Engagement, Innovation, and Impact in a Dietitian Contact Centre: The EatRight Ontario Experience.

Purpose: EatRight Ontario (ERO), a multi-modal dietitian service (phone, email, web), provided the public and health intermediaries with healthy eating advice, professional support, and health promotion tools from 2007 to 2018. An evaluation of ERO was conducted to assess the impact of the model on knowledge, attitudes, and behaviour for consumers, utilization, and support levels and satisfaction provided to health intermediaries. Methods: Consumer clients were sent a survey 1-4 weeks after using the ERO service to capture self-reported dietary changes, intentions, nutritional knowledge, and satisfaction. Health intermediaries were recruited through an electronic ERO newsletter and asked about how ERO supported their practice. Results: Of the 867 consumer respondents, 92% had either made a change or indicated that information from ERO confirmed their present behaviour, and 96% indicated they would recommend the services to others. Of the 337 health intermediaries who responded 71% indicated that ERO provided services they could not deliver. Conclusions: ERO's multi-modal dietitian contact centre provides a model for implementing successful remote service access for consumers and professionals to support healthy eating across diverse demographics and geographies, including those in geographically underserved areas.

A Qualitative Evaluation of Contact Centre Dietitian Support and Electronic Motivational Messaging for eaTracker My Goals Users.

PURPOSE: To conduct a qualitative evaluation of adjunct supports (brief motivational messaging regarding goals delivered by email/website, contact centre dietitian assistance) offered by EatRight Ontario (ERO) for users of a website-based nutrition/activity goal setting/tracking feature (eaTracker "My Goals"). METHODS: One-on-one semi-structured interviews were conducted with My Goals users in Ontario (n = 18) and Alberta (n = 5) recruited via the eaTracker website and ERO contact centre dietitians (n = 5). Interview transcripts were analyzed using content analysis. RESULTS: Participants had mixed experiences and perspectives with ERO motivational messaging. Messages targeted towards specific goals (e.g., tips, recipes) were generally well-liked, and generic messages (e.g., eaTracker login reminders) were less useful. No interviewed users had contacted ERO dietitians regarding goals, and dietitians reported encountering few callers asking for assistance while using My Goals. Limited user knowledge was one explanation for this finding. Participants provided suggestions to enhance these supports. CONCLUSION: Electronic motivational messaging and contact centre dietitian assistance have the potential to support achievement of goals set with website-based features. When considering using electronic messaging, researchers and practitioners should consider message content and delivery tailoring. Marketing that focuses on how contact centre dietitians can assist website users with their goals is needed when services are used in naturalistic settings.

The website-based eaTracker® 'My Goals' feature: a qualitative evaluation.

OBJECTIVE: In 2011, Dietitians of Canada added 'My Goals' to its website-based nutrition/activity tracking program (eaTracker®, http://www.eaTracker.ca/); this feature allows users to choose 'ready-made' or 'write-your-own' goals and to self-report progress. The purpose of the present study was to document experiences and perceptions of goal setting and My Goals, and report users' feedback on what is needed in future website-based goal setting/tracking tools. DESIGN: One-on-one semi-structured interviews were conducted with (i) My Goals users and (ii) dietitians providing a public information support service, EatRight Ontario (ERO). SETTING: My Goals users from Ontario and Alberta, Canada were recruited via an eaTracker website pop-up box; ERO dietitians working in Ontario, Canada were recruited via ERO. SUBJECTS: My Goals users (n 23; age 19-70 years; 91 % female; n 5 from Alberta/n 18 from Ontario) and ERO dietitians (n 5). RESULTS: Dietitians and users felt goal setting for nutrition (and activity) behaviour change was both a beneficial and a challenging process. Dietitians were concerned about users setting poor-quality goals and users felt it was difficult to stick to their goals. Both users and dietitians were enthusiastic about the My Goals concept, but felt the current feature had limitations that affected use. Dietitians and users provided suggestions to improve My Goals (e.g. more prominent presence of My Goals in eaTracker; assistance with goal setting; automated personalized feedback). CONCLUSIONS: Dietitians and users shared similar perspectives on the My Goals feature and both felt goal use was challenging. Several suggestions were provided to enhance My Goals that are relevant to website-based goal setting/tracking tool design in general.

A retrospective analysis of real-world use of the eaTracker® My Goals website by adults from Ontario and Alberta, Canada.

BACKGROUND: Little is known about use of goal setting and tracking tools within online programs to support nutrition and physical activity behaviour change. In 2011, Dietitians of Canada added "My Goals," a nutrition and physical activity behaviour goal setting and tracking tool to their free publicly available self-monitoring website (eaTracker® ( http://www.eaTracker.ca/ )). My Goals allows users to: a) set "ready-made" SMART (Specific, Measurable, Attainable, Realistic, Time-related) goals (choice of n = 87 goals from n = 13 categories) or "write your own" goals, and b) track progress using the "My Goals Tracker." The purpose of this study was to characterize: a) My Goals user demographics, b) types of goals set, and c) My Goals Tracker use. METHODS: Anonymous data on all goals set using the My Goals feature from December 6/2012-April 28/2014 by users ≥19y from Ontario and Alberta, Canada were obtained. This dataset contained: anonymous self-reported user demographic data, user set goals, and My Goals Tracker use data. Write your own goals were categorized by topic and specificity. Data were summarized using descriptive statistics. Multivariate binary logistic regression was used to determine associations between user demographics and a) goal topic areas and b) My Goals Tracker use. RESULTS: Overall, n = 16,511 goal statements (75.4 % ready-made; 24.6 % write your own) set by n = 8,067 adult users 19-85y (83.3 % female; mean age 41.1 ± 15.0y, mean BMI 28.8 ± 7.6kg/m(2)) were included for analysis. Overall, 33.1 % of ready-made goals were from the "Managing your Weight" category. Of write your own goal entries, 42.3 % were solely distal goals (most related to weight management); 38.6 % addressed nutrition behaviour change (16.6 % had unspecific general eating goals); 18.1 % addressed physical activity behaviour change (47.3 % had goals without information on exercise amount and type). Many write your own goals were poor quality (e.g., non-specific (e.g., missing amounts)), and possibly unrealistic (e.g., no sugar). Few goals were tracked (<10 %). Demographic variables had statistically significant relations with goal topic areas and My Goals Tracker use. CONCLUSIONS: eaTracker® users had high interest in goal setting and the My Goals feature, however, self-written goals were often poor quality and goal tracking was rare. Further research is needed to better support users.

Exploring the Feasibility and Potential of Virtual Panels for Soliciting Feedback on Nutrition Education Materials: A Proof-of-Concept Study.

BACKGROUND: A changing and cluttered information landscape has put pressure on health organizations to produce consumer information materials that are not only factual but high quality and engaging to audiences. User-centered design methods can be useful in obtaining feedback from consumers; however, they are labor intensive and slow, which is not responsive to the fast-paced communication landscape influenced by social media. EatRight Ontario (ERO), a provincial nutrition and health support program of Dietitians of Canada, develops evidence-based resources for consumers and sought to increase user-centered design activities by exploring whether the standard approach to feedback could be replicated online. While online feedback has been used in marketing research, few examples are available in health promotion and public health to guide programming and policy. OBJECTIVE: This study compared a traditional in-person approach for recruitment and feedback using paper surveys with an Internet-based approach using Facebook as a recruitment tool and collecting user feedback via the Web. The purpose of the proof-of-concept study was to explore the feasibility of the approach and compare an online versus traditional approach in terms of recruitment issues and response. METHODS: An exploratory, two-group comparative trial was conducted using a convenience and purposive sampling. Participants reviewed a handout on healthy eating and then completed an 18-item survey with both forced-choice items and open-ended responses. One group viewed a hard-copy prototype and completed a paper survey and the other viewed a PDF prototype via Web links and completed a Web survey. The total days required to fulfill the sample for each group were used as the primary method of efficiency calculation. RESULTS: In total, 44 participants (22 per condition) completed the study, consisting of 42 women and 2 men over the age of 18. Few significant differences were detected between the groups. Statistically significant (P≤.05) differences were detected on four attitudinal variables related to the document reviewed and include perceived length of the document, perceived attractiveness, likelihood of contacting ERO for food and nutrition questions in the future, and likelihood of recommending ERO to a friend. In all cases, the responses were more favorable to the document or ERO with the online group. All other variables showed no difference between them. A content review of the qualitative feedback found relative consistency in word use and number of words used, indicating relative parity in the amount of data generated between conditions. The online condition achieved its sampling target in 9 days, while the in-person method took 79 days to achieve the target. CONCLUSIONS: An online process of recruitment through Facebook and solicitation of online feedback is a feasible model that yields comparable response levels to in-person methods for user feedback. The online approach appears to be a faster and less resource-intensive approach than traditional in-person methods for feedback generation.

The Canadian Trial of Carbohydrates in Diabetes (CCD), a 1-y controlled trial of low-glycemic-index dietary carbohydrate in type 2 diabetes: no effect on glycated hemoglobin but reduction in C-reactive protein.

BACKGROUND: The optimal source and amount of dietary carbohydrate for managing type 2 diabetes (T2DM) are unknown. OBJECTIVE: We aimed to compare the effects of altering the glycemic index or the amount of carbohydrate on glycated hemoglobin (HbA1c), plasma glucose, lipids, and C-reactive protein (CRP) in T2DM patients. DESIGN: Subjects with T2DM managed by diet alone (n=162) were randomly assigned to receive high-carbohydrate, high-glycemic-index (high-GI), high-carbohydrate, low-glycemic-index (low-GI), or low-carbohydrate, high-monounsaturated-fat (low-CHO) diets for 1 y. RESULTS: The high-GI, low-GI, and low-CHO diets contained, respectively, 47%, 52%, and 39% of energy as carbohydrate and 31%, 27%, and 40% of energy as fat; they had GIs of 63, 55, and 59, respectively. Body weight and HbA1c did not differ significantly between diets. Fasting glucose was higher (P=0.041), but 2-h postload glucose was lower (P=0.010) after 12 mo of the low-GI diet. With the low-GI diet, overall mean triacylglycerol was 12% higher and HDL cholesterol 4% lower than with the low-CHO diet (P<0.05), but the difference in the ratio of total to HDL cholesterol disappeared by 6 mo (time x diet interaction, P=0.044). Overall mean CRP with the low-GI diet, 1.95 mg/L, was 30% less than that with the high-GI diet, 2.75 mg/L (P=0.0078); the concentration with the low-CHO diet, 2.35 mg/L, was intermediate. CONCLUSIONS: In subjects with T2DM managed by diet alone with optimal glycemic control, long-term HbA1c was not affected by altering the GI or the amount of dietary carbohydrate. Differences in total:HDL cholesterol among diets had disappeared by 6 mo. However, because of sustained reductions in postprandial glucose and CRP, a low-GI diet may be preferred for the dietary management of T2DM.

Long-term effect of varying the source or amount of dietary carbohydrate on postprandial plasma glucose, insulin, triacylglycerol, and free fatty acid concentrations in subjects with impaired glucose tolerance.

BACKGROUND: Reducing the glycemic load (GL) is considered beneficial for managing insulin resistance. The GL can be reduced either by reducing carbohydrate intake or by reducing the glycemic index (GI). OBJECTIVE: We studied whether these 2 dietary maneuvers have the same long-term effects on postprandial plasma glucose, insulin, triacylglycerol, and free fatty acid (FFA) concentrations in subjects with impaired glucose tolerance (IGT). DESIGN: Thirty-four subjects with IGT were randomly assigned to high-carbohydrate, high-GI (high-GI); high-carbohydrate, low-GI (low-GI); and low-carbohydrate, high-monounsaturated fatty acid (MUFA) diets for 4 mo. Plasma glucose, insulin, and FFAs were measured from 0800 to 1600 at baseline in response to high-GI meals (60% carbohydrate, GI = 61, GL = 63) and after 4 mo in response to meals representative of the study diet. RESULTS: Carbohydrate intake (% of energy), GI, and GL in the high-GI, low-GI, and MUFA groups (breakfast and lunch meals combined), respectively, were 60%, 61, and 63; 60%, 53, and 55; and 49%, 61, and 52. Compared with the change after 4 mo of the high-GI diet, both the low-GI and MUFA diets reduced 0-8-h mean plasma glucose concentrations by 0.35 mmol/L (P < 0.05). Mean plasma insulin was approximately 20% higher (P < 0.05) and FFAs approximately 12% lower (P < 0.05) after the low-GI diet than after the high-GI diet, with no significant effect of MUFA. Changes in 0-8-h mean plasma triacylglycerols in the 3 treatment groups differed significantly: -0.14, 0.04, and 0.18 mmol/L, respectively, with the high-GI, MUFA, and low-GI diets. CONCLUSIONS: In subjects with IGT, reducing the GI of the diet for 4 mo reduced postprandial plasma glucose by the same amount as did reducing carbohydrate intake. The 2 dietary maneuvers had different effects on postprandial plasma insulin, triacylglycerols, and FFAs.

High-carbohydrate-low-glycaemic index dietary advice improves glucose disposition index in subjects with impaired glucose tolerance.

Controversy exists about the optimal amount and source of dietary carbohydrate for managing insulin resistance. Therefore, we compared the effects on insulin sensitivity (SI), pancreatic responsivity (AIRglu) and glucose disposition index of dietary advice aimed at reducing the amount or altering the source of dietary carbohydrate in subjects with impaired glucose tolerance (IGT). Subjects were randomized to high-carbohydrate-high-glycaemic index (GI) (high-GI, n 11), high-carbohydrate-low-GI (low-GI, n 13), or low-carbohydrate-high-monounsaturated fat (MUFA, n 11) dietary advice, with SI, AIRglu and DI measured using a frequently sampled, intravenous glucose tolerance test before and after 4 months treatment. Carbohydrate and fat intakes and diet GI, respectively, were: high-GI, 53 %, 28 %, 83; low-GI, 55 %, 25 %, 76; MUFA, 47 %, 35 %, 82. Weight changes on each diet differed significantly from each other: high-GI, -0.49 (sem 0.29) kg; low-GI, -0.19 (sem 0.40) kg; MUFA +0.27 (sem 0.45) kg. Blood lipids did not change, but glycated haemoglobin increased significantly on MUFA, 0.02 (sem 0.11) %, relative to low-GI, -0.19 (sem 0.08) %, and high-GI, -0.13 (sem 0.14) %. Diastolic blood pressure fell by 8 mmHg on low-GI relative to MUFA (P=0.038). Although SI and AIRglu did not change significantly, DI, a measure of the ability of beta-cells to overcome insulin resistance by increasing insulin secretion, increased on low-GI by >50 % (P=0.02). After adjusting for baseline values, the increase in DI on low-GI, 0.17 (sem 0.07), was significantly greater than those on MUFA, -0.09 (sem 0.08) and high-GI, -0.03 (sem 0.02) (P=0.019). Thus, the long-term effects of altering the source of dietary carbohydrate differ from those of altering the amount. High-carbohydrate-low-GI dietary advice improved beta-cell function in subjects with IGT, and may, therefore, be useful in the management of IGT.

Soluble fiber intake at a dose approved by the US Food and Drug Administration for a claim of health benefits: serum lipid risk factors for cardiovascular disease assessed in a randomized controlled crossover trial.

BACKGROUND: The US Food and Drug Administration (FDA) approved health claims for 2 dietary fibers, beta-glucan (0.75 g/serving) and psyllium (1.78 g/serving), on the assumption that 4 servings/d would reduce cardiovascular disease risk. OBJECTIVE: We assessed the efficacy of this dose of fibers in reducing serum lipid risk factors for cardiovascular disease. DESIGN: Sixty-eight hyperlipidemic adults consumed a test (high-fiber) and a control low-fat (25% of energy), low-cholesterol (<150 mg/d) diet for 1 mo each in a randomized crossover study. The high-fiber diet included 4 servings/d of foods containing beta-glucan or psyllium that delivered 8 g/d more soluble fiber than did similar, unsupplemented foods in the control diet. Fasting blood samples and blood pressure readings were obtained at baseline and weeks 2 and 4, and the subjects' weight was monitored weekly. RESULTS: Compared with the control diet, the high-fiber diet reduced total cholesterol (2.1 +/- 0.7%; P = 0.003), total:HDL cholesterol (2.9 +/- 0.8%; P = 0.001), LDL:HDL cholesterol (2.4 +/- 1.0%; P = 0.015), and apolipoprotein B:A-I (1.4 +/- 0.8%; P = 0.076). Applying the Framingham cardiovascular disease risk equation to the data confirmed a reduction in risk of 4.2 +/- 1.4% (P = 0.003). Small reductions in blood pressure were found after both diets. The subjects reported no significant differences in palatability or gastrointestinal symptoms between the diets. CONCLUSIONS: The reduction in serum lipid risk factors for cardiovascular disease supports the FDA's approval of a health claim for a dietary fiber intake of 4 servings/d. Although relatively small in terms of patient treatment, the reduction in cardiovascular disease risk is likely to be significant on a population basis.