INTRODUCTION: Diabetes educators at Diabetes Grey Bruce (DGB) are interested in determining the value of social media and other online technologies as a tool for providing evidence-based information to at-risk children and their families.
OBJECTIVES: First, to examine the use of social media and technology for health promotion among children attending DGB (≤ 18 years old) who are at risk or have type 2 diabetes (T2D) and their accompanying parents. Second, to determine the interest in social media and technology for the dissemination of diet and lifestyle education. 
METHODS: This was an 8-week qualitative study aimed at improving online patient services at DGB. Children and parents were provided with two separate surveys. Nine children’s surveys were distributed, eight were completed. Ten parent surveys were distributed, nine were completed. 
RESULTS: Children had a greater interest than parents in getting healthy lifestyle information from mobile apps (75% vs. 33.3%), the internet (62.5% vs. 33.3%), and social media (37.5% vs. 11.1%). More specifically, children had a greater interest than parents in using technology such as videos (87.5% vs. 50%), games (87.5% vs. 25%), social media (62.5% vs. 37.5%), and mobile apps (50% vs. 37.5%) to access information about healthy living. Interest in accessing healthy lifestyle information through the DGB website is higher in children (37.5%) than in parents (33.3%). The top four learning interests of children included cooking skills (75%), physical activity (62.5%), healthy body weight (50%), and healthy meals and snack ideas (50%).
CONCLUSION: Despite the differences in learning methods and social media use, children had a greater interest in the use of social media and online technology platforms for learning about healthy living than their parents.
SIGNIFICANCE TO THE FIELD OF DIETETICS: Social media and online technology can be used as a tool for dietitians and diabetes educators to provide evidence-based material to at-risk youth.

Assessment of social media & technology as a tool for diabetes lifestyle education for youth at risk, or with type 2 diabetes (T2D) at Diabetes Grey Bruce (DGB) in Owen Sound, Ontario

INTRODUCTION: Supportive food environments are highly influential in the development and maintenance of healthy habits. In Grey Bruce, only around one in four students consume sufficient fruits and vegetables and 40% have reported eating junk foods more than four times a day(1). Elementary and secondary students consume about one-third of their calories at school(2). 

OBJECTIVES: Researchers sought to assess facilitators and barriers to a healthy food environment in Grey County and Bruce County schools. Research questions included “How are schools in Grey Bruce currently supporting healthy food environments in the school and classrooms? Are there examples of innovative or best practice approaches that support a healthy food environment?" 

METHODS: A mixed-methods approach was undertaken in this study. Fourteen semi-structured key informant interviews were conducted (n=18) with an adapted environmental scan (Appendix A). Key informants were identified by schools and included principals, faculty, and parent volunteers. An iterative approach and thematic content analysis was used.

RESULTS: School food environments were perceived as healthy or fairly healthy. Contributing factors included compliance with the provincial regulations, participation in meal/snack and milk programs, engagement of parents/parent council, and supportive staff modeling. Perceived barriers included: Foods sent from home, feasibility of healthy fundraising, accessibility of healthy foods, insufficient human, financial and material resources, insufficient allergy awareness and lack of policy support. Eight percent of schools reported no barriers to promoting supportive food environments. 

CONCLUSIONS: Recommendations include supporting: efforts to improve food brought from home; policy implementation and evaluation by establishing a healthy schools committee; and healthier fundraising options. Engaging student leadership may be particularly influential in secondary school settings.

SIGNIFICANCE TO DIETETICS: This study adds to literature on the school food environment and its influence on students' well-being. The results revealed needs for: greater support for caregivers; continued support for meal programs; and addressing gaps in evaluation practices.

Food for thought: A scan of rural school food environments

INTRODUCTION: Although intravenous lipid emulsions are routinely provided to patients requiring parenteral nutrition (PN), the evidence on the clinical effectiveness and safety of various formulations remains unclear. 

OBJECTIVES: CADTH’s objectives of this review were to examine the clinical effectiveness, cost-effectiveness and evidence-based guidelines associated with lipid formulations in adult and pediatric patients requiring PN.

METHODS: A limited literature search was conducted. The included SRs were critically appraised using AMSTAR, RCTs were critically appraised using the Downs and Black checklist, economic studies were assessed using the Drummond checklist, and guidelines were assessed with the AGREE II instrument.  

RESULTS: Low to moderate quality evidence from eight RCTs and ten SRs demonstrated that non-100% soybean emulsions, especially fish oil-containing emulsions, are no less safe than pure soybean emulsions and may confer clinical benefits in post-operative adult patients. Safety parameters related to liver function, inflammation, and adverse events were not adversely affected by non-100% soybean emulsions. The economic evaluations demonstrated the cost-effectiveness of fish oil emulsion over soybean-based emulsions. However, there were substantial limitations in the economic analyses and the results should be interpreted with caution. European guidelines suggest the use of fish-oil containing emulsions in post-operative adult patients.

CONCLUSIONS:  Due to the lack of high-quality evidence for the comparison of clinical outcomes between patients receiving PN with different intravenous lipid emulsions, it is not possible to draw any conclusions with a high level of confidence. However, there were consistent trends among studies. 

SIGNIFICANCE TO THE FIELD OF DIETETICS: Clinical dietitians receive conflicting messages on formulations of intravenous lipid emulsions for PN. CADTH’s review provides the latest evidence to inform decision making both in clinical practice as well as product procurement efforts within institutional settings.

Lipid formulations for patients requiring parenteral nutrition: A review of clinical and cost-effectiveness and guidelines

Introduction: 
In October, 2013, Nutri-eSTEP was launched on the Dietitians of Canada website (www.nutritionscreen.ca).  These internet adaptations of the toddler and preschool NutriSTEP® nutrition risk questionnaires are part of a broader web tool that provides immediate feedback to users and links to resources.
Objective: 
To assess usage and results from the first three years of Nutri-eSTEP (Oct 2013-Sept 2016). 
Methods: 
Data from Canadian Nutri-eSTEP users were analyzed using SPSS v24.  Data analysis included: descriptive statistics for total risk scores and individual NutriSTEP® questions; relationships between NutriSTEP® scores and demographics using independent t-tests; and associations between individual NutriSTEP® questions using bivariate statistics, where theoretical relationships were thought to exist. 
Results: 
Parents/caregivers completing Nutri-eSTEP, totaled 15,103 (7052 toddlers and 8051 preschoolers) with 73% from Ontario (Table 1).  Mean(±SD) risk scores for toddlers were 17(±9) and 20(±8) for preschoolers; males had significantly higher risk scores.  16% of toddlers and 22% of preschoolers were at high nutritional risk; 13% of toddlers and 18% of preschoolers were at moderate risk (Table 2).  For both groups, > 55% had low frequency of grain product consumption; > 40% had low frequency of consumption of meat and alternates; and, >33% had low frequency of fruit and vegetable consumption. Screen time ≥2 hours/day was found for 65% of preschoolers and 34% of toddlers.  More screen time was significantly associated with low physical activity, and parental concerns related to growth and weight.  Higher parental control of feeding and food insecurity were significantly associated with lower frequency of consumption of fruits and vegetables.
Conclusion: 
Nutri-eSTEP screening results for Canadian children illustrates concerns related to food group intake, screen time, parental control and food security, with more preschoolers at risk than toddlers.
Relevance to Practice: 
These results are useful for health practitioners in designing nutrition education messages and programming for Canadian families with toddlers and preschoolers.

Evaluation of the first 3 years of Nutri-eSTEP usage (2013-2016)

INTRODUCTION: Nuts have been shown to improve glycemic control in diabetes, yet diabetes guidelines caution against the overconsumption of nuts at the same time that they recommend them for CVD prevention suggesting nuts may contribute to weight gain due to their high energy density. 
Objective: To conduct a systematic review and meta-analysis of the effect of nut (tree nut and peanut) consumption in diabetes on markers of adiposity in randomized controlled trials.   
METHODS: We searched MEDLINE, EMBASE, and Cochrane databases (through August 8, 2017). Randomized controlled trials ≥ 3-weeks assessing the effect of nut intake on measures of adiposity in diabetes were included. Three independent reviewers extracted relevant data and assessed risk of bias of included trials.  Data were pooled using the generic inverse variance method and expressed as mean differences (MDs) with 95% confidence intervals (CIs). Heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). The overall certainty of the evidence was assessed using the GRADE approach.
RESULTS: 13 randomized controlled trials (including 741 people) met eligibility criteria. Nut consumption had no effect on global adiposity (BMI: MD -0.52 [95% CI: -1.35, 0.30]; body weight: MD 0.00 [95% CI: -0.28, 0.28], % body fat: MD 0.34 [95% CI: -1.19, 1.87]) or abdominal adiposity (waist circumference: MD 0.06 [95% CI: -0.73, 0.86]).  The overall certainty of the evidence was graded as “high” for body weight, % body fat, and waist circumference but “low” for BMI owing to imprecision, and publication bias. 
CONCLUSIONS: Pooled analyses show nut consumption does not have an adverse effect on measures of adiposity in diabetes. The concern that nut intake may result in weight gain appears unwarranted.
SIGNIFICANCE TO PRACTICE: These results provide diabetes guidelines and dietitians with evidence to inform advice given to individuals with diabetes in regards to nut intake without fear of weight gain.


Nut consumption and measures of adiposity in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

Purpose:

Protected Meal Times (PMT) was implemented on the acute Urban Health unit at St. Paul’s Hospital for specified patients. PMT is patient-focused nursing care during meals for malnourished patients or those who require more care during meals. We would like to share our experiences with implementation, including quantitative audits and testimonies from patients and staff.

Process or summary of content:

Audits on our unit showed that 90% of patients were interrupted 2-11x during meals, and of those who were not fully independent, only half were given assistance to eat. PMT is used to address some environmental and organizational barriers for optimal intake in hospital.  

Systematic approach used, including supporting information:
 
The implementation of a ward-specific, individualized PMT was designed with input from interdisciplinary staff, and evaluated with udits and informal interviews with patients and staff. 75% of patients were put on PMT due to weight loss/severe malnutrition and/or poor intake, and the remainder due to dysphagia or increased care needs. 63% of patients who were on PMT had significant increase in intake and 67% who had history of severe weight loss regained 5-10% of their weight. Staff report full support of PMT and feel it improves outcomes. Patients reported positive outcomes and experiences with PMT. 

Conclusions:
 
Implementation of PMT requires nursing and dietetic leadership and support from staff to be successful. PMT can reduce the exacerbation of inpatient malnutrition, improve overall patient health outcomes and provide patient-centred care.

Recommendations:

We encourage acute care dietitians to evaluate if PMT would work on their specific units and patient population. Joining quality assurance committees and completing pre-implementation audits can help gather support from interdisciplinary staff. 

Significance to the field of dietetics:

PMT has been shown to improve nutrition outcomes in an inpatient setting for patients struggling to maintain nutrition status.


Protected Meal Time implementation on an acute hospital unit: Addressing inpatient malnutrition

Background: Malnutrition remains a significant ongoing issue in Canada. Phase angle (PhA) from bioelectric impedance analysis (BIA) may be a surrogate marker for nutritional status. PhA results are confounded by age, gender, and BMI. Thus, standardized PhA (SPhA) is a better approach for monitoring. 

Objectives: Our primary objective was to determine PhA in a sample of Canadian, overweight/obese, community-dwelling adults categorized by age, gender, and BMI. Our secondary objective was to compare PhA of our sample to a reference population matched for age, gender, and BMI.  Our tertiary objective was to determine if PhA could be improved in response to a nutrition and lifestyle change intervention.

Methods: Overweight/obese adults attending a comprehensive weight management intervention underwent body composition analysis via BIA to determine PhA.  Participants’ PhA were matched for age, gender, and BMI based on reference values.  Z-scores, or SPhAs, were calculated to compare Canadian values to a reference population, then dichotomized into low or average/high PhA groups (< -1 SD or ≥ 1 SD, respectively).

Results: Baseline data was collected on seventy-two participants (mean PhA 5.3±0.8°).  Fifty-five participants had three-month data (mean PhA 5.2±0.7°, p=NS).  Overall, 40.3% had low SPhA, compared to 59.7% with average SPhA at baseline.  At 3 months, 38.2% had low SPhA, versus 61.8% with average SPhA value (p=NS).   

Conclusions:  When SPhA is used as a surrogate marker of malnutrition, 40% of participants are classified as malnourished at baseline and 38% at three months.  Three months is likely not enough time to see changes in PhA with this intervention. Future research will assess how changes in body weight influences SPhA.

Phase angle and malnutrition in Canadian community-dwelling adults


Introduction. The nutrient choline is considered to play an important role in reproductive health. It is essential during the early neonatal period to reduce the risk of neural tube defects but is critical for fetal neuronal and brain development. There is limited Canadian evidence of choline intakes during pregnancy but none looking at women of childbearing years (WCBY) in general. What evidence that does exist suggests that the majority of women, pregnant or otherwise, do not meet the recommendations. The AI for WCBY is 425 mg per day. Objectives. This study was designed to examine choline intakes nationally in WCBY and determine what food choices contribute to those intakes.  Methods. Diet recall data was collected for all non-pregnant and non-lactating women 18-45 yr age (N= 4308) using the Canadian Community Health Survey 2.2 (CCHS) data.  Nutrient information for choline was imported from the Canadian Nutrient File (2010 version) and matched to the foods in the CCHS 2.2 dietary recall data. Choline intakes and percent contributions were then estimated for all food sources in the CCHS for WCBY. Distributions of usual intakes for total choline were estimated using PC Side (version 1.11).  Results. For WCBY, the top 5 foods contributing to choline intake are: eggs, 1 and 2% milk, chicken and ground beef which contribute ~32% of intake.  Mean choline intake was 297 mg/d with ~ 85% having intakes below the AI. Conclusions. Food sources for choline are primarily animal in origin but the majority of WCBY are not meeting the AI for choline. Next steps are to examine choline intakes using the more recent 2015 CCHS Nutrition data to examine choline intakes and trends in choline food consumption patterns.  Significance to the field of dietetics. Dietitians need to focus not only on folate consumption in WCBY but choline as well. 


Food sources of choline for Canadian women of childbearing age. Is it enough?

Introduction: Proper childhood nutrition is important for optimal growth, development, and learning. School nutrition programs (SNPs) offering healthy options have the potential to positively influence children’s eating habits since children consume one-third of their daily intake at school. Currently, the food intake of children receiving SNPs is not known. 

Objective: To explore food intake during the school day in elementary schools where SNPs were implemented. 

Methods: Children (n=549) in Grades 4-8 from 22 schools in Southwestern Ontario recorded their intake during the school day using the self-administered Pupils Eating At School (PEAS) questionnaire. PEAS was created by modifying a previously-validated tool for this age group. Reported intake in PEAS was quantified into Eating Well with Canada’s Food Guide (CFG) servings and compared to one-third of CFG recommendations for children 9-13 years old. Fruit juice, sugar sweetened beverages (SSB), and snacks were counted separately. 

Results: Median (interquartile range) intake of servings were as follows: milk and alternatives (Mi) 0.5 (0.0, 1.5); meat and alternatives (Me) 0.5 (0.0, 1.0); grain products (G) 2.0 (0.0, 2.0); vegetables 0.0 (0.0, 1.0) and fruit 1.0 (0.0, 2.0) (VF); snacks 1.0 (0.0, 2.0); fruit juice 0.0 (0.0, 0.0); and SSB 0.0 (0.0, 1.5). In comparison to one-third of CFG recommendations, children met 50% for Mi; 152% for Me; 100% for G; and 50% for VF. 

Conclusions: Children did not meet the CFG recommendations for Mi and VF. Since VF intake can be indicative of overall diet quality, promoting increased servings at school should be a primary focus of SNPs. It is unknown if SNP offerings added to or displaced items packed in lunches. 

Significance to the field of dietetics: Exploring school day intake in children receiving SNPs provides context for evaluating these important programs.   

Exploring school day food intake in Southwestern Ontario elementary schools with student nutrition programs

Introduction: A low glycaemic index (LGI) diet may be beneficial to women with gestational diabetes (GDM) but it is not known whether this diet provides additional benefits on oxidative stress and antioxidant status.
Objective(s): To compare the effects of a LGI diet with that of standard care (SC) and the effects of GDM to normoglycemic pregnancies by examining markers of oxidative stress and antioxidant capacity.
Methods: Participants (n=43) with GDM from the glycemic index (GI) in GDM study (NCT01589757), provided plasma samples at baseline (V1), 4-6 weeks following dietary education intervention (V3), and 4-6 months post-partum (V4). Participants with GDM (n=8) and normoglycemic participants (n=10) provided breast milk (BM) samples. Plasma samples were analyzed for antioxidants by oxygen radical absorption capacity (ORAC), and for oxidative stress by the conjugated dienes to low density lipoprotein ratio (CD/LDL) and oxidized LDL (LDLox). BM was analyzed for antioxidants by ORAC.
Results: The main study participants (mean±SEM; age 34.2±0.7 years, pre-pregnancy BMI 26.4±0.9 kg.m2) were recruited at a mean gestational age of 25 weeks + 3.5 days. Between V1 and V3 the net change in mean plasma ORAC (±SEM) significantly increased in both diet groups (734±368 mM TE; p=0.006). Plasma LDLox increased significantly between V1 and V3 on the SC diet, but decreased slightly in LGI diet. As such, net change in LDLox was significantly different by diet group (LGI= -1.98±1.59; SC= 5.31±1.35; p=0.001). No significant differences were found in plasma CD/LDL or BM ORAC concentrations.
Conclusions: An LGI intervention may reduce plasma oxidative stress in women with GDM. Both SC and LGI diets may increase plasma antioxidants. GDM does not, however, appear to have any effect on BM antioxidants.
Significance: This study provides further insight into the beneficial mechanisms of registered dietitians administering a LGI diet for GDM patients.

Low glycaemic index diet for reduction of oxidative stress in women with gestational diabetes

Effect of creatine supplementation dosing strategies on aging muscle performance
J Chami, Author1, University of Regina, Regina, SK, D Candow, Author2, University of Regina, Regina SK
   
Introduction: Creatine supplementation has shown promise for increasing muscle strength, endurance and tasks of functionality during aging. Previous studies indicate low-dosage supplementation (0.1g/kg) for >6 weeks and high-dosage (0.3g/kg) for 5-7 days can increase intramuscular creatine which may subsequently benefit aging muscle performance. Proteins involved in sensing changes in osmolarity and signal transduction have been upregulated, along with proteins involved in satellite cell proliferation and differentiation in response to 10 days of creatine supplementation, independent of exercise.  Objective: Compare different creatine dosages independent of exercise on aging muscle performance and functionality. Methods: Using a double-blind, repeated measures design, participants were randomized to: Creatine-High (n = 11; 0.3 g/kg/day of creatine + 0.1 g/kg/day of maltodextrin), Creatine-Low (n = 9; 0.1 g/kg/day of creatine + 0.3 g/kg/day of maltodextrin) or Placebo (n = 11; 0.4 g/kg/day of maltodextrin) for 10 days. The Dependent Variables measured at baseline and after supplementation were muscle strength (1-RM leg, chest press, and hand grip), muscle endurance (leg, chest press; maximum repetitions at 80% and 70% baseline 1- RM), and tasks of functionality (walking speed, balance). Results: There was a significant increase over time for leg press strength (p = 0.000), chest press strength (p = 0.001), leg press endurance (p = 0.001) and chest press endurance (p = 0.001), with no differences between groups. There were no changes over time between groups for right-hand grip strength (p = 0.571), left-hand grip strength (p = 0.386), walking speed (p = 0.226) or falls (p = 0.414). Conclusion: short-term creatine supplementation, independent of dosage, has no effect on aging muscle performance. Significance to the field of Dietetics: Provide important information for the development of dietary and nutritional supplementation protocols for aging muscle health to prevent a loss of functional capacity and improve overall quality of life. 


Effect of creatine supplementation dosing strategies on aging muscle performance

Introduction: The home food environment is considered important in the development of children’s eating behaviours. Parents shape their children’s eating habits by role modelling and having certain foods in their household. Hence, it is important to understand how different media sources may be influencing parents’ food purchase decisions. 

Objective: The objective of this study was to explore which media sources may influence the food choices of parents of young children.  

Methods: Parents of young children (aged 2-5 years old) were invited through three childcare centres in Edmonton, Canada. Parents must have at least one child attending childcare to be included and be fluent in English. Three focus groups using a semi-structured interview guide were conducted from November 2017-January 2018 (4-6 participants in each group). NVivo 11 software was used to organize the data and transcripts were analyzed thematically.   

Results: The mean age of participants was 35 years (n=15); 13.3% were men and 86.7% women. Households had 1 to 2 children. Three major themes related to sources of media and food purchasing decisions were identified: parents were interested in nutrition information from different media sources such as Netflix documentaries, podcasts, and radio. Parents based their food decisions on what they see, hear and read. Furthermore, parents faced challenges regarding nutrition information.

Conclusion: The vast amount and incongruent nutrition messaging in the media can create confusion among parents when choosing healthier food choices. Dietitians have an advocacy role in increasing the general public's awareness of what is considered trustworthy and credible nutrition in the media. 

Significance to the field of dietetics: This study helps to understand that parents need more guidance to navigate the myriad of nutrition information. Dietitians can take the lead in media by sharing evidence-based nutrition information in an engaging way to enable parents to make well-informed food decisions.  


Exploring the influence of different media sources on food purchasing decisions: A qualitative study with parents of young children.

Introduction: In rural, Northern Vietnam, there are concurrent high levels of agricultural production, childhood anemia and malnutrition. The study, “Scaling up local production of fortified foods” attempts to promote food security among women farmers and decrease childhood malnutrition by producing local fortified complimentary foods.  Funding was provided by the Canadian International Food Security Fund, the International Development Research Centre and Global Affairs Canada.

Objective:  To observe the rate of anemia among children(<2y) and explore predictor variables among nine rural communes of Lao Cai, Lai Chau and Ha Giang province in Vietnam. This study is part of a larger project, “Scaling up Local Production of Fortified Food” to decrease malnutrition among children and women subsistence farmers in Vietnam.  

Methods: A cross-sectional survey was carried out among children(<2y) in 9 communes (n=309) in the rural northern provinces of Ha Giang, Lai Chau and Lao Cai in Vietnam. A three-stage sampling method was used and inclusion criteria required communes to be in rural areas with high poverty and malnutrition rates, where subsistence farming is predominant. Capillary blood sampling and visible-spectrometry of cyanmethemoglobin (Shimadzu DAGAIN 02681CD) was performed to assess hemoglobin levels.
A questionnaire probed associated factors such as; antenatal care visits, nutritional counselling, socio-economic factors, anthropometry of mother-child dyads, household dietary diversity and food security.  Associations were explored using a Pearson’s χ2 test and logistics regression analysis for predictors of anemia and linear multivariate analysis for Hemoglobin levels. 

Results:  The prevalence of anemia among children(<2y) was 45.6% (141/309) and did not differ significantly between provinces. Logistic regression models showed childhood anemia was lower among mothers who received antenatal care (>4 visits) as recommended by the WHO [OR 0.57, 95% CI 0.35- 0.93, P<0.05]. It was also lower among families who improved financially compared to the previous year [OR 1.33, 95% CI 1.00- 1.77, P<0.05]. There was a non-significant trend for lower anemia among girls [OR 0.64, 95% CI 0.40- 1.03, P=0.07] but there was a significantly higher level of Hemoglobin found among girls in linear regression models.  

Conclusion:  These anemia rates classify as a severe public health issue and of specific concern for the neurological development of children(<2y).  Lower rates of anemia were predicted by antenatal (>4 visits) care and if the family had an improved economic situation over the last year. Antenatal care may be an important intervention for anemia prevention in rural provinces in northern Vietnam.



Antenatal care attendance associated with anemia among children (<2y) in rural Lao Cai, Ha Giang and Lai Chau province, Vietnam: A cross sectional survey

J. Macdonald1, J. Koot2,  K. Hemphill3, J Bradbury1, T. Warshawski1, L. Mâsse2
1. Childhood Obesity Foundation, Vancouver, BC 2. BC Children’s Hospital Research Institute, School of Population and Public Health, University of British Columbia, Vancouver BC. 3. Ayogo Health, Vancouver BC.

Introduction The Childhood Obesity Foundation identified a gap in the availability of youth lifestyle apps that blend best evidence and best practices.
Objective To help with the development of a gamified mobile app to support youth and their families to adopt healthy behaviours, this study sought to understand what teens want in an app.

Methods A total of 15 youth (13-17 years; 10 males and 5 females) participated in a 135 minute focus group and/or two-60 minute prototype and content testing interviews. In the focus group, teens were asked to provide insights and opinions about what they wanted in a health app, what they valued, and how to make an app appealing to them. In the interviews, they tested a prototype of the app for usability and relatability of the content.

Results The qualitative analyses revealed that two main issues affected teens’ interests in using an app: 1) competing priorities and interests such as devoting time to school, homework/studying, spending time with friends/family, or using games; and 2) being pre-occupied with other issues such as their personal relationships and their future. About half of the focus group participants would be interested in using a health app. They were not asked if they were currently using a health app. Qualitative analyses from both the focus group and prototype testing interviews suggested that teens are looking for clear, friendly, positive and relatable health content presented in a unique 'non-school like' format.  They were less interested in working on an app alongside their parents. They seemed to value the safety of a private social wall to share experiences with their peers.

Conclusions Teens do not seem to be interested in accessing content that is similar to what they access for school. 

Significance to field of dietetics These results may be useful to practitioners recommending or developing e-health interventions targeted to youth.


What do teens want and not want in a health app?

PURPOSE: Human breast milk is identified as the best option for infants, and all efforts should be made to promote human milk feeding, even when a mother is unable to breastfeed her child. Donor breast milk (DBM) has been associated with improved outcomes over the use of preterm formula. Muslims living in Western countries may object to DBM use for their infant in the neonatal intensive care unit due to milk kinship, created when a non-biological mother nurses an infant. This review aims to educate clinicians on how these beliefs may impact their practice and how to communicate the benefits of DBM to Muslim patients. SUMMARY OF CONTENT: After delivering prematurely, a woman may have difficulty breastfeeding. Milk banks in North America pool the milk of up to 5 women, which does not pose a problem for most in the Western world. SYSTEMATIC APPROACH USED: Three databases; PubMed, Scopus and Web of Science were reviewed for relevant articles. Refence lists were verified for additional sources. A total of twelve articles were found and reviewed. CONCLUSIONS: Muslim religious officials have released a Fatwa (a ruling on a subject in Islamic law) supporting the use of DBM among Muslims. Clinicians can inform their Muslim patients that DBM use does not establish milk kinship and can be used as nutritional therapy for their preterm infants. RECOMMENDATIONS: Dietitians can educate Muslim patients on the acceptability of DBM. It is likely these families have not been made aware of the acceptability of DBM prior to having a premature infant. SIGNIFICANCE TO THE FIELD OF DIETETICS: In the past several decades, the number of Muslim immigrants in Canada has increased, thus Canadian dietitians working in NICU settings are more likely to encounter the concept of milk kinship. Dietitians need to be aware of these religious concerns. 

Donor breast milk acceptability in Muslim populations in Canada

Introduction: The purpose of this research was to investigate how, if at all, psychobiotics (probiotics with mental health benefits) and their proposed neural effects can be linked to antidepressant and anxiolytic activity via the gut-brain axis.

Objectives: To investigate the suggested mechanisms involved in the relationship between psychobiotics and their proposed beneficial neural effects. 

Methods: A literature review was conducted utilizing online databases including the Acadia Library, Science Direct, and Medscape. Personal communication with a dietitian specializing in this area was used to guide and supplement the literature review, as it became apparent early in the process that research from a nutrition perspective was limited. Animal and human studies were included, yielding a total of twenty-one articles reviewed.   

Results: Articles reviewed were predominantly neurological/psychological in nature or came from the field of biology. Two studies reviewed stemmed from nutrition. Four studies involved human subjects; seven used animal models. Results suggested that the relationship between psychobiotics and mental health is mediated along the gut-brain axis, utilizing the interoceptive awareness of the vagus nerve (VN). Secondary to psychobiotic administration, this connection appears to induce anxiolytic and antidepressant effects by influencing levels of serotonin, gamma-aminobutyric acid (GABA), and dopamine, neurotransmitters involved in mental stability.   

Conclusions: While the link between psychobiotics and antidepressant/anxiolytic effects seems supported in animal studies, more research in human populations is needed before additional conclusions can be drawn. It is also essential to consider how to increase research from a nutrition/dietetic-specific lens.  

Significance to the Field of Dietetics: Dietitians work with clients whose nutrition status may be impacted by mental health in a variety of ways. As the understanding of psychobiotics and their possible benefits increases, this could innovate how we approach nutrition therapy for this patient base. This also supports the potential for interdisciplinary research between dietetics, psychiatry, and neuroscience.  

[E] Psychobiotics and their neural effects on antidepressant and anxiolytic activity via the gut-brain axis

INTRODUCTION: Dietetics lacks a validated tool that captures inpatient nutrition acuity beyond malnutrition. Through an iterative process, a nutrition acuity scoring tool (NAS) was created. It was based on nutrition diagnoses seen with inpatients and their need for medical nutrition therapy (MNT) to avoid the onset or deterioration of a diagnosis. The tool underwent face validity testing at 12 hospitals but required further validation. OBJECTIVE: To measure the content validity of the NAS as a metric for inpatient nutrition acuity. METHODS: A modified Delphi approach as an online survey was used to examine the NAS content validity. Canadian dietitians with experience using and teaching nutrition care process terminology (NCPT) ranked each NAS item on a Likert scale for clarity (very clear to very unclear) and appropriateness (very appropriate to very inappropriate). The a priori content validity index threshold at the item (iCVI) and scale level (sCVI) was 0.78 and 0.9, respectively. Items not meeting the iCVI threshold in round 1 were modified for round 2. RESULTS: Participants (N=13) were from 5 provinces, averaged 14.2 years of work experience (SD 8.2), had used NCPT terminology for 5 years (SD 1.6), worked full time (76.9%, n=10), were from a teaching hospital (84.6%, n=11) and had provided NCPT instruction (84.6%, n=11).  Consensus was achieved on all items after two Delphi rounds. The sCVI for Delphi round 1 and 2 was 0.93 and 0.96, respectively. CONCLUSIONS: The NAS was found to be content valid with a sample of Canadian dietitians. This tool would benefit from reliability testing. SIGNIFICANCE TO THE FIELD OF DIETETICS: Inpatient acuity and complexity is rising. A metric that classifies nutrition acuity helps dietitians describe their patient population and is an essential step for triaging inpatients to receive dietitian services.

Content validity testing of a nutrition acuity scoring tool

Abstract Title: Implementing a Clinical Practice Change: Adopting the Nutrition Care Process
Introduction: Registered Dietitians (RDs) are fundamental players in the multidisciplinary healthcare team. They conduct nutrition assessments, develop nutrition care plans, and monitor and evaluate the effectiveness of those interventions. The Nutrition Care Process (NCP) provides a framework to promote uniform documentation between RDs across the profession, and creates a link between the nutrition intervention and the predicted or actual nutrition outcome. The benefits of standardized documentation has been well-recognized across other professions, and the NCP has been integrated in a number of institutions internationally.
Objective: A committee of non-management RDs at The Hospital for Sick Children (HSC) led the Department of Clinical Dietetics to adopt the NCP. The objective of the committee was to provide a transparent learning plan, evidence-based education sessions, and practical tools and resources to RDs to help them learn and easily adopt the NCP into their practice.
Methods: The committee developed and consecutively delivered a tailored education plan, including learning resources, to five groups of RDs. The committee administered pre- and post-education surveys to measure outcomes, including adequacy of training and confidence level in adopting NCP.
Results: Surveys were completed by all RDs in attendance (n=34 pre-education; n=26 post-education) to compare baseline with end of training results. The average attendance at the education sessions was 77%. Following education, RDs felt they had received sufficient training and felt confident about integrating the NCP into their practice (p<0.05). A decrease in charting time was also observed. 
Conclusions: Adopting the NCP was well-received by the department and RDs continue to integrate it into their practice. Part of the success of the NCP adoption may be attributed to the transparency of the education plan, the individualized scheduling of education sessions, and the peer-to-peer instruction style. 

Implementing a Clinical Practice Change: Adopting the Nutrition Care Process

INTRODUCTION: Dietetics lacks a nutrition acuity scoring (NAS) tool that categorizes inpatients based on nutrition diagnosis. We created an instrument that ranks nutrition diagnoses based on the need for medical nutrition therapy. The tool specifies a four-point scale and is organized according to nutrition diagnosis domains. The tool was content validated with a sample of Canadian dietitians but required inter-rater reliability testing. OBJECTIVE: To measure the inter-rater reliability of the NAS when applied to inpatients. METHODS: Dietitian raters were required to have a minimum of 1 year of experience in a variety of practice areas in acute care. Raters were trained concurrently using simulated cases until they indicated they understood the tool and study procedures. The cases reflected a variety of patient types and were previously tested with experienced staff. Patients were selected randomly. Raters prospectively assessed the same inpatients independent and within two hours of each other. Inpatient assignment order to raters was random. Raters were debriefed regarding NAS disagreement upon study completion. RESULTS: Raters (N=2) were female with 1.0 year of work experience. Inpatients (N=41) were from either surgical or medical wards in a teaching hospital, 64.3% male (n=26), averaged 62.2 years (SD 14.9, 64-85 years) and 24 days from admission to NAS assignment (SD 34 days). Agreement between raters was 0.52 (linear weighted kappa). Raters felt agreement could have improved with changes to their training rather than the tool itself. CONCLUSIONS: The NAS was found to be moderately reliable. Reliability may improve if raters were trained using actual patients rather than simulated cases. However, further research is required for confirmation. SIGNIFICANCE TO THE FIELD OF DIETETICS: With rising patient acuity and complexity of care, dietitians need a validated metric to describe and monitor their patients’ nutrition acuity. 


Reliability testing of a nutrition acuity tool


Introduction: New Westminster home health (HH) uses an assessment tool called the Interprofessional Assessment (IPA). One intended purpose of the IPA is to identify clients with needs that could be met by the interprofessional HH team. Currently, relative to the total number of referrals to HH services, the frequency of HH RD referrals is noticeably low. This pilot study investigates current use of the IPA and the frequency of referral to the HH RD.

Objectives:  This study investigated the frequency of IPA completion, and specifically documentation of nutrition-related indicators, for clients referred to HH nursing in New Westminster.  Additionally, it investigated the frequency of HH RD referrals between clients who had a completed IPA and/or documentation of nutrition-related indicators compared to those who did not.

Methods: A retrospective chart review of 349 Primary Access Regional Information System (PARIS) charts was conducted. Variables collected included: reason for HH referral, age, sex, if the IPA was completed, assessment of nutrition -related indicators, if a referral was made to the HH RD and the reason indicated.

Results: 267 charts (76.5%) had an IPA completed. Six (1.7%) of the 349 charts had referrals to the HH RD; of these, four had completed IPAs and two did not. Every completed IPA had a nutrition-related indicator documented. Notable nutrition-related indicators marked as a concern were weight change (n=93, 57.4%), appetite (n=45, 18.9%), and diet (n=31, 13.0%).

Conclusions: Despite documented nutrition concerns in the IPAs, many clients were not referred to the HH RD. This study highlights a need to revisit the use of the IPA and for standardized guidelines for HH RD referral.  

Significance to field of dietetics: Routine nutrition screening of patients in the HH setting would help to identify patients who are malnourished or at risk of malnutrition who could benefit from RD intervention.



A description of the use of the Interprofessional Assessment Tool and frequency of dietitian referral among New Westminster home health clients

Introduction: Anecdotal evidence from Fraser Health (FH) dietitians suggests a large number of children, seen as outpatients, are iron deficient. In view of the detrimental effects that iron deficiency (ID) has on early development, data was sought to quantify the problem.

Objectives: To determine the prevalence of iron deficiency in pediatric patients seen by outpatient dietitians at a large teaching hospital within FH and to identify nutrition related ID risk factors.

Methods: A cross-sectional, retrospective chart review of pediatric patients (0-5 years) seen by FH outpatient dietitians, regardless of the reason for initial referral. Prevalence of ID was based on: ferritin, a combination of hemoglobin and mean corpuscular volume, or % transferrin saturation (based on age). Anthropometric data and nutrition related ID risk factors as documented in the nutrition assessment report were also collected.   

Results: Of 847 pediatric patients, 290 met the inclusion criteria. The mean age was 23 months (SD 16 months, range 4 days to 4 years and 11 months). The proportion of pediatric patients with ID was 45.2 % (n=131). By age group, 36.5% were aged 0 to 2 years (n=66) and 59.6% (n=65) were between 2 and 5 years. Of the documented ID risk factors, 32.6% had poor iron intake (n=94), 17.2% excessive non-breast milk intake (n=50), and 16.6% followed vegetarian a diet (n=48).

Conclusion: Our findings confirm clinician’s observations of a high prevalence of ID among pediatric outpatients seen by dietitians. Our sample was limited to patients referred to the dietitian and therefore cannot be extended to the greater FH pediatric population. Further research is needed to explore the prevalence of ID and common risk factors among children in the FH region. 

Significance to dietetics: These findings may inform public health initiatives designed to mitigate the modifiable risks related to developing ID in early life.


Iron deficiency in a sample of pediatric nutrition outpatients

PURPOSE:


Given limited healthcare resources, there is value in dietitians seeing inpatients in priority order based on their need for medical nutrition therapy (MNT). With the absence of a published tool to inform this process, one was developed.

PROCESS OR SUMMARY OF CONTENT:

Fraser Health (FH) dietitians created an inpatient Priority Intervention Criteria Tool (PIC) that specifies four levels for dispatching dietitian services to patients based on their urgency for MNT. The PIC is informed by referral reason and Nutrition Acuity Score (a validated FH tool that incorporates patient nutrition diagnoses). It also acknowledges dietitian clinical judgment in determining monitoring plans.

SYSTEMATIC APPROACH USED, INCLUDING SUPPORTING INFORMATION:

The PIC was developed by a group of experienced dietitians then taken to front-line dietitians at 12 hospitals for review. PIC refinement was an iterative process focusing on the constructs of harm avoidance and risk reduction related to the urgency for MNT. As dietitians at each hospital reviewed the tool they accepted or rejected the changes from the previous hospital. Consensus was achieved after three rounds. The PIC has been in use at 12 hospitals by over 100 dietitians for 3 years. Evaluation by dietitians representing each hospital revealed revisions that will follow the same iterative process to achieve consensus.

CONCLUSIONS:

The PIC provides a standardized method of triaging inpatients and dispatching dietitian services to those with the greatest need for MNT. This approach helps ensure patients with the highest nutrition acuity receive dietitian service first. It also provides a common language to communicate MNT urgency for workload distribution.

RECOMMENDATIONS:

The PIC would benefit from additional validation in the form of reliability testing in the inpatient environment.

SIGNIFICANCE TO THE FIELD OF DIETETICS: 

This tool supports communication amongst the healthcare team and senior leadership related to the need for MNT. It also informs dietitian caseloads, resource planning and helps justify labour resource requirements.

Creation of a priority tool to triage hospital patients and dispatch dietitian services.

Introduction:  Prolonged use of soybean-oil (SO) based lipid emulsions in parenteral nutrition (PN) may contribute to the development of PN-associated liver disease (PNALD). Current research suggests a role for mixed-lipid emulsions in preventing, treating, or managing PNALD in acute-care settings. The use of mixed-lipid emulsions and their effects on liver function tests (LFTs) in adults receiving home PN (HPN) has not been widely studied.
Objectives: To describe demographic and clinical characteristics of BC HPN patients who have transitioned from Intralipid®, a SO-lipid emulsion, to SMOFlipid®, a mixed-oil emulsion, and to describe any changes with regards to LFTs before and after transition to SMOFlipid®.
Methods: A retrospective chart review was completed for BC HPN patients who transitioned from Intralipid® to SMOFlipid®and were active between January 1/13 and October 31/17. Data collected included demographic and clinical information, HPN prescription details, and monthly measurements of LFTs before and after lipid transition. Data was analyzed using descriptive statistics.
Results: 19 patients constituted the study group; 6 could not be analyzed, and 3 were outliers, leaving 10 for analysis. The most frequent indication for HPN was short bowel syndrome (90%, n=9). 50% of participants showed signs of liver injury on Intralipid®. After transition to SMOFlipid®, 70-80% of the study population had decreases in their mean LFT values, however the degree of change varied.
Conclusions: Overall, LFTs declined after transition to SMOFlipid®. These findings correspond with studies observing effects of SMOFlipid® on LFTs; however, most compare SO-based and mixed-lipid intravenous lipid emulsions (ILEs) in acute or surgical settings.
Significance to the field of dietetics: No other studies have looked at a transition from 
Intralipid® to SMOFlipid® in the HPN population. Further understanding of the long-term impact of mixed ILEs will help to inform whether SMOFlipid® should be considered for primary prevention of PNALD for BC HPN patients.

A description of liver functions tests amongst adult patients in the British Columbia Home Parenteral Nutrition (BC HPN) Program who have changed from a soybean oil emulsion to a mixed-lipid emulsion

Introduction: Malnutrition is under recognized and often undiagnosed in the hospital setting. Malnutrition contributes to increased mortality, morbidity, hospital admissions, length of hospital stay, healthcare costs and reduced quality of life. Dietitian involvement is critical in addressing malnutrition and its associated risk factors. Patients admitted to Vancouver General Hospital (VGH) are screened for malnutrition risk using a validated nutrition screening tool (Canadian Nutrition Screening Tool) within the Nursing Admission Assessment (NAA).

Objectives: The objectives of this study are (1) to determine the proportion of patients who are screened by and determined to be at risk for malnutrition upon admission to 3 hospitalist medicine units at VGH and (2) to determine the proportion of those patients seen by a dietitian.
 
Methods: A retrospective chart review of all patients admitted to VGH hospitalist medicine units from March 1-31, 2017 was conducted. Data collected included demographics, completion of the nutrition screen within the NAA, dietitian referrals and assessments.
 
Results: Of the 161 patients admitted, 51% (n=82) were screened for malnutrition upon admission. Of these patients, 24% (n=20) were determined to be at malnutrition risk. Despite only 15% (n=3) of these patients being referred to a dietitian, 50% (n=10) of patients at malnutrition risk were seen by a dietitian. The main reasons for dietitian assessment were physician referrals and dietitian routine screening.
 
Conclusions: The NAA was not consistently completed and patients at risk were not always referred to the dietitian. Suggestions to address these issues include identifying barriers for completing the NAA and providing nursing education about the importance of malnutrition screening, use of the tool, and how to refer to the dietitian.

Significance to the field of dietetics: Consistent completion of the validated malnutrition screening tool and resulting dietitian referrals could help identify malnutrition early and decrease routine screening time for dietitians.

Are patients identified to be at risk for malnutrition being seen by a dietitian upon admission to hospitalist medicine units at Vancouver General Hospital?