Ethnography in Nutrition and Dietetics Research: A Systematic Review

Enhancing or impeding? The influence of digital systems on interprofessional practice and person-centred care in nutrition care systems across rehabilitation units

AIMS

Digital health transformation may enhance or impede person-centred care and interprofessional practice, and thus the provision of high-quality rehabilitation and nutrition services. We aimed to understand how different elements and factors within existing digital nutrition and health systems in subacute rehabilitation units influence person-centred and/or interprofessional nutrition and mealtime care practices through the lens of complexity science.

METHODS

Our ethnographic study was completed through an interpretivist paradigm. Data were collected from observation and interviews with patients, support persons and staff. Overall, 58 h of ethnographic field work led to observing 125 participants and interviewing 77 participants, totalling 165 unique participants. We used reflexive thematic analysis to analyse the data with consideration of complexity science.

RESULTS

We developed four themes: (1) the interplay of local context and technology use in nutrition care systems; (2) digitalisation affects staff participation in nutrition and mealtime care; (3) embracing technology to support nutrition and food service flexibility; and (4) the (in)visibility of digitally enabled nutrition care systems.

CONCLUSIONS

While digital systems enhance the visibility and flexibility of nutrition care systems in some instances, they may also reduce the ability to customise nutrition and mealtime care and lead to siloing of nutrition-related activities. Our findings highlight that the introduction of digital systems alone may be insufficient to enable interprofessional practice and person-centred care within nutrition and mealtime care and thus should be accompanied by local processes and workflows to maximise digital potential.

East-Greenland traditional nutrition: a reanalysis of the Høygaard et al. nutritional data (1936-1937)

Greenlandic traditional nutrition was unique in the arctic environment. The aim of the present study was to reanalyse the Høygaard et al. data, focusing on two micronutrients object of discussion, i.e. Ca and vitamin C. Høygaard et al. left Copenhagen in August 1936 and stayed in East-Greenland until August 1937. The members of the expedition recorded nutritional intake whilst residing in families. However, the nutritional intake was analysed on a household level. In total, thirty-five adults and fourty-one children participated. Median total energy expenditure in kcal per d was estimated at 2978 and 2627 for male and female adults, respectively, and 1997 for children and adolescents. Median (IQR) energy consumption in kcal per d was 3881 (1568) for male and 2910 (882) for female adults. This was 2442 (857) and 2023 (1122) for male and female children and adolescents. Median (IQR) Ca intake in mg.d^-1 was 555 (1110) for male and 484 (883) for female adults. This was 458 (747) and 358 (838) for male and female children and adolescents. Median (IQR) vitamin C intake in mg.d^-1 was 79 (77) for male and 59 (56) for female adults. This was 44 (47) and 60 (52) for male and female children and adolescents. In this study, the importance of traditional foods in reaching an acceptable energy balance was emphasised, together with the confirmation of a low Ca intake in East-Greenland traditional dietary pattern, and the important role of algae consumption in Inuit traditional dietary pattern to avoid scurvy.

A qualitative exploration of ultra-processed foods consumption and eating out behaviours in an Indonesian urban food environment

Background: Increased consumption of ultra-processed foods and drinks high in unhealthy fats, salt and sugar is a major driver behind rising non-communicable disease rates in Asia-Pacific. Urban residence is considered a risk factor for increased consumption of these products; yet, evidence on consumption behaviours and drivers from urban populations in the region remains limited. Aim: To understand perceptions and drivers of unhealthy fats, salt and sugar foods and drinks consumption and eating out behaviours in Yogyakarta city, Indonesia. Methods: In-depth qualitative data were collected through open-ended interviews and prolonged interactions in the local food environment, from a purposeful sample (N = 45) equally distributed across three urban communities. Data were analysed according to the principles of content analysis and following an iterative approach. Results: Despite showing high nutritional health awareness, respondents and their household members consumed ultra-processed foods high in unhealthy fats, salt and sugar regularly. Home consumption of these products was based primarily on economic considerations and convenience, but also related to attending requests from other family members, individual preferences and tastes, and social functions. Similarly, despite a reported preference for home-cooked traditional foods, several participants or their family members would frequently eat ready-made meals away from home, due to conflicting school or work commitments. Discussion: Results suggest that public health interventions focused on nutrition education among Indonesian communities should be coupled with measures addressing urban food environment characteristics that promote the consumption of unhealthy diets, be tailored to specific age groups, and leverage traditional food cultures.

A Qualitative Study of Parental Perceptions of Baby Food Pouches: A Netnographic Analysis

Globally, a recent phenomenon in complementary feeding is the use of squeezable baby food pouches. However, some health agencies have raised concerns about their possible long-term health effects. The aim of this study was to describe parental perceptions of the use of baby food pouches during complementary feeding (i.e., the transition from an entirely milk-based diet to solid foods) using a netnographic analysis of discussions on publicly available forums. In this study, the community was parents of young children. Six parenting forums were identified through a Google search using defined selection criteria. Discussion threads relating to baby food pouches were collected and imported into NVivo12 for thematic analysis via inductive reasoning. Perceptions of baby food pouches fell within two broad categories—benefits and concerns. The most commonly reported themes related to benefits were: convenience, health, baby enjoys, variety, and cost; whereas the most common concerns reported were: health, cost, lack of dietary exposure, dependence, and waste. Many parents reported both benefits and concerns. Once research has determined the long-term effect of using pouches on infants’ health regarding eating habits, nutritional status, growth, and development, the findings of this study can inform educational strategies to either encourage or discourage their use.

Nutritional intake and foodservice satisfaction of adults receiving specialist inpatient mental health services

Aim

Meeting the nutritional needs and foodservice expectations of hospital inpatients is challenging. This study aimed to determine whether adults receiving specialist inpatient mental health services meet their energy and protein requirements and are satisfied with the foodservice.

Methods

An observational study of adults admitted to three specialist inpatient mental health services within a large health service. Energy and protein intake were determined over 24 h via observation, and nutritional requirements were estimated using standard procedures. Validated questionnaires were used to assess satisfaction with the lunch meal, elements of the foodservice system, and overall foodservice satisfaction.

Results

Among 74 participants, the median (IQR) energy intake (6954 [5111–10 250]kJ/day) was less than estimated requirements (8607 [7319–9951]kJ/day), whilst protein intake (85 [62–120]g/day) exceeded requirements (59 [46–70]g/day). Food from external sources was consumed by 50% of participants. Satisfaction surveys found vegetables were rated more poorly than the meat or carbohydrate portion of the meal, food quality was rated lowest compared with meal service, staffing and physical environment. The majority of participants (89%) rated their last meal as average, with the remainder (11%) rating it as poor.

Conclusion

There are opportunities to improve the meal and foodservice experience for this patient group to meet their nutritional requirements and expectations. Investment in quality food and menus that are appropriate for the demographics, exploration of the most appropriate foodservice system, and adequate dietetic resourcing are needed to improve nutrition care within specialist inpatient mental health services.

Expanding the limits of sex: a systematic review concerning food and nutrition in transgender populations

OBJECTIVE

To examine the literature and identify main themes, methods and results of studies concerning food and nutrition addressed in research on transgender populations.

DESIGN

A systematic review conducted through July 2020 in the MedLine/PubMed, Scopus and Web of Science databases.

RESULTS

Of the 778 studies identified in the databases, we selected thirty-seven. The studies were recent, most of them published after 2015, being produced in Global North countries. The most often used study design was cross-sectional; the least frequently used study design was ethnographic. Body image and weight control were predominant themes (n 25), followed by food and nutrition security (n 5), nutritional status (n 5), nutritional health assistance (n 1) and emic visions of healthy eating (n 1).

CONCLUSIONS

The transgender community presents body, food and nutritional relationships traversed by its unique gender experience, which challenges dietary and nutritional recommendations based on the traditional division by sex (male and female). We need to complete the lacking research and understand contexts in the Global South, strategically investing in exploratory-ethnographic research, to develop categories of analysis and recommendations that consider the transgender experience.

Subjective and objective nutritional assessment: nurses' role and the effect of cultural differences

BACKGROUND

Even though the nutritional assessment of chronically ill patients has a significant effect on outcomes, nurses' time constraints in clinical encounters may make the process impractical. Also, cultural background has an effect on nutritional assessment. Patient nutritional self-assessment can ease some of the nurses' workload.

OBJECTIVES

To compare tools for subjective and objective nutritional assessment and to examine cultural differences in nutritional assessment between Jews and Arabs living in Israel.

METHODS

The research design was cross-sectional; data were collected from Jews and Arabs with chronic illnesses living in the community during their visit to a public health clinic. The admitting nurse performed an objective nutritional assessment (Mini Nutritional Assessment (MNA)) after the patients completed the Subjective Nutritional Assessment (SANS). The data were analyzed using descriptive statistics, Pearson's correlation coefficients were calculated to test the relationships between the variables, and independent student t-tests were used to compare the means and differences between groups. The diagnostic accuracy of the MNA and of the SANS was determined using the area under the curve (AUC) analysis of receiver operating characteristic (ROC) curves. The agreement between the MNA and SANS measurements was estimated by a Bland Altman plot. The level of significance employed throughout the analysis was 0.05.

RESULTS

The sample was a convenience sample of 228 chronically ill patients, consisting of 121 Arabs and 107 Jews. A significant correlation was found between the subjective and objective nutritional assessments. The Bland-Altman plot demonstrated that the SANS and the MNA have a high level of agreement. Using the area under the curve (AUC) analysis of receiver operating characteristic (ROC) curves, showed an moderate diagnostic accuracy (73 % sensitivity and 30 % specificity).

CONCLUSIONS

Since the patient-completed nutritional assessment requires minimal time investment by nurses and we found a significant correlation and evidence for the accuracy and agreement of the objective and subjective assessments, further studies should assess and validate the possibility of replacing the objective nutritional assessment by the subjective assessment. Cultural background has a significant effect on patients' nutritional self-assessment; hence, culture should be considered as part of the nutritional assessment.

Dietary health perceptions and sources of nutritional knowledge in an urban food environment: a qualitative study from Indonesia

OBJECTIVE

To investigate dietary health understandings, healthy foods access perceptions and the main sources of nutritional knowledge of residents in three urban communities of varying socio-economic make-up.

DESIGN

An ethnographic approach to primary qualitative data collection, involving frequent visits to study areas over 4 months and in-depth interviews. Interviews were recorded, transcribed verbatim and analysed through an iterative approach.

SETTING

Yogyakarta, Indonesia.

PARTICIPANTS

A purposive sample of 45 participants divided equally among the 3 communities. Participants were mostly female (93 %), aged between 27 and 75 years (mean 47·7) and largely identified as the person responsible for household food-related decisions (93 %).

RESULTS

Three overarching themes emerged: (i) dietary health understandings; (ii) healthy foods access perceptions and (iii) sources of nutritional knowledge. Participants employed multifaceted conceptualisation of dietary health. Most identified healthy foods with traditional plant-based foods, inexpensive and locally available from multiple sources. Thus, all participants perceived healthy foods as highly available in the local environment and most (80 %) as affordable. Reported affordability issues referred to specific foods (particularly animal source products) and were independent of income levels. Participants acquired nutritional knowledge from multiple sources, including many community-based initiatives. These were overall perceived as useful, but also as presenting some limitations.

CONCLUSIONS

The variety in dietary health understandings reported by study participants, and their high perceptions of healthy foods availability in the local environment reinforce the idea that individual- and food environment-level determinants of nutritional behaviours are highly contextual.

East-Greenland traditional nutrition: a reanalysis of the Inuit energy balance and the macronutrient consumption from the Høygaard nutritional data (1936-1937)

Greenlandic traditional nutrition was unique in the arctic environment because it was an almost exclusive meat dietary pattern. Høygaard et al. left Copenhagen in August 1936, and stayed in East Greenland until August 1937. The four members of the expedition resided in Tasisaq and visited eight settlements around where nutritional intake was recorded by residing in families. However, the nutritional intake was analysed on a household level. The aim of the present study is to reanalyse the Høygaard et al. data according to modern scientific standards.

In total, 21 males and 14 females participated. Median (IQR) energy consumption was 3881 (1568) kcal.day⁻¹ for males and 2910 (882) kcal.day⁻¹ for females. Without the five participants living near trading centres, this was 3268 (219) kcal.day⁻¹ and 2634 (723) kcal.day⁻¹, respectively. Expressed in energy-percent, the macronutrient consumptions were 34% for protein, 37% for fat and 29% for carbohydrates. Without imported food, this was 41%, 49% and 10%, respectively.

The main findings of the present study are, as expected, that the food consumed came mainly from traditional hunting, was low in plant foods and extremely low in carbohydrates. The Inuit succeeded to stay in apparently healthy conditions with a traditional meat-based dietary pattern.

Maitjara Wangkanyi: Insights from an Ethnographic Study of Food Practices of Households in Remote Australian Aboriginal Communities

Many historical, environmental, socioeconomic, political, commercial, and geographic factors underscore the food insecurity and poor diet-related health experienced by Aboriginal people in Australia. Yet, there has been little exploration of Aboriginal food practices or perspectives on food choice recently. This study, with 13 households in remote communities on the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands, fills this gap using ethnographic and Indigenist methods. Results highlight Anangu resourcefulness, securing food despite poverty and adversity, and provide unique insights into factors influencing the three major types and range of dietary patterns identified. These factors include household economic cycles and budgeting challenges; overcrowding and family structures, mobility and ‘organization’; available food storage, preparation and cooking infrastructure; and familiarity and convenience. Structural and systemic reform, respecting Aboriginal leadership, is required to improve food security.

Assessing Cultural Intelligence and Study Abroad Experiences of Dietetics Students and Professionals

OBJECTIVE

To assess the relationship between study abroad participation and levels of cultural intelligence (CQ) of dietetics students and professionals.

METHODS

Participants were recruited via e-mail to complete an online survey, which included the Cultural Intelligence Scale and an additional 21 items developed and partially validated by the researchers. A mixed-method analysis was used to examine relationships between CQ levels, study abroad program participation, and international travel experiences.

RESULTS

Participation in study abroad programs and international travel experiences were related to higher levels of CQ in metacognitive (P = 0.003; P < 0.001), cognitive (P = 0.001; P = 0.001), motivational (P < 0.001; P < 0.001), and behavioral (P = 0.02; P < 0.001) dimensions.

CONCLUSIONS AND IMPLICATIONS

Results suggest that participation in study abroad programs and international travel experiences may result in high CQ levels and may equip students and practicing dietitians with skills, knowledge, and resources for practicing in culturally diverse communities. Future experimental research implementing study abroad programs and international travel opportunities for this population may help determine how these experiences impact dietetics practice in the long term.

Hidden Realities of Infant Feeding: Systematic Review of Qualitative Findings from Parents

A growing, global conversation, regarding realities and challenges that parents experience today is ever-present. To understand recent parent's attitudes, beliefs, and perceptions regarding infant feeding, we sought to systematically identify and synthesize original qualitative research findings. Following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework, electronic databases were searched with a priori terms applied to title/abstract fields and limited to studies published in English from 2015 to 2019, inclusive. Study quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) checklist, and thematic analyses performed. Of 73 studies meeting inclusion criteria, four major themes emerged. (1) Breastfeeding is best for an infant; (2) Distinct attitudes, beliefs, and perceptions of mothers that breastfeed, and those that could not or chose not to breastfeed, are evident; (3) Infant feeding behaviors are influenced by the socio-cultural environment of the family, and (4) Parent's expectations of education and support addressing personal infant feeding choices from health care providers are not always met. This systematic review, guided by constructs within behavioral models and theories, provides updated findings to help inform the development of nutrition education curricula and public policy programs. Results can be applied within scale-up nutrition and behavioral education interventions that support parents during infant feeding.

Seaweed Secondary Metabolites with Beneficial Health Effects: An Overview of Successes in In Vivo Studies and Clinical Trials

Macroalgae are increasingly viewed as a source of secondary metabolites with great potential for the development of new drugs. In this development, in vitro studies are only the first step in a long process, while in vivo studies and clinical trials are the most revealing stages of the true potential and limitations that a given metabolite may have as a new drug. This literature review aims to give a critical overview of the secondary metabolites that reveal the most interesting results in these two steps. Phlorotannins show great pharmaceutical potential in in vivo models and, among the several examples, the anti-dyslipidemia activity of dieckol must be highlighted because it was more effective than lovastatin in an in vivo model. The IRLIIVLMPILMA tridecapeptide that exhibits an in vivo level of activity similar to the hypotensive clinical drug captopril should still be stressed, as well as griffithsin which showed such stunning results over a variety of animal models and which will probably move onto clinical trials soon. Regarding clinical trials, studies with pure algal metabolites are scarce, limited to those carried out with kahalalide F and fucoxanthin. The majority of clinical trials currently aim to ascertain the effect of algae consumption, as extracts or fractions, on obesity and diabetes.

Nutrition-Related Messages Shared Among the Online Transgender Community: A Netnography of YouTube Vloggers

Purpose: Nutrition care guidelines for the transgender population do not exist, despite significant nutrition-related clinical and psychosocial considerations. Social networking sites (SNSs) provide multidirectional communication and have expanded in popularity among transgender users as a resource for health information and support. The nature of the content shared among the online transgender community is unknown, but may suggest the nutrition-related areas that are of most importance to the transgender population. The objective of this qualitative netnography was to describe the food and nutrition messages shared among the transgender community using video blogs (vlogs) on the SNS, YouTube. Methods: Public vlogs were assessed using the constant comparative method. Pseudoquantitative methods were used to capture the prevalence of each subtheme; quotes were documented verbatim. Data were collected from transgender users' public vlogs (n=30) self-published on YouTube from 2013 to 2018. Results: Six major themes were generated from the data analysis. These included the following: functions of diet and exercise; diet and exercise philosophies; "how to" vlogs; advice for success; using dietary supplements; and effects of hormone therapy. Conclusions: Nutrition-related messages are widely shared among the online transgender community through YouTube. The identified themes reflect topics of interest and expressed needs of transgender individuals. SNSs provide health care providers with a platform to improve patient education and health literacy. Health care providers may actively engage in online discussions to build trust, answer questions, and provide a source of accurate and evidence-based information.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program

BACKGROUND

The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze.

OBJECTIVES

We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program.

METHODS

We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions.

RESULTS

Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions.

CONCLUSIONS

Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.