The implementation of non-weight focused approaches in clinical practice: A Canadian cross-sectional study among registered dietitians.

BACKGROUND: An increasing number of dietitians use non-diet approaches, referred to as non-weight focused practice approaches (NWFAs), in clinical practice when working with higher weight adult clients. However, the factors that impact dietitians' ability to successfully implement these approaches in practice are unknown. METHODS: Aiming to examine how implementing NWFAs in clinical practice differs based on the extent to which a dietitian uses NWFAs with their clients, we conducted a cross-sectional online survey among Canadian registered dietitians who work with higher weight adults (May to July 2021), developed and validated following the Consolidated Framework for Implementation Research. Descriptive statistics were conducted to identify barriers and facilitators with respect to implementing NWFAs. The Kruskal-Wallis was used to test for differences in barriers and facilitators with respect to implementing NWFAs among five different practice approaches. The results showed that, among participants (n = 383; 82% white; 95% women) the most important barriers for implementation of NWFAs were clients' focus on weight as an outcome, when losing weight is a condition to access enhanced services, requiring changes to their practice philosophy, difficulty funding professional development and not having sufficient skills or knowledge to implement NWFAs in practice. Top-rated facilitators included the use of clinical guidelines, scientific publications and educational materials, which were rated with higher agreement across all implementation stages (p < 0.001). CONCLUSIONS: The present study highlights important factors that may impact the effective implementation of NWFAs in dietetic practice for higher weight adult clients, which is essential to minimise barriers in practice.

A feasibility study of a randomized controlled trial protocol to assess the impact of an eHealth intervention on the provision of dietary advice in primary care.

BACKGROUND: Canadian sodium intakes remain high despite population-wide sodium reduction initiatives, highlighting the need for personal action in reducing dietary sodium. eHealth interventions support patients in dietary change and assist clinicians in decision-making and delivering care, including provision of advice. To date, impact of diet-focused eHealth tools, like the Sodium Calculator (SC) dietary screening tool, on clinical outcomes has received minimal examination. This study assessed feasibility of a randomized controlled trial (RCT) protocol to examine the impact of the SC, a physician-focused intervention, on the quality of dietary sodium reduction advice provided by physicians to their patients with hypertension. METHODS: Primary care physicians from community-based primary care clinics were randomized to one of two groups: (1) 'usual care' for dietary sodium counselling or (2) dietary sodium counselling using the SC ('experimental group'). The primary endpoint was protocol feasibility defined by the following outcomes: process (e.g. recruitment, retention, protocol adherence, acceptability of intervention), resources (e.g. needs, impact on workflow), and management (e.g. staff requirements). Outcomes were assessed using direct observation, interviews, and questionnaires with patients, physicians, and clinic staff. RESULTS: Seven physicians (n = 4 in experimental group, n = 3 in usual care group) and 65 patients with hypertension (48.5% men, 69.8 ± 10.1 years) successfully participated. The main challenges identified is related to recruitment rate (48% for patients, 20% for physicians) and physician protocol adherence (76%). These improved with minor protocol modifications. There were several areas of protocol success such as no disruption to physician workflow, hiring clinic nurses as research staff, having a physician site lead to support physician recruitment, and a 'Protocol Prompt Form' to increase physician protocol adherence. Importantly, there was a high degree of acceptability of the SC intervention among experimental group physicians [n = 3 (75%)]. CONCLUSIONS: The modified RCT protocol was considered feasible. The identified successes can be leveraged, and the risks can be mitigated, during implementation of a full-scale RCT. Assessment of this RCT protocol is an important step in understanding the effectiveness of diet-focused eHealth tools to supporting physician self-efficacy in assessing, monitoring, and implementing dietary advice in routine clinical practice and supporting patients in effective behaviour change.

Dairy Product Consumption and Cardiovascular Health: A Systematic Review and Meta-analysis of Prospective Cohort Studies.

The association between dairy product consumption and cardiovascular health remains highly debated. We quantitatively synthesized prospective cohort evidence on the associations between dairy consumption and risk of hypertension (HTN), coronary heart disease (CHD), and stroke. We systematically searched PubMed, Embase, and Web of Science through August 1, 2020, to retrieve prospective cohort studies that reported on dairy consumption and risk of HTN, CHD, or stroke. We used random-effects models to calculate the pooled RR and 95% CI for the highest compared with the lowest category of intake and for a 1-serving/d increase in consumption. We rated the quality of evidence using NutriGrade. Fifty-five studies were included. Total dairy consumption was associated with a lower risk of HTN (RR for highest compared with lowest level of intake: 0.91, 95% CI: 0.86, 0.95, I2 = 73.5%; RR for 1-serving/d increase: 0.96, 95% CI: 0.94, 0.97, I2 = 66.5%), CHD (highest compared with lowest level of intake: 0.96, 95% CI: 0.92, 1.00, I2 = 46.6%; 1-serving/d increase: 0.98, 95% CI: 0.95, 1.00, I2 = 56.7%), and stroke (highest compared with lowest level of intake: 0.90, 95% CI: 0.85, 0.96, I2 = 60.8%; 1-serving/d increase: 0.96, 95% CI: 0.93, 0.99, I2 = 74.7%). Despite moderate to considerable heterogeneity, these associations remained consistent across multiple subgroups. Evidence on the relation between total dairy and risk of HTN and CHD was of moderate quality and of low quality for stroke. Low-fat dairy consumption was associated with lower risk of HTN and stroke and high-fat dairy with a lower risk of stroke. Milk, cheese, or yogurt consumption showed inconsistent associations with the cardiovascular outcomes in high compared with low intake and dose-response meta-analyses. Total dairy consumption was associated with a modestly lower risk of hypertension, CHD, and stroke. Moderate to considerable heterogeneity was observed in the estimates, and the overall quality of the evidence was low to moderate.

Knowledge, Attitudes and Behaviours Related to Physician-Delivered Dietary Advice for Patients with Hypertension.

Dietary modifications are key health behaviour recommendations for the prevention and management of hypertension, a leading contributor of global disease burden. Despite this, few primary care physicians discuss nutrition with their patients. This study describes the barriers and facilitators to the provision of dietary advice for hypertension prevention and management among Canadian physicians. A validated 62-item cross-sectional survey was distributed online to 103 Canadian primary care physicians between 2017 and 2019. Eighty participants were included in the analyses. The majority of participants were based in Ontario (68.7%) and saw 10-24 patients per week (53.5%). Fewer than half (47.5%) of participants were knowledgeable about the recommended sodium level by Hypertension Canada (< 2000 mg/day) and 38.8% felt it was difficult to know which foods are high or low in sodium. Approximately one quarter felt the findings about sodium and hypertension and cardiovascular disease are controversial. Other significant barriers were: not enough time to talk to patients about diet (76.3%), belief that patients are not truthful about their diet (76.3%), patients would not follow their advice (46.8%), and that it was difficult to keep up with so many guidelines (50.0%). Many identified that electronic medical record tools (80.8%), access to dietitians (84.9%), or more nutrition education in medical training (65.8%) would help facilitate advice. Given the importance of diet and the central role of physicians in motivating dietary change among patients, approaches are required to address identified barriers and facilitators to providing dietary advice to reduce the burden of hypertension.

Changing Sodium Knowledge, Attitudes and Intended Behaviours Using Web-Based Dietary Assessment Tools: A Proof-Of-Concept Study.

Despite public health efforts to reduce dietary sodium, sodium intakes in most countries remains high. The purpose of this study was to determine if using novel web-based tools that provide tailored feedback, the Sodium Calculator and Sodium Calculator Plus, improves users' sodium-related knowledge, attitudes, and intended behaviours (KAB). In this single arm pre- and post-test study, 199 healthy adults aged 18-34 years completed a validated questionnaire to assess changes to sodium-related KAB before and after using the calculators. After using the calculators, the proportion of participants who accurately identified the sodium adequate intake and chronic disease risk reduction level increased (19% to 74% and 23% to 74%, respectively, both p = 0.021). The proportion accurately self-assessing their sodium intake as 'high' also increased (41% to 66%, p = 0.021). Several intended behavioural changes were reported, i.e., buying foods with sodium-reduced labels, using the Nutrition Facts table, using spices and herbs instead of salt, and limiting eating out. Evidence-based eHealth tools that assess and provide personalized feedback on sodium intake have the potential to aid in facilitating sodium reduction in individuals. This study is an important first step in evaluating and optimizing the implementation of eHealth tools to help reduce Canadians' sodium intakes.

High sodium intake increases blood pressure and risk of kidney disease. From the Science of Salt: A regularly updated systematic review of salt and health outcomes (August 2016 to March 2017).

The purpose of this review was to identify, summarize, and critically appraise studies on dietary salt and health outcomes that were published from August 2016 to March 2017. The search strategy was adapted from a previous systematic review on dietary salt and health. Studies that meet standards for methodological quality criteria and eligible health outcomes are reported in detailed critical appraisals. Overall, 47 studies were identified and are summarized in this review. Two studies assessed all-cause or disease-specific mortality outcomes, eight studies assessed morbidity reduction-related outcomes, three studies assessed outcomes related to symptoms/quality of life/functional status, 25 studies assessed blood pressure (BP) outcomes and other clinically relevant surrogate outcomes, and nine studies assessed physiologic surrogate outcomes. Eight of these studies met the criteria for outcomes and methodological quality and underwent detailed critical appraisals and commentary. Five of these studies found adverse effects of salt intake on health outcomes (BP; death due to kidney disease and initiation of dialysis; total kidney volume and composite of kidney function; composite of cardiovascular disease (CVD) events including, and risk of mortality); one study reported the benefits of salt restriction in chronic BP and two studies reported neutral results (BP and risk of CKD). Overall, these articles confirm the negative effects of excessive sodium intake on health outcomes.

Examination of food industry progress in reducing the sodium content of packaged foods in Canada: 2010 to 2013.

In 2010, as part of a national sodium reduction strategy, Canada published sodium reduction benchmark targets for packaged foods; however, no evaluation of this policy has occurred. The objective was to evaluate changes in the sodium content of packaged foods, identify categories reduced in sodium, and determine the proportion meeting Health Canada's sodium reduction benchmarks. This was a cross-sectional analysis of Canadian packaged foods in 2010 and 2013 (n = 10 487 and n = 15 394, respectively). Sodium content was obtained from the Nutrition Facts table. Overall, 16.2% of food categories had significantly reduced sodium levels. The greatest shifts in the distribution of sodium within food categories occurred in imitation seafood (mean ± SD, mg/100 g; 602 ± 50 to 444 ± 81, 26.2%, p = 0.002), condiments (1309 ± 790 to 1048 ± 620, 19.9%, p = 0.005), breakfast cereals (375 ± 26 to 301 ± 242, 19.7%, p = 0.001), canned vegetables/legumes (269 ± 156 to 217 ± 180, 19.3%, p < 0.001), plain chips (462 ± 196 to 376 ± 198, 18.6% p = 0.004), hot cereals (453 ± 141 to 385 ± 155, 15.0%, p = 0.011), meat analogues (612 ± 226 to 524 ± 177, 14.4%, p = 0.003), canned condensed soup (291 ± 62 to 250 ± 57, 14.1%, p = 0.003), and sausages and wieners (912 ± 219 to 814 ± 195, 10.7%, p = 0.012). The proportion of foods meeting at least 1 of the 3 phases of the sodium reduction benchmark targets slightly increased (51.4% to 58.2%) and the proportion exceeding maximum benchmark levels decreased (25.2% to 20.8%). These data provide a critical evaluation of changes in sodium levels in the Canadian food supply. Although progress in reducing sodium in packaged foods is evident, the food industry needs to continue efforts in reducing the sodium in the foods they produce.

Effect of a Sodium-Restricted Diet on Intake of Other Nutrients in Heart Failure: Implications for Research and Clinical Practice.

BACKGROUND: Sodium restriction is the primary dietary therapy for heart failure (HF) patients. Currently, it is unknown if changing diets to reduce dietary sodium in HF causes secondary changes to the intake of other nutrients in this patient population already at nutritional risk. METHODS AND RESULTS: HF patients (n = 16; 52 ± 12 years old; 78% male) followed a sodium-restricted diet for 1 week. Nutritional changes were documented at baseline and after a <2,000 mg/d sodium-restricted diet, as measured by food records before baseline and each day during the study. After a 49% reduction in dietary sodium (3,626 ± 956 to 1,785 ± 696 mg/d), we observed a significant reduction in calorie (2,467 ± 748 to 1,931 ± 388 kcal/d; P < .016), carbohydrate (293 ± 108 to 232 ± 56 g/d; P = .013), calcium (995 ± 496 to 609 ± 208 mg/d; P < .004), thiamine (2.0 ± 0.8 to 1.5 ± 0.8 mg/d; P = .020), and folate (412 ± 192 to 331 ± 172 µg/d; P = .019) intakes. There was a decrease in saturated fat (32 ± 18 to 21 ± 6 g/d; P = .032) and a trend to lower total fat (89 ± 34 to 68 ± 19 g/d; P = .066) and higher potassium (1,262 ± 328 to 1,405 ± 268 mg/1,000 kcal; P = .055) intakes. CONCLUSIONS: We found multiple unintentional nutritional consequences with dietary sodium reduction in HF patients. These findings highlight the need to consider the whole diet when counseling HF patients to lower sodium intake.