Newly developed dietary assessment tools for lutein and zeaxanthin are correlated with 24-hour diet recalls, but are not a valid measure of intake in Australian and United Kingdom adults

Habitual dietary intake measurement of carotenoids lutein and zeaxanthin (L/Z) has often been omitted or attempted with tools of unknown validity in past research. It was hypothesized that the dietary assessment tool, the L/Z screener, developed as part of this study, would be valid with agreement within 0.25 mg/day when compared against multiple 24-hour diet recalls in healthy Australian and United Kingdom adults. Two screeners with 91 food items were developed, 1 with a recall timeframe of a month and the other a week. Over 4 weeks, 56 Australian and 47 United Kingdom participants completed 4 weekly screeners, 2 monthly screeners, and eight 24-hour diet recalls. Validity was assessed through Bland-Altman plot analysis. L/Z intake measured by all tools was significantly correlated, with correlation coefficients from 0.58 to 0.83. Despite these correlations, the screeners were not valid, with poor Bland-Altman plot agreement when compared with the diet recalls. The Australian weekly screener performed best, demonstrating a mean difference of 0.51 mg/day and 95% limits of agreement between -1.46 mg/day and 2.49 mg/day of L/Z intake. Baby spinach, broccoli, and pumpkin provided the greatest proportion of L/Z intake. The low validity may be explained by high rates of misestimation or missed capture of moderate to high L/Z containing foods such as baby spinach. Prior research reliant on correlational statistics for L/Z tool validity should be interpreted with caution, and future screener development should prioritize accurate capture of high contribution foods.

Assessing electronic device use behaviours in healthy adults: development and evaluation of a novel tool

BACKGROUND

Chronic exposure of the macula to blue light from electronic devices has been identified as a potential macular health concern. The impacts remain poorly investigated as no validated methods to capture usual device use behaviours exist.

PURPOSE

The aim of this study was to develop and validate the Electronic Device Use Questionnaire (EDUQ) against multiple 24-h electronic device use diaries in healthy Australian and United Kingdom adults.

METHODS

The EDUQ and diaries were developed to capture device use across categories (television, computer and handheld devices). Over eight weeks 56 Australian and 24 United Kingdom participants completed three questionnaires and eight diaries via online platforms. Tool validity was determined through Bland-Altman plot analysis of mean daily hours of device use between the tools.

RESULTS

The EDUQ demonstrated poor validity in both cohorts with poor agreement when compared with the diaries. When the device categories were combined, a mean difference between the tools of 1.54 h/day, and 95% limits of agreement between -2.72 h/day and 5.80 h/day was observed in the Australian cohort. Across both cohorts and all device categories the mean differences indicated individuals were more likely to report higher device use through the questionnaire rather than diaries.

CONCLUSIONS

The EDUQ is a novel tool and demonstrated the difficulty for participants of accurately recalling usual behaviour of device use. Poor agreement in reported device use occurred across all device categories. The poor agreement may be related to factors such as memory recall bias, and the number of diaries captured not being reflective of usual use. Future studies should look to address these factors to improve validity of device use capture.

The challenges facing residential aged care homes to participate in quality food and nutrition research

BACKGROUND

There is a clear need for food and nutrition research to lead to pragmatic and sustainable solutions to the ongoing problems in residential aged care, particularly within foodservices. The present study aimed to identify systemic challenges for residential aged care homes in Australia to participate in quality food and nutrition research, using a complexity science lens.

METHODS

Qualitative data from three studies in residential aged care were gathered, which included 28 participants across 21 aged care homes. Qualitative data consisted of in-depth interviews, field notes and email communications with aged care staff. Thematic analysis was undertaken using both inductive and deductive approaches.

RESULTS

Four themes were identified: (1) complex staffing issues deter or impede participation in research; (2) external pressure on the aged care system leads to research not being a priority; (3) funding issues are variable and pose a barrier for some aged care homes; and (4) research processes and requirements can lead to biased samples.

CONCLUSIONS

Several challenges to undertaking quality empirical research in residential aged care in Australia were identified. Research needs to be part of usual business, similar to hospitals, and operate independently of staffing and funding issues. Issues within foodservices are system issues and there is a need for quality empirical research to determine solutions.

Effect of supplements/intensive nutrition on pressure ulcer healing: a multicentre, randomised controlled study

OBJECTIVE

To investigate the effectiveness of an intensive nutrition intervention or use of wound healing supplements compared with standard nutritional care in pressure ulcer (PU) healing in hospitalised patients.

METHOD

Adult patients with a Stage II or greater PU and predicted length of stay (LOS) of at least seven days were eligible for inclusion in this pragmatic, multicentre, randomised controlled trial (RCT). Patients with a PU were randomised to receive either: standard nutritional care (n=46); intensive nutritional care delivered by a dietitian (n=42); or standard care plus provision of a wound healing nutritional formula (n=43). Relevant nutritional and PU parameters were collected at baseline and then weekly or until discharge.

RESULTS

Of the 546 patients screened, 131 were included in the study. Participant mean age was 66.1±16.9 years, 75 (57.2%) were male and 50 (38.5%) were malnourished at recruitment. Median length of stay was 14 (IQR: 7-25) days and 62 (46.7%) had ≥2 PUs at the time of recruitment. Median change from baseline to day 14 in PU area was -0.75cm² (IQR: -2.9_-0.03) and mean overall change in Pressure Ulcer Scale for Healing (PUSH) score was -2.9 (SD 3.2). Being in the nutrition intervention group was not a predictor of change in PUSH score, when adjusted for PU stage or location on recruitment (p=0.28); it was not a predictor of PU area at day 14, when adjusted for PU stage or area on recruitment (p=0.89) or PU stage and PUSH score on recruitment (p=0.91), nor a predictor of time to heal.

CONCLUSION

This study failed to confirm a significant positive impact on PU healing of use of an intensive nutrition intervention or wound healing supplements in hospitalised patients. Further research that focuses on practical mechanisms to meet protein and energy requirements is needed to guide practice.

An appraisal of trials investigating the effects on macular pigment optical density of lutein and zeaxanthin dietary interventions: a narrative review

Lutein and zeaxanthin (L/Z), xanthophylls obtained from the diet, are deposited in the macula of the eye. The macular concentration of L/Z is quantifiable as macular pigment optical density (MPOD). The aim of this review was to critically appraise the effect on MPOD of increasing L/Z intake by dietary intervention in adults. Pubmed, Cochrane Library, Web of Science, and Cinahl were searched up to April 2020. Ten studies investigating populations with and without age-related macular degeneration were included. MPOD increased significantly in 2 of the 8 controlled studies. Studies varied largely in the prescribed dietary L/Z dosage, duration, and participant characteristics. No relationships between types of dietary L/Z interventions and MPOD response could be determined. Limited monitoring of habitual dietary L/Z intake was identified as a major limitation of all 10 studies. Habitual dietary L/Z intake should be closely monitored in future studies to account for their effects on MPOD response to dietary L/Z interventions.

How well has part-time work on return from maternity leave been accepted in the workplace? Learnings from allied health professional managers in Queensland Health

Objective The aim of this study was to explore allied health professional (AHP) managers' implementation of the right to request part-time hours on return from maternity leave in Queensland Health (QH) hospitals. Methods Qualitative data were collected via interviews with AHP managers from a cross-section of professions with variations in workforce size and gender composition. Interviews were audio recorded, transcribed and analysed thematically. Results Twenty-one of a potential 40 AHP managers agreed to participate in the study (response rate 53%). The main finding was that the implementation of part-time work arrangements was being driven by regulation and work was being managed without complementary changes to established workplace practices or adequate organisational support. Conclusion The use of regulatory instruments to implement part-time work in organisations without complementary work redesign, change management and organisational support suggests that there are significant barriers to this type of flexible working arrangement (FWA) becoming accepted workplace practice for AHPs in QH. A whole-of-organisation approach is needed to make FWA a reality. What is known about the topic? Research has underlined the importance of implementation and management rather than simply the adoption of FWA policies. However, there have been few reports about AHP management of part-time hours on return from maternity leave. What does this paper add? This paper provides information specifically about the management response to part-time work entitlements for AHP in QH. It indicates that managers are implementing part-time work because it is a regulatory requirement, but often without a substantive commitment to FWA complementary redesign of services or sufficient organisational support. What are the implications for practitioners? Complementary work redesign measures and resources are needed to make workplaces genuinely flexible rather than just superficially consistent with regulatory requirements.

Allied health professionals in Queensland Health returning to work after maternity leave: hours of work and duration of time on part-time hours

Objective The aim of this study was to provide a detailed description of the flexible working arrangements (FWA) used by allied health professionals (AHP) on return from maternity leave. This is a crucial issue for staff management practices in a changing regulatory context. Methods A retrospective convenience sample of AHP employed by Queensland Health (QH) in 2006, using deidentified payroll data, was analysed descriptively to determine employment status on return from maternity leave in 2006 to December 2014. A qualitative study that surveyed managers of AHP departments was subsequently undertaken to complement the data from the payroll study. Twelve managers, across six allied health professions in three hospitals in south-east Queensland were surveyed for this component. Results The payroll study included 169 employees (138 full-time equivalent (FTE)), 61 of whom resigned over the study period. Of those who returned to work after the 2006 maternity event (n=152), 92% (n=140) initially returned part-time. At 31 December 2014, of the 108 staff working for QH, 77% (n=83) were part-time. In total, 75.4 FTE positions were released over the 8-year period through reduced working hours and resignations. The perceptions of surveyed managers were consistent with the data from the payroll study. Conclusion The study showed that most AHPs who took maternity leave returned to work part-time and remained part-time for an extended period. The data suggest that managers could permanently backfill a proportion of hours released due to FWA after maternity leave without major budgetary risk due to the need to accommodate existing employees' entitlements. However, this would require a significant policy change. What is known about this topic? Current research on this topic has concentrated on the benefits of paid maternity leave, timing of return to work and use of FWA by employees on return to work after maternity leave. What does this paper add? This paper presents the first comprehensive data on patterns of return to work and part-time hours following maternity leave for AHP employees. Access to a unique payroll dataset provided the opportunity to describe this for a cohort of AHP employees over a period of 8 years following a maternity event. A survey of AHP managers' experience with maternity leave and return to work arrangements supported the findings, underlining the associated difficulties with staff management. What are the implications for practitioners? The hours released through resignations or reduced hours over this period of study suggest that management could backfill a proportion of released hours permanently, or at least offer temporary staff longer-term contracts, once an employee returns from maternity leave on reduced hours.

Calculating the True Costs of Food Service in Long-Term Care: Development of a Costing Methodology

As population’s age and the need for long term care (LTC) increases, so too does the focus on the costs to provide that care. Providing food, oral nutrition supplements and meals, can be a considerable expense to a home. The objective of this research was to develop a valid foodservice costing tool (FCT), to calculate the real cost of providing foods and meals in LTC. Current costing methodologies are not specific to LTC and do not account for all costs of a foodservice, including staff, procurement and nutrition supplements. An initial tool was developed using the systems approach in conjunction with literature and professional knowledge. This was piloted in real world contexts, using volunteer LTC homes. Four iterations of the tool were completed to assess its feasibility in calculating costs and useability. Managers were interviewed after completing the tool to gather an understanding of how the tool was interpreted and to refine completion. Following feedback, the resulting tool consists of nine sections, measuring both costs incurred in meal production and service as well as analysis of staff workloads. Preliminary results show consistency between homes within Australia, indicating that the true cost is much higher than that reported in the literature to date. The development of a comprehensive, usable tool which captures the total cost of foodservice allows homes to accurately report and understand costs from a systems level. This information can be used to demonstrate cost effectiveness of a foodservice and the potential to justify and plan future system changes.

Implementation of the 'Healthier Drinks at Healthcare Facilities' strategy at a major tertiary children's hospital in Brisbane, Australia

OBJECTIVE

The World Health Organization recommends people reduce their free sugar consumption to <10% of daily energy intake. This study aimed to determine the viability of the 'Healthier Drinks at Healthcare Facilities' strategy to reduce the amount of free sugar available in beverages and influence consumer purchasing patterns.

METHODS

Beverage environment modifications at a children's hospital limited the availability of less healthy options. Using a convergent parallel mixed-methods design, sales data from retail food outlets (n=7) and vending machines (n=14) were collected from January 2017 to May 2018. Employees (n=105) and visitors (n=102) completed surveys, and retail food outlet managers (n=3) completed semi-structured interviews. Data were analysed via descriptive statistics, independent t-tests and content analysis.

RESULTS

The strategy decreased the availability of less healthy beverages and resulted in a significant increase in the proportion of 'green' (healthier) beverages sold (3%, p=0.002), and a decrease in the proportion of 'red' (less healthy) beverages sold (5%, p=0.011). Overall, sales did not change (p=0.243). The majority of participants supported the strategy.

CONCLUSIONS

Overall, a shift in consumer purchasing patterns resulted. Further modification of the beverage environment is encouraged to increase impact. Implications for public health: This strategy was feasible and acceptable in a healthcare setting.

Enhancing healthy eating patterns among Hong Kong young adults

Every year, the majority of Hong Kong young adults who graduate from secondary school progress onto tertiary education. Poor eating patterns among young adults could lead to long-term health implications associated with overweight and obesity. Using the socio-ecological model as a theoretical framework, this paper reviews the current food-related policies in Hong Kong and proposes a comprehensive policy approach relevant to a variety of organizational contexts that has the potential to support positive eating patterns among young adults by enhancing the local food environment. Hong Kong has an unusual food supply in that more than 95% of food is imported, making it vulnerable to food insecurity. Education interventions commonly conducted in Hong Kong are unlikely to be helpful because young adults acquire nutrition-related knowledge when they attend secondary school. There is a need to change the food environment in Hong Kong so that young adults can easily translate their nutrition knowledge into making healthy food choices. Policy approaches might be among the most effective strategies for bringing positive changes in eating patterns because they have the potential to directly influence the food environment and context where an individual lives. A comprehensive suite of approaches that fill the policy gaps, remove barriers of healthy food consumption and create more healthy food choices is required to improve diet and health.

Malnutrition, poor food intake, and adverse healthcare outcomes in non-critically ill obese acute care hospital patients

BACKGROUND & AIMS

Obesity, defined as a BMI ≥ 30 kg/m², has demonstrated protective associations with mortality in some diseases. However, recent evidence demonstrates that poor nutritional status in critically ill obese patients confounds this relationship. The purpose of this paper is to evaluate if poor nutritional status, poor food intake and adverse health-related outcomes have a demonstrated association in non-critically ill obese acute care hospital patients.

METHODS

This is a secondary analysis of the Australasian Nutrition Care Day Survey dataset (N = 3122), a prospective cohort study conducted in hospitals from Australia and New Zealand in 2010. At baseline, hospital dietitians recorded participants' BMI, evaluated nutritional status using Subjective Global Assessment (SGA), and recorded 24-h food intake (as 0%, 25%, 50%, 75%, and 100% of the offered food). Post-three months, participants' length of stay (LOS), readmissions, and in-hospital mortality data were collected. Bivariate and regression analyses were conducted to investigate if there were an association between BMI, nutritional status, poor food intake, and health-related outcomes.

RESULTS

Of the 3122 participants, 2889 (93%) had eligible data. Obesity was prevalent in 26% of the cohort (n = 750; 75% females; 61 ± 15 years; 37 ± 7 kg/m²). Fourteen percent (n = 105) of the obese patients were malnourished. Over a quarter of the malnourished obese patients (N = 30/105, 28%) consumed ≤25% of the offered meals. Most malnourished obese patients (74/105, 70%) received standard diets without additional nutritional support. After controlling for confounders (age, disease type and severity), malnutrition and intake ≤25% of the offered meals independently trebled the odds of in-hospital mortality within 90 days of hospital admission in obese patients.

CONCLUSION

Although malnourished obese experienced significantly adverse health-related outcomes they were least likely to receive additional nutritional support. This study demonstrates that BMI alone cannot be used as a surrogate measure for nutritional status and warrants routine nutritional screening for all hospital patients, and subsequent nutritional assessment and support for malnourished patients.

Note: A 102 dB dynamic-range charge-sampling readout for ionizing particle/radiation detectors based on an application-specific integrated circuit (ASIC)

An original technique for the measurement of charge signals from ionizing particle/radiation detectors has been implemented in an application-specific integrated circuit form. The device performs linear measurements of the charge both within and beyond its output voltage swing. The device features an unprecedented spectroscopic dynamic range of 102 dB and is suitable for high-resolution ion and X-γ ray spectroscopy. We believe that this approach may change a widespread paradigm according to which no high-resolution spectroscopy is possible when working close to or beyond the limit of the preamplifier's output voltage swing.

Impact of type, size and shape of plates on hospital patients' perceptions of the quality of meals and satisfaction with foodservices

Hospital meals are important for supporting nutrition goals and the overall hospital experience. The aim of this study was to assess if patients' perceptions of quality attributes of hot meals were impacted by the type of plate on which the meal was served. Eligible patients selected from medical and/or surgical wards at a 929 bed acute care hospital were randomised to receive hot meals served on either ceramic or disposable plates at eight evening meals. Patients from a multi-centre trial of pre-packaged meals where re-thermalised meals were presented on a variety of colour and shaped disposable plates were included in a second phase. Patient assessment of meal quality was undertaken using the Meal Assessment Tool (MAT)(Hannan-Jones & Capra, 2017) with data collected by interview. In phase one, 137 eligible patients competed the MAT (response 46.8%), with results showing no significant difference in the rating of appearance, quality, expectations or satisfaction when meals were served on disposable or ceramic plates. In phase two data were collected from 6189 patients (response 47.4%). No practical difference in rating of meals was found in relation to colour and sectioning of plates, however a statistical but non-practical difference was found regarding plate shape, with meals served on oblong/rectangular plates rated more positively. Of 3078 comments made concerning the meals, 99 (3.2%) concerned the plates on which the meals were served. This study has shown that quality, appearance and taste of meals, rather than the serving ware are important to patients. Findings suggest that attending to other quality aspects of meals may be far more important than the plate itself, and deserve attention.

Development of advanced practice competency standards for dietetics in Australia

AIM

This study aimed to explore the work roles, major tasks and core activities of advanced practice dietitians in Australia to define the Competency Standards for advanced practice.

METHODS

A qualitative approach was used to review advanced dietetic practice in Australia involving experienced professionals, mostly dietitians. Four focus groups were conducted with a total of 17 participants and an average of 20 years experience: 15 dietitian practitioners plus 2 employers (1 dietitian and 1 non-dietitian). The focus groups explored the key purpose, roles and outcomes of these practitioners. Data from the focus groups were confirmed with in-depth interviews about their core activities with a purposive sample of 10 individuals recently recognised as Advanced Accredited Practising Dietitians. Data from both focus groups and interviews were analysed adductively to identify key themes.

RESULTS

The key theme that emerged to define advanced dietetics practice was leadership, with four subthemes that described in more detail the major work roles and outcomes of advanced practice. These subthemes identified that advanced practitioners were (i) outcome-focused, having impact; (ii) influence others and advocate; (iii) innovate and embrace change; and (iv) inspire others and are recognised for their practice. These outcomes were conceptualised within a broad generalist framework to generate revised Competency Standards.

CONCLUSIONS

This study confirmed that leadership rather than specialist practice skills is the key determinant of advanced practice.

Are nutrition messages lost in transmission? Assessing the quality and consistency of diabetes guideline recommendations on the delivery of nutrition therapy

AIM

To provide an overview of (1) the consistency of Type 2 Diabetes Clinical Practice Guidelines recommendations on the delivery of nutrition therapy and (2) Clinical Practice Guideline quality.

METHODS

Large international clinical practice guideline repositories, diabetes organisation websites, and electronic databases (Pubmed, Scopus), were searched to identify Clinical Practice Guidelines for adults with type 2 diabetes published 2005 to August 2014. Recommendations on the delivery of nutrition therapy were extracted and inductive content analysis was used to analyse consistency. Two researchers independently assessed guideline quality using the AGREE II tool.

RESULTS

Nine topics were identified from the recommendations. Overall the consistency of the recommendations was related to guideline type. Compared with nutrition-specific guidelines, the broad ones had a broader focus and included more patient-focused recommendations. The ten Clinical Practice Guidelines assessed included six broad guidelines and four nutrition specific guidelines. Based on AGREE II analysis, the broad guidelines were higher quality than nutrition-specific ones.

CONCLUSIONS

Broad Clinical Practice Guidelines were higher quality and included more patient-focused recommendations than nutrition-specific ones.

PRACTICE IMPLICATIONS

Our findings suggest a need for nutrition-specific guidelines to be modified to include greater patient-focus, or for practitioners delivering nutrition therapy to adopt broad Clinical Practice Guidelines.

Food Skills of People with a Chronic Mental Illness: The Need for Intervention

This study quantified the food skills of people with a mental illness living in hospital-based care and the community using the Functional Needs Assessment — Nutritional Management Program (Dombrowski 1990). There were clear and marked food skills deficits among people living in hospital-based care. There were no significant differences between the food skills of male and female participants. The deficits that were identified may place patients at nutritional risk if they are moved into community accommodation without appropriate support mechanisms for the provision of food. Recommendations are made for intervention through the implementation of food skills training and incidental learning.

Developing a valid meal assessment tool for hospital patients

Patients' perspectives of meal items are critical in supporting effective decisions about meal provision in hospitals. The objective of this research was to develop a valid meal assessment tool (MAT), to quickly and accurately assess patient's views on meal items, for ultimate use in a large multi-centre trial. Nine iterations of the meal assessment tool were tested for content and construct validity in a large acute care hospital to determine wording, number scale and physical orientation for responses. Patients were interviewed to assess content validity, ease of completion, timing and assistance requirement. Following expert feedback, the resulting tool consisted of a 7 point scale measuring three meal components (meat, starch and vegetable), with ratings for flavour and taste combined, appearance and quality. Measures of overall satisfaction, meal expectation, age and gender were included for direct comparability with the valid published Acute Care Hospital Foodservice Patient Satisfaction Questionnaire (ACHFPSQ). Three hundred and four surveys were completed in the development process (77% response), 53% male, mean age 56 years. Best completion rates were by interview with completion times of 2-5 min. The tool was then made available in a large multi-centre meal assessment project (n = 14,500) and was able to detect differences between variations of the same meal and between the same ingredient prepared in alternative ways. The MAT proved successful in discriminating meal components in terms of quality, taste and appearance and is useful for those planning and assessing meals in a variety of healthcare settings.

Nutritional Therapy for Cancer-Induced Weight Loss

Nutrition issues facing people with cancer are significant. The role of nutrition therapy is often assumed to be less important than pharmacologic interventions as outcomes are less clear in the literature. Especially important has been the focus on traditional outcomes such as morbidity and mortality rather than adopting a more patient-centered approach and including quality of life as a key outcome. There is a general failure to recognize weight loss early enough and to implement nutrition interventions, which are effective. The nutrition intervention should be composed of both a prescription and an implementation method. To achieve compliance, the nutrition therapy should be implemented in an aggressive manner. Data show that when compliance is achieved, outcomes in the form of improved quality of life and functional capacity can be achieved. For people with cancer and their care-givers, outcomes such as quality of life have meaning, and for patients with poor prognoses, this may hold more meaning than mortality and morbidity outcomes. Clinicians need to implement triage systems to identify patients for early intervention and focus on nutrient combinations. They need to be confident that with the right prescription and implementation, nutrition therapy can be successful and bring real benefit to patients with cancer.

Factors Influencing Changes in Eating Patterns Among Hong Kong Young Adults Transitioning to Tertiary Education

Transitioning to tertiary education is a significant life course event that has the potential to influence lifelong eating patterns. This study used a theoretic model developed from a life course perspective to examine factors influencing the change of food choices among 31 young adults in Hong Kong after they moved on to tertiary education. Qualitative analysis of transcripts based on the constant comparative method revealed that present life course experiences, especially increased autonomy, and social-environmental factors strongly influenced young adults' present food choices. A model was developed from life course theory and social-ecological theory to reflect the factors that led to change of food choices among participants. The model provides unique insights on food choices of the future adult population. It could also be used as a reference for the development of nutrition education interventions targeting tertiary students as they experience increased autonomy. In conclusion, food choices of young adults on transitioning to tertiary education are strongly influenced by increased autonomy and change of social and environmental factors.

A Framework to Assist Health Professionals in Recommending High-Quality Apps for Supporting Chronic Disease Self-Management: Illustrative Assessment of Type 2 Diabetes Apps

BACKGROUND

This paper presents an approach to assist health professionals in recommending high quality apps for supporting chronic disease self-management. Most app reviews focus on popularity, aesthetics, functionality, usability, and information quality. There is no doubt these factors are important in selecting trustworthy apps which are appealing to users, but behavioral theory may be also be useful in matching the apps to user needs.

OBJECTIVE

The framework developed aims to be methodologically sound, capable of selecting popular apps which include content covered by evidence-based programs, consistent with behavioral theory, as well as a patient-centered approach for matching apps to patients' individual needs.

METHODS

A single disease-type 2 diabetes-was selected to illustrate how the framework can be applied as this was deemed to represent the types of strategies used in many chronic diseases. A systematic approach based on behavioral theory and recommendations from best practice guidelines was developed for matching apps to patients' needs. In March 2014, a series of search strategies was used to identify top-rated iPhone and Android health apps, representing 29 topics from five categories of type 2 diabetes self-management strategies. The topics were chosen from published international guidelines for the management of diabetes. The senior author (KH) assessed the most popular apps found that addressed these topics using the Behavioral Theory Content Survey (BTS), which is based on traditional behavioral theory. A tool to assist decision making when using apps was developed and trialed with health professionals for ease of use and understanding.

RESULTS

A total of 14 apps were assessed representing all five topic categories of self-management. Total theoretical scores (BTS scores) were less than 50 on a 100-point scale for all apps. Each app scored less than 50% of the total possible BTS score for all four behavioral theories and for most of the 20 behavioral strategies; however, apps scored higher than 50% of the total possible BTS score for specific strategies related to their primary focus. Our findings suggest that the apps studied would be more effective when used in conjunction with therapy than as stand-alone apps. Apps were categorized according to topic and core intervention strategies. A framework for matching apps to identified patient needs was developed based on app categorization and principles of patient-centered care. The approach was well accepted and understood by a convenience sample of health practitioners.

CONCLUSIONS

The framework presented can be used by health practitioners to better match apps with client needs. Some apps incorporate highly interactive strategies of behavioral theory, and when used as an adjunct may increase patient participation and the effectiveness of therapy.

Nutritional status of patients with ataxia-telangiectasia: A case for early and ongoing nutrition support and intervention

AIM

Ataxia-telangiectasia (A-T) is a rare genomic syndrome resulting in severe disability. Chronic childhood disorders can profoundly influence growth and development. Nutrition-related issues in A-T are not well described, and there are no nutritional guidelines. This study investigated the nutrition-related characteristics and behaviours of Australian A-T patients attending a national clinic.

METHODS

A cross-sectional analysis of 13 A-T patients (nine females; aged: 4-23 years): nutritional status was assessed by anthropometric and body cell mass (BCM) calculations. Parents reported their child's diet history and physical and behavioural factors that affect nutrition including fatigue and need for assistance.

RESULTS

Ten (77%) had short stature (height for age z scores <-1), and seven (54%) were underweight for height (weight/height z scores <-1). Significant malnutrition (BCM z scores <-2) was detected in nine (69%) including the one adult who was severely malnourished. Malnutrition increased significantly with age (BCM for height z scores and age, r = -0.937, P < 0.001). Eight (62%) patients ate poorly compared with estimated energy requirement for weight. Poor diet quality was characterised by high fat and sugar choices. Parents reported significant nutritional barriers as chronic tiredness and the need for care giver assistance with meals.

CONCLUSIONS

This study confirms profound malnutrition in Australian A-T patients. Poor intakes and diet quality suggest the need for early nutrition intervention. Ongoing support for families and early discussions on tube feeding are required to address changing needs in childhood and likely nutritional decline into adulthood. A prospective study is required to assess feasibility and effectiveness of nutrition interventions in young people with A-T.

Developing and evaluating interventions that are applicable and relevant to inpatients and those who care for them; a multiphase, pragmatic action research approach

Background

Randomised controlled trials may be of limited use to evaluate the multidisciplinary and multimodal interventions required to effectively treat complex patients in routine clinical practice; pragmatic action research approaches may provide a suitable alternative.

Methods

A multiphase, pragmatic, action research based approach was developed to identify and overcome barriers to nutritional care in patients admitted to a metropolitan hospital hip-fracture unit.

Results

Four sequential action research cycles built upon baseline data including 614 acute hip-fracture inpatients and 30 purposefully sampled clinicians. Reports from Phase I identified barriers to nutrition screening and assessment. Phase II reported post-fracture protein-energy intakes and intake barriers. Phase III built on earlier results; an explanatory mixed-methods study expanded and explored additional barriers and facilitators to nutritional care. Subsequent changes to routine clinical practice were developed and implemented by the treating team between Phase III and IV. These were implemented as a new multidisciplinary, multimodal nutritional model of care. A quasi-experimental controlled, ‘before-and-after’ study was then used to compare the new model of care with an individualised nutritional care model. Engagement of the multidisciplinary team in a multiphase, pragmatic action research intervention doubled energy and protein intakes, tripled return home discharge rates, and effected a 75% reduction in nutritional deterioration during admission in a reflective cohort of hip-fracture inpatients.

Conclusions

This approach allowed research to be conducted as part of routine clinical practice, captured a more representative patient cohort than previously reported studies, and facilitated exploration of barriers and engagement of the multidisciplinary healthcare workers to identify and implement practical solutions. This study demonstrates substantially different findings to those previously reported, and is the first to demonstrate that multidisciplinary, multimodal nutrition care reduces intake barriers, delivers a higher proportional increase in protein and energy intake compared with baseline than other published intervention studies, and improves patient outcomes when compared with individualised nutrition care. The findings are considered highly relevant to clinical practice and have high translation validity. The authors strongly encourage the development of similar study designs to investigate complex health problems in elderly, multi-morbid patient populations as a way to evaluate and change clinical practice.

Muscle function and omega-3 fatty acids in the prediction of lean body mass after breast cancer treatment

Background

Decreased lean body mass (LBM) is common in breast cancer survivors yet currently there is a lack of information regarding the determinants of LBM after treatment, in particular, the effect of physical activity and dietary factors, such as long-chain omega-3 fatty acids (LCn-3) on LBM and LBM function. This cross-sectional study explored associations of LBM and function with LCn-3 intake, dietary intake, inflammation, quality of life (QOL) and physical fitness in breast cancer survivors to improve clinical considerations when addressing body composition change.

Methods

Forty-nine women who had completed treatment (surgery, radiation and/or chemotherapy) were assessed for body composition (BODPOD), LCn-3 content of erythrocytes, C-reactive protein (CRP), QOL, dietary intake, objective physical activity, 1-min push-ups, 1-min sit-stand, sub-maximal treadmill (TM) test, and handgrip strength.

Results

After adjustment for age, LBM was associated with push-ups (r = 0.343, p = 0.000), stage reached on treadmill (StageTM) (r = 0.302, 0.001), % time spent ≥ moderate activity (Mod + Vig) (r = 0.228, p = 0.024). No associations were seen between anthropometric values and any treatment, diagnostic and demographical variables. Body mass, push-ups and StageTM accounted for 76.4% of the variability in LBM (adjusted r-square: 0.764, p = 0.000). After adjustment docosahexanoic acid (DHA) was positively associated with push-ups (β=0.399, p = 0.001), eicosapentanoic acid (EPA) was negatively associated with squats (r = −0.268, p = 0.041), with no other significant interactions found between LCn-3 and physical activity for LBM or LBM function.

Conclusion

This is the first investigation to report that a higher weight adjusted LBM is associated with higher estimated aerobic fitness and ability to perform push-ups in breast cancer survivors. Potential LCn-3 and physical activity interactions on LBM require further exploration.

An exploratory study to evaluate whether medical nutrition therapy can improve dietary intake in hospital patients who eat poorly

BACKGROUND

The Australasian Nutrition Care Day Survey (ANCDS) reported that two-fifths of patients consume ≤50% of the offered food in Australian and New Zealand hospitals. After controlling for confounders (nutritional status, age, disease type and severity), the ANCDS also established an independent association between poor food intake and increased in-hospital mortality. The present study aimed to evaluate whether medical nutrition therapy (MNT) could improve dietary intake in hospital patients eating poorly.

METHODS

An exploratory pilot study was conducted in the respiratory, neurology and orthopaedic wards of an Australian hospital. At baseline, percentage food intake (0%, 25%, 50%, 75% and 100%) was evaluated for each main meal and snack for a 24-h period in patients hospitalised for ≥2 days and not under dietetic review. Patients consuming ≤50% of offered meals as a result of nutrition-impact symptoms were referred to ward dietitians for MNT. Food intake was re-evaluated on the seventh day after recruitment (post-MNT).

RESULTS

One hundred and eighty-four patients were observed over 4 weeks; 32 patients were referred for MNT. Although baseline and post-MNT data for 20 participants [mean (SD) age 68 (17) years, 65% females] indicated a significant increase in median energy and protein intake post-MNT (3600 kJ day(-1) ; 40 g day(-1) ) versus baseline (2250 kJ day(-1) ; 25 g day(-1) ) (P < 0.05), the increased intake met only 50% of dietary requirements. Persistent nutrition impact symptoms affected intake.

CONCLUSIONS

In the present pilot study, although dietary intake improved, it remained inadequate to meet participants' estimated requirements as a result of ongoing nutrition-impact symptoms. Appropriate medical management and early enteral feeding could be a possible solution for such patients.

Determinants of foodservice satisfaction for patients in geriatrics/rehabilitation and residents in residential aged care

BACKGROUND

Poor satisfaction with institutional food is a significant moderator of food intake in geriatrics/rehabilitation and residential aged care.

PURPOSE

To quantify the relationship between foodservice satisfaction, foodservice characteristics, demographic and contextual variables in geriatrics/rehabilitation and residential aged care.

METHODS

The Resident Foodservice Satisfaction Questionnaire was administered to 103 patients of 2 geriatrics/rehabilitation units and 210 residents of nine residential aged care facilities in Brisbane, Australia. Ordered probit regression analysis measured the association of age, gender, ethnicity and appetite, timing and amount of meal choice, menu selectivity, menu cycle, production system, meal delivery system and therapeutic diets with foodservice satisfaction.

RESULTS

Patient and resident appetite (P < 0.01), the amount and timing of meal choice (P < 0.01), self-rated health (P < 0.01), accommodation style (P < 0.05) and age (P < 0.10) significantly moderated foodservice satisfaction. High protein/high energy therapeutic diets (P < 0.01), foodservice production (P < 0.01) and delivery systems (P > 0.01) were significant moderators for those with 'fair' self-rated health.

CONCLUSIONS

Patient and resident characteristics and structural and systems-related foodservice variables were more important for influencing foodservice satisfaction than characteristics of food quality. The results suggest modifications to current menu planning and foodservice delivery methods: reducing the time-lapse between meal choice and consumption, augmenting the number of meals at which choice is offered, and revising food production and delivery systems.It is important that residents in poorer health who are a high risk of under-nutrition are provided with sufficient high protein/high energy therapeutic diets. Diets that restrict macro- and micro-nutrients should be minimized for all patients and residents.

The malnutrition screening tool versus objective measures to detect malnutrition in hip fracture

BACKGROUND

The Malnutrition Screening Tool (MST) is the most commonly used screening tool in Australia. Poor screening tool sensitivity may lead to an under-diagnosis of malnutrition, with potential patient and economic ramifications. The present study aimed to determine whether the MST or anthropometric parameters adequately detect malnutrition in patients who were admitted to a hip fracture unit.

METHODS

Data were analysed for a prospective convenience sample (n = 100). MST screening was independently undertaken by nursing staff and a nutrition assistant. Mid upper arm circumference (MUAC) was measured by a trained nutrition assistant. Nutritional risk [MST score ≥ 2, body mass index (BMI) < 22 kg m(-2) , or MUAC < 25 cm] was compared with malnutrition diagnosed by accredited practicing dietitians using International Classification of Diseases version 10-Australian Modification (ICD10-AM) coding criteria.

RESULTS

Malnutrition prevalence was 37.5% using ICD10-AM criteria. Delirium, dementia or preadmission cognitive impairment was present in 65% of patients. The BMI as a nutrition risk screen was the most valid predictor of malnutrition (sensitivity 75%; specificity 93%; positive predictive value 73%; negative predictive value 84%). Nursing MST screening was the least valid (sensitivity 73%; specificity 55%; positive predictive value 50%; negative predictive value 77%). There was only fair agreement between nursing and nutrition assistant screening using the MST (κ = 0.28).

CONCLUSIONS

In this population with a high prevalence of delirium and dementia, further investigation is warranted into the performance of nutrition screening tools and anthropometric parameters such as BMI. All tools failed to predict a considerable number of patients with malnutrition. This may result in the under-diagnosis and treatment of malnutrition, leading to case-mix funding losses.

Barriers to nutritional intake in patients with acute hip fracture: time to treat malnutrition as a disease and food as a medicine?

Inadequate energy and protein intake leads to malnutrition; a clinical disease not without consequence post acute hip fracture. Data detailing malnutrition prevalence, incidence, and intake adequacy varies widely in this patient population. The limited success of reported interventional strategies may result from poorly defined diagnostic criteria, failure to address root causes of inadequate intake, or errors associated with selection bias. This pragmatic study used a sequential, explanatory mixed methods design to identify malnutrition aetiology, prevalence, incidence, intake adequacy, and barriers to intake in a representative sample of 44 acute hip fracture patients (73% female; mean age, 81.7 ± 10.8 years). On admission, malnutrition prevalence was 52.2%. Energy and protein requirements were only met twice in 58 weighed 24 h food records. Mean daily patient energy intake was 2957 kJ (50.9 ± 36.1 kJ·kg–1) and mean protein intake was 22.8 g (0.6 ± 0.46 g·kg–1). This contributed to a further in-patient malnutrition incidence of 11%. Barriers to intake included patient perceptions that malnutrition and (or) inadequate intake were not a problem, as well as patient and clinician perceptions that treatment for malnutrition was not a priority. Malnutrition needs to be treated as a disease not without consequence, and food should be considered as a medicine after acute hip fracture.

Omega-3 fatty acids and changes in LBM: alone or in synergy for better muscle health?

Myopenia or muscle wasting due to ageing, chronic disease, and various medical interventions has been associated with increased mortality, morbidity, and poorer physical function. Attempts through nutrient and exercise interventions have been made to prevent this deterioration. In addition, while a measure of lean body mass (LBM) is associated with health outcomes, LBM function may be a better prognostic tool. Long-chain omega-3 fatty acids (LCn-3s) are nutrients that may mitigate LBM losses in noncancer populations. The purpose of this review is to determine whether LCn-3s have a role in LBM sparing in noncancer populations, to establish a minimum dose and duration of LCn-3s that will result in LBM change, and to summarise the potential effects of LCn-3s on LBM function when combined with an anabolic stimulus. Overall, in noncancer populations, LCn-3s have limited utility in sparing LBM during energy balance, energy restriction, or in conjunction with aerobic exercise. Further investigations are required to determine the appropriate dose and duration of LCn-3s for optimal LBM function. Finally, compelling evidence exists for LCn-3s in conjunction with an anabolic stimulus to improve LBM function and quality. Functionality of LBM tissue is an important outcome for population health, and LCn-3s show some promise, albeit pending further study.

Are informal carers and community care workers effective in managing malnutrition in the older adult community? A systematic review of current evidence

BACKGROUND

Enhancing the effectiveness of the community and aged care workforce to prevent malnutrition and functional decline is important in reducing hospital and aged care facility demand.

OBJECTIVE

To investigate the impact of nutrition-related interventions delivered to or by informal carers and non-clinical community care workers on malnutrition-related health outcomes of community-dwelling older adults (≥65 years).

METHODS

Intervention studies were searched for using six electronic databases for English-language publications from January 1980 to 30 May 2012.

RESULTS

Nine studies were eligible for inclusion. The strength and quality of the evidence was moderate (six studies with level II intervention evidence, five with positive quality). Types of interventions used were highly varied. The majority of interventions were delivered to informal carers (6 studies), with three of these studies also involving older adult care recipients. Five interventions were targeted at identifying, preventing and/or treating malnutrition specifically (two positive quality, three neutral quality, n=2368). As a result of these interventions, nutritional status improved or stabilized (two positive quality, two neutral quality, n=2333). No study reported an improvement in functional status but two successfully prevented further decline in their participants (two neutral quality, n=1097).

CONCLUSION

Interventions targeted at identifying, preventing and/or treating malnutrition were able to improve or prevent decline in nutritional and functional status, without increasing informal carer burden. The findings of this review support the involvement of non-clinical community care workers and informal carers as part of the nutritional care team for community-dwelling older adults.

Developing dietetic positions in rural areas: what are the key lessons?

INTRODUCTION

Rural and remote communities in Australia are typically underserviced by dietitians. The recruitment of dietitians to rural areas has improved in recent years; however, retention remains an issue. Key factors that lead to an increase in funding and the development of more dietetic positions in rural areas are unknown. The purpose of this study was to describe dietetic services in rural areas and to determine the drivers for and barriers to the development of dietetic positions in rural areas.

METHODS

A sequential explanatory mixed methods approach was used to examine six case study sites of dietetic service delivery in rural northern New South Wales (NSW) Australia between 1991 and 2006. The six sites represented different models of dietetic service delivery from the study area. Data sources included workforce documents and in-depth individual interviews on position development with 40 key informants, including past and present dietitians, dietetic managers and health service managers. Interview data were thematically analysed with the aid of NVivo7 (www.qsrinternational.com). Themes were coded into common categories, using a constant comparison inductive approach.

RESULTS

Forty key informants agreed to participate in the in-depth, semi-structured interview. Participants included 28 dietitians (past and present), three dietetics managers and nine managers. The majority of participants were female (87.5%). Document analysis showed that the dietetic workforce had a 5.6-fold increase across the six sites over the 15 years. Themes that emerged from the interviews indicated that new positions were established through ad hoc and opportunistic funding, a gradual increase in funding or due to concerted efforts by champions advocating for increased funding.

CONCLUSION

The findings from this study have important implications for the development of dietetic staffing in rural areas. There is an inconsistent approach to the development of dietetic positions in rural areas of Australia. Factors that inhibited the development of positions included a general lack of funds and competing priorities. A systematic, planned approach to the development of dietetic positions is needed in rural Australia. Champions for the development of positions were effective in increasing positions, particularly when they have management support.

Nutrition advice in general practice: the role of general practitioners and practice nurses

General practice is an ideal setting to be providing nutrition advice; however, it is important that the role of general practitioners (GPs) and practice nurses in providing nutrition advice is acknowledged and defined. This article aims to discuss the role of GPs and practice nurses in the delivery of nutrition advice. Ten general practitioners and 12 practice nurses from a NSW urban Division of General Practice participated in questionnaires and a Lifescripts implementation study, as well as their consenting patients receiving Lifescripts (n=13). An online survey was conducted with 90 Australian private practice dietitians. Semi-structured telephone interviews were conducted with 52 Australian private practice dietitians. The provision of basic nutrition advice is acknowledged to be part of the role of GPs and practice nurses, as they are the first point of contact for patients, allowing them to raise nutrition awareness. However, it is important that this advice is evidence based and able to be delivered in a time-efficient manner. Increased nutrition education and the availability of appropriate resources and nutrition-related best practice guidelines will assist in this process.

Examination of the utility of the promoting action on research implementation in health services framework for implementation of evidence based practice in residential aged care settings

AIM

This study examined the relevance and fit of the PARiHS framework (Promoting Action on Research Implementation in Health Services) as an explanatory model for practice change in residential aged care.

BACKGROUND

Translation of research knowledge into routine practice is a complex matter in health and social care environments. Examination of the environment may identify factors likely to support and hinder practice change, inform strategy development, predict and explain successful uptake of new ways of working. Frameworks to enable this have been described but none has been tested in residential aged care.

METHODS

This paper reports preliminary qualitative analyses from the Encouraging Best Practice in Residential Aged Care Nutrition and Hydration project conducted in New South Wales in 2007-2009. We examined congruence with the PARiHS framework of factors staff described as influential for practice change during 29 digitally recorded and transcribed staff interviews and meetings at three facilities.

FINDINGS

Unique features of the setting were flagged, with facilities simultaneously filling the roles of residents' home, staff's workplace and businesses. Participants discussed many of the same characteristics identified by the PARiHS framework, but in addition temporal dimensions of practice change were flagged.

CONCLUSION

Overall factors described by staff as important for practice change in aged care settings showed good fit with those of the PARiHS framework. This framework can be recommended for use in this setting. Widespread adoption will enable cross-project and international synthesis of findings, a major step towards building a cumulative science of knowledge translation and practice change.

Foodservice satisfaction domains in geriatrics, rehabilitation and aged care

OBJECTIVE

To develop a foodservice satisfaction instrument for residential aged care and geriatric/rehabilitation units. The quality of care and food provided for clients in long-term care facilities is critical for the prevention of malnutrition.

DESIGN

Cross-sectional survey and in-depth interviews.

SETTING

Nine residential aged care facilities and two geriatric/rehabilitation units in Southeast Queensland, Australia.

PARTICIPANTS

A total of 103 geriatric/rehabilitation patients and 210 aged care residents. The median age was 84 years, with 72.1 % females.

MEASUREMENTS

Candidate satisfaction items were obtained from: (i) secondary analysis of acute care foodservice satisfaction data; (ii) focus groups with expert geriatrics/rehabilitation and aged care dietitians; (iii) pre-testing of instrument content, presentation format and response-scale (n=40) and (iv) pilot testing of the instrument (n=313). Sixty-one items on foodservice attributes, an overall satisfaction question, and demographic/contextual information were tested.

RESULTS

Principal components factor analysis and Velicer's MAP test revealed foodservice satisfaction was represented by 18 items within four factors: meal quality and enjoyment (α =0.91), autonomy (α =0.64), staff consideration (α =0.79), hunger and food quantity (α =0.67) and six independent items, totalling 24 foodservice characteristics. This represented around 40% of the variance in foodservice satisfaction. When a further 13 foodservice items were retained due to practical importance, the analysis explained around 64% of the variance in foodservice satisfaction.

CONCLUSION

The Resident Foodservice Satisfaction Questionnaire is a novel measure of resident foodservice satisfaction and can be used to provide evidence for changes to food services that may improve or enhance resident satisfaction and assist in the prevention of a significant and modifiable cause of malnutrition.