Digital disruption of dietetics: are we ready?

Digital health is transforming the delivery of health care around the world to meet the growing challenges presented by ageing populations with multiple chronic conditions. Digital health technologies can support the delivery of personalised nutrition care through the standardised Nutrition Care Process (NCP) by using personal data and technology-supported delivery modalities. The digital disruption of traditional dietetic services is occurring worldwide, supporting responsive and high-quality nutrition care. These disruptive technologies include integrated electronic and personal health records, mobile apps, wearables, artificial intelligence and machine learning, conversation agents, chatbots, and social robots. Here, we outline how digital health is disrupting the traditional model of nutrition care delivery and outline the potential for dietitians to not only embrace digital disruption, but also take ownership in shaping it, aiming to enhance patient care. An overview is provided of digital health concepts and disruptive technologies according to the four steps in the NCP: nutrition assessment, diagnosis, intervention, and monitoring and evaluation. It is imperative that dietitians stay abreast of these technological developments and be the leaders of the disruption, not simply subject to it. By doing so, dietitians now, as well as in the future, will maximise their impact and continue to champion evidence-based nutrition practice.

Evaluating the concurrent validity of body mass index (BMI) in the identification of malnutrition in older hospital inpatients.

BACKGROUND: Nutrition screening and assessment tools often include body mass index (BMI) as a component in identifying malnutrition risk. However, rising obesity levels will impact on the relevancy and applicability of BMI cut-off points which may require re-evaluation. This study aimed to explore the relationship between commonly applied BMI cut-offs and diagnosed malnutrition. METHODS: Data (age, gender, BMI and Subjective Global Assessment (SGA) ratings) were analysed for 1152 inpatients aged ≥65 years across annual malnutrition audits (2011-2015). The receiver operation characteristic (ROC) curve analysed the optimal BMI cut-off for malnutrition and concurrent validity of commonly applied BMI cut-offs in nutritional screening and assessment tools. RESULTS: Malnutrition prevalence was 36.0% (n = 372) using SGA criteria (not malnourished, moderate or severe malnutrition). Median age was 78.7 (IQR 72-85) years, median BMI 25.4 (IQR 21.8-29.7) kg/m2; 52.1% male and 51.2% overweight/obese. ROC analysis identified an optimal BMI cut-off of <26 kg/m2, 80.8% sensitivity and 61.5% specificity (AUC 0.802, 95% CI 0.773, 0.830; p < 0.0001). Commonly applied BMI cut-offs (between 18.5 and 23 kg/m2) failed to meet the alpha-priori requirement of 80% sensitivity and 60% specificity. However, BMI <23 kg/m2 had the highest agreement (κ = 0.458) with malnutrition diagnosed using the SGA. CONCLUSIONS: Both malnutrition and overweight/obesity are common in older inpatients. Continuing increases in the prevalence of overweight and obesity will impact on the sensitivity of BMI as a screening component for malnutrition risk. The current study suggests tools developed over a decade ago may need to be revisited in future.

The influence of deprivation on malnutrition risk in outpatients with chronic obstructive pulmonary disease (COPD).

BACKGROUND & AIMS: The social gradient in chronic obstructive pulmonary disease (COPD) is considerable, but the influence of deprivation on common clinical risk factors such as malnutrition is unclear. This study aimed to explore the relationship between COPD disease-severity, deprivation and malnutrition. METHODS: 424 outpatients with a confirmed diagnosis of COPD were routinely screened for malnutrition risk using the 'Malnutrition Universal Screening Tool' ('MUST') while attending respiratory clinics across two hospitals; a large city hospital (site A) and a smaller community hospital (site B). Deprivation was assessed for each outpatient according to their address (postcode) using the English governments' index of multiple deprivation (IMD) and related to malnutrition risk. Each postcode was attributed to both an IMD score and IMD rank, where a higher IMD score and a lower IMD ranking indicated increased deprivation. RESULTS: Overall prevalence of malnutrition was 22% (95% CI 18-26%; 9% medium risk, 13% high risk). It was significantly higher at site A (28% vs 17%; p = 0.004) where patients were also significantly more likely to reside in areas of more deprivation than those at site B (IMD rank: 15,510 SD 8137 vs 22,877 SD 6827; p < 0.001). COPD disease-severity was positively associated with malnutrition (p < 0.001) whilst a higher rank IMD was negatively associated with malnutrition (p = 0.014). CONCLUSIONS: Deprivation is a significant independent risk factor for malnutrition in outpatients with COPD. Consideration of deprivation is important in the identification of malnutrition and the nutritional management of patients with COPD.

Nutritional monitoring of patients post-bariatric surgery: implications for smartphone applications.

BACKGROUND: Optimal results from bariatric surgery are contingent on patient commitment to dietary and lifestyle changes and follow-up care. The present study aimed to investigate the attitudes and use of mobile health (mHealth) smartphone applications (apps) as a potential tool for maintaining connectivity between dietitians and patients post-bariatric surgery. METHODS: A cross-sectional online survey was developed and distributed to a purposeful sample of bariatric dietitians and bariatric patients in Australia. The survey questions explored technology penetration (smartphone and app use), communication preferences, nutrition monitoring methods, professional relationship expectations and reasons for loss to follow-up. RESULTS: Survey completion rate was 85% (n = 50/59) for dietitians and 80% (n = 39/49) for patients. Smartphone ownership was 98% and 95% for dietitians and patients, respectively. Common reasons given for losing patients to follow-up suggest that a traditional in-clinic practice setting could be a barrier for some. Most dietitians (n = 48; 91%) prefer to see patients face-to-face in their clinic, whereas patient preferences extended to e-mail and mobile messaging. Sixty-eight percent of bariatric patients were receptive to two-way communication with dietitians via an app between clinic visits. Both cohorts recognised the potential for emerging technologies to be used in practice, although there was no single routinely recommended mHealth app. CONCLUSIONS: The present study provides the first insight into the use of mobile devices and apps by post-bariatric patients and the dietitians who support them. A mixture of traditional methods and smartphone technology is desirable to both dietitians and patients. The utility and effectiveness of such technologies should be confirmed in future intervention studies.

Nutritional status of Vietnamese outpatients with chronic obstructive pulmonary disease.

BACKGROUND: Nutritional screening and assessment is not currently part of routine clinical practice in Vietnam. Therefore, the present study aimed to investigate the utility of the commonly used methods for identifying malnutrition in outpatients with chronic obstructive pulmonary disease (COPD). METHODS: A cross-sectional pilot study and a larger retrospective study were carried out in outpatients with COPD who were attending a respiratory clinic in Ho Chi Minh City, Vietnam. Routine clinical data were collected [body mass index (BMI), forced expiratory volume in 1 s (FEV1 )]. Nutritional screening and assessment were performed using the Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA) as the gold standard to diagnose malnutrition. RESULTS: In total, 393 outpatients had documented BMI and 29 were prospectively assessed using SGA: males, n = 25; females, n = 4; mean (SD) age 69.7 (9.6) years; mean (SD) BMI 21.0 (3.4) kg m-2 ; mean (SD) FEV1 percentage predicted 57.0% (19.7%). Malnutrition risk was identified in 20.7% (n = 6) of patients using the MST (38% sensitivity; 94% specificity). However, 45% (n = 13) were diagnosed as malnourished using the SGA (31% mild/moderate; 14% severe). All malnourished patients not identified by the MST had evidence of muscle wasting. BMI had a strong negative correlation with muscle wasting as assessed using the SGA (r = -0.857, n = 28; P < 0.001) and all malnourished patients had a BMI <21 kg m-2 (range 14.6-20.8 kg m-2 , nourished range 20.0-27.6 kg m-2 ). CONCLUSIONS: Malnutrition is common in Vietnamese outpatients with COPD. A BMI threshold of <21 kg m-2 appears to represent a useful and pragmatic cut-off point for identifying outpatients requiring comprehensive nutritional assessment and support.

Neurobiology of the structure of personality: dopamine, facilitation of incentive motivation, and extraversion.

Extraversion has two central characteristics: (1) interpersonal engagement, which consists of affiliation (enjoying and valuing close interpersonal bonds, being warm and affectionate) and agency (being socially dominant, enjoying leadership roles, being assertive, being exhibitionistic, and having a sense of potency in accomplishing goals) and (2) impulsivity, which emerges from the interaction of extraversion and a second, independent trait (constraint). Agency is a more general motivational disposition that includes dominance, ambition, mastery, efficacy, and achievement. Positive affect (a combination of positive feelings and motivation) is closely associated with extraversion. Extraversion is accordingly based on positive incentive motivation. Parallels between extraversion (particularly its agency component) and a mammalian behavioral approach system based on positive incentive motivation implicate a neuroanatomical network and modulatory neurotransmitters in the processing of incentive motivation. A corticolimbic-striatal-thalamic network (1) integrates the salient incentive context in the medial orbital cortex, amygdala, and hippocampus; (2) encodes the intensity of incentive stimuli in a motive circuit composed of the nucleus accumbens, ventral pallidum, and ventral tegmental area dopamine projection system; and (3) creates an incentive motivational state that can be transmitted to the motor system. Individual differences in the functioning of this network arise from functional variation in the ventral tegmental area dopamine projections, which are directly involved in coding the intensity of incentive motivation. The animal evidence suggests that there are three neurodevelopmental sources of individual differences in dopamine: genetic, "experience-expectant," and "experience-dependent." Individual differences in dopamine promote variation in the heterosynaptic plasticity that enhances the connection between incentive context and incentive motivation and behavior. Our psychobiological threshold model explains the effects of individual differences in dopamine transmission on behavior, and their relation to personality traits is discussed.

Opposing roles for dopamine and serotonin in the modulation of human spatial working memory functions.

Neurocognitive research has focused on monoaminergic influences over broad behavior patterns. For example, dopamine (DA) generally facilitates informational transfer within limbic and cortical networks to promote reward-seeking behavior. Specifically, DA activity in prefrontal cortex modulates the ability for nonhuman primates and humans to perform spatial working memory tasks. Serotonin (5HT) constrains the activity of DA, resulting in an opposing relationship between DA and 5HT with respect to emotional and motor behaviors. A role for 5HT in constraining prefrontally guided spatial working memory (WM) processes in humans has not been empirically demonstrated but is a logical avenue for study if these principles of neurotransmitter activity hold within cortical networks. In this study, normal humans completed a visuospatial WM task under pharmacological challenge with (i) bromocriptine, a DA agonist and (ii) fenfluramine, a serotonin agonist, in a double-blind, repeated-measures, placebo-controlled design. Findings indicate that bromocriptine facilitated spatial delayed, but not immediate, memory performance. Fenfluramine resulted in impaired delayed spatial memory. These effects were not due to nonspecific arousal, attentional, sensorimotor or perceptual changes. These findings suggest that monoaminergic neurotransmitters (DA and 5HT) may interact within cortical networks to modulate the expression of specific cognitive behaviors, particularly effortful processes associated with goal-directed activity.

Dopaminergic modulation of working memory for spatial but not object cues in normal humans.

It appears that functionally segregated visual pathways exist in the primate brain for the processing of visuospatial versus nonspatial information. Functional segregation has been demonstrated for the early associative processing of sensory information but may also exist at higher levels of cognitive analysis. Namely, connections between the dorsal visual system and dorsolateral prefrontal cortex (PFC) appear to mediate spatial working memory, which is modulated by dopamine receptor fields in the principal sulcal region of the PFC. It is speculated that nonspatial working memory may be modulated within connections between ventral visual processing regions and the inferior convexity of the PFC. Whether dopamine facilitates nonspatial memory through connections between the ventral visual system and ventral PFC has not been examined. In this study, normal humans completed spatial and nonspatial working memory tasks under pharmacological challenges with a dopamine receptor agonist (bromocriptine) and antagonist (haloperidol) in a double-blind placebcxontrolled repeated measures design. Findings indicated facilitation of spatial delayed working memory functions by bromocriptine and impairment of spatial working memory functions by haloperidol. Neither drug was effective in manipulating nonspatial memory performance. Control tasks were included to measure drug effects on basic sensorimotor and attentional processes. Findings suggest that separate processing mechanisms for remembering "What" versus "Where" an object is may exist at structural, but also neurochemical, levels in the human brain.

Neural and behavioral correlates of visual recognition memory in 4- and 8-month-old infants.

The neural and behavioral correlates of the 4- and 8-month-old infant's ability to distinguish between frequently and infrequently presented familiar and novel events was examined. Cortical event-related potentials (ERPs) were recorded as infants were familiarized to two faces. During the test trials that followed, one of these faces was presented frequently, and the other infrequently; on each of the remaining 20% of the trials, a previously unseen, novel face was presented. Following the ERP phase, infants' looking times were recorded to pairs of faces, some of which had been seen during the ERP testing, and some of which had not. At 4 months the ERP activity invoked by the three classes of events was similar, suggesting that infants were unable to distinguish among them. At 8 months the ERP activity differed only between the Infrequent Novel events and the two classes of familiar events, but did not differ between the frequently and infrequently presented familiar events. The ERP findings complement previously reported data from 6-month-old infants in describing a trend whereby infants become increasingly able to respond to stimuli on the basis of whether they have been seen before, and not on the basis of how often they had been seen. The behavioral data at both 4 and 8 months were less clear cut than the ERP data. These findings are discussed in the context of the neural and cognitive processes involved in dissociating probability information from novelty detection.

P300 brain activity in seizure patients preceding temporal lobectomy.

Event-related potentials were recorded over occipital and parietal scalp from 20 patients suffering from intractable partial complex seizures prior to undergoing a temporal lobectomy. Subjects were presented with language and nonlanguage visual stimuli using a divided-field, "odd-ball" paradigm. Although behavioral performance (button-press accuracy, reaction time, and running counts) was comparable across all groups (although accuracy was worse for those in the left temporal group), patients showed tremendous variability in both the amplitude and latency of the P300 response. Particularly notable was the observation that more slow wave activity was present among the patients than among the control subjects, and those scheduled for a left temporal resection evinced more amplitude reduction than those scheduled for a right temporal resection. In addition, a number of patients appeared not to show a P300 response at all. These results are discussed in the context of the utility of using noninvasive event-related potential measures to examine both memory impairment and the integrity of the neural structures that mediate memory functioning in certain patient populations.

Event-related potentials to emotional and neutral stimuli.

The present study examined subjects' cognitive processing of pictures of emotional and neutral facial expressions, as measured by Event-Related Potentials (ERPs). In Experiment 1, 10 subjects viewed two slides of a woman modelling angry and happy expressions; in Experiment 2, 10 subjects viewed slides of two women modelling neutral expressions. One face appeared on 20% of the trials and the other on 80% of the trials. Subjects counted the low frequency target face. In both experiments, the area of the P300 component was larger at Pz than Cz. In Experiment 1, P300 area was larger when the target was happy; peak amplitude was greater when the target was angry. No differences between neutral target faces were found for P300 amplitude or area in Experiment 2. These results suggest that emotional versus neutral facial expressions elicit different electrophysiological responses; responses are further differentiated to positive versus negative expressions.

The lateralization of language comprehension using event-related potentials.

Event-Related Potentials were recorded over occipital and parietal scalp from left- and right-handed adults presented with a language and a non-language visual stimulus using a divided field, "oddball" paradigm. The major finding of interest was that the P300 component was larger over the left than the right hemisphere of the right-handers when the language stimulus was presented to the left hemisphere; there were no hemispheric differences for the left-handers, regardless of field of presentation. These results are discussed in the context of developing noninvasive measures to lateralize language function.