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Malnutrition is an important clinical entity that is frequently underdiagnosed and undertreated, in part due to a lack of education and different perceptions by healthcare providers on its value in medical practice. Given this void, the purpose of this qualitative study was to explore physicians' clinical perspectives on malnutrition care, including its prevalence in their practice, and potential barriers that might preclude the delivery of malnutrition care. Using a directed content qualitative analysis approach, a total of 22 general and subspecialist physicians across three Canadian provinces were interviewed using a series of standardized questions developed by a multidisciplinary research team. Responses were transcribed and then analyzed using NVivo Version 14 software. While physicians recognized the importance of malnutrition screening and treatment, they did not view themselves as the primary drivers and often deferred this responsibility to dietitians. Lack of standard malnutrition screening, education amongst allied healthcare providers, time, personnel, and referral processes to have patients assessed and managed for malnutrition were also identified as contributing factors. For physicians, malnutrition education, standard malnutrition screening during patient encounters, and access to the necessary tools to manage malnutrition using a more centralized approach and standard referral process were viewed as strategies with the potential to improve the ability of the physician to identify and manage disease-related malnutrition and its negative consequences.

Malnutrition is prevalent among surgical candidates and associated with adverse outcomes. Despite being potentially modifiable, malnutrition risk screening is not a standard preoperative practice. We conducted a cross-sectional survey to understand healthcare professionals' (HCPs) opinions and barriers regarding screening and treatment of malnutrition. HCPs working with adult surgical patients in Canada were invited to complete an online survey. Barriers to preoperative malnutrition screening were assessed using the Capability Opportunity Motivation-Behaviour model. Quantitative data were analyzed using descriptive statistics and qualitative data were analyzed using summative content analysis. Of the 225 HCPs surveyed ( n  = 111 dietitians, n  = 72 physicians, n  = 42 allied HCPs), 96%-100% agreed that preoperative malnutrition is a modifiable risk factor associated with worse surgical outcomes and is a treatment priority. Yet, 65% ( n  = 142/220; dietitians: 88% vs. physicians: 40%) reported screening for malnutrition, which mostly occured in the postoperative period ( n  = 117) by dietitians ( n  = 94). Just 42% (48/113) of non-dietitian respondents referred positively screened patients to a dietitian for further assessment and treatment. The most prevalent barriers for malnutrition screening were related to opportunity, including availability of resources (57%, n  = 121/212), time (40%, n  = 84/212) and support from others (38%, n  = 80/212). In conclusion, there is a gap between opinion and practice among surgical HCPs pertaining to malnutrition. Although HCPs agreed malnutrition is a surgical priority, the opportunity to screen for nutrition risk was a great barrier., Competing Interests: CG has received honoraria for giving educational talks sponsored by Abbott Nutrition, Nestle Nutrition and Fresenius Kabi, which were unrelated to this manuscript. DSM has received honoraria for giving educational talks sponsored by Merck and Walnut Foundation which were unrelated to this manuscript. OL is a co-founder of the ERAS® Society and co-author of several of the guidelines from the ERAS®Society. He also held a patent for a preoperative carbohydrate drink until 2013, and has received honoraria for speaking, travel and advise unrelated to the current work from Nutricia, and Encare AB. LG has received honoraria for giving educational talks sponsored by Abbott Nutrition, Baxter and Fresenius Kabi, which were unrelated to this manuscript.

This commentary represents a dialogue on key aspects of disease-related malnutrition (DRM) from leaders and experts from academia, health across disciplines, and several countries across the world. The dialogue illuminates the problem of DRM, what impact it has on outcomes, nutrition care as a human right, and practice, implementation, and policy approaches to address DRM. The dialogue allowed the germination of an idea to register a commitment through the Canadian Nutrition Society and the Canadian Malnutrition Task Force in the UN/WHO Decade of Action on Nutrition to advance policy-based approaches for DRM. This commitment was successfully registered in October 2022 and is entitled CAN DReaM (Creating Alliances Nationally for Policy in Disease-Related Malnutrition). This commitment details five goals that will be pursued in the Decade of Action on Nutrition. The intent of this commentary is to record the proceedings of the workshop as a stepping stone to establishing a policy-based approach to DRM that is relevant in Canada and abroad., Competing Interests: The authors declare there are no competing interests.

Disease-related malnutrition is common in hospital patients. The Health Standards Organization Canadian Malnutrition Prevention, Detection, and Treatment Standard was published in 2021. The purpose of this study was to determine the current state of nutrition care in hospitals prior to implementation of the Standard. An online survey was distributed to hospitals across Canada via email. A representative reported on nutrition best practices based on the Standard at the hospital level. Descriptive and bivariate statistics were completed for selected variables based on size and type of hospital. One hundred and forty-three responses from nine provinces were received (56% community, 23% academic, and 21% other). Malnutrition risk screening was being completed on admission in 74% ( n  = 106/142) of hospitals, although not all units participated in screening all patients. Nutrition-focused physical exam is completed as part of a nutrition assessment in 74% ( n  = 101/139) of sites. Flagging a malnutrition diagnosis ( n  = 38/104) and physician documentation (18/136) were sporadic. Academic and medium (100-499 beds) and large hospitals (500+ beds) were more likely to have a physician document a malnutrition diagnosis. Some, but not all, best practices are occurring in Canadian hospitals on a regular basis. This demonstrates a need for continued knowledge mobilization of the Standard.

The gluten-free (GF) diet is the only treatment for coeliac disease (CD). While the GF diet can be nutritious, increased reliance on processed and packaged GF foods can result in higher fat/sugar and lower micronutrient intake in children with CD. Currently, there are no evidence-based nutrition guidelines that address the GF diet. The objective of this cross-sectional study was to describe the methodological considerations in forming a GF food guide for Canadian children and youth (4-18 years) with CD. Food guide development occurred in three phases: (1) evaluation of nutrient intake and dietary patterns of children on the GF diet, (2) pre-guide stakeholder consultations with 151 health care professionals and 383 community end users and (3) development of 1260 GF diet simulations that addressed cultural preferences and food traditions, diet patterns and diet quality. Stakeholder feedback identified nutrient intake and food literacy as important topics for guide content. Except for vitamin D, the diet simulations met 100 % macronutrient and micronutrient requirements for age-sex. The paediatric GF plate model recommends intake of >50 % fruits and vegetables (FV), <25 % grains and 25 % protein foods with a stronger emphasis on plant-based sources. Vitamin D-fortified fluid milk/unsweetened plant-based alternatives and other rich sources are important to optimise vitamin D intake. The GF food guide can help children consume a nutritiously adequate GF diet and inform policy makers regarding the need for nutrition guidelines in paediatric CD.

Background: Practical guidance for providers on preventing, detecting, and treating malnutrition in primary care (PC) and the community is limited. The purpose of this study was to develop nutrition care pathways for adult patients (aged ≥18 years) transitioning from hospital to community and community-dwelling older adults (aged ≥65 years) who are at risk for malnutrition., Methods: A review of best-practice nutrition evidence and guidelines published between 2009 and 2019 was performed using PubMed and CINAHL. Findings were summarized into two draft care pathways by the Primary Care Working Group of the Canadian Malnutrition Task Force. Diverse stakeholders (n = 21) reviewed and suggested revisions at a 1-day meeting. Revisions were made and an online survey was conducted to determine the relevance and importance of discrete care practices, and to establish consensus for which practices should be retained in the pathways. Providers (e.g., dietitians, physicians, nurses; n = 291) across healthcare settings completed the survey. Consensus on relevance and importance of practices was set at ≥80%., Results: One hundred twenty-eight resources were identified and used to develop the draft pathways. Survey participants assigned ratings of ≥80% for relevance and importance for all nutrition care practices, except community service providers monitoring patient weight and appetite., Conclusion: These evidence- and consensus-based nutrition pathways offer guidance to healthcare and service providers on how to deliver nutrition care during hospital-to-community transitions for malnourished adult patients and community-dwelling older adults at risk for malnutrition. These pathways are flexible for diverse PC and community models., (© 2021 American Society for Parenteral and Enteral Nutrition.)

Background: This study compares Canadian and German healthcare workers employment status and wages based on age, gender, and educational training. The German and Canadian healthcare systems are rarely compared, that if such a comparison between the two countries is available, can provide an insight of health workers employment status and how that might affect the wellbeing of elderly., Objectives: The study investigates the relation of age, gender and post-basic training with annual employment and income of health care workers in Canada and Germany., Methods: Secondary data on age, gender, post-basic education training, employment status and average monthly wages/salary was obtained from the German Socioeconomic Panel and the Canadian Survey of Labor and Income Dynamics data. The German dataset comprised 571 healthcare workers, including 219 nurses, 231 elder carers and 121 care assistants. The Canadian dataset comprised 2,580 healthcare workers, including 947 nurses, 493 elder carers and 1,140 care assistants., Results: Primarily, there was a strong relationship between post-basic training and wages for both the Canadian and German samples among elder carers and care assistants. Older healthcare workers (46 years old and above) were generally employed, and age had no predictive power on annual labor earnings. This difference in age was significant among the Canadian than the German nurses. Post-basic training had a significant relation with annual earnings and monthly wages in both the Canadian and German samples., Conclusions: This study suggests that the socio-demographics of healthcare workers as age, gender and advanced training are associated with their employment opportunities, financial rewards, and better career opportunities. The relationship between demographic variables helps understand the relation of healthcare workers employment dispositions and how it might improve the quality of life of older people in nursing homes, hospitals and elderly private homes in Canada and Germany.

Purpose: The study aimed to determine current practice, barriers, and enablers of foodservices in Canadian hospitals relative to guiding principles for best practice to prevent malnutrition. Methods: Foodservice managers completed a 55-item cross-sectional, online survey (closed- and open-ended questions). Results: Survey responses (n = 286) were from diverse hospitals in all Canadian regions; 56% acute care; 13% had foodservices contracted out; and 60% had a reporting structure combined with clinical nutrition. Predominantly, foodservice systems were 43% in-house versus 41% pre-prepared, 46% cook-serve food production, 64% meals assembled centrally (on-site), and 40% non-selective menus with limited opportunities for patient choice in advance or at meals. The "regular menu" (44%) was most commonly served as 3 meals, no snacks at specific times. Energy and protein-dense menus were available, but not widespread (9%). Daily energy targets ranged from 1200 to 2400 kcal and 32% of respondents viewed protein targets as important. The number of therapeutic diets varied from 2 to 150. Conclusions: Although hospital foodservice practices vary across Canada, the survey results demonstrate gaps in national evidence-based practices and an opportunity to formalize guiding principles. This work highlights the need for standards to improve practice through patient-centered, foodservice practices focused on addressing malnutrition.

Purpose: Living Your Best Weight (LYBW) is an outpatient program based on Health at Every Size (HAES) principles for adults interested in managing their weight. The purpose of this pilot study was to determine perceptions of participants and their satisfaction with the LYBW program. Methods: A survey was developed to determine participant satisfaction of the LYBW program. Fifty-six participants who completed the LYBW program from June 2017 to February 2018 were contacted via telephone and invited to participate in the study. Forty-five participants agreed to receive the survey by mail or email. Results: Thirty-four participants completed the survey for a response rate of 61%. The average age of respondents was 52 years. Seventy-nine percent of respondents agreed that the program helped them to focus on health instead of weight. Eighty-two percent agreed that the program helped them respond to internal cues of hunger and fullness, and 94% were satisfied with the program. Conclusion: Participants reported that they were satisfied with the LYBW program and perceived improvements in their health. Future programming may benefit from using a HAES-based approach with adults.

Introduction: Celiac disease (CD) is an autoimmune disease requiring lifelong adherence to the gluten-free diet (GFD). The GFD has significant nutritional limitations which may result in poor diet quality (DQ). We hypothesized that biopsy-proven children with CD (CCD) would have dietary patterns characterized by high saturated fat/simple sugar intake with a low micronutrient density contributing to lower DQ when compared to children with mild-gastrointestinal complaints (GI-CON). In addition, we hypothesized that ethnicity may further impact DQ., Methods: Socio-demographic (age, CD duration, parent/child ethnicity, education), household characteristics, anthropometric, dietary intake (24-h recalls), gastrointestinal pain and adherence was collected in CCD (n = 243) and GI-CON (n = 148). Dietary patterns were determined using k-mean Cluster Analysis., Results: GI-CON had significantly lower DQ than CCD (p < 0.001). Most CCD and GI-CON (>80%) had dietary patterns characterized by1) Western Diet (Cluster 1: %BMR: 110-150, low DQ, high fat, moderate CHO, high sodium) and 2) High Fat-Western Diet (Cluster 2: %BMR:130-150, low DQ, high Fat, high processed meats, high fat dairy products, CHO. Fewer children (<20%) had Prudent, Lower Fat/High Carbohydrate dietary patterns (% BMR:100-150, higher DQ, lower fat/sodium, higher CHO) with a greater proportion of non-Caucasian CCD consuming a Prudent dietary pattern. Seventy-seven percent and 37.5% of CCD and GI-CON, respectively, did not meet estimated average requirements for folate (p < 0.001)., Conclusions: CCD and GI-CON have predominantly Western dietary patterns with low DQ, particularly GI-CON. Non-caucasian CCD consume more prudent dietary patterns with higher DQ. Nutrition education is warranted to ensure optimal DQ in children with chronic gastrointestinal diseases., (Copyright © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Early detection of malnutrition in hospitalized patients is of paramount importance. As poor food intake is a marker of malnutrition risk, a simple and accurate method to monitor intake is valuable. This quality assurance project aimed to determine if food service workers (FSW) were able to provide accurate estimates of patient intakes through visually assessing meal trays at an acute care hospital. FSW conducted visual estimates of patient trays after meals using the meal plate pictorial rating scale adapted from the My Meal Intake Tool and translated their estimates into one of 5 consumption levels (0%, 25%, 50%, 75%, or 100%). A total of 401 patient meal estimates were validated using the food weighing method. Spearman's correlations between percent calories consumed (determined by weight) and estimates by FSW were 0.624 (n = 137, P < 0.001), 0.771 (n = 134, P < 0.001), and 0.829 (n = 130, P < 0.001), for breakfast, lunch, and supper, respectively. Paired Wilcoxon tests and the Kruskal-Wallis H test showed that accuracy varied for breakfast, lunch, and supper. The overall sensitivity and specificity of FSW for detecting patient intake ≤50% was 81% and 88%, respectively. These findings identify that FSW can accurately estimate patient intake, contributing an important marker for the detection of malnutrition.

The older adult population in Canada is growing, creating a greater demand for long-term care (LTC) facilities. Seniors living in LTC are more vulnerable to malnutrition, making it important to implement nutrition screening tools on a routine basis. The purpose of this study was to explore the practices of Registered Dietitians (RDs) related to nutritional screening, nutritional assessment, and follow-ups conducted within LTC facilities. This study also explored possible barriers hindering the application of these practices. Nine RDs from two health regions in Southern Saskatchewan completed a phone interview to address nutrition care practices/policies and barriers in LTC facilities. Results showed a considerable amount of variability in nutrition care practices for screening and assessment with lack of time identified as the greatest barrier. These findings highlight the importance of having consistent policies and a sufficient amount of RDs available in LTC facilities to provide the expected level of nutrition care for residents.

The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensus based pathway developed to guide health care professionals in the prevention, detection, and treatment of malnutrition in medical and surgical patients. From 2015 to 2017, the More-2-Eat implementation project (M2E) used a participatory action research approach to determine the feasibility, and evaluate the implementation of INPAC in 5 hospital units across Canada. Based on the findings of M2E and consensus with M2E stakeholders, updates have been made to INPAC to enhance feasibility in Canadian hospitals. The learnings from M2E have been converted into an online toolkit that outlines how to implement the key steps within INPAC. The aim of this short report is to highlight the updated version of INPAC, and introduce the implementation toolkit that was used to support practice improvements towards this standard.

Purpose: Through consultation with Canadian dietitian informants, we aimed to identify the desired knowledge, skills, and attitudes (KSA) for preceptors, training opportunities, and the barriers that prevent preceptor training., Methods: In this qualitative study, an open-ended survey was sent electronically to 100 key informants across Canada. Informants had experience as preceptors or with dietitian preceptors. Informants were asked to reflect upon the desired KSA, training needs, and barriers to training for dietitian preceptors. Categories of responses under each of these headings were developed on the basis of informants' responses., Results: Forty-nine key informants completed the survey, for a 49% response rate. Of the respondents, 41% (20/49) were in clinical practice and 35% (17/49) worked in community/public health areas. The knowledge and skills domains consisted of themes related to teaching and learning, including assessing, planning, and evaluating. Attitudes expressed included considering learners as colleagues and the training of learners as a professional responsibility. Perceived barriers to training preceptors included workload demands and a lack of recognition from peers and employers for this work. Dietitian preceptor training opportunities ranged from no training to formal programs., Conclusions: These findings are integral to the basic understanding of the desired KSA and training needs of Canadian dietitian preceptors.

The purpose of this study was to determine consumers' perceptions of industrially produced trans fats. A cross-sectional study was conducted in Regina at 3 different grocery store chains located in 3 different regions. A 21-item survey was administered in English by 3 research assistants at the grocery stores over a 5-day period. Of 498 potential respondents who were approached, 211 completed the survey, for a 42% response rate. The majority of respondents were female and over 61 years of age. When respondents were asked if they looked for information on food packages while grocery shopping, none of the respondents indicated that they looked for trans fat on the food label. Ninety-six percent of respondents identified that trans fat is found in processed foods, whereas 42% of respondents incorrectly identified trans fat as being found in nonhydrogenated margarines. More female respondents self-reported that they had made dietary changes to decrease trans fat intake as compared with male respondents (p < 0.05). Those participants who made dietary changes to decrease trans fat intake had higher mean knowledge scores than did those who did not make changes (p < 0.043). Sixty-three percent of respondents indicated that they would not make dietary changes to their snack food selections even if their selections contained trans fat. Consumers know a little about trans fats and consider them to be a concern. However, consumers are reluctant to make dietary changes to limit these fats in their snack food selections.

Patients routinely seek physicians' guidance about diet and the relation between nutrition and the prevention and treatment of disease. However, the adequacy of nutrition instruction in undergraduate medical education is questionable. The purpose of this study was to investigate Canadian medical students' perceptions of and satisfaction with their education in nutrition. At 9 universities across Canada, a 23-item survey questionnaire was distributed in English and French to undergraduate medical students after at least 8 months of medical school. Overall, 9 of 17 universities participated in the survey, and 933 of the 3267 medical students approached completed the survey (response rate, 28.6%). Mean satisfaction with nutrition instruction received during medical school was 4.7 (+/-0.06) on a scale of 1-10, where 1 is very dissatisfied and 10 is very satisfied, and there were significant differences among schools (p < 0.0001). Students were comfortable in their ability to counsel patients regarding basic nutrition concepts and the role of nutrition in prevention of disease, but were much less comfortable discussing the role of nutrition in the treatment of disease and nutrient requirements across the lifecycle, and in identifying credible sources of nutrition information. Of the 933 respondents, 87.2% believe that their undergraduate program should dedicate more time to nutrition education. The amount of nutrition instruction correlated with student satisfaction (p < 0.0001), but varied among schools. A significant number of students are dissatisfied with the nutrition education they receive and their ability to provide relevant and appropriate nutrition counselling. This study paves the way for further discussions and development of strategies to improve nutrition education in medical schools in Canada.