41 research outputs found
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A Scoping Review of Interventions to Help Practicing Physicians Address Nutrition in Ambulatory Care
No full textThe importance of effective nutrition counseling is underscored by the increasing prevalence of obesity, diabetes, and cardiovascular diseases, which collectively affect millions of individuals globally and contribute to significant healthcare costs. Despite physicians’ unique positioning to integrate dietary guidance into patient care, barriers such as insufficient training, time constraints, and inadequate resources often hinder their ability to provide effective counseling. This thesis explores interventions designed to enhance practicing physicians’ capacity for nutrition counseling in ambulatory care settings. Through a scoping review of 46 studies, four main intervention modalities were identified: workshops, screening tools, practice-based tools (including clinic reminders, clinical support tools, and patient handouts), and multimodal strategies. These interventions demonstrated varied improvements in physicians’ knowledge, confidence, and counseling practices while positively influencing patient outcomes such as weight loss and improved biomarkers. However, challenges such as implementation barriers and limited long-term sustainability were noted. The findings emphasize the importance of integrating multimodal approaches tailored to clinical workflows to maximize impact. This review also highlights critical gaps in longitudinal research and scalability assessments, underscoring the need for future studies to focus on sustainable solutions that address systemic barriers for providers and patients in nutrition care delivery.Polymathic Scholar
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Longer duration of maternity leave is a predictor of exclusive breastfeeding in a multi-ethnic, majority Hispanic sample
No full textExclusive breastfeeding (EBF)—without supplementing formula or other milk—for the first 6 months of life is recommended for benefits to mother and infant. However, breastfeeding rates remain low, with only 25% of women able to achieve this. Understanding factors influencing EBF assists the development of interventions to increase EBF. This paper aims to evaluate identified social and structural determinants of EBF in a multi-ethnic, majority Hispanic sample of women with high intention to breastfeed followed from pregnancy (T1) to postpartum (T2). The Study of Nutrition in Perinatal and Early Life (SUPER Clinic), an ongoing observational study, team collaborated with Ascension Seton Maternal-Fetal Medicine (MFM) clinic to recruit and follow pregnant women and their term infants. At T1, participants reported demographics, completed surveys about social support, intention to breastfeed, work status, anticipated leave, and 2 diet recalls. At T2, participants reported their infants’ formula intake over the past 7 days, determining EBF status for this analysis. Descriptive statistics on baseline information, Chi-squared, t-tests, and logistic regression were performed for the relationship between T1 characteristics and EBF. Chi-squared and ANOVA were used to evaluate characteristics of women anticipating 12+ weeks of maternity leave compared to women anticipating less leave or not working during pregnancy. This complete case analysis included 65 participants. At T2, 24 women were EBF and 41 were not. Social support from others (T1) was positively associated with EBF (p = 0.023), while having 3+ adults in the home was associated with not EBF (p= 0.038). There was a significant positive association between anticipated maternity leave (paid or unpaid) and EBF (p= 0.001). In comparing characteristics of women anticipating 12+ weeks of leave versus less than 12 weeks or not working, women who anticipated 12+ weeks were significantly older than women not working (p= 0.035) and had fewer children than women anticipating less than 12 weeks of leave and those not working (p= 0.009). In conclusion, length of maternity leave, household size, and support during pregnancy influence EBF rates. Identifying these factors can inform interventions intending to extend EBF duration to target prior to and after birth.Nutritional Science
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Diet goal setting for behavior change in primary care appointments
No full textBackground: The prevalence of chronic disease, overweight, and obesity in the United States continues to increase. The prevention of chronic disease is influenced by targeting modifiable risk factors, such as diet. Goal setting has been proposed as a strategy to elicit dietary behavior change. Specifically, primary care is one potential setting to implement behavior change interventions using goal setting, as patients frequently prefer that primary care providers (PCPs) deliver nutrition care over other healthcare professionals. Yet, nutrition discussions in primary care are scarce due to limited time and PCP training in nutrition. Our team developed Nutri, a clinical decision support system that facilitates collaborative goal setting in a primary care setting. However, there is a gap in our understanding of the impact of brief PCP diet counseling on patient’s behavioral intention and initiation. Objective: The objective of this paper is to assess patient-reported diet goal setting, specifically how well patient-reported goals aligned with the Dietary Guidelines for Americans (DGAs), and whether dietary behavior change was initiated. Methods: Thirty-four patients from a federally qualified health center (FQHC) who attended an eligible appointment completed a baseline and post-appointment 24-hour diet recall and a post-appointment survey about diet goal setting where they indicated whether they set a diet goal with their provider. Patients were asked an open-ended question on the goals set with the provider, which were then qualitatively coded for components aligned with the DGAs according to Healthy Eating Index (HEI) components. HEI is a measure that assesses diet quality based on alignment with the DGAs. The content of goals was coded for HEI-aligned components, and goal initiation was measured via changes in HEI component scores between ASA24 surveys. Results: Patients who received Nutri more frequently reported talking with their PCP about nutrition and about changing something about their eating during their appointment, and more reported a diet goal. More goals reported by Nutri patients contained Total Vegetable and Total Fruit codes, compared to Sodium and Saturated Fat codes in control. We were able to assess goal initiation in about half the cases. 86% of patients who set a goal that contained an HEI component initiated a dietary change consistent with their goal. Conclusion: This analysis suggests the potential value of diet goal setting in primary care appointments: among our participants, when patients set an evidence-based goal with their PCP, most of the time they initiated it.Nutritional Science
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User-centered design of nutri, a novel goal setting clinical decision support technology to improve the equity of data-driven dietary behavior change interventions in primary care
No full textInterventions for dietary management of chronic disease increasingly leverage smartphone applications with the promise that data-driven personalization will improve effectiveness. However, since these interventions require users to collect, synthesize, and interpret data, users with more resources are more likely to benefit, thereby exacerbating existing health disparities. Multilevel interventions that distribute responsibility for dietary behavior change between patients and providers may improve equity; however, primary care providers (PCPs) lack time and training to elicit, synthesize, and interpret diet data. We hypothesize these limitations can be overcome with clinical decision support (CDS) technology that captures and synthesizes patient diet data into knowledge for PCPs to engage patients in collaborative diet goal setting, an effective behavior change technique.
The aim of this study is to identify system requirements that would motivate providers to use a collaborative diet goal setting CDS and evaluate implementation design choices with the CDS prototype.
We performed a 2-phase qualitative study with English and Spanish-speaking adult patients and PCPs from a federally qualified health center and an academic clinic in 30 to 60-minute semi-structured generative and usability interviews. We used an iterative design process involving user-experience designers, software engineers, and providers to develop the final CDS prototype.
Using inductive thematic analysis, eight PCP and patient themes emerged. From PCP interviews we identified that: (1) Time constraints and patient characteristics influence if PCPs use personalized or generic goal setting, (2) Subjective and non-standardized processes guide personalized goal setting, (3) PCPs regard patient-generated data as an inaccurate and non-holistic representation of the patient’s diet, (4) Current clinical workflows make diet goal setting and monitoring cumbersome. For patients we found that: (1) PCP is seen as an authority figure, (2) Listening and dialog are facilitators for shared decision-making, (3) patients regard diet data as a source of truth, and (4) Goal achievement is distinct from goal setting. These themes, along with refinements identified in usability interviews, guided the iterative design of “Nutri,” a workflow-compatible CDS that synthesizes patient diet data from 24-hour recalls via a series of computational rules and presents diet goals for PCPs to discuss with patients through collaborative goal setting.
The results from this study demonstrate the potential of a data-driven CDS for collaborative diet goal setting in primary care. The 2-phase user-centered iterative design process we used to design Nutri demonstrates how usability interviews can refine the operationalization of insights generated from traditional qualitative approaches. Follow-up studies will test Nutri in a clinic setting.Nutritional Science
Disseminating Evidence-Based Information about Nutrition to Practitioners
No full textPrimary care practitioners (PCPs) have a role to play in the primary and secondary prevention of diet/weight-related chronic disease through nutrition assessment, education, counseling, and referral. Although PCPs tend to have positive attitudes about nutrition, many do not engage in nutrition related practice behaviors. In this research, it is assumed that improving PCPs’ current nutrition knowledge of and access to evolving, evidence-based information about nutrition will lead them to be more likely to engage in nutrition assessment, education, counseling, and appropriate referrals with the ultimate aim of positive patient outcomes. This research used concept mapping, a participatory, mixed methods approach to explore practitioners’ (n=14) and researchers’ (n=30) perspectives about the importance and feasibility of actions, tools, and resources that would facilitate the dissemination of evidence-based information about nutrition to primary care medical practitioners. Concept mapping uses similarity matrices, multidimensional scale modeling, and hierarchical clustering to analyze participant brainstorming, sorting, and rating data. This exploratory study found a gap between researchers’ and practitioners’ importance ratings for the brainstormed ideas, but a high correlation (r=.94, p=.000) between researchers’ and practitioners’ feasibility ratings for the ideas. The study also identified areas for potential future research and development based on X,Y (importance, feasibility) plots of the brainstormed ideas
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Food, Health and Choices Implementation and Context: The Case for a Comprehensive Approach to Process Evaluation in School-Based Childhood Obesity Prevention Trials
No full textChildhood obesity is an important societal problem for reasons of justice, economy, and well-being; therefore, significant resources are expended on childhood obesity prevention interventions. We need strong evaluations to ensure that we use these resources efficiently and effectively. While randomized controlled trials are focused on internal validity, process evaluations can be focused on more generative evaluation questions and can be a powerful compliment to a randomized controlled trial if they employ methodological pluralism and methodological rigor.
In this dissertation, a systematic framework for a Comprehensive Approach to Process Evaluation is presented. The Comprehensive Approach to Process Evaluation was developed based on a review of 17 process evaluation and similar studies and emphasizes the examination of both implementation and contextual factors together in a process evaluation. The Comprehensive Approach to Process Evaluation is applied in this dissertation to the Food, Health & Choices childhood obesity prevention cluster randomized trial, which was implemented in 20 high-need NYC public elementary schools and included 1,358 students in 55 5th grade classes.
The Comprehensive Approach to Process Evaluation was used to evaluate Food, Health & Choices in three articles. The first used hierarchical linear modeling to examine relationships among implementation factors, contextual factors, and behavioral outcomes, while accounting for the clustering of these variables at both the classroom and school levels. Important findings were that student reception of the intervention was related to outcome behaviors; class engagement was related to curriculum recall; and teacher interest was related to delivery of the wellness intervention, the only aspect of Food, Health & Choices that depended on classroom teachers for implementation. Additionally, student responses to behavior items on questionnaires were grouped as three logical factors, which not only increased statistical power but also provided insight into how students think about energy balance related behavior. The second article used mixed methods to examine the relationship between intervention delivery and reception, energy balance related behavior, and intrapersonal and external contexts by comparing classrooms with high and low buy-in based on measures of classroom context. This comparison led to the finding that there were quantitative differences in energy balance related behavior in high buy-in and low buy-in classes at baseline and posttest, but no other constructs. A qualitative comparison of student perceptions of supports and barriers to maintaining energy balance uncovered neighborhood environment as a universal barrier, preferences as a more salient barrier for students in low buy-in classes, and more awareness of the home environment as both a support and barrier among students in high buy-in classes. The third article used qualitative methods to examine the relationship between energy balance related behavior and intrapersonal and external contexts. Findings were that four patterns of behavior adoption existed among the interviewees and that corresponding intrapersonal and external contextual factors facilitated and hindered energy balance related behavior adoption in each of these groups.
In all, the Comprehensive Approach to Process Evaluation proved to be a useful and rigorous compliment to the Food, Health & Choices randomized controlled trial outcome evaluation and provided a more nuanced explanation of what happened during Food, Health & Choices. A synthesis of findings across the three studies highlights both implementation and contextual factors that were important during the intervention, including: 1) Intervention reception – satisfaction and recall of Food, Health & Choices were associated with energy balance related behaviors; 2) Intervention delivery – using trained nutrition educators seemed to positively influence the completion of the intervention; 3) Intrapersonal context – students responded differently to the intervention based on prior experiences and personality; 4) External context – neighborhood environments were powerful in influencing energy balance related behaviors. This has implications for intervention sustainability and improvement as well as research, practice, and policy in childhood obesity prevention. Research should be conducted to clarify the relationship between intervention satisfaction and behavioral outcomes; practice should consider the value of trained nutrition educators versus classroom teacher professional development, the importance of parent education about exposure to fruits and vegetables in early childhood, and how interventions might be tailored for different student energy balance related behavior adoption profiles; and policies that support children in choosing healthy food outside of school should be adopted. The Comprehensive Approach to Process Evaluation should be tested in other interventions to determine if it is recommended as an approach to process evaluation across school-based childhood obesity prevention interventions
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Animal-based beef and plant-based beef: HEI-2015 score comparisons
No full textMaternal diet can affect breastmilk composition, and breastfeeding women gravitate towards a healthier diet compared to other women. However, a healthy diet can be difficult to navigate. For example, plant-based food is marketed as healthy but is also ultra-processed which leaves health-conscious consumers, like many new moms, wondering how to make healthy choices. Therefore, this report aims to determine whether HEI-2015 scores are higher on a beef or plant-based beef diet, with all other ingredients identical, and how either diet condition compares to HEI-2015 scores of participants’ usual dietary intake.
This report uses data from participants who completed a double-blinded randomized cross-over controlled feeding trial (SUPER-BEEF) at the time of this report. Participants underwent a 6-day normal eating period followed by a 6-day diet condition (Diet A), 6-day washout period, and the other 6-day diet condition (Diet B). Because the blinded study is ongoing, Diet A was considered the beef and Diet B was considered the plant-based beef condition for this report. The feeding trial meals were designed to meet acceptable macronutrient ranges and energy requirements of breastfeeding women with Nutritionist Pro software. Additionally, meals were formulated to have equal amounts of beef or plant-based beef (113g) and dietary fat (13g). We entered data from normal eating 24-hour diet recalls and diet condition menu checkoffs into the Nutrition Data System for Research (NDSR) software from which Healthy Eating Index-2015 (HEI-2015) scores were calculated.
The beef condition had higher average HEI-2015 scores and lower average daily calories compared to plant-based beef (mean 72.9 vs. 58.9, 2222 kcals vs. 2337 kcals; respectively). In Diet A (beef), average HEI-2015 scores were higher for all participants (mean 70.5-72.5) compared to normal eating (mean 42.6-66.8). In Diet B (plant-based beef), average HEI-2015 scores were mixed (mean 56.1-58.2) compared to normal eating. In conclusion, our trial diets with acceptable macronutrient distribution and calorie requirements for breastfeeding women only differing in plant-based vs. animal-based beef differed in HEI-2015 scores. Compared to participants’ usual diets, the beef diet universally yielded higher diet quality scores while the plant-based diet yielded a higher diet quality score for 44% of participants.Nutritional Science
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Optimizing nutrition education in medical training : a curriculum and learning science evaluation of a novel didactic
No full textPhysician-led nutrition counseling is a critical yet underdeveloped skill in medical education. To address this gap, researchers at a large academic institution developed the Nutri MedEd curriculum, integrating Nutri, a point-of-care nutrition counseling software, into the Family Medicine clerkship. This curriculum employs the DECIDe framework to guide structured, goal-oriented dietary discussions. This report evaluates the instructional design of the Nutri MedEd session using the Kern Six-Step Approach and human learning theories. The analysis assesses the alignment of learning objectives with current ACGME nutrition competencies. This report contributes to broader efforts to integrate effective, evidence-based nutrition education into medical training, ultimately improving physicians’ ability to address diet-related chronic diseases in clinical practice.Educational Psycholog
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Dietary avoidance behaviors in a clinical sample of adults with inflammatory bowel disease
No full textBackground: Inflammatory Bowel Disease (IBD) presents a significant clinical challenge due to its chronic nature and the unpredictable cycle of remission and relapse. Medical treatment often fails to fully control the disease leaving patients to endure debilitating gastrointestinal symptoms. Therefore, patients tend to seek dietary approaches to manage and prevent symptoms. Specifically, most of the patients prefer avoiding foods they perceive as problematic over following a special diet. However, there is a lack in understanding the rationale behind food avoidance and how food avoidance behaviors impact nutritional status and disease activity in IBD patients. Objectives: To qualitatively identify the factors influencing food avoidance in IBD patients and to examine the association between these avoidance behaviors and both malnutrition risk and inflammatory biomarkers. Methods: A secondary analysis was conducted using data from a multicenter cross-sectional study of adults diagnosed with IBD. Participants completed questionnaires assessing food avoidance and malnutrition risk, while inflammatory biomarkers were collected from health records. Qualitative thematic analysis was applied to identify the reasons behind food avoidance. Results: The study included 137 participants with a median age of 35 years. The thematic analysis revealed eight key themes for habitual food avoidance and nine themes for avoidance during flare-ups, with symptom management and advice from others and personal preference being prominent factors. Correlation analysis showed no significant association between food avoidance and the risk of malnutrition or inflammatory biomarkers. Conclusions: Among a clinical cohort of adult patients, food avoidance was influenced by a combination of past experiences, anticipatory fears, and external advice. These findings highlight the need for personalized dietary counseling to addresses individual differences and prevent unnecessary dietary avoidance.Nutritional Science
Nasal Feeding Tubes Are Associated With Fewer Adverse Events Than Feeding Via Ostomy in Hospitalized Patients Receiving Enteral Nutrition
No full textBACKGROUND: Surgical feeding ostomies (e.g. gastrostomy) have have become required by many nursing facilities for all patients receiving enteral nutrition, whether for short- or long-term use. These policies lack supportive evidence. Comparisons of adverse event rates between surgical and natural orifice tubes are few, and lacking in the inpatient setting. Additionally, we hypothesize that adverse events related to feeding tubes are under-reported. We sought to quantify adverse events to test the relative safety of surgical feeding ostomies and natural orifice (e.g. nasogastric or orogastric) feeding tubes in hospitalized patients. METHODS: A prospective observational cohort study of enterally fed inpatients using semiweekly focused physical exam, scripted survey, and chart review. RESULTS: All tube-fed patients admitted to a large, urban, adacemic hospital received semiweekly bedside evaluation and chart review over a 9 week period (n = 226 unique patients, mean 6.25 visits each, total 1118 observations). Demographics were comparable between 148 subjects with natural orifice and 113 subjects with surgical feeding tubes. A higher incidence of adverse events were observed with surgical tubes (3.34 versus 1.25 events per 100 subject days, p<0.001). Only 50% of all adverse events were documented in the medical record. More patients with surgical tubes were discharged to skilled nursing facilities (58% versus 24%). CONCLUSIONS: Surgical feeding tubes are associated with significantly higher in-hospital adverse events rates when compared to natural orifice (nasal/oral) feeding tubes. Policies requiring surgical feeding ostomies should be reevaluated. FUNDING: National Heart, Lung, and Blood Institute (Burgermaster—training grant T32 HL 7343– 37)
