'Focus on diet quality': a qualitative study of clinicians' perspectives of use of the Mediterranean dietary pattern for non-alcoholic fatty liver disease

Translating Evidence for a Mediterranean-Style Dietary Pattern into Routine Care for Coronary Heart Disease and Type 2 Diabetes: Implementation and Evaluation in a Targeted Public Health Service in Australia

Background: A Mediterranean-style dietary pattern (MDP) is embedded across coronary heart disease (CHD) and type 2 diabetes (T2D) clinical guidelines. However, MDP evidence has not consistently been translated into practice. This study aimed to develop, integrate and evaluate implementation strategies to support clinicians in translating MDP evidence into routine care for CHD and T2D in the local context of a public health service. Methods: This study documents the implementation and evaluation phases of a broader knowledge translation project guided by the Knowledge-to-Action cycle. Multi-disciplinary clinicians in the cardiology and diabetes services of two large metropolitan hospitals and a post-acute community service were targeted. Strategies were prioritised utilising theory and stakeholder engagement and included facilitation, building a coalition, the engagement of clinical champions and local opinion leaders, educational meetings, consensus discussions, sharing local knowledge, consumer consultation, and the development and distribution of education materials. Surveys were conducted with clinicians and patients of targeted services to evaluate the reach, acceptability, feasibility, adoption and perceived sustainability of MDP in practice. Results: In total, 57 clinicians (7 dietitians, 29 nurses/diabetes educators, 15 doctors and 6 other allied health professionals) and 55 patients completed post-implementation evaluation surveys. The majority of clinicians agreed an MDP is appropriate to recommend in their clinical setting (95%), and most of the time/always their advice (85%) aligns. Education sessions were attended by 65% of clinicians, of which the majority indicated improved knowledge (100%) and change in practice (86%). Factors deemed most important to maintaining an MDP approach in practice were hard-copy education materials (85%) and access to a dietitian (62%). Of the patients who had received care from a dietitian of targeted services (n = 32, 58%), 100% recalled having discussed ≥1 MDP topic and 89% received education material. Of the patients who had received dietary advice from non-dietetic clinicians (n = 33, 60%), 67% recalled having discussed ≥1 MDP topic and 70% received education material. Conclusions: Targeted and theory-informed implementation reached the majority of surveyed clinicians and patients, and positively influenced the adoption, acceptability and feasibility of an MDP approach in routine care. Ongoing sustainability strategies are crucial with rotating clinician roles.

'Nutrition has everything to do with wound healing'-health professionals' perceptions of assessment and management of nutrition in individuals with diabetes-related foot ulceration

Determine how healthcare professionals perceive their role in nutrition assessment and management, and explore barriers and enablers to assessment and management of nutrition in individuals with DFU. Mixed methods including a cross-sectional online survey derived from current international guidelines and theoretical domains framework, and semi-structured interviews with conventional content analysis was performed. One hundred and ninety-one participants completed the survey, with 19 participating in interviews. Many health professionals are not confident in their ability in this area of practice, are uncertain their nutrition advice or management will be effective in assisting wound healing outcomes and are uncertain their intervention would result in adequate behaviour change by the individual with DFU. Major barriers to implementation of nutrition assessment and management were: inadequate time, lack of knowledge and lack of clinical guidance and enablers were as follows: professional development, a standardised clinical pathway and screening tool and a resource addressing wound healing and diabetes management. Nutrition assessment and management in individuals with DFU is not consistently applied. Whilst health professionals believed nutrition was important for wound healing, they lacked confidence in implementing into their practice. Further dissemination of existing guidance and implementation of education programs and resources would help overcome cited barriers.

Exploring dietitians' views on digital nutrition educational tools in Malaysia: a qualitative study

BACKGROUND/OBJECTIVES

Dietitians frequently use nutrition education tools to facilitate dietary counselling sessions. Nevertheless, these tools may require adaptation to keep pace with technological advancements. This study had a 2-fold purpose: first, to identify the types of nutrition education tools currently in use, identify their limitations, and explore dietitians' perspectives on the importance of these tools; second, to investigate the features that dietitians prefer in digital nutrition education tools.

SUBJECTS/METHODS

A semi-structured face-to-face interview was conducted among 15 dietitians from selected public hospitals, primary care clinics, and teaching hospitals in Malaysia. Inductive thematic analysis of the responses was conducted using NVivo version 12 software.

RESULTS

Most dietitians used physical education tools including the healthy plate model, pamphlets, food models, and flip charts. These tools were perceived as important as they facilitate the nutrition assessment process, deliver nutrition intervention, and are time efficient. However, dietitians described the current educational tools as impersonal, outdated, limited in availability due to financial constraints, unhandy, and difficult to visualise. Alternatively, they strongly favoured digital education tools that provided instant feedback, utilised an automated system, included a local food database, were user-friendly, developed by experts in the field, and seamlessly integrated into the healthcare system.

CONCLUSION

Presently, although dietitians have a preference for digital educational tools, they heavily rely on physical nutrition education tools due to their availability despite the perception that these tools are outdated, impersonal, and inconvenient. Transitioning to digital dietary education tools could potentially address these issues.

Provision of dietary education in UK-based cardiac rehabilitation: a cross-sectional survey conducted in conjunction with the British Association for Cardiovascular Prevention and Rehabilitation

Dietary education is a core component of cardiac rehabilitation (CR). It is unknown how or what dietary education is delivered across the UK. We aimed to characterise practitioners who deliver dietary education in UK CR and determine the format and content of the education sessions. A fifty-four-item survey was approved by the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) committee and circulated between July and October 2021 via two emails to the BACPR mailing list and on social media. Practitioners providing dietary education within CR programmes were eligible to respond. Survey questions encompassed: practitioner job title and qualifications, resources, and the format, content and individual tailoring of diet education. Forty-nine different centres responded. Nurses (65·1 %) and dietitians (55·3 %) frequently provided dietary education. Practitioners had no nutrition-related qualifications in 46·9 % of services. Most services used credible resources to support their education, and 24·5 % used BACPR core competencies. CR programmes were mostly community based (40·8 %), lasting 8 weeks (range: 2-25) and included two (range: 1-7) diet sessions. Dietary history was assessed at the start (79·6 %) and followed up (83·7 %) by most centres; barriers to completing assessment were insufficient time, staffing or other priorities. Services mainly focused on the Mediterranean diet while topics such as malnutrition and protein intake were lower priority topics. Service improvement should focus on increasing qualifications of practitioners, standardisation of dietary assessment and improvement in protein and malnutrition screening and assessment.

The Connection between Non-Alcoholic Fatty-Liver Disease, Dietary Behavior, and Food Literacy in German Working Adults

(1) Background: German working adults are particularly at risk of non-alcoholic fatty-liver disease (NAFLD), which is connected to increased cardiovascular and overall morbidity and mortality. Dietary behavior (DB) and health knowledge are crucial factors in the conceptual NAFLD model, which can directly influence this disease. These two factors largely align with the concept of food literacy (FL), which deals with proficiency in food-related skills and knowledge to promote healthy DB and prevent NAFLD. However, the potential of FL for NAFLD prevention remains unknown, because FL has not been tested in connection with DB and NAFLD. Therefore, the current study examined the direct and indirect connections between FL, DB, and NAFLD in a mediation model. (2) Methods: A total of 372 working adults (38% female) participated in a cross-sectional study by completing self-report questionnaires on FL and DB. In addition, an independent physician assessed the fatty-liver index (FLI) as an indicator of NAFLD in an occupational health checkup. (3) Results: The mediation model revealed that FL had a direct moderate connection with DB (β = 0.25, p < 0.01), but no direct connection with the FLI (β = -0.05, p = 0.36). However, DB showed a small to moderate connection with the FLI (β = -0.14, p = 0.01), which could indicate the indirect-only mediation of the relationship between FL and NAFLD via DB. (4) Conclusion: These results confirm the value of DB for the prevention of NAFLD. In addition, FL might be a vital component for improving DB and thereby function as a resource in the prevention of NAFLD. However, future longitudinal research is needed to substantiate the value of FL with respect to NAFLD.

Barriers and enabling factors in weight management of patients with nonalcoholic fatty liver disease: A qualitative study using the COM-B model of behaviour

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a global public health problem. Lifestyle modifications aimed at promoting weight loss and weight maintenance remain the current first-line treatments for NAFLD.

OBJECTIVE

We aim to identify barriers and enabling factors in weight management among patients with NAFLD using the capability, opportunity, motivation, behaviour (COM-B) model of behaviour.

DESIGN

This study adopted a qualitative design using semistructured interviews analysed with content analysis and the COM-B framework.

SETTING AND PARTICIPANTS

Interviews were conducted with 27 patients with NAFLD who experienced successful or unsuccessful weight reduction.

RESULTS

Our study included 27 participants: 15 participants with successful weight loss (successful weight loss refers to a decrease in body weight ≥7% of the initial body weight for patients with NAFLD) and 12 participants with unsuccessful weight loss. Thirty-five themes (19 barriers and 16 facilitators) were mapped onto the COM-B model as barriers and facilitators to weight management among patients with NAFLD. The key barriers were lack of time and energy, lack of awareness of weight, lack of attention to NAFLD, treating food as a reward or compensation and social entertainment. The key facilitators were having basic weight loss knowledge and skills, strong motivation, attention to NAFLD, unsuccessful weight loss experiences and positive feedback from phased success.

CONCLUSION

In addition to identifying factors consistent with existing studies, this study identified factors that influence weight management in NAFLD patients, such as basic weight loss skills and rational thinking before weight loss, which were not previously reported. This has clinical implications for clinical healthcare providers and health management services for the improvement of education and support regarding lifestyle improvement and weight management in patients with NAFLD.

PATIENT OR PUBLIC CONTRIBUTION

We recruited potential participants from the Bariatric Clinic, Hepatology Clinic and Physical Examination Center of hospitals between March 2021 and October 2021. Twenty-seven patients with NAFLD who had successful or unsuccessful weight loss experiences participated in the study and responded to questions on weight management.

Technology-supported models of nutrition care: Perspectives of health service providers

Objective

To determine the perspectives to the adoption, scale-up, sustainability, and spread of technology-supported models of nutrition care, in hospital and ambulatory care settings.

Methods

Thirty-one health service providers participated in individual semi-structured interviews from a tertiary health service in Queensland, Australia. The Non-adoption, Abandonment, and challenges to the Scale up, Spread and Sustainability (NASSS) framework, designed to evaluate technology-supported models’ success, informed the qualitative design.

Results

Key findings were that technology-supported models of care could benefit many chronic condition patient groups; dietitians are well suited to adopting this technology: and the value proposition in creating efficiency gains in the health service. However, challenges of transitioning and sustainability were identified. Perceived enablers for technology supported models of care included: previous intentions for technology supported models of care prior to the 2019 novel coronavirus pandemic; opportunity for clinicians to complete higher valued tasks; and integration of technology systems and assisted staff roles. Perceived barriers included: suitability for patients is dependent on experience and ability to use technology, varied confidence by clinicians when conducting clinical assessments; high investment required for set up and ongoing maintenance; and patients desire for adopting face-to-face care over technology. Health service providers perceived that embedding and adapting such models requires maintenance of high-quality service and continued research.

Conclusions

Health service providers recognize adopting, scaling, and sustaining technology-supported models of nutrition care benefits patients, clinicians, and health services in general. Robust clinical trials and health service evaluations of technology-supported models of care, across practice settings are now needed.

NAFLD Nutritional Management: Results from a Multidisciplinary Approach

Introduction

Lifestyle changes are the mainstay treatment of nonalcoholic fatty liver disease (NAFLD). We aimed to assess the magnitude of weight loss in a group of NAFLD patients followed on a combined lifestyle intervention by a multidisciplinary team.

Methods

Patients were assessed before and after a 12-month dietary intervention (Mediterranean diet aiming at weight loss). Patients who received a structured dietary plan along with general lifestyle recommendations were designated as the multidisciplinary treatment (MdT) group. Patients who declined follow-up still received general lifestyle recommendations and were designated as the conventional treatment group, being used as a control group.

Results

From the 77 patients with documented NAFLD, 31.2% of patients were overweight and 55.8% obese; 66 patients constituted the MdT group and 11 the conventional treatment group. After 3 months, 89% of patients lost weight; at 6 months, 75.4% maintained the weight lost. At 12 months, 65% of patients still decreased their weight, with 92.2% of patients in the MdT group still maintaining a lower weight than baseline versus just 50% in the conventional group (p = 0.008). Only patients in the MdT group presented a weight loss higher than 10% (9.6%; n = 6). At 12 months patients in the MdT group presented an average reduction of 4.2 kg versus a reduction of just 0.6 kg in the conventional treatment group (p = 0.016). The MdT group, but not the conventional group, presented significant differences in liver enzymes at 12 months compared to baseline.

Conclusion

Adherence to a multidisciplinary approach, compared to management solely by a hepatologist, in NAFLD patients, is effective with greater weight loss after a 12-month follow-up and a lower rate of weight gain recurrence.

A Qualitative Study of Clinician Barriers and Enablers to Implementing the Mediterranean Dietary Pattern with Kidney and Liver Transplant Recipients

INTRODUCTION

Solid organ transplant recipients experience greater cardiometabolic risk than the general population. Following a Mediterranean dietary pattern has been shown to reduce cardiometabolic risk. This study aimed to assess multidisciplinary clinician perspectives of routine nutrition care for kidney and liver transplant recipients and barriers and enablers to implementation of the Mediterranean dietary pattern.

METHODS

Semi-structured individual interviews were conducted with clinicians in a metropolitan health service at tertiary/quaternary transplant centres involved in longer-term management of kidney and liver transplants recipients. Audio-recorded interviews were transcribed verbatim and analysed using thematic content analysis.

FINDINGS

Nineteen clinicians (9 medical officers, 5 dietitians, 3 nurses and 2 other allied health professionals) were interviewed. Four themes with 11 subthemes were identified: the Mediterranean dietary pattern is not part of routine care (there are competing clinical priorities; healthy eating principles aligned with but not the full dietary pattern are recommended); variation in knowledge and acceptance of this dietary approach (variances in information sources and degree of knowledge of Mediterranean dietary pattern clinical evidence); nutrition advice is influenced by service delivery and culture (there is lack of consistent nutrition advice; limited consultation time; and reliance on existing patient education resources); and patient-centred care influences decisions on nutrition advice (clinicians do not know how to recommend this dietary pattern in a patient-centred manner).

DISCUSSION

The Mediterranean dietary pattern is not considered part of routine post-transplant nutrition care. To be implemented in these services intervention strategies which address the identified barriers and potential enablers need to be considered.