## 4 Discussion
These results suggest the efficacy of virtual cooking class-based nutrition education; however, the magnitude of the change in diet may have been limited by the provision of one class over multiple class sessions. Additional longitudinal investigation should be completed to observe the long-term impact of these dietary changes, and if changes can be sustainably adopted. After one-month post-intervention, our cohort demonstrated significant improvement in self-reported cognitive function in the areas of perceived cognitive impairments, comments from others, and quality of life. However, there was no significant increase in perceived cognitive ability. [PERSON] et al. previously sought to define clinically significant changes in FACT-Cog scores among adult cancer survivors after they received a 15-week cognitive training program [58]. Here, a mean change (standard deviation) in COG-PCI of at least 4.6 (6.5) points was considered a clinically meaningful change, with a mean change of 17.9 (12.7) points indicating a much better performance six months post-intervention [58]. In the present study, the median COG-PCI score increased by 38 points one month after the intervention, suggesting this was a clinically meaningful change in COG-PCI, and this should be confirmed with quantitative cognitive assessment in future studies. The baseline E-DII was correlated with a baseline cognition-driven quality of life, wherein a higher baseline COG-QOL was correlated to more pro-inflammatory E-DII scores. However, our study did not find a relationship between cognitive function and E-DII score after adjustment in cancer survivors. While this relationship has had minimal investigation overall, and predominantly within an older adult population, our finding contradicts previous findings. Most recently, a 2022 meta-analysis of nine observational studies found a 46% elevated risk of cognitive impairment in those with more pro-inflammatory DII scores (OR = 1.46, 95% CI = 1.26, 1.69) [59]. Based on the literature and predominant observations, a cause-and-effect relationship between DII and cognitive impairment cannot be established. This study was not specifically powered to determine a relationship between E-DII and cognition; thus, our sample size could have impacted our findings. Therefore, larger studies of populations at risk of cognitive decline, including cancer survivors, should be further evaluated. Dietary factors, including changes in calorie and fruit intake, were significantly and positively correlated with changes in perceived cognitive abilities. After adjustment, a change in calorie intake was a significant predictor of a change in perceived cognitive abilities, where for every 100-calorie increase in the change in calorie intake, we expect the change in COG-PCA to increase by 0.7 points. This indicates that those who had positive increases in calorie intake had more positive changes in perceived cognitive ability. This finding may be explained by the overall relatively lower calorie intake seen in this cohort, where those with increased calorie changes may be eating more nutrients to provide for better outcomes once a threshold for impact is reached. The body's response to nutrients is often sigmoidal, meaning low exposure results in a minimal response, while progressively increasing exposure will show an increased response, followed by a plateaued effect once the physiological norm is met [60]. These findings may also align with previous research identifying the risk of undernutrition and cognitive status, such as the development of dementia in non-cancer populations [61; 62]. In addition to calorie changes, changes in fiber intake trended toward significance after adjustment, where for every 1 g increase in fiber, we expect the change in COG-PCA to increase by 0.49 points. This means those with more positive changes in fiber intake had improved perceived cognitive abilities. However, this finding may be limited by our sample size and should be repeated in a larger, more diverse cohort.