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.

Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial.

BACKGROUND: Dietary restriction of sodium has been suggested to prevent fluid overload and adverse outcomes for patients with heart failure. We designed the Study of Dietary Intervention under 100 mmol in Heart Failure (SODIUM-HF) to test whether or not a reduction in dietary sodium reduces the incidence of future clinical events. METHODS: SODIUM-HF is an international, open-label, randomised, controlled trial that enrolled patients at 26 sites in six countries (Australia, Canada, Chile, Colombia, Mexico, and New Zealand). Eligible patients were aged 18 years or older, with chronic heart failure (New York Heart Association [NYHA] functional class 2-3), and receiving optimally tolerated guideline-directed medical treatment. Patients were randomly assigned (1:1), using a standard number generator and varying block sizes of two, four, or six, stratified by site, to either usual care according to local guidelines or a low sodium diet of less than 100 mmol (ie, <1500 mg/day). The primary outcome was the composite of cardiovascular-related admission to hospital, cardiovascular-related emergency department visit, or all-cause death within 12 months in the intention-to-treat (ITT) population (ie, all randomly assigned patients). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT02012179, and is closed to accrual. FINDINGS: Between March 24, 2014, and Dec 9, 2020, 806 patients were randomly assigned to a low sodium diet (n=397) or usual care (n=409). Median age was 67 years (IQR 58-74) and 268 (33%) were women and 538 (66%) were men. Between baseline and 12 months, the median sodium intake decreased from 2286 mg/day (IQR 1653-3005) to 1658 mg/day (1301-2189) in the low sodium group and from 2119 mg/day (1673-2804) to 2073 mg/day (1541-2900) in the usual care group. By 12 months, events comprising the primary outcome had occurred in 60 (15%) of 397 patients in the low sodium diet group and 70 (17%) of 409 in the usual care group (hazard ratio [HR] 0·89 [95% CI 0·63-1·26]; p=0·53). All-cause death occurred in 22 (6%) patients in the low sodium diet group and 17 (4%) in the usual care group (HR 1·38 [0·73-2·60]; p=0·32), cardiovascular-related hospitalisation occurred in 40 (10%) patients in the low sodium diet group and 51 (12%) patients in the usual care group (HR 0·82 [0·54-1·24]; p=0·36), and cardiovascular-related emergency department visits occurred in 17 (4%) patients in the low sodium diet group and 15 (4%) patients in the usual care group (HR 1·21 [0·60-2·41]; p=0·60). No safety events related to the study treatment were reported in either group. INTERPRETATION: In ambulatory patients with heart failure, a dietary intervention to reduce sodium intake did not reduce clinical events. FUNDING: Canadian Institutes of Health Research and the University Hospital Foundation, Edmonton, Alberta, Canada, and Health Research Council of New Zealand.

Evaluating the confounding effects of medical therapies on potassium intake assessment in patients with heart failure.

BACKGROUND AND AIMS: Potassium-wasting (loop diuretics [LD]) and potassium-sparing (spironolactone) medications used for heart failure (HF) may alter renal potassium handling and confound the use of twenty-four-hour (24-h) urine collections as a surrogate marker for potassium intake, an effect that has been observed with dietary sodium assessment. The objective was to determine the strength of association between 24-h urine collections and weighed food records in assessing potassium intake in HF patients stratified by LD usage and spironolactone usage. METHODS AND RESULTS: Stable outpatients with HF simultaneously completed two 24-h urine collections and two weighed food records on consecutive days. Analyses compared patients stratified by LD and/or spironolactone use. Pearson's correlation and the Bland-Altman method of agreement assessed the relationship between the techniques. Overall, 109 patients (61 ± 11 yrs, 74% male) were included. The mean difference in dietary potassium estimated between 24-h urine collections and food records was -353 ± 1043 mg (p < 0.01) for all patients, with no differences between measures among subgroups. The association between the two methods was r = 0.551 (95% CI, 0.373 to 0.852, p < 0.001) for LD users; r = 0.287 (95% CI, 0.01 to 0.570, p = 0.050) for LD non-users; r = 0.321 (95% CI, 0.13 to 0.798, p = 0.043) for spironolactone users, and; r = 0.534 (95% CI, 0.331 to 0.747, p < 0.001) for spironolactone non-users. There were no significant mean biases identified as part of the Bland-Altman analysis. CONCLUSION: Among HF patients, potassium-wasting and potassium-sparing medications do not influence the agreement between the two methods in the assessment of potassium intake.

Progress towards eliminating industrially produced trans-fatty acids in the Canadian marketplace, 2013-2017.

OBJECTIVE: To assess the prevalence of partially hydrogenated oils (PHO), hydrogenated oils (HO) and/or both in Canadian packaged foods in 2013 and 2017 and to determine the mean trans-fatty acid (TFA) content of products declaring such oils. DESIGN: Repeated cross-sectional study of the Food Label Information Program. SETTING: Food labels (n 32 875) were collected from top Canadian grocery retailers in 2013 and 2017. Proportions of products declaring PHO, HO and/or both in the Ingredients List were calculated by year and food category. The percentage contribution of TFA (g) to total fat (g) was calculated and compared against the voluntary TFA limits, defined as <2 % of total fat content for fats and oils, and <5 % for all other foods. Foods exceeding limits were identified. The mean TFA content (in g/serving and per 100 g) was calculated for products with these oils. RESULTS: The use of PHO, HO and/or both significantly decreased in Canadian foods from 2013 to 2017 (0·8 to 0·2 %, 5 to 2·4 % and 5·7 to 2·6 %, respectively, for PHO, HO and/or both). The mean TFA content of products containing PHO increased (0·34 to 0·57 g TFA/serving); although it was not statistically significant, it is still concerning that TFA content increased. The TFA content significantly decreased in foods with HO (0·24 to 0·16 g TFA/serving, P < 0·05) during 2013-2017. CONCLUSIONS: Products with PHO continue to be present in the Canadian marketplace, despite voluntary efforts to eliminate them. Products with HO should also be monitored, as they can also contribute to TFA content in foods.

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.

Development of an online tool for sodium intake assessment in Mexico.

Excess sodium intake is associated with adverse health effects, and reducing its intake is a strategy that improves population health. However, estimating sodium intake is challenging and new options for assessment are needed. This review describes the design and development of a web-based, publicly-accessible, dietary sodium intake screening tool (Calculadora de Sodio) for individuals in Mexico. Sodium data from 2017 - 2018 for 3 429 packaged foods, 655 restaurant and cafeteria foods, and 320 home-style meals and street foods (determined by chemical analysis) comprised the 71-question tool. It was piloted with 10 nutrition experts for feedback on content and face validity; and with 30 potential users to test its usability and interface. Improvements were made to content, language, and formatting following the pilot. Its predictive validity will be established in the future. The Calculadora de Sodio provides instant feedback on an individual's average daily sodium intake, computed by frequency of intake, average number of servings, and sodium content per serving of each sodium-focused food category. This is the first web-based dietary sodium screening tool developed for the general population of Mexico. It is an efficient and practical way to assess sodium intake and can serve as a model for similar tools for other countries and regions.

La ingesta excesiva de sodio se asocia a efectos nocivos para la salud y su reducción constituye una estrategia para mejorar la salud de la población. Sin embargo, es complicado estimar la ingesta de sodio y se necesitan nuevas alternativas para evaluarla. En este examen se describe el diseño y la creación de una herramienta en línea y de acceso público con el fin de establecer la ingesta de sodio en la alimentación (denominada la "calculadora de sodio") para la población de México. La herramienta, consistente en 71 preguntas, incluye los datos de sodio correspondientes al 2017-2018 de 3 429 alimentos envasados, 655 alimentos de restaurantes y cafeterías y 320 comidas caseras y alimentos de puestos de venta de la calle (determinados mediante análisis químicos). Se hizo una prueba piloto con diez nutricionistas que aportaron su opinión experta en materia de validez del contenido y diseño, además de 30 usuarios potenciales que probaron la facilidad de uso y su interfaz. Tras la prueba piloto, se incluyeron mejoras de contenido, idioma y formato. En el futuro se podrá determinar su valor predictivo. La calculadora de sodio ofrece una evaluación instantánea sobre la ingesta de sodio promedio diaria de una persona, calculada según la frecuencia de la ingesta, la cantidad promedio de raciones y el contenido de sodio por ración de cada categoría de alimentos con sodio. Esta es la primera herramienta en línea de detección de sodio en los alimentos creada para la población general de México. Es una manera eficaz y práctica de evaluar la ingesta de sodio, y puede servir de modelo para herramientas similares en otros países y regiones.

A ingestão de sódio em excesso está associada a efeitos adversos à saúde, e a redução do consumo alimentar de sódio é uma estratégia que contribui para a melhoria da saúde das pessoas. Porém, como é difícil estimar a ingestão de sódio, são necessários novos métodos de avaliação. Neste estudo são apresentados o projeto e o desenvolvimento de um instrumento on-line e aberto ao público (denominado ''calculadora de sódio'') para a triagem da ingestão alimentar de sódio por indivíduos no México. O instrumento contém 71 perguntas preparadas com base em dados do teor de sódio, coletados no período de 2017 a 2018, de 3.429 alimentos embalados, 655 alimentos comercializados em restaurantes e lanchonetes e 320 refeições do tipo caseiro e comidas de rua (medidos com análises químicas). Um teste-piloto foi realizado com 10 especialistas em nutrição, que fizeram observações sobre a validade de conteúdo e a validade aparente do instrumento, e 30 possíveis usuários que avaliaram sua usabilidade e interface. O conteúdo, os enunciados e o formato foram aperfeiçoados após o teste-piloto. A validade preditiva do instrumento será determinada futuramente. A ''calculadora de sódio'' proporciona uma avaliação imediata da ingestão alimentar média de sódio de uma pessoa, calculada pela frequência de consumo, número médio de porções e teor de sódio por porção de cada categoria de alimento que contém sódio. Este é o primeiro instrumento on-line para a triagem de sódio alimentar desenvolvido para a população do México. É um recurso eficiente e prático para avaliar a ingestão de sódio e pode servir de modelo para o desenvolvimento de instrumentos semelhantes em outros países e regiões.

The Impact of Additives on the Phosphorus, Potassium, and Sodium Content of Commonly Consumed Meat, Poultry, and Fish Products Among Patients With Chronic Kidney Disease.

OBJECTIVE: Patients with chronic kidney disease (CKD) are advised to limit their dietary intake of phosphorus and potassium as hyperphosphatemia and hyperkalemia are both associated with an increased risk of mortality. There is uncertainty concerning the actual content of these minerals in the Canadian food supply, as phosphorus and potassium are increasingly being used as food additives. This study aimed to determine the impact of food additives on the chemically analyzed content of phosphorus, potassium, sodium, and protein in commonly consumed meat, poultry, and fish products (MPFs). DESIGN: Foods representing commonly consumed MPF identified by a food frequency questionnaire in dialysis patients were purchased from three major grocery store chains in Canada. MPF with and without phosphorus and potassium additives listed on their ingredient list (n = 76) as well as reference MPF that was additive free (n = 15) were chemically analyzed for phosphorus, potassium, sodium, and protein content according to Association of Analytical Community official methods. RESULTS: Phosphorus, potassium, and sodium additives were present on the ingredient list in 37%, 9%, and 72% of MPF, respectively. Among MPF categories that contained a phosphorus additive, phosphorus content was significantly (P < .05) higher in MPF with phosphorus additives versus MPF without phosphorus additives and MPF reference foods (median [min, max]): (270 [140, 500] mg/100 g) versus (200 [130, 510] mg/100 g) versus (210 [100, 260] mg/100 g), respectively. Among MPF categories containing a potassium additive, foods listing a potassium additive had significantly more (P < .05) potassium than foods that did not list potassium additives and reference foods (900 [750, 1100] mg/100 g) versus (325 [260, 470] mg/100 g) versus (420 [270, 450] mg/100 g). CONCLUSIONS: The use of additives in packaged MPF products as indicated by the ingredient list can significantly contribute to the dietary phosphorus and potassium loads in patients with CKD. Patients with CKD should be educated to avoid MPF foods listing phosphorus and/or potassium additives on the ingredient list, which may lead to improved dietary adherence.

Estimates of Dietary Sodium Consumption in Patients With Chronic Heart Failure.

Estimating dietary sodium intake is a key component of dietary assessment in the clinical setting of HF to effectively implement appropriate dietary interventions for sodium reduction and monitor adherence to the dietary treatment. In a research setting, assessment of sodium intake is crucial to an essential methodology to evaluate outcomes after a dietary or behavioral intervention. Current available sodium intake assessment methods include 24-hour urine collection, spot urine collections, multiple day food records, food recalls, and food frequency questionnaires. However, these methods have inherent limitations that make assessment of sodium intake challenging, and the utility of traditional methods may be questionable for estimating sodium intake in patients with HF. Thus, there are remaining questions about how to best assess dietary sodium intake in this patient population, and there is a need to identify a reliable method to assess and monitor sodium intake in the research and clinical setting of HF. This paper provides a comprehensive review of the current methods for sodium intake assessment, addresses the challenges for its accurate evaluation, and highlights the relevance of applying the highest-quality measurement methods in the research setting to minimize the risk of biased data.

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.

Assessment of consumers' level of engagement in following recommendations for lowering sodium intake.

Population-wide sodium reduction strategies encourage consumer participation in lowering dietary sodium. This study aims to measure and rank consumers' level of engagement in following 23 recommendations to reduce dietary sodium and to compare variation in level of consumers' engagement by sociodemographic sub-groups. The study included 869 randomly selected participants of an online food panel survey from Ontario during November and December 2010. Rasch modelling was used for the analysis. Consumers were less likely to be engaged in 9 out of the 23 recommendations, in particular those related to avoiding foods higher in sodium and implementing sodium reduction strategies while eating in restaurants. Higher level of consumers' engagement was observed in relation to food preparation practices, including use of low sodium ingredients. In comparison to the relevant reference group, men, older individuals, with lower educational level, single, and those who do not prepare food from scratch showed an overall lower level of engagement in following recommendations to lowering dietary sodium, particularly related to avoiding processed foods. These data provide novel insights and can inform public education campaigns, and highlight the need for interventions and programs targeted at the food supply that can assist consumers in lowering their sodium intake.

The current state of evidence for sodium and fluid restriction in heart failure.

The field of heart failure has evolved in terms of the therapies that are available including pharmaceutical and device therapies. There is now substantial randomized trial data to indicate that dietary sodium restriction does not provide the reduction in clinical events with accepted heterogeneity in the clinical trial results. Dietary sodium restriction should be considered for some but not all patients and with different objectives than clinical outcomes but instead for potential quality of life benefit. In addition, fluid restriction, once the mainstay of clinical practice, has not shown to be of any additional benefit for patients in hospital or in the ambulatory care setting and therefore should be considered to be used cautiously (if at all) in clinical practice. Further developments and clinical trials are needed in this area to better identify patients who may benefit or have harm from these lower cost interventions and future research should focus on large scale, high quality, clinical trials rather than observational data to drive clinical practice.

Updating the Foodbot Factory serious game with new interactive engaging features and enhanced educational content.

Serious games (i.e., digital games designed for educational purposes) can foster positive learning attitudes and are increasingly used as educational tools. Foodbot Factory is a serious game application (app) that helps children learn about healthy eating based on Canada's Food Guide principles and has demonstrated to increase nutrition knowledge among this group. This paper describes the process followed to expand Foodbot Factory's educational content and integrate immersive technologies and innovative features into the app. The revision process, which was guided by the Obesity-Related Behavioral Intervention Trials model, included the following phases: first, an interdisciplinary team of nutrition scientists, education experts, and computer scientists analyzed data from the original pilot study, recently published literature, and feedback from stakeholders to define areas to improve Foodbot Factory. The five original Foodbot Factory modules were evaluated by the team during weekly meetings, where the educational content, interactive features, and other elements that required updates (e.g., aesthetics and accessibility) were identified. Second, prototypes were created and refined until a final version of Foodbot Factory was approved. Nineteen children tested the updated Foodbot Factory and found it "easy to use" (89%) and "fun" (95%). The new version of Foodbot Factory contains 19 learning objectives, including 13 original and six new objectives. Interactive engagement features in the updated Foodbot Factory included augmented reality incorporated into two learning modules; new mini-games were created, including a memory game; an overhaul of the aesthetics; (e.g., new food images); and accessibility features were included to support users with cognitive and vision disabilities.

An Examination of the Practice Approaches of Canadian Dietitians Who Counsel Higher-Weight Adults Using a Novel Framework: Emerging Data on Non-Weight-Focused Approaches.

Non-weight-focused approaches (NWFAs) may be used by some clinicians when working with higher-weight clients. In contrast to weight-focused approaches (WFAs), NWFAs de-emphasize or negate weight loss and emphasize overall diet quality and physical activity. The extent to which WFAs, NWFAs, or a combination of both WFAs and NWFAs are used by dietitians is unknown in Canada and globally. This study surveyed Canadian Registered Dietitians (RDs) who counsel higher-weight clients to assess which practice approaches are most commonly used, how they view the importance of weight, and how they define "obesity" for the study population. Five practice approaches were initially defined and used to inform the survey: solely weight-focused; moderately weight-focused; those who fluctuate between weight-focused/weight-inclusive approaches (e.g., used both approaches); weight inclusive and; weight liberated. Participants (n = 383; 94.8% women; 82.2% white) were recruited using social media and professional listservs. Overall, 45.4% of participants used NWFAs, 40.5% fluctuated between weight-focused/moderately weight-focused, and 14.1% used weight-focused approaches (solely weight focused and moderately weight focused). Many participants (63%) agreed that weight loss was not important for higher-weight clients. However, 81% of participants received no formal preparation in NWFAs during their education or training. More research is needed to understand NWFAs and to inform dietetic education in support of efforts to eliminate weight stigma and provide inclusive access to care.

Factors Impacting the Uptake of Research into Dietary Sodium Reduction Policies in Five Latin American Countries: A Qualitative Study.

Background: Diets high in sodium are a risk factor for cardiovascular disease (CVD). Latin American countries (LAC) consume more than double the recommended sodium levels. Research uptake in dietary sodium reduction policies has been inconsistent in LAC, and the factors impacting research uptake are largely unknown. This study aimed to describe the barriers and facilitators to the uptake of research into sodium reduction policies from a funded research consortium with 5 LAC (Argentina, Brazil, Costa Rica, Paraguay, and Peru). Methods: A qualitative case study included 5 researchers and 4 Ministry of Health officers from the funded consortium. Dimensions from Trostle's framework of actors, content, context, and process and relative advantages from the Diffusion of Innovation informed the semi-structured interview guide and analysis. One-on-one interviews were completed from November 2019 to January 2020. The participants validated transcripts, coded, and analyzed using NVivo software. Results: Key barriers to policy advancements included 1) conflicts of interest from the food industry and some government actors; 2) government turnover resulting in policy and personnel changes; 3) a lack of human and financial resources; and 4) and communication gaps among key actors. Key facilitators to policy advancement included: 1) the content and quality of health economic, food supply, and qualitative data; 2) support, technical assistance, and alliances with the government, non-governmental organizations, and international experts; and 3) researchers enhanced skillsets facilitated with communication and dissemination with policymakers. Conclusion: Researchers and policymakers are faced with several barriers and facilitators on research uptake in policies and programs in LAC; these factors should be addressed and leveraged to advance sodium reduction policy development. Future LAC studies can draw from the insights and lessons learned from this case study and apply the results to future efforts on policy nutrition to promote healthy eating and reduce CVD risk.

Patient perspectives on the use of mobile apps to support heart failure management: A qualitative descriptive study.

BACKGROUND: Adherence to diet and medical therapies are key to improving heart failure (HF) outcomes; however, nonadherence is common. While mobile apps may be a promising way to support patients with adherence via education and monitoring, HF patient perspectives regarding the use of apps for HF management in unknown. This data is critical for these tools to be successfully developed, implemented, and adopted to optimize adherence and improve HF outcomes. OBJECTIVE: To determine patients' needs, motivations, and challenges on the use of mobile apps to support HF management. METHODS: A qualitative descriptive study using focus groups (n = 4,60 minutes) was conducted among HF patients from outpatient HF clinics in Toronto, Canada. The Diffusion of Innovation theory informed a ten-question interview guide. Interview transcripts were independently coded by two researchers and analyzed using content analysis. RESULTS: Nineteen HF patients (65 ± 10 yrs, 12 men) identified a total of four key themes related to the use of mobile apps. The theme 'Factors impacting technology use by patients' identified motivations and challenges to app use, including access to credible information, easy and accessible user-interface. Three themes described patients' needs on the use of mobile apps to support HF management: 1) 'Providing patient support through access to information and self-monitoring', apps could provide education on HF-related content (e.g., diet, medication, symptoms); 2) 'Facilitating connection and communication', through information sharing with healthcare providers and connecting with other patients; 3) 'Patient preferences', app features such as reminders for medication, and visuals to show changes in HF symptoms were favoured. CONCLUSIONS: HF patients perceive several benefits and challenges to app use for HF self-management. Capitalizing on the benefits and addressing the challenges during the app development process may maximize adoption of such tools in this patient population.

Impact of mHealth Interventions on Supporting Dietary Adherence in Cardiovascular Disease: A Systematic Review.

INTRODUCTION: A systematic review was conducted to determine if mobile health (mHealth) interventions, and which intervention characteristics, effectively support dietary adherence and reduce risk factors in patients with cardiovascular disease (CVD). METHOD: Using 7 databases, studies involving adult participants with specific CVD diagnoses, mHealth intervention testing, and dietary adherence assessment were identified. Systematic reviews, qualitative studies, or studies testing interventions involving open dialogue between participants and health care providers or researchers were excluded. Two independent reviewers conducted screening and assessed the risk of bias. RESULTS: Thirteen studies involved participants with prehypertension (n = 1), hypertension (n = 9), coronary artery disease (n = 2), and heart failure (n = 1). mHealth interventions in 8 studies improved dietary adherence, 4 showed mixed results, and 1 showed no improvements. Eight studies found interactive text and/or application-based mHealth intervention features effectively improved dietary adherence. One study had a low risk of bias, 2 had some concerns/moderate risk, and 10 had a high/critical or serious risk. DISCUSSION: In most included studies, mHealth interventions positively impacted dietary adherence for patients with CVD. IMPLICATIONS FOR RESEARCH AND PRACTICE: Clinicians may recommend mHealth interventions to support nutrition education and self-management for their patients with CVD.

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.

The Content, Quality, and Behavior Change Techniques in Nutrition-Themed Mobile Apps for Children in Canada: App Review and Evaluation Study.

BACKGROUND: Children increasingly use mobile apps. Strategies to increase child engagement with apps include the use of gamification and images that incite fun and interaction, such as food. However, the foods and beverages that children are exposed to while using apps are unknown and may vary by app type. OBJECTIVE: The aim of this study is to identify the app content (ie, types of foods and beverages) included in nutrition-themed apps intended for children, to assess the use of game-like features, and to examine app characteristics such as overall quality and behavior change techniques (BCTs). METHODS: This analysis used a cross-sectional database of nutrition-themed apps intended for children (≤12 years), collected between May 2018 and June 2019 from the Apple App Store and Google Play Store (n=259). Apps were classified into four types: food games or nongames that included didactic nutrition guides, habit trackers, and other. Food and beverages were identified in apps and classified into 16 food categories, as recommended (8/16, 50%) and as not recommended (8/16, 50%) by dietary guidelines, and quantified by app type. Binomial logistic regression assessed whether game apps were associated with foods and beverages not recommended by guidelines. App quality, overall and by subscales, was determined using the Mobile App Rating Scale. The BCT Taxonomy was used to classify the different behavioral techniques that were identified in a subsample of apps (124/259, 47.9%). RESULTS: A total of 259 apps displayed a median of 6 (IQR 3) foods and beverages. Moreover, 62.5% (162/259) of apps were classified as food games, 27.4% (71/259) as didactic nutrition guides, 6.6% (17/259) as habit trackers, and 3.5% (9/259) as other. Most apps (198/259, 76.4%) displayed at least one food or beverage that was not recommended by the dietary guidelines. Food game apps were almost 3 times more likely to display food and beverages not recommended by the guidelines compared with nongame apps (ß=2.8; P<.001). The overall app quality was moderate, with a median Mobile App Rating Scale score of 3.6 (IQR 0.7). Functionality was the subscale with the highest score (median 4, IQR 0.3). Nutrition guides were more likely to be educational and contain informative content on healthy eating (score 3.7), compared with the other app types, although they also scored significantly lower in engagement (score 2.3). Most apps (105/124, 84.7%) displayed at least one BCT, with the most common BCT being information about health consequences. CONCLUSIONS: Findings suggest nutrition-themed apps intended for children displayed food and beverage content not recommended by dietary guidelines, with gaming apps more likely to display not recommended foods than their nongame counterparts. Many apps have a moderate app quality, and the use of consequences (instead of rewards) was the most common BCT.

A Program Evaluation of a Dietary Sodium Reduction Research Consortium of Five Low- and Middle-Income Countries in Latin America.

Excess dietary sodium is a global public health priority, particularly in low- and middle-income countries where rates of hypertension and cardiovascular disease are high. The International Development Research Centre funded a research consortium of five Latin American countries (LAC) to inform public health policy for dietary sodium reduction (2016-2020). The objective of this study was to determine the outcomes of this funding on short-term (e.g., research, capacity building) and intermediary outcomes (e.g., policies). A summative program evaluation was conducted, using a logic model and multiple data sources including document review, surveys and interviews. Researchers from Argentina, Costa Rica, Brazil, Peru and Paraguay produced a significant amount of scientific evidence to guide decision making on sodium policy related to its content in foods, consumer behaviors (social marketing), and the health and economic benefits of dietary reduction. A substantive number of knowledge translation products were produced. The funding enabled training opportunities for researchers who developed skills that can be scaled-up to other critical nutrients and health issues. It was unexpected that intermediary policy changes would occur, however several countries demonstrated early policy improvements derived from this research. A funded research consortium of LAC is a practical approach to invoke policy innovations.