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Background: SODIUM-HF was a large clinical trial testing dietary sodium restriction compared to usual care in patients with heart failure that showed no reduction in clinical events. It has been suggested that diuretic doses in response to dietary sodium modification may have influenced the trial results., Objective: We assessed the effects of baseline diuretic dose and diuretic dose changes on clinical outcomes in the SODIUM-HF trial., Methods: Diuretics were converted to furosemide-equivalent diuretic total daily doses. Furosemide dose was treated as a continuous variable and also stratified into 0mg, 1mg to 39mg, 40mg, 41mg to 80mg, and > 80mg daily. The baseline diuretic dose and change in diuretic dose were assessed and correlated with dietary sodium restriction and changes in dietary sodium intake. We then examined the relationship between diuretic dosing and the primary outcomes of SODIUM-HF (cardiovascular-related emergency department visit, cardiovascular-related hospitalization, and all-cause mortality)., Results: Of the 806 patients enrolled in the SODIUM-HF trial, 784 had known diuretic status at baseline: 209 patients (26.7%) with 0mg, 134 patients (17%) with 1mg to 39mg, 205 patients (26.1%) with 40mg, 118 patients (15.1%) with 41mg to 80mg, and 118 patients (15.1%) with > 80mg. No correlation was found between dietary sodium intake and diuretic dose, either at baseline or change throughout the study (P > .05). For the primary outcomes, the 2-year risk of primary outcomes was strongly correlated with diuretic dose at baseline across the overall SODIUM-HF population (P < .001). No significant association was found between the treatment arm and the risk of primary outcomes, within each baseline diuretic dose range or with change in diuretic dose (both P > .05)., Conclusions: Although a higher baseline diuretic dose was associated with worse clinical outcomes, no association was found between dietary sodium restriction, baseline or change in diuretic dose and the primary outcomes., Competing Interests: Conflict of interest JAE is supported by the Alberta Health Services \(AHS) Chair in Cardiac Sciences; reports research support for trial leadership from Bayer, Merck & Co, Novo Nordisk, Cytokinetics, Applied Therapeutics, American Regent; reports honoraria for consultancy from AstraZeneca, Boehringer Ingelheim, Novo Nordisk, Otsuka, Bayer, Novartis; and serves as an advisor to US2.ai. All other authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Schools are an important setting for supporting children's development of food literacy, but minimal research has assessed which strategies are most suitable for school nutrition education. The Foodbot Factory intervention, consisting of serious game (ie, a digital game designed for education) and curriculum-based lesson plans, was developed to support teachers and children ages 8-12 with nutrition education. Pilot data have demonstrated that Foodbot Factory can significantly improve children's nutrition knowledge, but it has not yet been evaluated in classrooms., Methods and Analysis: A single-blinded cluster randomised controlled trial was designed in 2022 by a research team based at Ontario Tech University to determine the efficacy of the Foodbot Factory intervention in improving children's nutrition knowledge, attitudes and behaviours. 32 grade 4 and 4/5 classrooms in Ontario will be randomised to receive (1) the Foodbot Factory intervention or (2) a control nutrition education intervention using conventional materials (eg, activity sheets). The study's primary outcome is to determine the overall nutrition knowledge acquired from the intervention. Secondary outcomes include nutrition knowledge subscores (ie, knowledge of specific food groups), nutrition attitudes, dietary intake, general nutrition behaviours (eg, eating breakfast) and intervention acceptability. An Ontario-certified teacher will deliver the intervention to both groups for 35-40 min/day for five consecutive days. Outcomes will be assessed at baseline, immediately postintervention, and 4 weeks and 3 months postintervention using the Nutrition Attitudes and Knowledge questionnaire, the Block Kids Food Screener, a modified Family Nutrition and Physical Activity screener and an acceptability questionnaire. Generalised linear mixed models will assess changes in outcomes between groups., Ethics and Dissemination: The study protocol is approved by research ethics boards at Ontario Tech University and participating school boards. Results of the trial will be published in peer-reviewed journals and lay summaries will be available to stakeholders., Trial Registration Number: NCT05979259., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

In an effort to improve high sodium consumption in the population, in 2012 Health Canada released voluntary sodium reduction targets for prepackaged foods to be met before 2017. This study used the University of Toronto's Food Label Information Program database (FLIP), 2013 and 2017 collections, to evaluate changes and differences in mean sodium content of Canadian prepackaged foods and manufacturers' progress in meeting Health Canada's average and maximum sodium reduction targets. Changes to sodium content (reformulation) in products present in both FLIP years and differences across years including both new and existing products were assessed via paired and independent t-tests, respectively. The average sodium content from FLIP 2017 was also compared to previously published sales-weighted average sodium content published by Health Canada to aid in the interpretation of our results. Our reformulation analyses of consistent products between years revealed that 50% of food subcategories did not have significant changes in mean sodium from 2013 to 2017. Examining both new and existing foods, 59% of subcategories had no significant difference in mean sodium content between 2013 and 2017. The proportion of foods meeting final sodium targets was 33.6% in 2013 and 37.3% in 2017. In 2013 and 2017, 20.8% and 19.6% of products exceeded the maximum sodium targets, respectively. For almost all major food categories, a greater proportion of new products in 2017 met final sodium targets compared to existing foods (present in both FLIP 2013 and 2017). Nearly, half the major food categories examined had more new products meeting the maximum sodium target than existing products. Less than half of food subcategories (48%, n  = 45/94) from FLIP 2017 differed by ≥20% compared to sales-weighted averages published by Health Canada. Our findings reveal limited progress in the reduction of sodium in prepackaged foods. Calls for more robust policy initiatives and the continued independent monitoring of food industry efforts in Canada are warranted., Competing Interests: N/A

Background/objectives: School-based nutrition education interventions can support the development of children's food literacy and healthy eating habits. The Foodbot Factory serious game was developed to support school nutrition education based on Canada's Food Guide and Ontario curriculum. The objective of this research was to refine the Foodbot Factory intervention to include curriculum-based lesson plans that had a high-level of acceptability by stakeholders to support implementation by teachers in classrooms., Methods: A co-design approach was used to engage teacher and dietitian stakeholders in developing five lesson plans for the intervention, who contributed to creating the intervention content in three stages. The stages included reviewing and providing feedback on the initial draft of the lesson plans, participating in facilitated discussion rounds to come to a consensus on the changes required, and completing a final review of the intervention's acceptability. Qualitative data included notes on the lesson plans and recordings from meetings that were analyzed thematically., Results: During the first co-design stage, major revisions were suggested for two-fifths of the lessons by stakeholders. Further stakeholder suggestions were discussed and integrated into the intervention from facilitated discussions, improving the lesson plan content and intervention feasibility. All stakeholders agreed that the final version of the intervention was acceptable and would support classroom nutrition education. Five lesson plans were created and compiled into a unit plan, containing additional teaching resources, to support nutrition education with Foodbot Factory., Conclusions: The co-design process greatly improved the Foodbot Factory intervention and its feasibility for classroom implementation. Including diverse stakeholder perspectives led to unique and different insights to improve the intervention.

Background: An increasing number of dietitians use non-diet approaches, referred to as non-weight focused practice approaches (NWFAs), in clinical practice when working with higher weight adult clients. However, the factors that impact dietitians' ability to successfully implement these approaches in practice are unknown., Methods: Aiming to examine how implementing NWFAs in clinical practice differs based on the extent to which a dietitian uses NWFAs with their clients, we conducted a cross-sectional online survey among Canadian registered dietitians who work with higher weight adults (May to July 2021), developed and validated following the Consolidated Framework for Implementation Research. Descriptive statistics were conducted to identify barriers and facilitators with respect to implementing NWFAs. The Kruskal-Wallis was used to test for differences in barriers and facilitators with respect to implementing NWFAs among five different practice approaches. The results showed that, among participants (n = 383; 82% white; 95% women) the most important barriers for implementation of NWFAs were clients' focus on weight as an outcome, when losing weight is a condition to access enhanced services, requiring changes to their practice philosophy, difficulty funding professional development and not having sufficient skills or knowledge to implement NWFAs in practice. Top-rated facilitators included the use of clinical guidelines, scientific publications and educational materials, which were rated with higher agreement across all implementation stages (p < 0.001)., Conclusions: The present study highlights important factors that may impact the effective implementation of NWFAs in dietetic practice for higher weight adult clients, which is essential to minimise barriers in practice., (© 2024 The Authors. Journal of Human Nutrition and Dietetics published by John Wiley & Sons Ltd on behalf of British Dietetic Association.)

Serious games (i.e., digital games designed for educational purposes) can foster positive learning attitudes and are increasingly used as educational tools. Foodbot Factory is a serious game application (app) that helps children learn about healthy eating based on Canada's Food Guide principles and has demonstrated to increase nutrition knowledge among this group. This paper describes the process followed to expand Foodbot Factory's educational content and integrate immersive technologies and innovative features into the app. The revision process, which was guided by the Obesity-Related Behavioral Intervention Trials model, included the following phases: first, an interdisciplinary team of nutrition scientists, education experts, and computer scientists analyzed data from the original pilot study, recently published literature, and feedback from stakeholders to define areas to improve Foodbot Factory. The five original Foodbot Factory modules were evaluated by the team during weekly meetings, where the educational content, interactive features, and other elements that required updates (e.g., aesthetics and accessibility) were identified. Second, prototypes were created and refined until a final version of Foodbot Factory was approved. Nineteen children tested the updated Foodbot Factory and found it "easy to use" (89%) and "fun" (95%). The new version of Foodbot Factory contains 19 learning objectives, including 13 original and six new objectives. Interactive engagement features in the updated Foodbot Factory included augmented reality incorporated into two learning modules; new mini-games were created, including a memory game; an overhaul of the aesthetics; (e.g., new food images); and accessibility features were included to support users with cognitive and vision disabilities., Competing Interests: The authors declare there are no competing interests.

The field of heart failure has evolved in terms of the therapies that are available including pharmaceutical and device therapies. There is now substantial randomized trial data to indicate that dietary sodium restriction does not provide the reduction in clinical events with accepted heterogeneity in the clinical trial results. Dietary sodium restriction should be considered for some but not all patients and with different objectives than clinical outcomes but instead for potential quality of life benefit. In addition, fluid restriction, once the mainstay of clinical practice, has not shown to be of any additional benefit for patients in hospital or in the ambulatory care setting and therefore should be considered to be used cautiously (if at all) in clinical practice. Further developments and clinical trials are needed in this area to better identify patients who may benefit or have harm from these lower cost interventions and future research should focus on large scale, high quality, clinical trials rather than observational data to drive clinical practice., Competing Interests: Declaration of competing interest The authors confirm that they have no conflicts of interest. Dr. Ezekowitz reports research support for trial leadership or grants from American Regent, Applied Therapeutics, AstraZeneca, Bayer, Cytokinetics, Merck & Co, Novo Nordisk, Otsuka; honoraria for consultancy from AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, Novo Nordisk, Otsuka; serves as an advisor to US2.ai., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: A systematic review was conducted to determine if mobile health (mHealth) interventions, and which intervention characteristics, effectively support dietary adherence and reduce risk factors in patients with cardiovascular disease (CVD)., Method: Using 7 databases, studies involving adult participants with specific CVD diagnoses, mHealth intervention testing, and dietary adherence assessment were identified. Systematic reviews, qualitative studies, or studies testing interventions involving open dialogue between participants and health care providers or researchers were excluded. Two independent reviewers conducted screening and assessed the risk of bias., Results: Thirteen studies involved participants with prehypertension (n = 1), hypertension (n = 9), coronary artery disease (n = 2), and heart failure (n = 1). mHealth interventions in 8 studies improved dietary adherence, 4 showed mixed results, and 1 showed no improvements. Eight studies found interactive text and/or application-based mHealth intervention features effectively improved dietary adherence. One study had a low risk of bias, 2 had some concerns/moderate risk, and 10 had a high/critical or serious risk., Discussion: In most included studies, mHealth interventions positively impacted dietary adherence for patients with CVD., Implications for Research and Practice: Clinicians may recommend mHealth interventions to support nutrition education and self-management for their patients with CVD., (Copyright © 2023 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Background: Adherence to diet and medical therapies are key to improving heart failure (HF) outcomes; however, nonadherence is common. While mobile apps may be a promising way to support patients with adherence via education and monitoring, HF patient perspectives regarding the use of apps for HF management in unknown. This data is critical for these tools to be successfully developed, implemented, and adopted to optimize adherence and improve HF outcomes., Objective: To determine patients' needs, motivations, and challenges on the use of mobile apps to support HF management., Methods: A qualitative descriptive study using focus groups (n = 4,60 minutes) was conducted among HF patients from outpatient HF clinics in Toronto, Canada. The Diffusion of Innovation theory informed a ten-question interview guide. Interview transcripts were independently coded by two researchers and analyzed using content analysis., Results: Nineteen HF patients (65 ± 10 yrs, 12 men) identified a total of four key themes related to the use of mobile apps. The theme 'Factors impacting technology use by patients' identified motivations and challenges to app use, including access to credible information, easy and accessible user-interface. Three themes described patients' needs on the use of mobile apps to support HF management: 1) 'Providing patient support through access to information and self-monitoring', apps could provide education on HF-related content (e.g., diet, medication, symptoms); 2) 'Facilitating connection and communication', through information sharing with healthcare providers and connecting with other patients; 3) 'Patient preferences', app features such as reminders for medication, and visuals to show changes in HF symptoms were favoured., Conclusions: HF patients perceive several benefits and challenges to app use for HF self-management. Capitalizing on the benefits and addressing the challenges during the app development process may maximize adoption of such tools in this patient population., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Sivakumar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Diets high in sodium are a risk factor for cardiovascular disease (CVD). Latin American countries (LAC) consume more than double the recommended sodium levels. Research uptake in dietary sodium reduction policies has been inconsistent in LAC, and the factors impacting research uptake are largely unknown. This study aimed to describe the barriers and facilitators to the uptake of research into sodium reduction policies from a funded research consortium with 5 LAC (Argentina, Brazil, Costa Rica, Paraguay, and Peru)., Methods: A qualitative case study included 5 researchers and 4 Ministry of Health officers from the funded consortium. Dimensions from Trostle's framework of actors, content, context, and process and relative advantages from the Diffusion of Innovation informed the semi-structured interview guide and analysis. One-on-one interviews were completed from November 2019 to January 2020. The participants validated transcripts, coded, and analyzed using NVivo software., Results: Key barriers to policy advancements included 1 ) conflicts of interest from the food industry and some government actors; 2 ) government turnover resulting in policy and personnel changes; 3 ) a lack of human and financial resources; and 4 ) and communication gaps among key actors. Key facilitators to policy advancement included: 1 ) the content and quality of health economic, food supply, and qualitative data; 2 ) support, technical assistance, and alliances with the government, non-governmental organizations, and international experts; and 3 ) researchers enhanced skillsets facilitated with communication and dissemination with policymakers., Conclusion: Researchers and policymakers are faced with several barriers and facilitators on research uptake in policies and programs in LAC; these factors should be addressed and leveraged to advance sodium reduction policy development. Future LAC studies can draw from the insights and lessons learned from this case study and apply the results to future efforts on policy nutrition to promote healthy eating and reduce CVD risk., (© 2023 The Author(s).)

Non-weight-focused approaches (NWFAs) may be used by some clinicians when working with higher-weight clients. In contrast to weight-focused approaches (WFAs), NWFAs de-emphasize or negate weight loss and emphasize overall diet quality and physical activity. The extent to which WFAs, NWFAs, or a combination of both WFAs and NWFAs are used by dietitians is unknown in Canada and globally. This study surveyed Canadian Registered Dietitians (RDs) who counsel higher-weight clients to assess which practice approaches are most commonly used, how they view the importance of weight, and how they define "obesity" for the study population. Five practice approaches were initially defined and used to inform the survey: solely weight-focused; moderately weight-focused; those who fluctuate between weight-focused/weight-inclusive approaches (e.g., used both approaches); weight inclusive and; weight liberated. Participants (n = 383; 94.8% women; 82.2% white) were recruited using social media and professional listservs. Overall, 45.4% of participants used NWFAs, 40.5% fluctuated between weight-focused/moderately weight-focused, and 14.1% used weight-focused approaches (solely weight focused and moderately weight focused). Many participants (63%) agreed that weight loss was not important for higher-weight clients. However, 81% of participants received no formal preparation in NWFAs during their education or training. More research is needed to understand NWFAs and to inform dietetic education in support of efforts to eliminate weight stigma and provide inclusive access to care.

The World Hypertension League Science of Salt health outcomes review series highlights high-quality publications relating to salt intake and health outcomes. This review uses a standardised method, outlined in previous reviews and based on methods developed by WHO, to identify and critically appraise published articles on dietary salt intake and health outcomes. We identified 41 articles published between September 2019 to December 2020. Amongst these, two studies met the pre-specified methodological quality criteria for critical appraisal. They were prospective cohort studies and examined physical performance and composite renal outcomes as health outcomes. Both found an association between increased/higher sodium intake and poorer health outcomes. Few studies meet criteria for high-quality methods. This review adds further evidence that dietary salt reduction has health benefits and strengthens evidence relating to health outcomes other than blood pressure and cardiovascular disease. We observe that most studies on dietary sodium do not have adequate methodology to reliably assess sodium intake and its association with health outcomes., (© 2022. The Author(s).)

Background: Nonadherence to diet and medical therapies in heart failure (HF) contributes to poor HF outcomes. Mobile apps may be a promising way to improve adherence because they increase knowledge and behavior change via education and monitoring. Well-designed apps with input from health care providers (HCPs) can lead to successful adoption of such apps in practice. However, little is known about HCPs' perspectives on the use of mobile apps to support HF management., Objective: The aim of this study is to determine HCPs' perspectives (needs, motivations, and challenges) on the use of mobile apps to support patients with HF management., Methods: A qualitative descriptive study using one-on-one semistructured interviews, informed by the diffusion of innovation theory, was conducted among HF HCPs, including cardiologists, nurses, and nurse practitioners. Transcripts were independently coded by 2 researchers and analyzed using content analysis., Results: The 21 HCPs (cardiologists: n=8, 38%; nurses: n=6, 29%; and nurse practitioners: n=7, 33%) identified challenges and opportunities for app adoption across 5 themes: participant-perceived factors that affect app adoption-these include patient age, technology savviness, technology access, and ease of use; improved delivery of care-apps can support remote care; collect, share, and assess health information; identify adverse events; prevent hospitalizations; and limit clinic visits; facilitating patient engagement in care-apps can provide feedback and reinforcement, facilitate connection and communication between patients and their HCPs, support monitoring, and track self-care; providing patient support through education-apps can provide HF-related information (ie, diet and medications); and participant views on app features for their patients-HCPs felt that useful apps would have reminders and alarms and participative elements (gamification, food scanner, and quizzes)., Conclusions: HCPs had positive views on the use of mobile apps to support patients with HF management. These findings can inform effective development and implementation strategies of HF management apps in clinical practice., (©Bridve Sivakumar, Manon Lemonde, Matthew Stein, Sarah Goldstein, Susanna Mak, JoAnne Arcand. Originally published in JMIR Cardio (https://cardio.jmir.org), 26.10.2022.)

Excess dietary sodium is a global public health priority, particularly in low- and middle-income countries where rates of hypertension and cardiovascular disease are high. The International Development Research Centre funded a research consortium of five Latin American countries (LAC) to inform public health policy for dietary sodium reduction (2016-2020). The objective of this study was to determine the outcomes of this funding on short-term (e.g., research, capacity building) and intermediary outcomes (e.g., policies). A summative program evaluation was conducted, using a logic model and multiple data sources including document review, surveys and interviews. Researchers from Argentina, Costa Rica, Brazil, Peru and Paraguay produced a significant amount of scientific evidence to guide decision making on sodium policy related to its content in foods, consumer behaviors (social marketing), and the health and economic benefits of dietary reduction. A substantive number of knowledge translation products were produced. The funding enabled training opportunities for researchers who developed skills that can be scaled-up to other critical nutrients and health issues. It was unexpected that intermediary policy changes would occur, however several countries demonstrated early policy improvements derived from this research. A funded research consortium of LAC is a practical approach to invoke policy innovations.

Background: Canadian sodium intakes remain high despite population-wide sodium reduction initiatives, highlighting the need for personal action in reducing dietary sodium. eHealth interventions support patients in dietary change and assist clinicians in decision-making and delivering care, including provision of advice. To date, impact of diet-focused eHealth tools, like the Sodium Calculator (SC) dietary screening tool, on clinical outcomes has received minimal examination. This study assessed feasibility of a randomized controlled trial (RCT) protocol to examine the impact of the SC, a physician-focused intervention, on the quality of dietary sodium reduction advice provided by physicians to their patients with hypertension., Methods: Primary care physicians from community-based primary care clinics were randomized to one of two groups: (1) 'usual care' for dietary sodium counselling or (2) dietary sodium counselling using the SC ('experimental group'). The primary endpoint was protocol feasibility defined by the following outcomes: process (e.g. recruitment, retention, protocol adherence, acceptability of intervention), resources (e.g. needs, impact on workflow), and management (e.g. staff requirements). Outcomes were assessed using direct observation, interviews, and questionnaires with patients, physicians, and clinic staff., Results: Seven physicians (n = 4 in experimental group, n = 3 in usual care group) and 65 patients with hypertension (48.5% men, 69.8 ± 10.1 years) successfully participated. The main challenges identified is related to recruitment rate (48% for patients, 20% for physicians) and physician protocol adherence (76%). These improved with minor protocol modifications. There were several areas of protocol success such as no disruption to physician workflow, hiring clinic nurses as research staff, having a physician site lead to support physician recruitment, and a 'Protocol Prompt Form' to increase physician protocol adherence. Importantly, there was a high degree of acceptability of the SC intervention among experimental group physicians [n = 3 (75%)]., Conclusions: The modified RCT protocol was considered feasible. The identified successes can be leveraged, and the risks can be mitigated, during implementation of a full-scale RCT. Assessment of this RCT protocol is an important step in understanding the effectiveness of diet-focused eHealth tools to supporting physician self-efficacy in assessing, monitoring, and implementing dietary advice in routine clinical practice and supporting patients in effective behaviour change., (© 2022. The Author(s).)