of avoidant/restrictive food intake disorder. Int J Eat Disord. (2022) 55:108–19. doi: 10.1002/eat.23639
48. Katz, DL, and Meller, S. Can we say what diet is best for health? Annu Rev Public Health. (2014) 35:83–103. doi: 10.1146/annurev-publhealth-032013-182351
49. LeBlanc, KE, Baer-Sinnott, S, Lancaster, KJ, Campos, H, Lau, KHK, Tucker, KL, et al. Perspective: beyond the Mediterranean diet-exploring Latin American, Asian, and African heritage diets as cultural models of healthy eating. Adv Nutr. (2024) 15:100221. doi: 10.1016/j.advnut.2024.100221
50. Buettner, D, and Skemp, S. Blue zones: lessons from the World’s longest lived. Am J Lifestyle Med. (2016) 10:318–21. doi: 10.1177/1559827616637066
51. Murphy, KJ, and Parletta, N. Implementing a Mediterranean-style diet outside the Mediterranean region. Curr Atheroscler Rep. (2018) 20:28. doi: 10.1007/s11883-018-0732-z
52. Meccariello, R, and D'Angelo, S. Impact of polyphenolic-food on longevity: an elixir of life. An overview. Antioxidants. (2021) 10:507. doi: 10.3390/antiox10040507
53. Kelesidis, T, and Pothoulakis, C. Efficacy and safety of the probiotic Saccharomyces boulardii for the prevention and therapy of gastrointestinal disorders. Ther Adv Gastroenterol. (2012) 5:111–25. doi: 10.1177/1756283x11428502
54. McFarland, LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J Gastroenterol. (2010) 16:2202–22. doi: 10.3748/wjg.v16.i18.2202
55. Bustos Fernández, LM, Man, F, and Lasa, JS. Impact of Saccharomyces boulardii CNCM I-745 on bacterial overgrowth and composition of intestinal microbiota in diarrhea-predominant irritable bowel syndrome patients: results of a randomized pilot study. Dig Dis. (2023) 41:798–809. doi: 10.1159/000528954
56. Sniffen, JC, McFarland, LV, Evans, CT, and Goldstein, EJC. Choosing an appropriate probiotic product for your patient: an evidence-based practical guide. PLoS One. (2018) 13:e0209205. doi: 10.1371/journal.pone.0209205
57. Ansari, F, Alian Samakkhah, S, Bahadori, A, Jafari, SM, Ziaee, M, Khodayari, MT, et al. Health-promoting properties of Saccharomyces cerevisiae var. boulardii as a probiotic; characteristics, isolation, and applications in dairy products. Crit Rev Food Sci Nutr. (2023) 63:457–85. doi: 10.1080/10408398.2021.1949577
58. Lee, JJ, McWhorter, JW, Bryant, G, Zisser, H, and Eisenberg, DM. Standard patient history can be augmented using ethnographic food life questions. Nutrients. (2023) 15:4272. doi: 10.3390/nu15194272
59. Medina, F-X. Looking for commensality: on culture, health, heritage, and the Mediterranean diet. Int J Environ Res Public Health. (2021) 18:2605. doi: 10.3390/ijerph18052605
60. Wang, C, Huang, J, and Wan, X. A cross-cultural study of beliefs about the influence of food sharing on interpersonal relationships and food choices. Appetite. (2021) 161:105129. doi: 10.1016/j.appet.2021.105129
61. McKinley, CE, and Walters, KL. “It’s always about sharing, and caring, and loving, and giving”: decolonized and transcendent indigenist foodways fostering health and resilience. Advers Resil Sci. (2023) 4:89–103. doi: 10.1007/s42844-022-00086-6
62. Wastyk, HC, Fragiadakis, GK, Perelman, D, Dahan, D, Merrill, BD, Yu, FB, et al. Gut-microbiota-targeted diets modulate human immune status. Cell. (2021) 184:4137–4153.e14. doi: 10.1016/j.cell.2021.06.019
63. Marco, ML, Heeney, D, Binda, S, Cifelli, CJ, Cotter, PD, Foligné, B, et al. Health benefits of fermented foods: microbiota and beyond. Curr Opin Biotechnol. (2017) 44:94–102. doi: 10.1016/j.copbio.2016.11.010
64. Akamine, Y, Millman, JF, Uema, T, Okamoto, S, Yonamine, M, Uehara, M, et al. Fermented brown rice beverage distinctively modulates the gut microbiota in Okinawans with metabolic syndrome: a randomized controlled trial. Nutr Res. (2022) 103:68–81. doi: 10.1016/j.nutres.2022.03.013
65. Anbalagan, C, Nandabalan, SK, Sankar, P, Rajaram, PS, Govindaraj, K, Rupert, S, et al. Postbiotics of naturally fermented synbiotic mixture of Rice water aids in promoting colonocyte health. Biomol Ther. (2024) 14:344. doi: 10.3390/biom14030344
66. Neela, S, and Fanta, SW. Injera (an ethnic, traditional staple food of Ethiopia): a review on traditional practice to scientific developments. J Ethnic Foods. (2020) 7:32. doi: 10.1186/s42779-020-00069-x
67. Narayanan, J, Sanjeevi, V, Rohini, U, Trueman, P, and Viswanathan, V. Postprandial glycaemic response of foxtail millet dosa in comparison to a rice dosa in patients with type 2 diabetes. Indian J Med Res. (2016) 144:712–7. doi: 10.4103/ijmr.IJMR_551_15
68. Afzaal, M, Saeed, F, Islam, F, Ateeq, H, Asghar, A, Shah, YA, et al. Nutritional health perspective of Natto: a critical review. Biochem Res Int. (2022) 2022:5863887–9. doi: 10.1155/2022/5863887
69. Ahnan-Winarno, AD, Cordeiro, L, Winarno, FG, Gibbons, J, and Xiao, H. Tempeh: a semicentennial review on its health benefits, fermentation, safety, processing, sustainability, and affordability. Compr Rev Food Sci Food Saf. (2021) 20:1717–67. doi: 10.1111/1541-4337.12710
70. Wang, K, Gao, Y, Zhao, J, Wu, Y, Sun, J, Niu, G, et al. Effects of in vitro digestion on protein degradation, phenolic compound release, and bioactivity of black bean tempeh. Front Nutr. (2022) 9:1017765. doi: 10.3389/fnut.2022.1017765
71. Kok, CR, and Hutkins, R. Yogurt and other fermented foods as sources of health-promoting bacteria. Nutr Rev. (2018) 76:4–15. doi: 10.1093/nutrit/nuy056
72. Azizi, NF, Kumar, MR, Yeap, SK, Abdullah, JO, Khalid, M, Omar, AR, et al. Kefir and its biological activities. Food Secur. (2021) 10:6. doi: 10.3390/foods10061210
73. Costa, MAC, Vilela, DLS, Fraiz, GM, Lopes, IL, Coelho, AIM, Castro, LCV, et al. Effect of kombucha intake on the gut microbiota and obesity-related comorbidities: a systematic review. Crit Rev Food Sci Nutr. (2023) 63:3851–66. doi: 10.1080/10408398.2021.1995321
74. Fischer, L, Bodrick, N, Mackey, ER, McClenny, A, Dazelle, W, McCarron, K, et al. Feasibility of a home-delivery produce prescription program to address food insecurity and diet quality in adults and children. Nutrients. (2022) 14:2006. doi: 10.3390/nu14102006
75. Tonumaipe'a, D, Cammock, R, and Conn, C. Food havens not swamps: a strength-based approach to sustainable food environments. Health Promot Int. (2021) 36:1795–805. doi: 10.1093/heapro/daab021
76. Satter, E. Hierarchy of food needs. J Nutr Educ Behav. (2007) 39:S187–8. doi: 10.1016/j.jneb.2007.01.003
77. Insolera, N, Cohen, A, and Wolfson, JA. SNAP and WIC participation during childhood and food security in adulthood, 1984-2019. Am J Public Health. (2022) 112:1498–506. doi: 10.2105/ajph.2022.306967
78. Thomas, R.. Week on WIC. Developed in partnership with San Bernadino County Department of Public Health WIC Program. (2023). Available at: https://www.drrenaethomas.com/wic (Accessed March 11, 2023)
79. The teaching kitchen at Lenox HIll neighborhood house farm to institution cookbook. Available at: https://www.lenoxhill.org/recipes (Accessed July 14, 2023)
80. Sallee, MW, Kohler, CW, Haumesser, LC, and Hine, JC. Falling through the cracks: examining one Institution’s response to food insecure student-parents. J High Educ. (2023) 94:415–43. doi: 10.1080/00221546.2023.2187175
81. Landry, MJ, Gundersen, C, and Eicher-Miller, HA. Food insecurity on college and university campuses: a context and rationale for solutions. J Acad Nutr Diet. (2022) 122:519–24. doi: 10.1016/j.jand.2021.10.021
82. Bruening, M, Argo, K, Payne-Sturges, D, and Laska, MN. The struggle is real: a systematic review of food insecurity on postsecondary education campuses. J Acad Nutr Diet. (2017) 117:1767–91. doi: 10.1016/j.jand.2017.05.022
83. DeMunter, J, Rdesinski, R, Vintro, A, and Carney, PA. Food insecurity among students in six health professions’ training programs. J Stud Aff Res Pract. (2021) 58:372–87. doi: 10.1080/19496591.2020.1796690
84. Laska, MN, Fleischhacker, S, Petsoulis, C, Bruening, M, and Stebleton, MJ. Addressing college food insecurity: an assessment of Federal Legislation before and during coronavirus Disease-2019. J Nutr Educ Behav. (2020) 52:982–7. doi: 10.1016/j.jneb.2020.07.001
85. Flynn, MM, Monteiro, K, George, P, and Tunkel, AR. Assessing food insecurity in medical students. Fam Med. (2020) 52:512–3. doi: 10.22454/FamMed.2020.722238
86. Savoie-Roskos, MR, Hood, LB, Hagedorn-Hatfield, RL, Landry, MJ, Patton-López, MM, Richards, R, et al. Creating a culture that supports food security and health equity at higher education institutions. Public Health Nutr. (2022) 26:503–9. doi: 10.1017/s1368980022002294
87. Landry, MJ, Savoie-Roskos, MR, Gray, V, Mann, G, Qamar, Z, Hagedorn-Hatfield, RL, et al. Food security as a basic need: college students need greater support from institutional administration. J Am Coll Heal. (2024) 72:1–4. doi: 10.1080/07448481.2024.2334074
88. Trapp, GS, Reid, N, Hickling, S, Bivoltsis, A, Mandzufas, J, and Howard, J. Nutritional quality of children's menus in restaurants: does cuisine type matter? Public Health Nutr. (2023) 26:1451–5. doi: 10.1017/s1368980023000344
89. Komakech, MD, and Jackson, SF. A study of the role of small ethnic retail grocery Stores in Urban Renewal in a social housing project, Toronto, Canada. J Urban Health. (2016) 93:414–24. doi: 10.1007/s11524-016-0041-1
90. Yi, SS, Russo, RG, Liu, B, Kum, S, Rummo, P, and Li, Y. Characterising urban immigrants' interactions with the food retail environment. Public Health Nutr. (2021) 24:3009–17. doi: 10.1017/s1368980020002682
91. Dastgerdizad, H, Dombrowski, RD, Bode, B, Knoff, KAG, Kulik, N, Mallare, J, et al. Community solutions to increase the healthfulness of grocery stores: perspectives of immigrant parents. Int J Environ Res Public Health. (2023) 20:6536. doi: 10.3390/ijerph20156536
92. Hashimi, H, Boggs, K, and Harada, CN. Cooking demonstrations to teach nutrition counseling and social determinants of health. Educ Health. (2020) 33:74–8. doi: 10.4103/efh.EfH_234_19
93. Thomas, OW, Reilly, JM, Wood, NI, and Albin, J. Culinary medicine: needs and strategies for incorporating nutrition into medical education in the United States. J Med Educat Curri Develop. (2024) 11:23821205241249379. doi: 10.1177/23821205241249379
94. Weinstein, E, Galindo, RJ, Fried, M, Rucker, L, and Davis, NJ. Impact of a focused nutrition educational intervention coupled with improved access to fresh produce on purchasing behavior and consumption of fruits and vegetables in overweight patients with diabetes mellitus. Diabetes Educ. (2014) 40:100–6. doi: 10.1177/0145721713508823
95. Tiwari, A, Aggarwal, A, Tang, W, and Drewnowski, A. Cooking at home: a strategy to comply with U.S. dietary guidelines at no extra cost. Am J Prev Med. (2017) 52:616–24. doi: 10.1016/j.amepre.2017.01.017
96. Godbharle, S, Jeyakumar, A, Giri, BR, and Kesa, H. Pooled prevalence of food away from home (FAFH) and associated non-communicable disease (NCD) markers: a systematic review and meta-analysis. J Health Popul Nutr. (2022) 41:55. doi: 10.1186/s41043-022-00335-5
97. Guthrie, JF, Lin, BH, and Frazao, E. Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: changes and consequences. J Nutr Educ Behav. (2002) 34:140–50. doi: 10.1016/s1499-4046(06)60083-3
98. Nagao-Sato, S, and Reicks, M. Food away from home frequency, diet quality, and health: cross-sectional analysis of NHANES data 2011-2018. Nutrients. (2022) 14:3386. doi: 10.3390/nu14163386
99. Monsivais, P, Aggarwal, A, and Drewnowski, A. Time spent on home food preparation and indicators of healthy eating. Am J Prev Med. (2014) 47:796–802. doi: 10.1016/j.amepre.2014.07.033
100. Virudachalam, S, Long, JA, Harhay, MO, Polsky, DE, and Feudtner, C. Prevalence and patterns of cooking dinner at home in the USA: National Health and nutrition examination survey (NHANES) 2007-2008. Public Health Nutr. (2014) 17:1022–30. doi: 10.1017/s1368980013002589
101. Wolfson, JA, Leung, CW, and Richardson, CR. More frequent cooking at home is associated with higher healthy eating Index-2015 score. Public Health Nutr. (2020) 23:2384–94. doi: 10.1017/s1368980019003549
102. Larson, N, Fulkerson, J, Story, M, and Neumark-Sztainer, D. Shared meals among young adults are associated with better diet quality and predicted by family meal patterns during adolescence. Public Health Nutr. (2013) 16:883–93. doi: 10.1017/s1368980012003539
103. Elgar, FJ, Craig, W, and Trites, SJ. Family dinners, communication, and mental health in Canadian adolescents. J Adolesc Health. (2013) 52:433–8. doi: 10.1016/j.jadohealth.2012.07.012
104. Harbec, MJ, and Pagani, LS. Associations between early family meal environment quality and later well-being in school-age children. J Dev Behav Pediatr. (2018) 39:136–43. doi: 10.1097/dbp.0000000000000520
105. Skeer, MR, and Ballard, EL. Are family meals as good for youth as we think they are? A review of the literature on family meals as they pertain to adolescent risk prevention. J Youth Adolesc. (2013) 42:943–63. doi: 10.1007/s10964-013-9963-z
106. Corona, R, Rodríguez, VM, McDonald, SE, Velazquez, E, Rodríguez, A, and Fuentes, VE. Associations between cultural stressors, cultural values, and Latina/o college Students' mental health. J Youth Adolesc. (2017) 46:63–77. doi: 10.1007/s10964-016-0600-5
107. Brooks, M, Foster, C, Holmes, M, and Wiltshire, J. Does consuming seasonal foods benefit the environment? Insights from recent research. Nutr Bull. (2011) 36:449–53. doi: 10.1111/j.1467-3010.2011.01932.x
108. Vargas, AM, de Moura, AP, Deliza, R, and Cunha, LM. The role of local seasonal foods in enhancing sustainable food consumption: a systematic literature review. Food Secur. (2021) 10:2206. doi: 10.3390/foods10092206
109. Mitchell Katz, EA. Expansion of plant-based meals as default option for patients in NYC public hospitals. (2023). Available at: https://www.nyc.gov/office-of-the-mayor/news/705-22/mayor-adams-nyc-h-h-ceo-katz-successful-rollout-expansion-plant-based-meals-as (accessed May 28, 2023)
110. Erhard, A, Boztuğ, Y, and Lemken, D. How do defaults and framing influence food choice? An intervention aimed at promoting plant-based choice in online menus. Appetite. (2023) 190:107005. doi: 10.1016/j.appet.2023.107005
111. Ginn, J, and Sparkman, G. Can you default to vegan? Plant-based defaults to change dining practices on college campuses. J Environ Psychol. (2024) 93:102226. doi: 10.1016/j.jenvp.2023.102226
112. Bellemare, MF, Fajardo-Gonzalez, J, and Gitter, SR. Foods and fads: the welfare impacts of rising quinoa prices in Peru. World Dev. (2018) 112:163–79. doi: 10.1016/j.worlddev.2018.07.012
113. Lutz, M, and Bascuñán-Godoy, L. The revival of quinoa: a crop for health. United Kingdom: In Tech Open. (2017).
114. Martins, T, Barros, AN, Rosa, E, and Antunes, L. Enhancing health benefits through chlorophylls and chlorophyll-rich agro-food: a comprehensive review. Molecules. (2023) 28:5344. doi: 10.3390/molecules28145344
115. Rivera, J, de Lisser, R, Dhruva, A, Fitzsimmons, A, Hyde, S, Reddy, S, et al. Integrative health: an Interprofessional standardized patient case for prelicensure learners. MedEdPORTAL. (2018) 14:10715. doi: 10.15766/mep_2374-8265.10715
116. Carson, TL, Cardel, MI, Stanley, TL, Grinspoon, S, Hill, JO, Ard, J, et al. Racial and ethnic representation among a sample of nutrition- and obesity-focused professional organizations in the United States. Am J Clin Nutr. (2021) 114:1869–72. doi: 10.1093/ajcn/nqab284
117. Loy, M. Shared medical appointments (SMAs) at an academic institution: an engaging, effective, efficient educational model benefitting patients and clinicians. Academic consortium integrative medicine and health symposium. (2023)
118. Loy, MBE. Implementing culinary medicine at an Academic Medical Center. J Integrat Complement Med. (2023) 29:102–8. doi: 10.1089/ict.2023.29076.mlo
119. Dhruva, A, Wu, C, Miaskowski, C, Hartogensis, W, Rugo, HS, Adler, SR, et al. A 4-month whole-systems ayurvedic medicine nutrition and lifestyle intervention is feasible and acceptable for breast Cancer survivors: results of a single-arm pilot clinical trial. Glob Adv Health Med. (2020) 9:2164956120964712. doi: 10.1177/2164956120964712
120. Babich, JS, McMacken, M, Correa, L, Polito-Moller, K, Chen, K, Adams, E, et al. Advancing lifestyle medicine in new York City's public health care system. Mayo Clin Proc Innov Qual Outcomes. (2024) 8:279–92. doi: 10.1016/j.mayocpiqo.2024.01.005
121. Eisenberg, DM, Cole, A, Maile, EJ, Salt, M, Armstrong, E, Leib, EB, et al. Proposed Nutrition Competencies for Medical Students and Physician Trainees: A Consensus Statement. JAMA Netw Open. (2024) 7:e2435425. doi: 10.1001/jamanetworkopen.2024.35425
Keywords: cultural practices, culturally responsive care, sociocultural health practices, cultural competence, culinary medicine, diversity equity inclusion belonging, environmental sustainability, healthcare system sextuple aims
Citation: Loy MH (2024) From plate to planet: culturally responsive culinary practices for health system innovation. Front. Nutr. 11:1476503. doi: 10.3389/fnut.2024.1476503
Edited by:
Rani Polak, Spaulding Rehabilitation Hospital, United StatesReviewed by:
Galya Bigman, University of Maryland, United StatesCopyright © 2024 Loy. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Michelle H. Loy, bWhsb3lAbWVkLmNvcm5lbGwuZWR1