Reflections on specific Course Content and Structure 
The format of the course introduction was another key area of discussion. Participants were asked to compare the traditional course start of reflective group sharing with an alternative approach based on “dialogue dyads”. Dialogue dyads invite pairs of individuals to engage in a direct, focused conversation that emphasizes empathic and active listening, thus promoting social connectedness (Kok & Singer, 2017). Dialogue dyads were largely perceived as more personal and emotionally engaging compared to the group setting of the traditional course start: “That’s what I find valuable, that you truly have someone who listens and you can speak voluntarily. I believe that, overall, more is shared this way than when speaking in a group.” (S2). Many participants felt that speaking in pairs encouraged deeper, more authentic exchanges and fostered a stronger sense of empathy and recognition. Having an active listener was described as validating, and the dyadic format was considered to create a safer space for personal reflection and sharing: “In this way, the other person feels comprehensively acknowledged or recognizes that the other is genuinely interested in them.” (S5). 

However, not all feedback was positive. Some participants found the format too intimate, particularly when seated near other pairs: “The challenge then, since there are several pairs doing this at the same time, is to create a calm atmosphere that everyone can accept and settle into, so that they feel comfortable enough to open up.” (S2). In addition, it has been noted that the format can feel uncomfortable for individuals unfamiliar with personal disclosure: “In the dyadic setting, I realized that it feels close, like I experienced it as close and intimate for me, and I thought that this would be a hurdle for me.” (S4). Nevertheless, the majority of participants preferred dialogue dyads over the traditional course start, referring to the increased emotional depth and interpersonal connectedness it fostered.

Discussion
This study aimed to investigate the perceptions and attitudes of patients who have participated, or expressed interest, in the BERN course in order to create a modified version of the traditional BERN course with focus on healthier, mindful nutrition. The data were collected through a focus group discussion conducted with primary care patients (n=5) and a health therapist in May 2025. Patients were asked to describe an ideal course format that would support the development of positive and fulfilling experiences with healthy eating. Furthermore, participants were asked how the course could better convey the connection between nutrition, stress, and overall health. Lastly, participants were encouraged to reflect on an alternative format applied at the beginning of each session called the “dialogue dyads”. In summary, the focus group discussion provided valuable insights into how the BERN course could be adapted to better support engagement with healthy, mindful eating. Participants consistently emphasized the importance of emotionally engaging and socially embedded learning formats. Key themes included the desire for group-based and interactive activities, the inclusion of real-life simulations and self-reflection tools, and a stronger focus on the affective/emotional and social dimensions of dietary behavior. These findings suggest that restructuring the course to emphasize connectedness, enjoyment, and personal relevance may enhance its impact and sustainability.

Findings in Context of Existing Research
The findings of this study align with a growing body of research emphasizing the crucial role of emotional and experiential dimensions in supporting sustainable lifestyle changes, particularly in the context of nutrition. As Esch and Stefano (2022) highlight, emotional engagement serves as a mechanism for behavioral transformation, suggesting that interventions must go beyond cognitive or informational approaches. This is particularly relevant in nutrition education, where studies have repeatedly shown that providing information alone is often not enough to promote long-term adherence to healthy eating habits (Atoloye et al., 2021; Whatnall et al., 2018; Middleton et al., 2013).

This is also consistent with the principles of Self-Determination Theory (Ryan & Deci, 2000), which posits that intrinsic motivation is more likely to lead to sustained behavioral change when the basic psychological needs of autonomy, competence, and relatedness are met. In this study, participants described a desire for course formats that not only convey knowledge but also create a sense of joy and social connection. Hands-on and experiential activities support autonomy by allowing personal choice and competence by building skills, while social and emotionally engaging elements foster relatedness through connection and support. By addressing these three needs, such formats make healthy eating more meaningful and intrinsically motivating, increasing the likelihood of sustained dietary behavior change.

Further, the participants’ emphasis on social learning formats further supports existing research on group-based health interventions. Greaves et al. (2011) provide evidence that peer support and opportunities for shared reflection play vital roles in reinforcing behavior change. 

Finally, participants generally viewed dialogue dyads as a valuable alternative to the traditional course start, highlighting the format’s ability to foster personal connection and active listening. This finding is consistent with research on dialogic learning, which emphasizes the role of interpersonal dialogue in deepening understanding and engagement (Smith, 1978; García-Carrión et al., 2020). It also aligns with principles from motivational interviewing and person-centered approaches, where empathic, nonjudgmental exchange supports motivation and behavior change (Miller & Rollnick, 2013; Bilgin et al., 2022; Evcimen & Bilgin, 2025).

Strengths and Limitations
A strength of this study lies in its participatory and patient-centered approach. By involving individuals with lived experience in the development of a dietary behavior change intervention, the research generated insights that are directly applicable to practice. The combination of prior interviews (Herker et al., submitted) and the subsequent focus group discussion allowed for deeper exploration of patient needs and preferences.

However, several limitations must be acknowledged. The sample size was small (n=5), and participation in the focus group discussion was voluntary, which could indicate higher motivation and health awareness of the participants. In addition, the provision of a monetary compensation could have influenced participation (Abdelazeem et al., 2022). Further, all participants had prior contact with the BERN course, which may have influenced their expectations and evaluations. Moreover, social desirability bias in a group interview setting cannot be excluded, particularly when discussing personal challenges or preferences (Bispo Júnior et al., 2022). Lastly, the analysis was based on a single focus group, which limits generalizability. 

Future research
Future research should seek to include a larger and more diverse sample size or conduct multiple focus group discussions. Further, future studies can build upon the presented findings by developing and evaluating course formats implementing the recommended adjustments, using mixed-methods or longitudinal designs to capture both behavioral outcomes and participants´ experiences over time.

Conclusion
The results challenge traditional knowledge-based approaches and call for the redesign of health promoting interventions to include emotional and social components. Activities like group cooking, reflection exercises, and real-life scenario simulations can create meaningful learning experiences that enhance motivation and promote lasting behavior change. The findings provide a foundation for refining the BERN course and similar interventions around the topic of nutrition and healthy eating to enhance their effectiveness in relevant patient populations in primary care.

Author Contributions: Conceptualization, M.M., J.H., T.E.; investigation, J.H., L.F.; writing: L.F.; review and editing: M.M., J.H., T.E.; All authors have read and agreed to this version of the manuscript.

Funding: The study was funded by Software AG Stiftung.

Institutional Review Board Statement: Ethical approval has been obtained from the Ethics Committee of the University of Witten/Herdecke, Germany (S-58/2024).

Informed Consent Statement: All patients received both oral and written information and gave their informed consent to participate. Verbal consent was obtained from participants prior to the focus group, after reading a participant information sheet. Written informed consent was obtained from all participants prior to the focus group.

Data Availability Statement: Requests for de-identified data may be requested by written application to the corresponding author.

Acknowledgments: ChatGPT was used in the creation of this manuscript to assist in optimizing translations by reviewing and refining existing versions. It was also utilized to articulate notes of the first author's own ideas/ generated findings.

Conflicts of Interest: The authors declare no conflicts of interest.