You Can't Replace Insulin With Cooking Classes

Why cooking classes are a terrible way to stop people from being fat

Pictured: Cooking. Photo by Kevin McCutcheon on Unsplash

Yesterday, the current head of the United States Federal Drug Administration, Dr. Marty Makary, said this:

“We’ve got to stop and ask ourselves, should we be focusing more on school lunch programs, not just putting every kid on Ozempic…and maybe we need to treat more diabetes with cooking classes, not just throwing insulin at people.”

If you want to see the full rant which appeared on Fox news, you can click the first link there. In context, the statements are no more convincing than they are isolated. This is an astonishingly ignorant thing for any senior scientist to say, never mind the person nominally in charge of all food and drug safety for the U.S.

I’m not going to go into the various ways that the statements are offensive. People have already pointed out that this sort of rhetoric is hugely problematic for people with Type 1 diabetes, and it’s obviously absurd to say that any pediatrician anywhere in the world is considering putting all of their patients on Ozempic*.

But there is one fairly obvious scientific error here. It’s a common mistake made by people who believe that health is largely under individual control, and therefore merely a matter of educating everyone about their risks.

“Just tell everyone to go running” - the head of the FDA, apparently. Photo by Fitsum Admasu on Unsplash

Let’s talk about cooking classes, and why they do very little to prevent obesity and chronic disease.

Education Shmeducation

I think it’s important to steel man Dr. Makary here. That is, to take the strongest possible argument that he could be making, even if his actual words are not strong at all. In this case, the argument is fairly simple - treating diabetes is very expensive and difficult, and we know that most cases of diabetes are in theory preventable, so why don’t we implement more interventions that are aimed at preventing the disease in the first place? In particular, we know that diabetes has a strong relationship with obesity, and if we could drop obesity rates substantially we’d see fewer people being diagnosed.

So far, so reasonable. While the reality is much more complicated than the Dr. Makarys of the world might argue, it is true that dropping obesity rates would probably result in fewer cases of diabetes.

But that brings us to cooking classes. As a rhetorical device, they are a lovely idea, but the problem is that they are also a great example of why this stuff is dramatically harder than the MAHA movement portrays. To put it bluntly, cooking classes have few if any benefits for the health of the people who get them.

Pictured: Great fun, not as useful as Ozempic. Photo by Odiseo Castrejon on Unsplash

We have quite a bit of evidence on the question of cooking classes. There are a number of studies that show that people who have cooking lessons tend to really enjoy them, and self-report healthier eating behaviors in the weeks that follow. For example, this small randomized trial in university students showed people who got the intervention felt more confident cooking, and said they were eating healthier than those who did not take part in the program.

The problem is that self-reported improvements in diet aren’t a very useful metric on which to measure health. People regularly say that they’re doing things, but the proof is in the pudding - if the intervention group doesn’t have any benefits for things like weight loss and blood pressure, then self-reported healthy eating scores don’t really matter.

And when it comes to the things that we really care about, cooking classes don’t seem to have a benefit. Or, more broadly, education interventions where people are taught healthy eating by professionals which include cooking classes and a range of other stuff generally show little to no improvements for BMI or other health-related outcomes.

For example, the very large WHEL trial, published in 2007. Women with breast cancer were randomized to receive either a comprehensive dietary intervention including telephone counselling, 12 cooking classes, and monthly newsletters or a substantially reduced intervention that mostly consisted of a healthy eating pamphlet. By the end of the 7-year study, both the intervention and control groups had gained weight despite reporting eating fewer calories than at the start.

Another large randomized trial looked at a culturally-targeted lifestyle intervention - including cooking classes - to reduce risk of type 2 diabetes in people of South Asian descent. After 1 year, people who got the intervention had almost identical weight loss - almost none - to those who were in the control group.

The story is similar in intervention after intervention. The LA Sprouts randomized trial did find a benefit for a combined weight loss intervention in children, but the reduction in BMI was so small that it was barely measurable. One of the largest clinical trials ever on the topic was conducted in Denmark, comparing an individually tailored dietary and physical activity intervention that included cooking classes. To quote the study:

“At mean 2.7 years after the baseline examination, no differences were observed between the intervention and control group in [change in] BMI”

A recent systematic review of the topic found that there was no evidence that cooking classes had any impact on biological parameters such as weight or blood pressure, even though they did improve people’s self-reported cooking ability.

In other words, there is no evidence that cooking classes can prevent diabetes. Despite dozens of randomized trials, education-based healthy eating interventions mostly seem to make people feel better about their eating without doing much to change their risk of health problems in the future.

This actually ties in very well to the general evidence that behavior change interventions just aren’t that effective in the real world. Just read the 2019 Cochrane review into the effect of interventions for preventing obesity in children. It’s a very wordy paper, but the basic message is that there is no existing strategy that we’ve tried - across hundreds of different interventions including everything from sports activities, cooking classes, healthy diet education, and more - that has a consistent long-term benefit for health or wellbeing. At best, by spending millions of dollars, you can usually get people to lose a few pounds over the course of six months which they will then spend the next six months putting back on.

Pictured: Exercise. Probably. Maybe it’s staged? Photo by Anupam Mahapatra on Unsplash

This is not to say that exercise and diet are meaningless to health. Rather, it is incredibly difficult to modify people’s behaviors without modifying their lived environment. You can tell obese people that they need to exercise more regularly, or run all the cooking classes you want, but until you fix things like how safe people feel exercising outdoors food people are still going to stay home and eat cheap, easy meals.

The problem with Dr. Makary’s statements is not that they are glib and absurd. They are, but they also reveal the deep, underlying ignorance behind the entire MAHA movement. Public health authorities have spent the last 40 years trying to get people to lose weight through individually-targeted measures like cooking classes. As a case in point, the USDA, CDC, and American Diabetes Association all offer free online healthy eating courses including cooking classes. It’s not like we haven’t tried this stuff before - rather, we have invested billions of dollars doing it only to realize that on the whole it is ineffective.

Addressing the chronic disease increases in the United States requires more than solutions that were failing in clinical trials in the early 00s. There are structural barriers to good health that include everything from racism to the high rate of incarceration. The biggest killers of children nationally are guns and automobiles. Air pollution is likely one of the biggest reasons kids get asthma.

These are complex problems that have no easy answer. Reducing obesity rates probably requires the US to substantially restructure its food system. Increasing physical activity is a decades-long goal that needs a whole catalog of interventions to work.

Education is a nice-sounding idea. It’s very feel-good, and in a perfect world it would work very well. But the reason people eat poorly has very little to do with knowledge, particularly in our online world. You can download 1,000 free cooking apps with healthy recipes if you really want to cook your family better food, but none of them will lower the price of eggs or give you an extra hour in the day to caramelize onions.

*Note: Specifically, despite recent increases, data suggests that substantially fewer than 1% of kids have been prescribed semaglutide (Ozempic) in the years since it was authorized.