Digital disruption of dietetics: are we ready?

Digital health is transforming the delivery of health care around the world to meet the growing challenges presented by ageing populations with multiple chronic conditions. Digital health technologies can support the delivery of personalised nutrition care through the standardised Nutrition Care Process (NCP) by using personal data and technology-supported delivery modalities. The digital disruption of traditional dietetic services is occurring worldwide, supporting responsive and high-quality nutrition care. These disruptive technologies include integrated electronic and personal health records, mobile apps, wearables, artificial intelligence and machine learning, conversation agents, chatbots, and social robots. Here, we outline how digital health is disrupting the traditional model of nutrition care delivery and outline the potential for dietitians to not only embrace digital disruption, but also take ownership in shaping it, aiming to enhance patient care. An overview is provided of digital health concepts and disruptive technologies according to the four steps in the NCP: nutrition assessment, diagnosis, intervention, and monitoring and evaluation. It is imperative that dietitians stay abreast of these technological developments and be the leaders of the disruption, not simply subject to it. By doing so, dietitians now, as well as in the future, will maximise their impact and continue to champion evidence-based nutrition practice.

Development and psychometric testing of an inventory to measure patient-centred care in dietetic practice - dietitian version.

BACKGROUND: The lack of a valid instrument to measure patient-centred care (PCC) in dietetic practice makes it challenging to evaluate how patient-centred dietitians are. The present study aimed to develop and psychometrically test a dietitian-reported inventory to measure PCC in dietetic practice. METHODS: The inventory was compiled based on a literature review of existing validated scales that measured the dimensions of PCC. Next, the inventory was distributed as a cross-sectional survey to 180 Australian Accredited Practicing Dietitians who worked in primary care. Exploratory factor analysis was performed using principal factor analysis with Promax rotation. Cronbach's alpha (criteria ≥0.80), inter-item correlations and corrected item-total correlations (criteria 0.30-0.70) were computed to evaluate the internal consistency of each scale. RESULTS: Five factors were extracted accounting for 56.9% of the variance. Most variables had strong loadings on only one factor. Factors were labelled as: shared decision-making; holistic and individualised care; patient-dietitian communication; knowing the patient; and caring patient-dietitian relationships. Cronbach's alpha was 0.94 for the total inventory and ranged from 0.73 to 0.91 for the individual factors. Inter-item correlations and corrected item-total correlations mostly fell in the desired range. CONCLUSIONS: The present study offers a preliminary, conceptually grounded dietitian-reported inventory, which is the first instrument developed and tested to measure PCC in dietetic practice. These findings illustrate the underlying factor structure of the inventory and support the reliability of the scales. With further testing, this inventory may provide useful to clinicians and researchers working to better understand and improve dietetic practice.

Patients' perceptions and experiences of patient-centred care in dietetic consultations.

BACKGROUND: Patient-centred care (PCC) is essential to quality healthcare. However, there is a paucity of research on PCC in dietetics, particularly regarding patients' experiences and perspectives of PCC. We aimed to enhance our understanding of PCC in dietetics by exploring patients' perceptions and experiences of PCC in individual dietetic consultations. METHODS: The present study used qualitative methods, situated in a constructivist-interpretivist paradigm. Maximum variation purposive sampling was used to recruit English speaking adult participants who had participated in ≥1 dietetic consultations for nutrition care. Individual semi-structured interviews explored participants' perceptions and experiences of PCC in dietetic consultations. Data were analysed thematically. RESULTS: Eleven patients were interviewed between September and November 2016. Four overarching themes emerged: (i) fostering and maintaining caring relationships; (ii) delivering individualised care; (iii) enabling patient involvement; and (iv) taking control of one's own health. CONCLUSIONS: PCC is important to patients. Thus, there is opportunity for dietitians to enhance the care they provide by adopting patient-centred practices. As the first study of its kind, these findings can inform future dietetic practice, education and research by contributing patients' perspectives of PCC. By understanding patients' unique needs and preferences, dietitians can better align their practice with a patient-centred approach. Furthermore, these findings are useful for informing future dietetic research and education.

Promotion of nutrition care by Australian fitness businesses: a website analysis.

OBJECTIVES: To investigate the intention of fitness businesses to promote the provision of nutrition care from personal trainers. STUDY DESIGN: Cross-sectional evaluation of webpage content. METHODS: Fitness businesses within two Australian federal electorates were identified using the Fitness Australia list of registered fitness businesses. Inductive content analysis of these fitness business websites and associated social media sites was undertaken to compare website content to the Fitness Australia Position Statement outlining the Roles and Responsibilities of Registered Fitness Professionals. Fitness businesses were classified as 'within scope of practice' if they referred to national nutrition guidelines or dietetic services. 'At risk of being beyond scope' included websites which did not include enough information to definitively state within or beyond scope. Fitness businesses were classified as 'definitely beyond scope of practice' if they advertised nutrition care which clearly extended beyond translation of the national dietary guidelines. RESULTS: Of the businesses reviewed, 15% were within scope despite none referring to a dietitian; 34% were at risk of being beyond scope; and 51% were beyond scope as they advertised nutrition care such as personalized diets without indicating dietetic input. CONCLUSIONS: A considerable portion of fitness businesses reviewed advertised their personal trainers as able to provide nutrition care outside the recommended scope of practice. Strategies that help fitness businesses and personal trainers to support clients to have healthy dietary behaviours without extending outside the scope of practice are warranted.

Personal trainers are confident in their ability to provide nutrition care: a cross-sectional investigation.

OBJECTIVE: To measure the self-perceived competence of Australian personal trainers in providing nutrition care. STUDY DESIGN: Cross-sectional online survey. METHODS: A validated survey was used to measure confidence in the ability to provide nutrition care among a snowball sample of 142 Australian-based personal trainers. The survey used 5-point Likert scale statements across four nutrition related constructs: knowledge; skills; communication and counselling; and attitudes. Scores for each construct were averaged and summed to provide a self-reported nutrition competence score as a percentage. Pearson Chi-squared analyses were used to identify associations between demographic variables and competence scores, and associations between construct scores. RESULTS: Personal trainers felt confident to provide nutrition care for all clients (mean score 76%; 'very confident'). Greater confidence in nutrition knowledge was seen in personal trainers with greater experience (χ2 = 6.946, P = 0.008) and education higher than a certificate IV (χ2 = 5.079, P = 0.024). Greater confidence in nutrition knowledge was also associated with greater confidence in nutrition skills (χ2 = 49.67, P ≤ 0.001) and more favourable attitudes towards providing nutrition care (χ2 = 4.73, P = 0.03). CONCLUSIONS: Personal trainers feel confident in their ability and show favourable attitudes towards providing nutrition care to clients. This workforce has the potential to support lifestyle modification for chronic disease prevention.

Australian general practitioners' views regarding providing nutrition care: results of a national survey.

BACKGROUND: The prevalence of chronic disease is considerable, and dietary behaviours influence the progression of many chronic diseases. Practice guidelines recommend that general practitioners (GPs) promote healthy dietary behaviours in relevant consultations with patients in order to improve health outcomes at a population level. OBJECTIVE: To describe GPs' perceived interest, confidence and barriers to support patients to have a healthy diet. METHOD: A 24-item online and written survey was distributed in a national weekly newsletter to GPs in Australia. Results were descriptively analysed and investigated for associations with GPs' demographic characteristics. RESULTS: A total of 322 GPs responded to the survey. Nearly all (n = 295, 91.6%) were interested in supporting patients to eat well, and most (n = 231, 71.7%) reported moderately high confidence for providing nutrition care with clear public health messages for conditions, such as cardiovascular disease. Many GPs (n = 170, 52.8%) cited lack of time as the biggest barrier to providing nutrition care, and the overwhelming majority (n = 289, 89.8%) were interested in receiving additional education and training to enhance their nutrition knowledge and skills. DISCUSSION: Many GPs are interested in nutrition and would benefit from educational programmes that improve their competence to provide nutrition care. Professional development opportunities should focus on the identification of nutritional risk and the promotion of healthy dietary behaviours within the time constraints of a standard consultation.

Prelicensure evaluation of combination vaccines.

There is considerable public health interest in licensing safe and effective combination vaccines. Because combination vaccines may progress rapidly from phase 1 to a pivotal phase 2 immunogenicity trial, a rigorous approach to address product issues early in development is warranted. Clinical studies to evaluate the safety, immunogenicity, and (when necessary) clinical end point efficacy of combination vaccines should be randomized and well controlled in most cases. A large phase 3 safety study (i.e., a study that enrolls thousands of vaccinees) should be included in the development plan if a phase 3 (clinical end point) efficacy trial will not be conducted. Often, the new combination vaccine under development contains immunogens that have all been previously licensed, have demonstrated efficacy in earlier clinical trials, or both. For such products, comparative immunogenicity data may be sufficient to support efficacy. When applicable, clinical data to support simultaneous administration with other relevant vaccines should be obtained. Given the complexity of combination vaccine development, early consultation with United States Food and Drug Administration can be invaluable.

Current status and future trends in vaccine regulation--USA.

In regulating vaccines, the US Food and Drug Administration (FDA) is governed by the Code of Federal Regulations. These regulations serve as the framework for product characterization, as well as preclinical and clinical testing strategies. Novel vaccine approaches such as combination vaccines, vectored vaccines, new adjuvants, and novel delivery systems pose unique regulatory challenges for the FDA. If US licensure is sought, communication with the FDA throughout the clinical development of a product is essential to identify and implement the appropriate strategies for demonstrating the safety and effectiveness of a new product.

Light-mediated antifungal activity of Echinacea extracts.

This study demonstrated that plant extracts containing acetylenic isobutylamides and polyacetylenes, previously reported as occurring in Echinacea, have phototoxic antimicrobial activity against fungi, including clinically relevant pathogenic fungi. Results show that hexane extracts of Echinacea variably inhibit growth of yeast strains of Saccharomyces cerevisiae, Candida shehata, C. kefyr, C. albicans, C. steatulytica and C. tropicalis under near UV irradiation (phototoxicity) and to a lower extent without irradiation (conventional antifungal activity). The presence of polyacetylenes and alkylamides in extracts of different organs was confirmed in Echinacea purpurea by HPLC in agreement with previously reported data in the literature, and was related to phototoxic activity. Two representative pure compounds, undeca-2E,4Z-diene-8,10-diynoic acid isobutylamide and dodeca-2E,4E,8Z,10E/Z-tetraenoic acid isobutylamide, were isolated from Echinacea purpurea root extracts, and compared in a disk assay (5 micrograms/disk) with the highly conjugated trideca-1-ene-3,5,7,9,10-pentayne (previously isolated in our laboratory and found here in E. purpurea). Significant phototoxicity was demonstrated by pure trideca-1-ene-3,5,7,9,10-pentayne, while only minor phototoxicity was induced by the other two acetylenic compounds. Phototoxic activity of Echinacea spp. is primarily attributed to the ketoalkenes and ketoalkynes abundantly present in the roots.

Comparative and experimental pathology of fibrosing colonopathy.

Although the occurrence of fibrosing colonopathy is temporally associated with the introduction of high-strength pancreatic enzyme supplements, its pathogenesis remains uncertain. The UK case-control study showed fibrosing colonopathy to be associated with high doses of high-strength pancreatic enzyme supplements and with a group of brands which occupy only 30% of the market. Two alternative hypotheses were proposed to explain the aetiology of fibrosing colonopathy: exposure to high levels of enzymes or to as yet unidentified components of the formulation. Comparison of the anatomical pathology of fibrosing colonopathy with that of previously encountered forms of obstructive gastrointestinal pathology, such as stricturing lesions due to potassium chloride preparations and nonsteroidal anti-inflammatory drugs, confirmed it to be a previously unencountered, long-segment lesion of the colon. Thus the use of the descriptive term 'stricture' is a misnomer leading to much clinical confusion when discussing obstructive bowel pathology in cystic fibrosis patients. Gavage studies in the rat with one of the two monomers (ethyl acrylate) forming the methacrylic acid copolymer (Eudragit L30D55) used for the enteric coating of the high-strength pancreatic enzyme supplements, have shown pathology comparable to fibrosing colonopathy. These findings prompted a series of exploratory studies in adolescent pigs. After seven days caecal gavage of Eudragit L30D55 at doses of 10, 50 or 500 mg/kg/day (comparable to human intake), extensive fibrosing colonopathy-like changes, inclusive of dense submucosal fibrosis, were noted at all dose levels in seven out of nine animals. Similar studies of the monomer components of the Eudragit L30D55 copolymer, at dose levels of 0.015 to 50 mg/kg/day, representing possible residues in Eudragit L30D55, did not produce comparable changes. The conclusion is that, although the precise mechanisms have not been elucidated, the role of enteric coatings containing Eudragit L30D55 in the pathogenesis of fibrosing colonopathy requires urgent further study.

Development and testing of a bovine trichomoniasis vaccine.

Eighteen culled dairy cows were randomly allocated into 1 of 5 treatment groups. Six cows were vaccinated twice (2V), 21 days apart, 3 with whole cell (2WC) and 3 with fragmented cell membrane (2FC) containing 1 x 10(9)Trichomonas fetus organisms or protein equivalent in a commercial mineral oil adjuvant vaccine. Six more cows were vaccinated once (1V), 3 with whole cell (1WC) and 3 with fragmented cell vaccine (1FC), using the same vaccine, while 6 cows were used as the unvaccinated controls. All cows were challenged with 1 x 10(5) organisms 4 weeks after the second or the only vaccination. After challenge, cervico-vaginal mucus (CVM) samples were cultured for T . fetus weekly for 9 weeks. Whole cell vaccines were superior to fragmented cell vaccines, and both performed better than no vaccination for apparent elimination of trichomonad infections in dairy cows. In addition, 2V was superior to 1V, which, in turn, was superior to no vaccination. Furthermore, clearance time was reduced most by 2V and whole cell vaccination compared with 1V and fragmented cell vaccination. Clearance time was decreased significantly in all vaccinated cows compared with that in unvaccinated cows.

Susceptibility to ciprofloxacin of nosocomial gram-negative bacteria and staphylococci isolated in the UK.

At the end of 1989 the Division of Hospital Infection of the Central Public Health Laboratory completed five years of continuous surveillance of ciprofloxacin susceptibility amongst strains of Staphylococcus aureus and Pseudomonas aeruginosa. The strains studied were referred from many different UK laboratories for epidemiological or other typing. Between 1987 and 1989, referred cultures of coagulase-negative staphylococci, Klebsiella spp. and Enterobacter spp. were also examined. In total, 25,728 cultures from 254 different laboratories were included in the study, and S. aureus was the most common species amongst the survey material. Resistance to non-quinolone antimicrobials was common amongst the isolates. Over the study period there has been a gradual decline in the percentage of cultures received that were fully susceptible to ciprofloxacin and an increase in the number of laboratories referring strains with resistance or reduced sensitivity. Full susceptibility of S. aureus to ciprofloxacin has declined from 99.6% of 8981 cultures isolated in the two years before launch to 92.8% of 1968 cultures isolated during 1989. Amongst the coagulase-negative staphylococci there has been a similar decline in susceptibility from 99.4% of 658 cultures examined in 1987 to 92.6% of 433 cultures studied in 1989. There was also a decrease in susceptibility of P. aeruginosa isolates to ciprofloxacin from 98.6% of 2579 cultures isolated in 1985 and 1986 to 86.3% of 1152 cultures examined during 1989. Most of this decrease was attributable to the appearance of strains of intermediate susceptibility to ciprofloxacin (MICs 2 or 4 mg/l). Virtually no resistance to ciprofloxacin was observed amongst isolates of Klebsiella spp. and Enterobacter spp. referred between 1987 and 1989. The emergence of ciprofloxacin resistance, and by implication cross resistance to many of the other fluoroquinolones, is a worrying development and suggests that caution should be exerted in the use of these compounds for the treatment of infections due to staphylococci and P. aeruginosa.