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# Peer-led plant-based cooking workshops for post-cancer patients: an observational pilot study on dietary practices

A Murat-Ringot, R Lan, E Goetz, L Basbous, M T Charreyre, F Carrouel

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A Murat-Ringot, R Lan, E Goetz, L Basbous, M T Charreyre, et al. Peer-led plant-based cooking workshops for post-cancer patients: an observational pilot study on dietary practices. Supportive Care in Cancer, 2025, 33, 10.1007/s00520-025-10049-z. [https://hal.science/hal-05345138v1](https://hal.science/hal-05345138v1)

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# Peer-led plant-based cooking workshops for post-cancer patients: an observational pilot study on dietary practices

A. Murat-Ringot<fnref n="1" />,<fnref n="2" /> · R. Lan<fnref n="3" /> · E. Goetz<fnref n="4" /> · L. Basbous<fnref n="2" /> · M. T. Charreyre<fnref n="5" /> · F. Carrouel<fnref n="1" />

Received: 21 January 2025 / Accepted: 14 October 2025

© The Author(s) 2025

## Abstract

**Purpose** This study aimed to assess the impact of peer-led cooking workshops on dietary knowledge, skills, and behavioral changes in adopting protein-rich cereals such as spelt, emmer, and einkorn among post-treatment cancer patients. It addressed barriers to sustainable dietary practices, contributing to improved well-being and alignment with the planetary health diet (PHD).

**Methods** This cohort observational study, part of the BIOQUALIM protocol, adhered to STROBE guidelines and evaluated six post-cancer patients attending six bi-weekly, 2-h cooking workshops at Lyon Sud Hospital, France, between March and June 2024. Workshops focused on savory and sweet recipes using protein-rich cereals (spelt, einkorn, and emmer). Data were collected and analyzed following Kirkpatrick's four-level model using pre- and post-workshop questionnaires (Wilcoxon test analysis) and semi-structured interviews (thematic analysis).

**Results** Participants demonstrated a significant increase in knowledge of protein-rich cereals (mean score improvement from 1.9 to 4.0, *p* = 0.035) and a non-significant improvement in their skills (from 2.5 to 4.1, *p* = 0.063). Participants reported improved digestion, well-being, and increased confidence in adopting such plant-based diets. The thematic analysis showed that group dynamics fostered social support and self-efficacy. Obstacles such as ingredient availability and preparation time were identified.

**Conclusion** Peer-led cooking workshops effectively promote dietary knowledge, sustainable practices, and well-being in post-cancer patients, aligning with PHD principles. This intervention demonstrates potential as a scalable approach for integrating sustainable and health-promoting dietary behaviors. Further research with larger, diverse samples is needed to enhance generalizability and long-term impact assessment.

**Keywords** Cancer · Protein-rich cereal · Cooking workshops · Planetary health diet · Peer-led

<figure><img src="image_3.png" /></figure>

## Introduction

Diet plays a pivotal role in public health, particularly in preventing non-communicable diseases (NCDs) such as cardiovascular diseases, diabetes, and cancers [1]. To address these challenges, the planetary health diet (PHD) has emerged as a framework that promotes human health and aligns dietary practices with environmental sustainability [2]. This diet emphasizes increased consumption of plant-based foods, including fruits, vegetables, legumes, whole grains, and nuts, while reducing intake of animal-sourced foods and highly processed products. The Food and Agriculture Organization (FAO) of the USA follows these principles by encouraging organic, local, and seasonal food consumption alongside home-cooked meals [3, 4]. Evidence demonstrates that adopting a plant-based diet protects against

<footnote>A. Murat-Ringot
audrey.ringot@univ-lyon1.fr</footnote>

<footnote n="1">¹ Present Address: Laboratory "Health, Systemic, Process" (P2S), UR4129,, University Claude Bernard Lyon 1, University of Lyon, 69008 Lyon, France</footnote>

<footnote n="2">² Hospices Civils de Lyon, 69002 Lyon, France</footnote>

<footnote n="3">³ Laboratory Anthropologie Bio-Culturelle, Droit, Ethique Et Santé (ADES), Centre National de La Recherche Scientifique (CNRS), Etablissement Français du Sang (EFS), Aix Marseille University, 13005 Marseille, France</footnote>

<footnote n="4">⁴ Unité U1296 "Radiations : Défense, Santé, Environnement", Université Lumière Lyon 2, 69007 Lyon, France</footnote>

<footnote n="5">⁵ UMR 5223, Ingénierie Des Matériaux Polymères, Centre National de La Recherche Scientifique (CNRS), Université Claude Bernard Lyon 1, INSA Lyon, Université Jean Monnet, 69622 Villeurbanne Cédex, France</footnote>
NCDs, lowers all-cause mortality, and improves nutrient intake [5, 6]. Environmentally, plant-based proteins have a significantly smaller ecological footprint than animal-based proteins, requiring fewer natural resources and emitting less greenhouse gases [7].

Thus, a plant-based diet supports environmental sustainability and promotes health by reducing NCDs risk and improving nutrient intake, aligning with holistic well-being principles in the One Health framework [8, 9]. The French National Health and Environment Plan emphasizes reducing environmental pollution, limiting exposure to food-related chemicals, and minimizing zoonosis risks—concerns linked to sustainable food systems [10].

However, despite these initiatives, the population faces dietary challenges, including insufficient intake of micro-nutrients (e.g., vitamins, antioxidants, and minerals) and fibers. This is reinforced by the declining nutritional quality of commonly consumed fruits, vegetables, cereals, and legumes due to intensive agricultural practices and a dramatic 75% loss of cultivated biodiversity over the last century, according to the FAO [4, 11].

These challenges are particularly acute among people living with and beyond cancer (LWBC). According to the European Society for Clinical Nutrition and Metabolism [12], cancer patients often require protein intakes ranging from 1.2 to 2.0 g per kilogram of body weight daily to support immune function, prevent muscle wasting, and improve treatment tolerance and recovery outcomes [12]. However, due to symptoms associated with cancer and its treatments, patients often fail to meet these protein recommendations, leading to nutritional deficits [13].

To address these nutritional challenges, protein-rich cereals like einkorn, emmer, and spelt offer nutrient-dense and sustainable alternatives [14]. These grains possess protein content approximately 20–80% higher than modern wheat varieties, containing 13–15 g of proteins per 100 g for spelt varieties, 13–18 g for emmer, and up to 16–20 g for einkorn, compared to 10–12 g for modern wheat varieties, as quantified in a recent study where 31 varieties have been organically cultivated in the same location [15]. Furthermore, these grains are richer than modern wheat varieties in minerals like magnesium and in micronutrients like iron, zinc, selenium, and B-vitamins [16], all of which support immunological function, muscle maintenance, and recovery processes during cancer treatment [12, 17]. Given their nutritional profiles, einkorn, emmer, and spelt can contribute to address these protein and micronutrient inadequacies, common among cancer patients. Incorporating these grains into the diet perfectly aligns with the nutritional and environmental objectives of the planetary health diet (PHD), providing both sustainable and health-promoting dietary solutions specifically adapted to populations with increased nutritional needs [12]. Cancer and its treatments often lead to eating-related

symptoms such as loss of appetite (anorexia), altered taste (dysgeusia), and impaired smell (anosmia or hyposmia). These symptoms can disrupt normal eating behavior and nutritional intake [18–20]. Consequently, tailored dietary interventions—delivered by nutrition professionals based on individual assessments—that address these specific sensory and nutritional challenges are essential for reducing undernutrition, enhancing treatment adherence, improving patient follow-up, and ultimately influencing survival rates positively [20–22].

Alongside practitioner-led workshops, which are typically delivered by clinicians or dietitians using structured, didactic methods, peer-led workshops offer a complementary, community-based approach to dietary support—particularly valuable for people LWBC. In fact, peer-led cooking workshops, particularly those facilitated by people LWBC, emphasize experiential learning, shared identity, and mutual encouragement, thereby fostering trust and emotional safety. Group-based cooking interventions have been shown to improve self-esteem, social connectedness, and reduce anxiety, highlighting their psychosocial value beyond nutritional education [23–26].

These workshops are not only focused on culinary skills; they often include nutritional literacy, psychosocial support, and behavioral change strategies tailored to survivors’ lived realities. For example, they help participants navigate post-treatment taste changes, cooking anxiety, and unfamiliar ingredients, especially when transitioning to plant-rich diets [24, 27, 28]. The peer-led format enhances group cohesion and long-term motivation, which are critical to sustain dietary adherence in survivorship contexts.

Recent research confirms that peer-led cooking or lifestyle interventions in cancer care can effectively improve dietary intake, reduce social isolation, and increase confidence in meal preparation [25, 29]. By integrating both clinical and lived expertise, combining practitioner-led and peer-led formats creates a synergistic model well-suited to the multiple challenges of dietary behavior change in people LWBC. Practitioner-led sessions provide essential clinical knowledge but may overlook emotional, cultural, and behavioral aspects of dietary change. In contrast, peer-led cooking workshops, particularly those facilitated by people living with and beyond cancer (LWBC), emphasize experiential learning, shared identity, and mutual encouragement, thereby fostering trust and emotional safety. Group-based cooking interventions have been shown to improve self-esteem and social connectedness and reduce anxiety, highlighting their psychosocial value beyond nutritional education. Flexible and tailored interventions, such as peer-led culinary workshops, have been shown to facilitate dietary adherence by mitigating barriers to the preparation and consumption of plant-based meals [30]. Additionally, these approaches address patients’ sensory preferences and
organizational challenges—such as meal planning, time constraints, and food preparation skills—thereby supporting health recovery and promoting sustainable dietary behavior change.

This study adopted a practice-based observational design in line with early-phase evaluation frameworks for complex interventions, where rigid control conditions may compromise ecological validity and participant engagement. It aimed to evaluate the potential of peer-led, plant-based cooking workshops, facilitated by former patients, to promote PHD adoption among cancer patients, focusing on reducing barriers to preparing and consuming protein-rich cereals such as einkorn, emmer, and spelt. The primary outcome was to assess the workshop impact on participants’ knowledge of the PHD and their intention to integrate these cereals into their diet. Secondary outcomes included (i) analysis of the immediate reaction after each cooking workshop; (ii) analysis of knowledge and skills about those cereals for the PHD; and (iii) analysis of changes in cooking, dietary behaviors, and patient satisfaction with health outcomes and cooking workshops.

By addressing both practical and psychological challenges, this study seeks to improve nutritional outcomes, enhance well-being and contribute to broader public health and environmental sustainability goals.

# Material and method

## Study design

This cohort observational study is part of the BIOQUALIM protocol [31] and follows STROBE guidelines [32] (Supplementary file 1 STROBE statement). This exploratory study was designed to evaluate feasibility and experiential outcomes in a real-world clinical context. The absence of a control group reflects its implementation-oriented nature, which prioritized ecological validity and patient engagement over efficacy testing.

## Study setting

This study, conducted between March 2024 and June 2024 at Lyon Sud Hospital HCL (Lyon, France), adhered to the Declaration of Helsinki. Each participant, before enrolment, signed informed consent.

## Study population

Inclusions criteria were patients (i) aged > 18, (ii) in post-treatment for cancer (< 2 years for solid tumor and < 5 years for hematologic cancers), and (iii) with an oncological performance status (PS) score < 2 according to the Eastern

Cooperative Oncology Group (ECOG) criteria, indicating that patients were fully active (PS 0) or had mild restrictions but could carry out work of a light or sedentary nature (PS 1) [33]. Exclusion criteria included (i) contraindications to consuming whole grains, pulses, fruits, and vegetables and (ii) unavailability on workshop dates.

## Sample size

To optimize the experience and maintain interactivity between members, a group of six participants recruited by purposive sampling [34] was formed.

## Recruitment

The study was proposed by oncologists to post-cancer patients meeting the inclusion criteria during their follow-up consultations after cancer treatment.

## Procedure

Participants attended six bi-weekly, 2-h cooking workshops in an equipped therapeutic kitchen (Fig. 1). Each workshop was co-facilitated by a patient partner—who is also a health-care professional trained in nutrition and environmental health—and a caregiver partner who has completed formal studies in dietetics. The workshops aimed to introduce participants to the principles of healthy and sustainable eating through hands-on cooking sessions focused on protein-rich grains such as einkorn, emmer, and spelt. While no standardized teaching protocol was applied, public health nutrition recommendations in France, as well as the guidelines of the planetary health diet (PHD), were shared with participants in a conversational and responsive manner—based on the questions and interests expressed by attendees during each session. The workshops focused on preparing two main meal recipes (one salty and one sweet) using einkorn, emmer, or spelt in various forms (whole grains, couscous grains, flakes, flour, and crushed grains). The recipes were co-designed by the non-profit association Ripaï (a registered trademark) specifically to illustrate the principles of the PHD and reflect a balanced and environmentally conscious diet (supplementary file 2). All recipes were first tested to assess taste, flavor, and ease of preparation. This collaborative process ensured that the recipes were both nutritionally balanced and practical for everyday use, while also reflecting the preferences and lived experiences of the participants. Across the six workshops, participants prepared a total of 12 recipes, combining complete meals pairing protein-rich cereals and legumes, and desserts with reduced refined sugar content, incorporating nuts, fruits, and protein-rich cereals. These recipes were carefully designed to minimize strong cooking
<figure><img src="image_4.png" /><figcaption>Fig. 1 Cooking workshop timeline. Tn, time number</figcaption></figure>

smells, such as those from cooked meat, fried foods, fish, or
dairy products, which can trigger nausea.

Participants also received occasional input on the carbon footprint of various food groups, food packaging, and storage, as well as on the nutritional value of the prepared dishes, particularly in terms of minerals and vitamins. They completed questionnaire A before workshop 1 and after workshop 6 to assess PHD knowledge and skills, as well as questionnaire B after each workshop to evaluate satisfaction. Post-workshop 6, participants were interviewed one-on-one.

Data collection analysis

Data analysis followed Kirkpatrick's model [35], assessing
4 levels. Levels 1 and 2 were analyzed using 2 question-
naires while levels 3 and 4 were assessed through one-on-
one interviews.

Immediate reaction (level 1) and knowledge and skills
acquisition (level 2)

Level 1 evaluated participants' immediate reactions (pedagogical evaluation) using questionnaire B, immediately at the end of each cooking workshop (supplementary file 3 "questionnaire B").

Level 2 of the Kirkpatrick model evaluated knowledge
and skills acquisition using questionnaire A, administered

before Workshop 1 and after Workshop 6 (supplementary
file 4 “questionnaire A”). The questions were designed to
capture the following dimensions:

1. Participants' ability to find and understand information related to food and cancer. Assessed through questions 7 and 8 (pre) and questions 2 and 3 (post), which focus on participants' self-reported knowledge of spelt, including its nutritional value, forms, and uses. These questions indirectly reflect their exposure to and understanding of food-related information relevant to cancer care.

2. Their ability to interpret this information critically and apply it in practice. Also captured in questions 8 (pre) and 3 (post), which assess practical skills such as selecting ingredients, designing recipes, and applying cooking techniques. These items reflect the ability to translate information into meaningful dietary choices and culinary actions.

3. Empowerment outcomes, including increased confidence in cooking and plant-protein consumption. Explored through participants' responses to questions 2 and 3 (post-workshop) about whether the workshops met their expectations and how they perceive their progress in culinary confidence, particularly regarding spelt and plant proteins.

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As no pre-existing or validated models were found, the research team designed questionnaires A and B, using a consensus-building process, employing the Delphi method [36, 37] to reach a unified opinion. Experts from healthcare and public health independently proposed questions, which were consolidated and rated for relevance on a scale from 1 (completely disagree) to 9 (completely agree). Ratings were analyzed according to the criteria outlined in supplementary file 5. Questions deemed appropriate were included in the questionnaires, while those rated as inappropriate were excluded. For questions with uncertain ratings or missing values, the group engaged in a second round of discussion and re-evaluation. If consensus could not be achieved during the second round, the question was ultimately excluded from the questionnaire.

The questionnaires were tested by 2 individuals not involved in the study to gather feedback and adapt them. Questionnaire A had 19 questions before the first workshop and 14 questions after the sixth workshop. Questionnaire B included seven questions (five closed questions with Likert scale, from 1 “not at all satisfied” to 5 “fully satisfied,” and two open questions) and free comment.

Data analysis was both descriptive and qualitative. Descriptive analysis used mean and standard deviation. The Wilcoxon test identified differences in knowledge and skills, before and after the workshop. Statistical analyses were conducted using R 4.4.2 software, with a significance level at *p* < 0.05. Open-ended questions provided deeper insights into scores.

## Modification of cooking and consumption behaviors (level 3) and patient satisfaction (level 4)

Level 3 evaluated changes in cooking and consumption behaviors, while level 4 evaluated patient satisfaction with (i) their general health (Patient-Reported Experience Measures, PREMs) [38] and (ii) the relevance of the cooking workshops relative to their needs at the end of the treatment period (tertiary prevention) in order to ensure workshop reproducibility. These two levels were assessed during semi-structured individual interviews.

The interview guide was developed by the research team based on consensus principles (Supplementary File 6 “one-on-one interview guide”) and included four sections: (i) “theme of cancer food” to explore food representations; (ii) “benefits of cooking workshops” to identify perceived social support, self-efficacy, and representations about group dynamics; (iii) “after the cooking workshops” to analyze behavioral intentions to introduce einkorn, emmer, or spelt cereals into eating habits; and (iv) “final questions” to collect global satisfaction level, comments, and opinions.

This interview guide was tested in a pilot interview with a patient that was not participating in the study to assess

timing, question clarity, and adjustments. After completing the six workshops, participants attended a lecture by a pharmacist specializing in whole grains and sustainable nutrition, focusing on protein-rich cereals to reinforce and deepen their knowledge.

Interviews were conducted by EG (woman, Master’s degree in social-psychology, trained in qualitative studies) via videoconference or phone. Each interview started with an explanation of procedures, data protection, and purpose, followed by guidance through the topics, using prompts or requests for rephrasing. Interviews were recorded and transcribed verbatim using Microsoft® Word 2019 MSO, and transcripts were checked by AR.

The one-on-one interviews analysis followed the five steps of thematic analysis methodology by Braun and Clarke [39]:

1. Familiarization with the data: reading to become immersed with its content (EG).

2. Encoding: coding the entire dataset (FC, PhD, AR, PhD, and EG).

3. Searching for themes: three researchers (FC, PhD, AR, PhD, and EG) validated a comprehensive interpretation and grouped code into themes.

4. Themes were compared and discussed among researchers.

5. Refined coding was applied to the verbatim used to illustrate themes.

Microsoft® Excel® 2019 MSO software was used for analysis.

## Bias risk assessment

Selection bias may have occurred due to purposive sampling of a small, motivated group, a known limitation in feasibility studies that prioritize depth and contextual understanding over generalizability [40]. Measurement bias was minimized through the use of expert-developed and pretested questionnaires and interview guides, in line with best practices for tool development in implementation science [41]. Interviewer bias was limited by involving a trained external interviewer, a recommended strategy to enhance neutrality and reduce expectancy effects [42]. Recall bias was reduced by collecting immediate post-workshop feedback, which is particularly effective in time-sensitive intervention assessments [43]. However, the risk of social desirability bias remains, especially given the interactive and supportive nature of the intervention context [44].
## Ethics

This study adhered to the Declaration of Helsinki and was approved by the Hospices Civils of Lyon local ethics committees (n° 23-5456, 21/05/2024, France) and the National Commission for Computing and Liberties (MR004 declaration).

## Results

### Characteristic of participants

Six women LWBC participated in the cooking workshops, with an average age of 57.5 years (range 46–70). All experienced side effects from cancer or treatment (poor digestion, diarrhea, nausea, loss of taste and appetite, etc.) that impacted their diet (Table 1).

### Analysis of the immediate reaction after each cooking workshops (level 1)

The participants' immediate reactions after each cooking workshop are presented in Table 2.

Global satisfaction ranged from 4.77 (SD 0.04) to 5 (SD 0).

All participants were satisfied with preparing dishes together (mean 4.98 (0.06)). In workshop 2, the ease of preparing the salty recipe scored 4.5 (SD 1), and the sweet recipe scored 4.75 (SD 0.75). However, one participant (E, 70 years) scored 3 (ease and timing for salty and sweet dishes) explaining that it is “difficult to obtain all ingredients and preparation time is a little long.” She suggested including preparation times in recipes.

<table><caption>**Table 1** Characteristics of participants. PS performance status</caption><thead><tr><th>Participant</th><th>Age</th><th>Sex</th><th>Cancer</th><th>PS</th><th>Post-treatment (month)</th><th>Attendance rate for each workshop</th><th>Side effects during treatment (treatment)</th></tr></thead><tbody><tr><td>A</td><td>57</td><td>F</td><td>Breast</td><td>0</td><td>18</td><td>100%</td><td>Digestion trouble, easily smeared (surgery, chemotherapy, radiotherapy, and hormonotherapy)</td></tr><tr><td>B</td><td>46</td><td>F</td><td>Breast</td><td>0</td><td>4</td><td>100%</td><td>Loss of taste and appetite (surgery, chemotherapy, radiotherapy, and hormonotherapy)</td></tr><tr><td>C</td><td>64</td><td>F</td><td>Lymphoma</td><td>0</td><td>4</td><td>100%</td><td>Digestive troubles (chemotherapy)</td></tr><tr><td>D</td><td>51</td><td>F</td><td>Breast</td><td>0</td><td>9</td><td>100%</td><td>Sweet tooth (surgery, radiotherapy, and hormonotherapy)</td></tr><tr><td>E</td><td>70</td><td>F</td><td>Colon</td><td>1</td><td>16</td><td>83%</td><td>Lack of appetite, diarrhea, nausea, stomach ache, and weight on the stomach (surgery and chemotherapy)</td></tr><tr><td>F</td><td>57</td><td>F</td><td>Myeloma</td><td>1</td><td>30</td><td>100%</td><td>Nausea and diarrhea (autotransplant and chemotherapy)</td></tr></tbody></table>

<table><caption>**Table 2** Analysis of the immediate reaction to workshops (mean (SD); n=6)</caption><thead><tr><th rowspan="2">Cooking workshop number</th><th rowspan="2">Recipe</th><th colspan="5">Criteria satisfaction</th><th rowspan="2">Global satisfaction per recipe</th><th rowspan="2">Global satisfaction</th></tr><tr><th>Preparing the dish together</th><th>Easy recipe preparation</th><th>Time taken to prepare the recipe</th><th>Visual appearance of the recipe</th><th>Taste of the recipe</th></tr></thead><tbody><tr><td rowspan="2">1</td><td>Salty</td><td>5</td><td>5</td><td>5</td><td>5</td><td>5</td><td>5 (0)</td><td>5 (0)</td></tr><tr><td>Sweet</td><td>5</td><td>5</td><td>5</td><td>5</td><td>5</td><td>5 (0)</td><td></td></tr><tr><td rowspan="2">2</td><td>Salty</td><td>5</td><td>4.5</td><td>4.5</td><td>4.75</td><td>5</td><td>4.75 (0.25)</td><td>4.77 (0.04)</td></tr><tr><td>Sweet</td><td>5</td><td>4.75</td><td>4.5</td><td>4.75</td><td>5</td><td>4.8 (0.21)</td><td></td></tr><tr><td rowspan="2">3</td><td>Salty</td><td>5</td><td>4.8</td><td>4.8</td><td>5</td><td>5</td><td>4.92 (0.11)</td><td>4.94 (0.03)</td></tr><tr><td>Sweet</td><td>5</td><td>5</td><td>4.8</td><td>5</td><td>5</td><td>4.96 (0.09)</td><td></td></tr><tr><td rowspan="2">4</td><td>Salty</td><td>4.8</td><td>4.8</td><td>4.6</td><td>4.8</td><td>4.8</td><td>4.76 (0.09)</td><td>4.86 (0.14)</td></tr><tr><td>Sweet</td><td>5</td><td>5</td><td>5</td><td>4.8</td><td>5</td><td>4.96 (0.09)</td><td></td></tr><tr><td rowspan="2">5</td><td>Salty</td><td>5</td><td>5</td><td>4.8</td><td>5</td><td>5</td><td>4.96 (0.09)</td><td>4.88 (0.11)</td></tr><tr><td>Sweet</td><td>5</td><td>5</td><td>4.8</td><td>4.6</td><td>4.6</td><td>4.8 (0.20)</td><td></td></tr><tr><td rowspan="2">6</td><td>Salty</td><td>5</td><td>5</td><td>5</td><td>5</td><td>4.5</td><td>4.9 (0.22)</td><td>4.95 (0.07)</td></tr><tr><td>Sweet</td><td>5</td><td>5</td><td>5</td><td>5</td><td>5</td><td>5 (0)</td><td></td></tr></tbody></table>
## Analysis of knowledge and skills on spelt cereals for the PHD (level 2)

Before workshop 1, participants' mean knowledge score was 1.9 (SD 0.7), and the mean skills score was 2.5 (1.5). Mean knowledge significantly increased to 4.0 (0.7; *p* < 0.035) by the end of the workshops, while mean skills increased to 4.1 (0.7; *p* > 0.063) but without statistical significance (Table 3).

<table><caption>**Table 3** Knowledge and skills differences before and after cooking workshop series (six participants)</caption><thead><tr><th>Score</th><th>Before workshop 1<br>Mean (SD)</th><th>After workshop 6<br>Mean (SD)</th><th>Wilcoxon test<br><i>p</i>-value</th></tr></thead><tbody><tr><td>Knowledge</td><td>1.9 (0.7)</td><td>4.0 (0.7)</td><td>0.035</td></tr><tr><td>Skills</td><td>2.5 (1.5)</td><td>4.1 (0.7)</td><td>0.063</td></tr></tbody></table>

## Changes in cooking, dietary behaviors, and patient satisfaction with health outcomes and cooking workshops (levels 3 and 4)

Six one-on-one interviews were analyzed using a thematic content analysis methodology that revealed seven themes and eleven sub-themes (Table 4).

Participants' relationship with food and cancer impact

Some participants linked their diet to personal values, a passion for cooking, home-cooked meals, using organic, local or seasonal ingredients:

Food has been a topic for me since 2011, since I went vegan (...) I've embraced everything organic, local, seasonal (...) I've learned to eat healthy, balanced meals without deficiencies. (Participant D)

They also described dietary adjustments consecutive to cancer or treatments, with avoiding some foods, or adopting

<table><caption>**Table 4** Emerging themes and sub-themes after analysis of interviews</caption><thead><tr><th>Themes</th><th>Sub-themes</th><th>Description</th></tr></thead><tbody><tr><td>Relationship with food and impact of cancer</td><td>Difficulties encountered with cancer food<br>Commitment/behavioral eating</td><td>Side effects, personal difficulties, perception of diet<br>Actions in response to difficulties: strategies for adapting to f.... because of the side effects. ..... at which point you stop eating. There are so many side effects.... Nausea, diarrhea, ... diets, changing habits, developing values related to food, etc.</td></tr><tr><td>Familiarity with spelt before workshop</td><td></td><td>Past knowledge, prejudices, opinions, attitudes, consumer habits</td></tr><tr><td>Feedback on the workshops and their impact</td><td>Appreciation of the organization<br>Impact on participant health</td><td>Interests in being together, connections between members and associated feelings<br>A feeling of well-being, better digestion, greater comfort</td></tr><tr><td>Changes in habits and perspectives on food</td><td>Changes in cooking practices<br>Reflections on food choices</td><td>Sharing and reproducing recipes for others, passing on the messages conveyed in workshops<br>Testing new recipes and/or foods, thinking about new values related to food</td></tr><tr><td>Sharing knowledge and skills acquired</td><td></td><td>Learn about cooking with spelt and the other foods featured: recipes, cooking techniques, food characteristics, effects on the body, etc.</td></tr><tr><td>Intentions and challenges related to spelt integration</td><td>Intention to introduce spelt into the diet<br>Perceived benefits of introducing spelt into the diet<br>Perceived challenges</td><td>Expression of whether expectations have been met and their desire to cook spelt<br>Health benefits, good taste, ideological aspect (vegan food, less animal protein)<br>Personal organization, habits and preferences (e.g., meat texture), lack of time, etc.</td></tr><tr><td>Expectations of workshops and suggestions for improvement</td><td>Initial expectations<br>Suggestions for improvement</td><td>Future motivations, desires, preconceived ideas, requirements<br>Suggestions for other formats that would better meet the needs for introducing spelt, explanations of what does not work (number of workshops, level of difficulty, etc.)</td></tr></tbody></table>
specific diets. For example, digestive problems can make it difficult to "find something that stays longer to [enjoy]" (Participant E). Additionally, some participants shared experiences related to eating disorders, stating: "... because of the side effects. ... at which point you stop eating. There are so many side effects... Nausea, diarrhoea, ..." (participant F).

Familiarity with einkorn, emmer, and spelt before the workshops.

Before the workshops, all participants knew spelt, but their knowledge and consumption habits varied. Most of them associated spelt with transformed products like bread, flour, or pasta:

Once, I bought spelt flour spaghetti. (Participant C).

Conversely, one participant regularly consumed spelt in her vegan diet:

It's one of my favorite grains (...) For example, I often bought einkorn bread. (...) In my plant-based milks (...) I buy spelt yogurts, spelt milk. And from time to time (...), I buy spelt grains. (Participant D)

Feedback on workshops and impact
Appreciation of workshop organization.

Participants underlined a positive group dynamic with openness, mutual support, and inclusiveness:

I felt as though we had been doing things together for a long time. And it was quite natural; there were really no issues at all. (Participant A)

Participants valued their relationship with the facilitators (a patient partner and a caregiver) recognizing their trustworthy guidance and supportive behavior:

I was easier for me because I trusted the girls [the facilitators]. Absolutely! They said, 'This is how you do it, you have to do it like this,' and I knew that they were right. (Participant C)

Impact on participant health.

Participants who implemented the recipes at home reported significant improvements regarding their digestion, energy, and overall well-being for themselves and their household members. These self-reported outcomes were collected qualitatively during post-workshop discussions and written feedback. While well-being was not measured using a standardized scale, participants often associated it with improved digestive comfort and increased vitality. For instance, several reported incorporating workshop recipes at least once or twice per week:

It also allowed me to digest better, feel better, and have fewer digestive issues. (...) [My husband] is happy and tells me that, indeed, he feels better in terms of energy as well. (Participant A)

Changes in habits and perspectives on food

Changes in cooking practices.

Participants reported a meaningful impact on their daily lives, particularly in cooking habits and perspectives, gaining confidence in experimenting with new techniques and ingredients:

I felt courage to try some dishes at home. (Participant C)

I decided (...) to use [these ingredients] at home. (Participant F)

Reflections on food choices.

The workshops raised awareness of health, environmental and animal welfare issues.

It made me realize the importance of being very careful about the products I buy. (Participant B)

Thinking also about substitutes for meat, dairy, or eggs. So many possible options (...) but it's important. (Participant F)

Sharing knowledge and skills acquired

Participants shared recipes and discussed the workshops benefits:

Well, teenagers are a bit tricky (...) but the cake lasted as long as usual, which means not even a day, so it had a good effect. (Participant B)

I talk about everything I do because I'm so happy to be able to do something. And it's something I find pleasant (...) I can talk about positive things. (Participant E)

Intentions and challenges related to einkorn, emmer, or spelt integration

Participants reported different levels of commitment, from immediate action to long-term planning:

It's already done since I bought textured spelt as I went along (...). (Participant F)

I fully intend to buy some. (Participant D)

Participants highlighted the enjoyable taste, simplicity, and health benefits of the recipes:

These are recipes I will reproduce because they are excellent and, above all, they're filling. You're not hungry afterward. (Participant B)

Participants analyzed the alignment with ethical and environmental values:

Since it's a way to get the necessary proteins for your body while significantly reducing the environmental impact. (Participant F)

Perceived challenges.

Participants encountered obstacles outside workshops due to personal organization, ingredient availability, and cost:

It requires cooking efforts, planning, because soaking spelt overnight is something I've never done before. (Participant E)
I noticed that organic sections in stores are expanding. But it's not exactly what we used (...). And it's not very specialized yet. (Participant F)

Participants had to adapt to vegetable textures despite acceptable tastes:

The taste doesn't bother me, but the texture... I don't know. I can't quite get there. (Participant C)

Expectations from workshops and suggestions for improvement

Initial expectations.

Participants expressed curiosity to explore new cooking practices for health reasons:

I wanted to know if it would help digestion. (Participant C)

Participants suggested to plan more sessions to establish habits:

10 workshops a year regularly (...) one workshop each month.” (...) It’s important in order to daily anchor these habits over the long term. (Participant D)

Participants highlighted the need for personalized support, including home adaptations, tailored advice, and motivational guidance:

Going to people's homes and seeing what they have.
(...)'We're missing a robot...' (Participant D)

The thematic organization provides a structured framework for analyzing participants' experiences, intentions, and suggestions regarding the introduction of spelt into their diet through cooking workshops (Fig. 2). Participants aimed to integrate spelt into their dietary habits, although various factors either promoted or hindered this intention.

Internal workshop factors—including participants’ acquisition of knowledge and skills about spelt cooking, perceived health benefits, and changing daily habits—were positively influenced by how well the workshop content and facilitation matched their expectations. When participants felt that the workshop met their personal goals (e.g., learning simple, healthy recipes or understanding plant-based nutrition), they expressed greater engagement and motivation to apply what they learned. Satisfaction with the group atmosphere and the interactive format further enhanced retention and confidence, encouraging open discussions and peer support. This collaborative environment served as a crucial bridge between theoretical understanding and practical application, empowering participants to implement actionable dietary changes more confidently and consistently.

External workshop factors also played a significant role in shaping participants’ intentions. These included the individual’s broader relationship with spelt, commitment to behavioral changes, and eating disorders exacerbated by their illness. These factors interacted with internal workshop dynamics, either supporting or complicating efforts to integrate spelt into participants’ diets.

Perceived barriers, both internal and external to the workshops, often created challenges. Internal barriers stemmed from the workshops themselves, such as difficulties in sourcing ingredients or managing preparation times. External barriers included personal constraints like time, cost, or resistance to changing ingrained eating habits. Each participant already possessed skills and knowledge prior to attending the workshops, which helped them overcome the obstacles to incorporating spelt, in addition to the group dynamics and mutual support.

<figure><img src="image_6.png" /><figcaption>**Fig. 2** Schematic linking of themes resulting from thematic content analysis of the corpus</figcaption></figure>
Discussion

This pilot observational study explored the feasibility and experiential outcomes of peer-led culinary workshops designed to promote the adoption of protein-rich cereals—einkorn, emmer, and spelt—among post-cancer patients, within the framework of the planetary health diet (PHD). By focusing on the inclusion of protein-rich cereals such as einkorn, emmer, and spelt, the intervention aimed to address persistent nutritional, psychosocial, and environmental challenges that characterize post-cancer patients. The findings from this pilot study suggest that the peer-led cooking workshops are not only acceptable but also potentially beneficial. The workshops led to significant improvements in participants’ knowledge about protein-rich cereals, cooking confidence, well-being, and sustainability awareness. These outcomes were reflected in both questionnaire data and thematic interviews, highlighting the model effectiveness in promoting knowledge acquisition, behavioral change, and psychosocial support among post-treatment cancer patients.

Regarding knowledge and skills development, the workshops significantly increased participants’ knowledge regarding the nutritional and culinary value of ancient grains (p = 0.035) and revealed a strong, though not statistically significant, trend toward enhanced practical skills (p = 0.063). These findings support previous research on interactive, peer-led nutrition interventions. Miller et al. demonstrated group-based, hands-on cooking sessions significantly improved dietary knowledge and skills. Participants reported greater confidence in using sustainable ingredients, aligning with the PHD’s focus on local, seasonal, and organic food consumption [45]. Moreover, Fredericks et al. [46] emphasized the importance of experiential learning—particularly when it is social and interactive—for translating nutrition knowledge into everyday action [46].

In our study, participants not only learned to cook with novel ingredients but also developed a better understanding of plant-based protein sources, cooking techniques, and food planning strategies. This holistic learning model supports broader goals in people LWBC care: equipping patients with the tools to maintain nutritional adequacy and autonomy in the face of ongoing treatment-related challenges.

Regarding behavioral changes and sustainable practices, participants reported substantial changes in food preparation habits, including frequent replication of workshop recipes at home and a greater willingness to introduce einkorn, emmer, or spelt into daily meals. These behavioral intentions—corroborated through qualitative interviews—underscore the workshop success in transforming

theoretical knowledge into tangible practice. Similar trends were observed in Moore et al. [27], where peer-led dietary interventions showed sustained behavioral impacts due to their social reinforcement mechanisms.

Importantly, these shifts were not only cognitive but practical and emotional, marking a transition from passive knowledge acquisition to active, autonomous dietary engagement—an outcome especially critical in addressing long-term cancer survivorship challenges such as malnutrition and disempowerment [12, 47].

Regarding well-being and digestive health, participants reported improved well-being, including better digestion and a positive health perception following the adoption of workshop recipes, consistent with evidence linking plant-based diets to better health [48]. Indeed, people LWBC frequently report persistent treatment-related dietary issues such as gastrointestinal discomfort, altered taste, appetite loss, and food-related anxiety [12, 49]. These symptoms often interfere with adherence to dietary recommendations, particularly plant-based and high-fiber diets. However, when dietary approaches are tailored to patients’ preferences and tolerances—as in our progressive, peer-led workshops—whole grains such as spelt, emmer, and einkorn were well tolerated and even positively received. Importantly, these grains are increasingly recognized for their prebiotic properties, owing to their richness in fermentable fibers like arabinoxylans and beta-glucans, which selectively support the growth of beneficial gut microbiota [50]. By promoting a more diverse and resilient microbiome, these grains may contribute to immune homeostasis and recovery in people LWBC [51].

Emerging research underscores the microbiome’s pivotal role in modulating systemic inflammation, enhancing metabolic resilience, and improving responses to both immunotherapy and chemotherapy [52, 53]. Given that oncologic treatments often disrupt microbial balance, dietary strategies centered on whole grain, fiber-rich foods may confer both digestive and immunological benefits [52, 53]. The incorporation of these grains into workshop activities may thus not only support symptom management and food-related confidence but also foster longer-term immune regulation and overall well-being through microbiome modulation [50, 51]. These findings resonate with broader evidence that culinary interventions grounded in food literacy and psychosocial support help patients rebuild food confidence, reduce malnutrition risk, and promote sustainable dietary practices post-treatment [47].

Regarding emotional empowerment and social connection, the workshops fostered a supportive emotionally safe environment where participants felt heard and understood. This setting was particularly conducive to mutual encouragement, trust-building, and peer affirmation—factors that amplified engagement and reduced food-related anxiety. Such psychosocial dimensions are crucial in dietary
interventions for cancer survivors, who often struggle with isolation, reduced confidence, and altered food relationships post-treatment [24, 54].

As emphasized by Kowitt et al. [55], peer-led models offer unique relational dynamics that enhance participant adherence and motivation, especially when facilitators are viewed as relatable, empathetic, and credible. These dynamics likely contributed to the positive reception and strong participation observed in our study.

Integrating Planetary Health and Ethical Awareness through Post-Cancer Peer-Supported Cooking Workshops appeared as essential. These results align with the PHD principles, which focus on human health (primary and tertiary prevention) and ecological sustainability by reducing animal product consumption and increasing plant-based, local, and organic food intake [2]. While the peer-supported cooking workshops are effective in reintegrating post-cancer patients into a balanced and sustainable diet as previously described [27], the findings reflect feasibility and experiential value within a specific setting and sample, rather than generalizable evidence of broad effectiveness or scalability. Further research is required to assess whether similar interventions could be successfully implemented at scale and in more diverse populations.

Results point to wider public health implications. The workshops raised awareness about sustainable ingredients and fostering environmentally conscious eating behaviors, supporting findings by Beeken et al. [56] and Gavazzi et al. (2018) that people LWBCs seek health-related information to modify their diet and lifestyle [56, 57]. Participants' willingness to adopt healthier habits reflects the potential of PHD-centered interventions for promoting individual and planetary health. Moreover, although sustainability was not a primary endpoint, several participants spontaneously expressed interest in food sourcing, animal welfare, and environmental impact—indicating an emergent ethical awareness catalyzed by experiential exposure to plant-based, seasonal cooking. This finding aligns with research suggesting that hands-on, socially supported dietary experiences can facilitate environmental consciousness more effectively than abstract message (2,48). This organic alignment with the PHD—prioritizing health and ecological sustainability—points that could the potential for such workshops to serve as gateways for broader lifestyle shifts in line with planetary health principles.

## Public health implications and recommendations

The findings suggest that PHD-centered interventions may support individual and planetary health [56]. In this exploratory setting, the workshops appeared to raise awareness

about sustainable ingredients and foster interest in environmentally conscious dietary practices. While this is consistent with previous studies on the public health relevance of plant-based diets in reducing chronic disease and environmental degradation [48, 58, 59], broader claims about effectiveness or scalability cannot be made from the current data alone. Future studies should test these approaches in larger, more diverse populations and in real-world implementation contexts to assess their replicability and long-term impact.

To enhance these interventions, several recommendations emerge.

First, personalizing interventions with modules on cost management, ingredient substitution, and strategies for collective catering integration can add importance to diverse participant needs [60].

Second, building partnerships and public campaigns is crucial. Collaborations with local communities, schools, and healthcare institutions can broaden reach through subsidized workshops and incorporation of PHD principles into school curricula and catering services [61, 62]. Leveraging public campaigns and social media could enhance engagement and promote the adoption of sustainable dietary practices [63, 64].

Third, promoting the accessibility of sustainable ingredients is vital for dietary changes [65]. Financial support for producing and distributing sustainable foods, particularly protein-rich cereals like einkorn, emmer, and spelt, along with initiatives like farmers' markets and short supply chains, can enhance accessibility [66, 67].

Moreover, collaborating with influencers or opinion leaders in health and environmental fields could increase public engagement with these dietary changes. For example, YouTubers promoting plant-based eating impact followers' diets, suggesting that public campaigns could benefit from this channel [68]. Additionally, initiatives like the “Veggie Challenge” encourage plant-based diets [69].

Finally, these workshops deepened participants' understanding of plant-based eating, encouraging the incorporation of protein-rich cereals and other plant-based ingredients into their routines. This shift from awareness to action highlights the workshops' influence in promoting sustainable dietary changes.

Regarding methodological considerations and contextual insights, this observational study was not intended to establish causality but to assess the acceptability and experiential value of a peer-led dietary intervention for post-treatment cancer patients. While the absence of a control group limits the strength of causal inferences, this design aligns with guidance for early-phase evaluation of complex interventions in supportive care, where participant interaction and emotional safety are core to the intervention mechanism. This approach is supported by frameworks developed by the UK Medical Research Council for pilot and feasibility
studies [70, 71]. In addition, qualitative research plays a cru-
cial role in understanding contextual and experiential factors
that influence intervention outcomes and implementation,
particularly in complex and person-centered health settings
[72].

Limitations

This study has several limitations. First, the sample size was
small, and the lack of diversity among participants—par-
ticularly regarding gender, age, and socioeconomic back-
ground—limits the generalizability of the findings. As a
pilot and hypothesis-generating study, it aimed to assess
feasibility and generate patient-centered insights rather
than establish efficacy. Second, the absence of a control
group precluded attribution of observed effects solely to the
intervention. However, as an exploratory implementation-
phase study, the goal was not to test efficacy but to generate
insights into feasibility and patient-perceived outcomes, in
alignment with guidance for evaluating complex interven-
tions. Third, the number and duration of workshops may
have been insufficient to produce significant improvements
in cooking skills. It is possible that more frequent or longer
sessions, combined with personalized skill-building activi-
ties, could yield greater outcomes. Additionally, the curricu-
lum may not have fully addressed the practical challenges
participants face, such as managing food costs, substitut-
ing ingredients, or balancing cooking with time constraints.
Fourth, the short-term nature of the evaluation limits conclu-
sions about the sustainability of dietary behavior changes
and improvements in participants’ quality of life. Longitu-
dinal studies are needed to assess the long-term impact of
the workshops and to determine whether periodic follow-up
sessions or reinforcement strategies are necessary to main-
tain behavioral changes. Finally, reliance on self-reported
data can introduce recall bias and social desirability bias,
potentially compromising the accuracy of results [73, 74].
While self-reporting is common in exploratory studies [75],
future research should incorporate objective measures where
possible to improve validity [76].

Conclusion

This study highlights the potential of peer-led culinary work-
shops to promote sustainable eating tailored to post-cancer
patients’ needs. By reducing barriers to incorporating pro-
tein-rich cereals like einkorn, emmer, and spelt and enhanc-
ing cooking skills, these workshops represent a promising
strategy for improving both individual health and environ-
mental sustainability. However, further efforts are needed

to maximize their impact and make them accessible to a
broader audience.

**Supplementary Information** The online version contains supplementary material available at https://doi.org/10.1007/s00520-025-10049-z.

**Acknowledgements** The authors would like to thank all participants; Marie Préau and Maëva Pitton who carried out the interview guide; Sofia Correa who cultivated the emmer used in this study in the farm of Denis Mignard and Honorine Périno; those who helped for emmer dehulling (Diego, Joëlle Montant, Margot le Trionnaire and Anne Lastmann); Laurence Mayaud who helped design the recipes and Anne Lastmann who led the cooking workshops with Lama Basbous.

**Author contribution** A.M-R.: conception and design, methodology, investigation, funding acquisition, project administration, writing—original draft, writing—review and editing; R.L.: methodology, investigation, writing—original draft, writing—review and editing; E.G.: methodology, investigation, writing—review and editing; L.B.: methodology, investigation, writing—review and editing; A.L.: methodology, investigation, writing—review and editing; M.T.C.: conception and design, methodology, investigation, funding acquisition, project administration, writing—review and editing; F.C.: conception and design, methodology, investigation, funding acquisition, project administration, writing—original draft, writing—review and editing. All authors have read and agreed to the published version of the manuscript. A.M-R., E.G. and L.B. prepared figures 1 and 2.

**Funding** This work was supported by a grant from the French National Research Agency as part of the "Investissements d'Avenir ExcellencES" program from France 2030 (SHAPE-Med@Lyon; ANR-22-EXES-0012).

**Data Availability** No datasets were generated or analysed during the current study.

Declarations

**Competing interests** The authors declare no competing interests.

**Open Access** This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

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