Dietetic Care Research Articles

Dietitian-led clinics in primary care: a scoping review protocol.

This scoping review aims to examine and map the existing evidence exploring and/or evaluating the implementation, cost and/or effectiveness of dietitian-led clinics in primary care. Dietitians may be able to offer new models of care within the primary care setting for relevant diagnosed patients, providing cheaper, more efficient and effective service in comparison to the traditional approach of general practitioner support and referral for specialist treatment. There is some evidence for the efficacy of dietetic care in primary care, but there is a lack of information concerning the broader contribution dietitians may make, including cost effectiveness and the range of conditions that dietitians may successfully manage. Eligible studies will explore dietitian- or nutritionist-led clinics treating patients with any condition, and will be based in primary care or general practice settings in developed countries. Studies may include experimental, quasi-experimental, observational and qualitative studies. The searches will be limited to the past 10 years to ensure retrieved information will be relevant to today's healthcare setting. There will be no limit for language. The following databases will be searched: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), AMED (EBSCO), British Nursing Index (ProQuest), and Cochrane Database of Systematic Reviews (Wiley). Retrieved papers will be screened for inclusion by at least two reviewers. Where a decision is not possible, full text will be retrieved and reviewed. Data will be extracted from the included papers and a narrative summary will accompany the charted results and will describe how the results relate to the review's objective.

Towards a nationwide implementation of a standardized nutrition and dietetics terminology in clinical practice: a pre-implementation focus group study including a pretest and using the consolidated framework for implementation research

Background & AimsIn order to assure high quality of nutrition and dietetic care as well as research, the implementation of a standardized terminology, such as the World Health Organization (WHO) International Classification of Functioning, Disability and Health for Dietetics (ICF-Dietetics) is indispensable. The aim of this study was to explore the clinical practicability and applicability of the ICF-Dietetics in the field of nutrition and dietetic practice prior to the implementation in order to develop criteria (points to consider) for a targeted implementation strategy.MethodsA focus group study including a pretest of the ICF-Dietetics was conducted. Subsequently, facilitators and barriers for a nationwide implementation of the ICF-Dietetics in clinical nutrition and dietetic practice were identified and linked to interventions (combining theory-based and group-based approach) using the Consolidated Framework of Implementation Research (CFIR) to organize and represent data and summarized in a logic model.ResultsIn the pretest 55 clinical documentations which consisted of 248 different ICF-Dietetics categories were received. In four focus groups with 22 health professionals, 66 relevant higher-level themes and implementation strategy criteria (points to consider) were identified. These themes referred to all five domains of the CFIR, namely intervention characteristics, inner setting, outer setting, characteristics of individuals and implementation process and contained important barriers and facilitators that were linked to six implementation objectives as well as six context requirements and five main actors.ConclusionsThis study provides facilitators and barriers to be addressed when implementing the ICF-Dietetics in clinical practice and shows potential interventions based on this analysis. A nationwide implementation was mainly seen as a great advantage for enhancing quality and continuity of care and for providing comparable data. However, it requires further refinements and a multifaceted implementation strategy where the engagement of leadership of institutions plays a crucial role. These results have provided a foundation for a targeted implementation strategy to increase the success, reproducibility and comparability.

1785P - The patient voice: An Irish survey of nutrition attitudes & access to dietetic care throughout the cancer journey

BackgroundThe attitudes of cancer patients towards nutrition and nutrition care has never been captured in Ireland. An awareness of the nutritional needs and attitudes of cancer patients along with a review of their experiences would help inform service planning. MethodsIn September 2018, a national survey was conducted to examine patient attitudes towards nutrition and access to dietetic services during their cancer journey. Patients diagnosed or treated in Ireland since 2015 were asked to complete a 25-item survey (available online and at 20 hospitals across Ireland). ResultsIn total, 1085 valid responses were received (63% female, mean age 58 years). All major cancer groups were represented & 33% had metastatic disease. Overall, 45% reported suffering from a diet-related problem and 44% reported weight loss since diagnosis. Muscle loss was noted by 52%. Amongst weight losers, 42% were ‘unhappy/worried’ while 27% reported being ‘delighted/happy’. Although 80% are ‘always/usually’ weighed in clinic, just 43% reported that they are ‘always/usually’ asked about diet. Nutrition was rated ‘very/extremely’ important by 89% of respondents. Only 39% had received dietary advice from a dietitian and 74% rated this advice as ‘very/extremely’ helpful. Overall, 57% of those who did not see an RD said they would have liked more support with diet. While 58% reported trying general healthy eating as a result of their diagnosis, 38% and 32% admitted trying at least one alternative dietary strategy or avoiding a specific food due to their diagnosis, respectively. ConclusionsWhile nutrition is highly important to Irish cancer patients, fewer than half surveyed had accessed a dietitian. Weight and muscle loss are common, but their significance is not always understood by patients. Almost half used alternative dietary strategies, highlighting the need to screen oncology patients for potentially restrictive diet or supplement use to guide appropriate referrals and education. Legal entity responsible for the studyThe authors. FundingIrSPEN. DisclosureAll authors have declared no conflicts of interest.

Associations of dietetic management with maternal and neonatal health outcomes in women diagnosed with gestational diabetes: a retrospective cohort study.

In 2010, the recommended diagnostic thresholds for gestational diabetes mellitus (GDM) were amended, which has increased GDM diagnoses, as well as pressure on the services involved in GDM management, specifically impacting dietetic workloads. The present study examined the associations between dietetic intervention in women with GDM and maternal and neonatal health outcomes. The present study involved 1233 adult women with GDM who delivered at The Royal Women's Hospital (RWH), Melbourne, Australia, between July 2015 and May 2017. Retrospective data assessing GDM-care (therapy type, diagnosis time and model of care, maternal and neonatal health outcomes, and outpatient dietetic consultations) were retrieved from patient medical records. Unadjusted and adjusted linear and logistic regression were used to assess associations of GDM care dietetic intervention and GDM care and dietetic intervention with maternal and neonatal health outcomes. Women receiving dietetic intervention had a decreased likelihood of infant admission to the neonatal intensive care unit or special care nursery than women who not receiving dietetic intervention [adjusted odds ratio (OR)=0.41, 95% confidence interval (CI)=0.22-0.75; P=0.004). Women requiring pharmacotherapy were more likely to experience maternal complications (adjusted OR=3.13, 95% CI=2.23-4.41; P<0.001) and had a greater number of dietetic consultations (β-coefficient=0.28, 95% CI=0.17-0.39; P<0.001) compared to women managed through diet. Dietetic intervention plays a key role in optimising maternal and neonatal health outcomes for women with GDM. Exploring further the impact of dietetic intervention in women diagnosed with GDM is key with respect to understanding the optimal delivery of care for these women. The type and number of consultations included in a dietetic intervention should be investigated further.

1396-P: Lessons Learned from Implementing a Dietician-Led Low Risk Model of Care

Research from the U.S. and Australia indicates that individualized medical nutrition therapy provided by a Registered Dietician over a minimum of three appointments can reduce pharmacotherapy requirements for women with GDM. We used an implementation science approach to develop a dietician-led model of care for low risk GDM women. Our evaluation used a pre-post intervention comparison, with primary outcomes of pharmacotherapy use and adherence to clinical guidelines which includes the recommendation of three dietician appointments. Although there were significantly more women who received best-practice dietetic care in the post-intervention cohort, pharmacotherapy use increased (Table). However, other changes over time need to be considered when interpreting these results. Women in the post-intervention cohort were more likely to: have been diagnosed before 24 weeks; have had previous GDM; and be prescribed metformin (Table). Lessons learned included: timing of dietician appointments; ongoing facilitation of the implementation process; workforce engagement; lower targets for commencing pharmacotherapy; and increased surveillance of low-risk women, all of which may have resulted in higher pharmacotherapy conversion rates. Our results have highlighted the importance of measuring process outcomes alongside clinical outcomes and using an implementation science approach when aiming to provide best-practice care. Disclosure N.J.L. Meloncelli: None. A.G. Barnett: None. S.J. de Jersey: None. Funding Health Practitioner Research Scheme

Nutritional Considerations for Peripheral Arterial Disease: A Narrative Review.

Those with peripheral arterial disease (PAD) require important considerations with respect to food and nutrition, owing to advanced age, poor diet behaviours and immobility associated with the disease process and co-morbid state. These considerations, coupled with the economic effectiveness of medical nutrition therapy, mandate that dietetic care plays a vital role in the management of PAD. Despite this, optimising dietetic care in PAD remains poorly understood. This narrative review considers the role of medical nutrition therapy in every stage of the PAD process, ranging from the onset and initiation of disease to well established and advanced disease. In each case, the potential benefits of traditional and novel medical nutrition therapy are discussed.

Family in Rehabilitation, Empowering Carers for Improved Malnutrition Outcomes: Protocol for the FREER Pilot Study.

BackgroundInterventions to improve the nutritional status of older adults and the integration of formal and family care systems are critical research areas to improve the independence and health of aging communities and are particularly relevant in the rehabilitation setting.ObjectiveThe primary outcome aimed to determine if the FREER (Family in Rehabilitation: EmpowERing Carers for improved malnutrition outcomes) intervention in malnourished older adults during and postrehabilitation improve nutritional status, physical function, quality of life, service satisfaction, and hospital and aged care admission rates up to 3 months postdischarge, compared with usual care. Secondary outcomes evaluated include family carer burden, carer services satisfaction, and patient and carer experiences. This pilot study will also assess feasibility and intervention fidelity to inform a larger randomized controlled trial.MethodsThis protocol is for a mixed-methods two-arm historically-controlled prospective pilot study intervention. The historical control group has 30 participants, and the pilot intervention group aims to recruit 30 patient-carer pairs. The FREER intervention delivers nutrition counseling during rehabilitation, 3 months of postdischarge telehealth follow-up, and provides supportive resources using a novel model of patient-centered and carer-centered nutrition care. The primary outcome is nutritional status measured by the Scored Patient-Generated Subjective Global Assessment Score. Qualitative outcomes such as experiences and perceptions of value will be measured using semistructured interviews followed by thematic analysis. The process evaluation addresses intervention fidelity and feasibility.ResultsRecruitment commenced on July 4, 2018, and is ongoing with eight patient-carer pairs recruited at the time of manuscript submission.ConclusionsThis research will inform a larger randomized controlled trial, with potential for translation to health service policies and new models of dietetic care to support the optimization of nutritional status across a continuum of nutrition care from rehabilitation to home.Trial RegistrationAustralian New Zealand Clinical Trials Registry Number (ACTRN) 12618000338268; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374608&isReview=true (Archived by WebCite at http://www.webcitation.org/74gtZplU2).International Registered Report Identifier (IRRID)DERR1-10.2196/12647

Nutrition assessment in process-driven, personalized dietetic intervention – The potential importance of assessing behavioural components to improve behavioural change: Results of the EU-funded IMPECD project

Although up-to-date definitions for nutrition assessment integrate behavioural components, it is not clear what behavioural components are to be assessed. Since behavioural modification is linked to effective therapeutic dietetic interventions, assessing behaviour and factors influencing behaviour might be beneficial to improve personalized dietetic outcome. The aim of the following report is to emphasize the role of behavioural components and factors affecting behaviour at baseline nutrition assessment in personalized dietetic intervention. The present work is part of the EU-funded project IMPECD ("Improvement of Education and Competences in Dietetics", www.impecd.eu). The project aims to improve the clarity and consistency of national dietetic process models to unify education and training of future dietitians. Experts from five European Universities of Applied Sciences (UAS) in Antwerp (BE), Fulda (DE), Groningen (NL), Neubrandenburg (DE) and St. Pölten (AT) developed a Massive Open Online Course (MOOC) consisting of several clinical cases. It warranted a detailed evaluation of all dietetic care process steps, starting with nutrition assessment. Results for motivation assessed during nutrition assessment are not consistently positively associated with outcome and the added value of assessing them at baseline is still unclear. However, depressive symptoms, emotional distress, and anxiety negatively affect eating and physical activity and therefore limit the efficacy of the dietetic intervention. Assessing behavioural components including nutrition literacy is an important precondition for influence on behavioural modification. Indisputably, baseline assessment of behavioural components and factors influencing behaviour are important to increase the therapeutic efficacy of personalized dietetic interventions.

Guidelines for review of patients on haemodialysis: Are we meeting patient needs?

This study aimed to determine satisfaction with dietetic services, identify barriers and enablers to engaging with dietetic services and acceptable methods of delivering nutrition care to patients on haemodialysis. A questionnaire was developed based on existing satisfaction surveys and key constructs from the Theoretical Domains Framework to understand patient behaviours around accessing dietetic services. Constructs were grouped according to the COM-B model (Capability, Opportunity and Motivation) of the Behaviour Change Wheel to inform future interventions. Patients at three Brisbane haemodialysis units participated, with questionnaire administered via laptop (by dietetic assistants) or paper-based version (by nurses). Sixty-six patients completed the questionnaire (response rate 40%, 62 ± 14 years, 58% male). Most respondents (n = 63, 95%) reported seeing a dietitian since commencing haemodialysis. A quarter of respondents reported declining or not wanting to see the dietitian. Despite this, questions pertaining to service satisfaction were largely positive. Questions related to enablers and barriers to engaging with the dietitian revealed the domain of motivation as the main barrier with 41% (n = 26) participants not wanting to make dietary changes. The domains of capability and opportunity were not barriers. Patients preferred receiving nutrition information from dietitians, when they had a question or concern, rather than at predefined intervals. Telehealth was not acceptable to the majority of participants. While patients were satisfied with dietetic care, their preferences for dietetic service delivery were not aligned with current evidence-based guidelines, highlighting need for alternative models of care. Dietetic interventions need to be delivered in a way that addresses motivation.

Process models in dietetic care: a comparison between models in Europe

Using a Dietetic Care Process (DCP) can lead to improved application of evidence-based guidelines and critical thinking in dietetics. One aim of the project Improvement of Education and Competences in Dietetics (IMPECD) is to develop a unified DCP for international educational purposes. Therefore, a comparison of European DCPs was needed.A concise literature search and semi-structured interviews with experts representing the full EFAD (European Federation of the Associations of Dietitians) member states were conducted from June to October 2017.16 out of 23 EFAD member states responded (70%) from which 13 indicated to use a DCP. Eight different DCPs were found, with four to six core steps and three graphical representations. In one country the use of a dietetic process is indicated by law. The DCPs have more similarities than differences as they follow the same principles. Differences in language or form may not limit the improvement in collaboration and international exchange in dietetic practice. These results provide a good basis for the development of a unified DCP for educational purposes.

Proactive dietetic care makes a difference to the nutritional well-being of gastrointestinal radiotherapy patients

Gastrointestinal cancer (GI) patients have a 60 % incidence of malnutrition at diagnosis. This is exacerbated by the treatments provided. Patients who decline nutritionally are more at risk of losing their functional independence and a greater risk of admissions (1).

A multicentre Study of Nutrition Risk Assessment in Adult Patients with Inflammatory Bowel Disease Attending Outpatient Clinics

Background: Overnutrition and undernutrition can affect patients with inflammatory bowel disease (IBD). Although all IBD outpatients should be screened for nutrition risk, screening is not routinely performed, potentially leading to reduced identification and treatment. This study aimed to estimate the prevalence of nutrition risk in adult IBD outpatients and the proportion of cases who discussed diet and/or nutrition during their routine clinical appointment. Methods: Adults with IBD attending outpatient clinics at 4 hospitals in Greece and in UK were recruited. Demographic and anthropometric data were collected using face-to-face patient interviews and clinical records. Patients were classified as high (i.e., body mass index [BMI] < 18.5 or 18.5–20 kg/m² and weight loss > 5%), moderate (i.e., BMI 20–25 kg/m² and weight loss > 5%) or low risk of undernutrition and high risk of obesity (i.e., BMI 25–30% and weight gain > 5%). The proportion of patients who discussed diet and/or nutrition during their clinical appointment was calculated. Results: In total, 390 IBD patients participated. Sixteen (4%) patients were underweight, 113 (29%) were overweight and 71 (18%) were obese. Twenty-one (5%) patients were at high risk of undernutrition; of these 4 (19%) were under dietetic care. Of those at high risk of undernutrition, 11 (52%) had discussed diet and/or nutrition during their routine clinical appointment. Fifty-six (14%) patients had gained more than 5% weight since their last recorded/reported weight and 19 (5%) were at high risk of obesity. Conclusions: Few patients were identified to be at high risk of undernutrition and less than a fifth of these were under dietetic care. Overnutrition is a growing problem in IBD with almost half of adult patients being overweight or obese. Diet and/or nutrition were not routinely discussed in this group of IBD outpatients.

Improve efficiency of dietetic care for effective interventions in care home residents at high nutritional risk

Improve efficiency of dietetic care for effective interventions in care home residents at high nutritional risk

Views and experiences of ethnic minority diabetes patients on dietetic care in the Netherlands - a qualitative study.

BackgroundDiabetes type 2 is more prevalent in people from ethnic minorities in the Netherlands, and outcomes of care are worse compared with other Dutch people. Dieticians experience difficulties in managing these groups in self-management and adherence to dietary advice. The aim of this study was to explore the views regarding a healthy diet and dietetic care among ethnic minority type 2 diabetes patients.MethodsSemi-structured interviews were held with 12 migrants with diabetes from Turkey, Morocco, Iraq and Curacao, who visited a dietician. Inclusion went on until saturation was reached. The interview guide was based on the Attitudes, Social influence and self-Efficacy (ASE) model and Kleinman’s explanatory model of illness. Interviews were held in the language preferred by the respondent. Transcripts were coded and thematically analyzed.ResultsSeveral respondents expected a more rigorous, directive and technical approach of the dietician. All respondents acknowledged the importance of a healthy diet. What they considered healthy was determined by culturally influenced ideas about health benefits of specific foods. Important hindrances for dietary change were lack of self-efficacy and social support. Social influences were experienced both as supportive and a hindrance.ConclusionsMigrant diabetic patients’ opinions about healthy food are determined by culturally influenced ideas rather than by dietary guidelines. Dutch dietary care is not tailored to the needs of these patients and should take into account migrants’ expectations, cultural differences in dietary habits and specifically address the role of family.

Proposed standard model and consistent terminology for monitoring and outcome evaluation in different dietetic care settings: Results from the EU-sponsored IMPECD project

Dietetic interventions contribute to certain health objectives and other outcomes, but are mostly part of a multimodal and multidisciplinary approach what makes evaluating the actual effects of dietitians' involvement rather complex. Although monitoring and outcome evaluation (M&OE) can provide routine data to prove the effectiveness of dietetic interventions, this has not been established yet in different dietetic settings. A comprehensive framework for M&OE in dietetics was developed by dietetic experts from fiveEuropean higher education institutes for dietetics in the course of the EU sponsored project "Improvement of Education and Competences in Dietetics (IMPECD)". Firstly, clear definitions on M&OE are proposed to facilitate the use of consistent terminology, with a specific emphasis on the term "impact" covering macro-level outcomes such as cost-effectiveness. Secondly, the Dietetic Care Process (DCP) was merged into a logic model to demonstrate the position of M&OE in relation to intervention planning and implementation, in both group and individual settings. Thirdly, selecting the appropriate indicators is indispensable to monitor and evaluate outcomes, and requires a high level of dietitians' critical reasoning. A categorized overview of indicators is provided to support this process. Lastly, the consortium developed a checklist to give dietitians a handle on what elements could be included in their M&OE plan and trigger them to perform M&OE in practice. Innovative M&OE models may help dietitians to demonstrate their effectiveness in improving clinical outcomes and justify their role in health care.

WS07.1 Moving into the 21st century with dietetic care - changing patient perceptions

WS07.1 Moving into the 21st century with dietetic care - changing patient perceptions

Update of Diabetes UK Evidence-Based Nutritional Guidelines for 2018: a celebration of two leading journals working together to improve nutritional science and dietetic care for people living with diabetes.

Update of Diabetes UK Evidence-Based Nutritional Guidelines for 2018: a celebration of two leading journals working together to improve nutritional science and dietetic care for people living with diabetes.

Associations of lifetime traumatic experience with dysfunctional eating patterns and postsurgery weight loss in adults with obesity: A retrospective study.

This study aimed to examine the associations of lifetime traumatic experience with presurgery and postsurgery eating pathology and postoperative weight loss in a sample of adult bariatric surgery patients using electronic medical record (EMR) data. Presurgery lifetime exposure to traumatic event, presurgery and postsurgery dysfunctional eating patterns, and post-operative total and excess weight losses were extracted from electronic medical records of 200 adult bariatric surgery patients in 2013 and 2014. Logistic regression analyses were conducted. During their lifetime, 60.5% of the patients (81.5% women, age=44.4±11.5years; BMIpre=44.9±5.5kg/m2 ) reported that they were exposed to a traumatic event. Before surgery, trauma exposure was associated with impulsive, compulsive, or restrictive eating patterns (OR=2.40), overeating or disturbed eating (OR=1.55), and grazing or night eating behaviours (OR=1.72). After surgery, trauma exposure was associated with lower total weight loss at 6 (OR=2.06) and 24months (OR=2.06), and to overeating or disturbed eating (OR=1.53) 12months after surgery. Bariatric surgery candidates with a history of trauma exposure could benefit from closer medical, dietetic, and/or psychological follow-up care to avoid insufficient postoperative weight loss as well as reappearance of dysfunctional eating patterns after surgery.

Towards a standardized nutrition and dietetics terminology for clinical practice: An Austrian multicenter clinical documentation analysis based on the International Classification of Functioning, Disability and Health (ICF)-Dietetics

High quality, continuity and safe interdisciplinary healthcare is essential. Nutrition and dietetics plays an important part within the interdisciplinary team in many health conditions. In order to work more effectively as an interdisciplinary team, a common terminology is needed. This study investigates which categories of the ICF-Dietetics are used in clinical dietetic care records in Austria and which are most relevant to shared language in different medical areas. A national multicenter retrospective study was conducted to collect clinical dietetic care documentation reports. The analysis included the "best fit" framework synthesis, and a mapping exercise using the ICF Linking Rules. Medical diagnosis and intervention concepts were excluded from the mapping, since they are not supposed to be classified by the ICF. From 100 dietetic records, 307 concepts from 1807 quotations were extracted. Of these, 241 assessment, dietetics diagnosis, goal setting and evaluation concepts were linked to 153 ICF-Dietetics categories. The majority (91.3%) could be mapped to a precise ICF-Dietetics category. The highest number of ICF-Dietetics categories was found in the medical area of diabetes and metabolism and belonged to the ICF component Body Function, while very few categories were used from the component Participation and Environmental Factors. The integration of the ICF-Dietetics in nutrition and dietetic care process is possible. Moreover, it could be considered as a conceptual framework for interdisciplinary nutrition and dietetics care. However, a successful implementation of the ICF-Dietetics in clinical practice requires a paradigm shift from medical diagnosis-focused health care to a holistic perspective of functioning with more attention on Participation and Environmental Factors.

Patient pathway: the ideal approach.

Hepatic encephalopathy (HE) can be a devastating complication of cirrhosis, affecting patients and their families. Multidisciplinary community and specialist teams must work together with patients and their families to recognise HE, identify and treat problems early, and minimise time spent unwell or in hospital. Primary care provides an ideal setting for patient education and reinforcement of the salient points on self-care. In the acute setting, the use of care pathways can ensure that the critical aspects of pharmacological, dietetic and supportive care are offered in a timely fashion to reduce morbidity and mortality. This article discusses strategies that can be used in primary and secondary care to help teams deliver excellent practice in HE management.