Tamara Cohen

Background: In 2019, Canada’s Food Guide (CFG) adopted a plate-based approach to promote healthier eating. Mobile health apps provide a promising solution for dietary self-monitoring, yet many focus on calorie tracking, which can be inaccessible for users with limited health literacy and misaligned with the plate-based approach. iCANPlate was designed as a simplified, visual, plate-based app to improve accessibility and adherence. Users track foods as fruits/vegetables, grains, proteins, and ‘other’ foods on a pie chart-style ‘plate,’ with beverages tracked separately.Objective: To assess the acceptability and usability of iCANPlate as a tool for dietary self-monitoring among individuals with low health literacy.Methods: Using purposive sampling, 25 participants (screened with the Newest Vital Sign, score ≤3) were recruited virtually across Canada and asked to use iCANPlate to record their intake over a five-week period. Usability was assessed using the user version of the Mobile App Rating Scale (uMARS), and acceptability was examined with a modified Technology Acceptance Model 3 (TAM3). Quantitative data were analyzed descriptively, while semi-structured interviews with a subset of participants were thematically analyzed using NVivo12 and mapped to the COM-B model.Results: iCANPlate demonstrated good usability with a score of 14.6 out of 20. Participants reported high perceived ease of use (mean = 5.14) and perceived usefulness (mean = 5.74) on the TAM3 scale (1–7), reflecting strong acceptability of the app. Qualitative findings reinforced these results, emphasizing the app’s simplicity and visual appeal as facilitators. Participants also identified areas for refinement, including improved support for categorizing foods, estimating proportions, and setting personalized goals. Importantly, 62.5% of users reported greater awareness of eating patterns, underscoring iCANPlate’s potential to promote dietary reflection rather than numerical tracking.Conclusion: iCANPlate was found to be a usable and acceptable dietary self-monitoring tool among individuals with low health literacy. Its visual, plate-based format supported users in increasing awareness of their eating patterns. These findings suggest that iCANPlate offers a promising and accessible alternative to conventional calorie-tracking apps, potentially reducing barriers to dietary self-monitoring for diverse populations. Further evaluation in larger, more heterogeneous samples is warranted to determine its long-term effectiveness and scalability.

View record

Background: Pregnancy is a critical window of opportunity for health behavior interventions that can impact both maternal and fetal health. Evidence highlights low adherence to key health behaviors during pregnancy (e.g., physical activity and nutrition), along with a high prevalence of gestational weight gain above the recommendations. Although guidance from healthcare providers is crucial, barriers like time, knowledge gaps, and sensitive topics, along with communication gaps between pregnant individuals and prenatal care providers, often hinder patient-centered care and its effectiveness in discussing health behaviours during pregnancy. Dialogue tools like conversation cards are often used in other fields of clinical practice to improve communication, yet none exist for pregnancy. Objective: To explore key discussion topics from pregnant individuals’ and prenatal care providers’ perspectives that will be used to inform the development of PregnancyCards, a dialogue tool to improve communication on health behaviours.Methods: Using a qualitative study design, semi-structured virtual interviews were conducted with pregnant individuals (n= 21) and prenatal care providers (n= 14) across five Canadian provinces. Interview questions were grounded in the COM-B framework, and transcripts were analyzed thematically to identify topics relevant to prenatal care. Results: Analyses generated six themes, including (1) lifestyle and health behaviors, (2) mental health, (3) education and expectation-setting, (4) medical decision-making, (5) birth preparation and postpartum care, and (6) sociocultural and economic influences. Both pregnant individuals and prenatal care providers emphasized communication challenges around nutrition, substance use, mental health, and physical activity. Both groups highlighted the need for open dialogue, cultural sensitivity, and shared decision-making.Conclusions: Health-related topics can be challenging to discuss for both PIs and PCPs. This study identified the key discussion topics during prenatal care. Data from this study will be used to create and further evaluate the feasibility of using PregnancyCards as a conversation tool in clinical practice, their efficacy in enhancing communication on these topics, and their impact on health behaviours that influence maternal and fetal health outcomes.

View record

Background: Registered dietitians (RD) use nutrition education resources to educate themselves and their patients to understand various nutrition topics. Research has shown that RDs have perceived barriers towards using the Canadian Sugar Institute’s (CSI) resources, and the suitability of their resources for use by RDs has yet to be explored. Objectives: The primary objective of this study was to conduct suitability testing of nutrition education resources for RDs that centre on sugars and health. The secondary objective was to develop a series of recommendations in the form of a “checklist” that can be used to create and/or refine current nutrition education resources.Methods: This study recruited RDs to virtually assess two nutrition education resources (one on sugars and metabolic disease and the other on sources of sucrose) using the adjusted Suitability Assessment of Materials (SAM) through three iterative rounds. SAM evaluates resources based on Content, Literacy Demand, Graphic Material, Layout & Typography, Learning, Stimulation & Motivation, and Suitability and has participants rank the subscales as ‘superior’, ‘adequate’, or ‘not suitable’. A checklist was created to help CSI refine the resources between each survey round. Participants re-evaluated the refined resources using the SAM. Descriptive statistics and one-way ANOVA were performed to explore differences among total SAM scores between surveys.Results: RDs (n=45, n=37, n=27) participated in the first, second, and third surveys, respectively. The total SAM score of Resource 1 improved from 66.61 ± 16.0% (‘adequate’) in Survey 1, to 72.71 ± 14% (‘superior’) in Survey 2, to 78.83 ± 16% (‘superior’) in Survey 3 (p=0.007). The total SAM score of Resource 2 improved from 70.55 ± 18% (superior) in Survey 1 to 72.78 ± 16% (superior) in Survey 2, to 81.98 ± 16% in Survey 3 (p=0.016).Conclusion: Overall, rankings of CSI’s RD-facing resources improved after refinements were made using the checklist. Future studies are needed to test the use of the checklist in improving other resources intended for RDs on different nutrition topics.

View record

Adopting sustainable eating patterns can help address climate change and manage chronic diseases like type 2 diabetes (T2D). Medical nutrition therapy (MNT) describes evidence-based nutrition interventions provided by registered dietitians and are known to improve T2D outcomes. Health professionals, including dietitians, are well-positioned to influence individual behaviors and systemic factors to promote sustainable eating patterns. As such, MNT for T2D provides opportunities to promote sustainable dietary practices and planetary health. However, it is unclear if sustainability concepts are included in MNT guidelines for T2D. This study aims to explore if and how dietary guidelines used in Canadian MNT for T2D include the domains of sustainability. A systematic grey literature search identified 46 professional resources and 295 patient resources used in Canadian MNT for T2D. Qualitative content analysis of both types of documents was conducted using the Sustainability in Food Based Dietary Guidelines Framework, which specifies five domains of sustainability (Health; Sociocultural; Food Security; Markets; Environment). Five themes were found. First, while the presence of concepts relating to all five sustainability domains were found across the aggregate collection of resources, most messages related to Health and Sociocultural domains. Second, comprehensive inclusion of sustainability domains within individual resources was rare. Third, while dietary recommendations provided in MNT for T2D have implicit benefits and trade-offs to multiple sustainability domains, such connections were rarely explicitly discussed. Fourth, messages framed for improving Food Security and Markets lacked guidance for action. Fifth, resources specific to Indigenous populations contained the most prevalent, abundant, and interconnected representation of sustainability domains. These themes suggest missed opportunities for MNT for T2D to guide professionals towards clinical practices that support planetary health and to support patients’ adoption of sustainable dietary patterns. Paradigmatic shifts towards valuing sustainability in civil society and health care systems and learning from Indigenous perspectives are needed to promote more comprehensive and abundant inclusion of Food Security, Markets, and Environment concepts in MNT guidelines for T2D.

View record

Background: Childhood obesity continues to be a global health concern.¹ Health risks associated with childhood obesity include hypertension and orthopedic disorders, among others.² However, not all children with obesity present with obesity-associated health risks.³,⁴ These health risks are thought to be part of one’s obesity phenotype.⁵ Distinguishing among them may lead to better treatment and management strategies.⁶⁻⁸ For this reason, obesity without metabolic syndrome health risk factors (i.e., lowered HDL, elevated triglycerides, blood pressure, fasting glucose) is known as metabolically healthy obesity (MHO), and those with abnormal metabolic markers are classified as metabolically unhealthy obesity (MUO).⁵,⁹ Objectives: Using data from the CANadian Pediatric Weight-Management Registry (CANPWR), this thesis aims to (i) establish the prevalence of MHO in participants 6-17 years old at baseline and one-year follow-up; and (ii) explore which health behaviour factors (diet, physical activity, sedentary, and sleep behaviours) are associated with MHO status. Methods: This secondary analysis included participants (n = 387, 52.7% female; mean age: 12.8 ± 2.9 years). Questionnaires were used to capture all non-metabolic variables. T-tests and chi-square tests were used to analyze continuous and categorical variables. Anthropometrics and biochemical assessments occurred at CANPWR sites at baseline and 1-year. Results: At baseline, n = 135 (34.9%) of participants were classified as MHO; n = 254 (65.1%) were identified as MUO. At follow-up, a similar percentage were classified as MHO (34.4%) and MUO (65.6%). However, n = 108 (27.9%) participants who were MHO at baseline presented as MUO at follow-up. Reported lifestyle behaviours that significantly differed for MHO/MUO were inconsistent at baseline and follow-up (baseline: fruit juice intake, weekly screen time hours, computer/video game hours; follow-up: fruit, ice cream/frozen yogurt intake). A lower BMI z-score was associated with MHO at both baseline and follow-up. Conclusion: The overall prevalence of MHO and MUO was similar at baseline and follow-up. Further analyses revealed variables that predicated this switching of status. This study highlights the need for more research in assessing metabolic health of children who are referred to weight-management programs, as children can present with worsening of metabolic health status at follow-up.

View record

Background and Purpose: Dietary self-monitoring is a behavioural technique that helps to elicit and sustain dietary changes over time. Current dietary self-monitoring tools focus on itemizing foods and serving sizes (portions), making them complex, time-consuming, and hard to use for people with limited or low health literacy. Furthermore, there are no plate-based dietary self-monitoring tools that conform to the 2019 Canada Food Guide (CFG). This thesis explored the perceptions of potential end-users (i.e., members from the general public) and Registered Dietitians (RDs) on a dietary self-monitoring mobile application (app) resembling the CFG, called iCANPlateᵀᴹ.Methods: Qualitative data were collected through virtual focus groups. Questions in the focus group guide were based on the Capability, Opportunity, Motivation- Behaviour (COM-B) model to explore perceptions of using the CFG and available dietary self-monitoring tools. A prototype of iCANPlateᵀᴹ (version 0.1) was presented to gain feedback on perceived barriers and facilitators to using the app, and suggestions on future versions. Trained researchers used transcripts of audio-recorded focus groups to conduct thematic analysis.Results: Seven focus groups with RDs (n=44) and nine focus groups with members from the general public (n=52) were conducted. During the focus groups, participants discussed potential facilitators and barriers to using the current iteration of iCANPlate. They were interested in the simplicity of iCANPlate and its capacity to foster self-awareness of dietary behaviours rather than weight or calorie counting. However, concerns were raised regarding iCANPlate’s potential to improve adherence to dietary self-monitoring, primarily caused by a lack of food classifications, conceptualizing proportions, and lack of inclusivity. In addition, participants suggested necessary and optional components for iCANPlate’s future versions. Conclusions: Overall, participants liked the simplicity of iCANPlate and its ability to promote self-awareness of dietary intakes, primarily through visual representation of foods on a plate as opposed to reliance on numerical values or serving sizes. Findings from this study will be used to further develop the app with the goal of increasing adherence to plate-based dietary approaches.

View record