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The objective of this evaluation was to determine Northern Ontario School of Medicine (NOSM) undergraduate medical education (UME) students’ perceptions of the curriculum related to their nutrition knowledge, attitudes, and counseling self-efficacy/confidence. A 16-item electronic survey (Qualtrics©) was developed, and it included nutrition competency statements, adult and pediatric nutrition assessment and counseling confidence, and nutrition curriculum satisfaction. Students in Years 2, 3, and 4 (n = 192, 66%–73% female) were invited to answer the survey. Of the 61 respondents, 50.8% were Year 2, 34.9% Year 3, and 10.6% Year 4. Overall, 72.1% of the respondents were dissatisfied. Respondents perceived they were least competent in strategies to prevent and treat disease (72.1%), in applying basic dietary strategies (65.6%), and in ethics and nutrition management (62.3%), whereas 52.5% felt competent in the team approach to nutrition care. Respondents reported lowest confidence (less than 10%–15%) in specialized nutrition support, cancer care, renal nutrition, and mental health/eating disorders for both populations. NOSM medical learners reported curriculum dissatisfaction, nutrition incompetence, and poor levels of perceived confidence in nutrition management. Results will be used to inform nutrition curriculum enhancements and future outcome evaluations. Current and future physicians with enhanced nutrition knowledge, awareness of the Registered Dietitian (RD) roles, and an understanding of when to refer patients to an RD can provide better patient-centred care.

Purpose: We explored Registered Dietitians’ (RDs’) perceptions about expressive touch (ET) as a means to provide client-centred care, a practice unreported to date. For this study, ET is defined as relatively spontaneous, responsive, and affective contact by dietitians. Methods: This exploratory study used an explanatory sequential mixed-methods approach. RDs in Northern Ontario were surveyed (54% response, n = 135) and these results were further explored in interviews with a subset of participants (n = 17). Analysis included descriptive and association statistics and qualitative description. Results: Most RDs considered ET a useful tool for effective client communication (66%–77%), yet they were hesitant to enact the practice (81%). Analysis of interviews revealed ET to be “situationally beneficial” with uptake influenced by an interplay of factors, described as: perceived client openness to touch, the environment, and RD comfort with touch. Greater uptake was reported among RDs working with distressed clients and clients in ambulatory clinics and long-term care. ET practice was limited by personal safety concerns, unknown client customs, and client misinterpretation. Conclusion: ET was valued by many RDs as an enhancement to client-centred care. Selective use of ET is influenced by the context of dietetic practice and by perceived client and RD comfort with the use of ET.

NutriSTEP(®) screens for nutritional risk in preschoolers (3-5 years of age). Availability has been limited to paper versions. The objective is to test reliability for Internet and Onscreen use.Two studies were conducted with parents in several Ontario Early Years Centres (Internet (n = 63)) and in the community and schools in Timmons, Guelph, and Ottawa, Ontario (Onscreen (n = 64)). Parents completed NutriSTEP(®) either on paper or using Internet or Onscreen versions. Two weeks later, the alternate mode was completed. Reliability was assessed using Intraclass Correlations (ICC) and Pearson Correlations (PC) on total and attribute scores, Kappa coefficients (κ) for risk, and Wilcoxon Signed Rank Test for responses on individual questions.For total scores, Internet and Onscreen ICCs were 0.94 and 0.91, respectively, with PCs of 0.89 and 0.84, respectively. Attribute scores were 0.69-0.91 (ICC) and 0.70-0.84 (PC) for Internet, and 0.81-0.92 (ICC) and 0.68-0.85 (PC) for Onscreen. κ amongst risk categories was 0.58 (P = 0.000) for Internet and 0.50 (P = 0.000) for Onscreen. For individual dichotomized questions, 5 of 17 (Onscreen and Internet) were excellent (κ0.75); 11 of 17 (Internet) and 9 of 17 (Onscreen) were adequate (0.40κ0.75); 0 of 17 (Internet) and 2 of 17 (Onscreen) questions were poor (κ0.4) in agreement between modes.Internet and Onscreen versions of NutriSTEP(®) are reliable.

Little has been published on cultural competency curriculum and dietetics considering the impact of food-related beliefs and behaviours on health. A 14-item online survey was administered in January 2016 to 145 participants (125 members of Dietitians of Canada Aboriginal Nutrition Network and 20 dietitians with an interest in Aboriginal nutrition). Questions included multiple choice and ranking responses and were pretested by 4 preceptors with the Northern Ontario Dietetic Internship Program (NODIP). Quantitative data analysis included frequencies, pivot tables, and averaging/grouping of ranking scores. A total of 42 individuals (29%) completed the survey. The majority rated the 5 health and cultural competencies and 6 food and nutrition competencies as "important" (90%-98% and 86%-100%, respectively). Overall, the competency related to identifying health status was ranked highest (78%), whereas developing culturally appropriate recipes was ranked lowest (83%). Most participants (95%) believed that all dietitians and graduating dietetic interns should be minimally competent in Aboriginal health and culture. The initial 11 draft competencies for dietetic interns were condensed to 6 minimum and 2 advanced competencies. Results will inform dietitians working with Aboriginal peoples and refinement of NODIP intern and preceptor tools, with the potential to integrate across Canadian dietetic internship programs.

There is evidence that Aboriginal children and youth in Canada and elsewhere are at higher risk of obesity and overweight than other children. However, there has been no review of healthy weights interventions specifically aimed at Aboriginal children. A structured search for peer-reviewed articles presenting and evaluating healthy weights interventions for Aboriginal children and youth was conducted. Seventeen articles, representing seven interventions, were reviewed to identify their main characteristics, evaluation design, and evaluation outcomes. Interventions included several large community-based programs as well as several more focused programs that all targeted First Nations or American Indians, rather than Métis or Inuit. Only 1 program served an urban Aboriginal population. None of the published evaluations reported significant reductions in obesity or overweight or sustained increases in physical activity, although some evaluations presented evidence of positive effects on children's diets or on nutrition knowledge or intentions. We conclude that broader structural factors affecting the health of Aboriginal children may limit the effectiveness of these interventions, and that more evidence is required regarding interventions for Aboriginal children in various geographic and cultural contexts in Canada including Inuit and Métis communities.

Nutrition screening with NutriSTEP (Nutrition Screening Tool for Every Preschooler) requires parents to complete a 17-item, self-administered questionnaire and follow through with appropriate recommendations. Parents’ perceptions of screening and referral procedures can be used to evaluate the process of an ethical child nutrition screening program. Targeted implementation of NutriSTEP took place in 3 diverse Ontario communities using an assisted or self-referral model. Of the 364 respondents, 264 parents consented to a follow-up telephone interview, with 164 (62%) interviews conducted in English or French. The interview focused on parents’ reasons for participating, their perspectives of screening and referral processes, and any perceived barriers to, concerns about, and benefits of screening. Most parents reported that screening confirmed their perception of risk; reminded them about healthy preschool diets and areas to improve; increased their nutrition awareness, motivation, and confidence; and informed them about additional information sources. Some barriers to seeking referrals or further education included not being concerned, no time for referrals or dietary changes, and not knowing where to go for more information. Overall, nutrition risk screening using NutriSTEP was well accepted, yet referral uptake was modest. Efforts are needed to encourage parents of children at risk to follow through with recommendations.

ObjectiveFolic acid food fortification has successfully reduced neural tube defect-affected pregnancies across Canada. The effect of this uncontrolled public health intervention on folate intake among Canadian children is, however, unknown. Our objectives were to determine folic acid intake from food fortification and whether fortification promoted adequate folate intakes, and to describe folic acid-fortified food usage among Ontario preschoolers.DesignCross-sectional data were used from the NutriSTEP™ validation project with preschoolers recruited using convenience sampling. Mean daily total folate and folic acid intakes were estimated from 3 d food records, which included multivitamin supplement use. Comparisons were made to Dietary Reference Intakes, accounting for and excluding fortificant folic acid, to determine the prevalence of inadequate and excessive intakes.SettingCanada.SubjectsTwo hundred and fifty-four preschoolers (aged 3–5 years).ResultsAll participants (130 girls, 124 boys) ate folic acid-fortified foods and 30 % (n76) used folic acid-containing supplements. Mean (se) fortificant folic acid intake was 83 (2) μg/d, which contributed 30 % and 50 % to total folate intake for supplement users and non-users, respectively. The prevalence of total folate intakes below the Estimated Average Requirement was ConclusionsFolic acid food fortification promotes dietary folate adequacy and did not appear to result in excessive folic acid intake unless folic acid-containing supplements were consumed.

This study describes fruit juice consumption and associated factors for a sample of Ontario preschoolers and determines potential relationships between intake and body mass index (BMI). Secondary data analysis was conducted on growth, dietary, and demographic data collected during the validation of NutriSTEP (Nutrition Screening Tool for Every Preschooler) with 254 preschoolers, aged 3 to 5 years. Dietary data were collected through parent-completed 3-day food intake records. BMI was determined using child weight and height measurements taken by a registered dietitian. Demographic characteristics were gathered using an 8-item standardized questionnaire adapted from Statistics Canada. Bivariate analyses were performed to determine associations with juice intake, BMI category, and child, parental, and family characteristics. Almost one quarter (23.6%) of the preschoolers were at risk of being overweight or were overweight, 73.2% were within the normal range, and 3.1% were underweight. Overall, 88.1% of the children consumed 100% fruit juice during the intake period, with a mean intake of 210 ± 183.1 mL/d. Fifty-seven percent consumed more than 125 mL/d of fruit juice, and 31.1% consumed more than 250 mL/d, whereas US recommendations limit intake to 125 to 175 mL/d. No significant differences were seen in fruit juice intake among the BMI categories or with selected child, parental, or family characteristics. Consuming 100% fruit juice does not appear to be associated with preschoolers' BMI, but further longitudinal research is needed in larger, more diverse groups to confirm this finding. Meanwhile, increased parent education around appropriate beverage intake, including fruit juice, is warranted.

Study 1: To establish the validity of scores on Nutrition Screening Tool for Every Preschooler (NutriSTEP), a community-based parent-administered screening tool for assessing nutrition risk, by comparing scores to an expert rating. Study 2: To demonstrate test-retest reliability of NutriSTEP.Study 1: Parents of 269 preschoolers (of 294 parents recruited from the community), completed the NutriSTEP questionnaire; a registered dietitian (RD) assessed the nutritional status (based on medical and nutritional history, 3 days of dietary recall and anthropometric measurements) of these preschoolers and rated their nutritional risk (1 (low) to 10 (high risk)). Receiver operating characteristic (ROC) curves were used to establish validity and determine appropriate cut points based on sensitivity and specificity. Study 2: Parents of 140 preschoolers (of 161 recruited) completed NutriSTEP on two occasions. Intraclass correlation (ICC) and kappa were used to assess reliability.Study 1: Scores on NutriSTEP and the RD rating were correlated (r=0.48, P=0.01). Area under the ROC curve for the high risk RD rating (score 8+) and the moderate risk rating (score 5+) were 81.5 and 73.8%, respectively. A moderate risk cut point of20 and high risk cut point of25 were identified for the NutriSTEP scores. Study 2: The NutriSTEP score was reliable between administrations (ICC=0.89, F=16.7, P0.001). Most items on the questionnaire had adequate (kappa0.5) or excellent (kappa0.75) agreement.The NutriSTEP questionnaire is both valid and reliable for determining nutritional risk in preschoolers.

Nutrition is vital for optimal growth and development of young children. Nutrition risk screening can facilitate early intervention when followed by nutritional assessment and treatment. NutriSTEP (Nutrition Screening Tool for Every Preschooler) is a valid and reliable nutrition risk screening questionnaire for preschoolers (aged 3–5 years). A need was identified for a similar questionnaire for toddlers (aged 18–35 months). The purpose was to develop a reliable and valid Toddler NutriSTEP. Toddler NutriSTEP was developed in 4 phases. Content and face validity were determined with a literature review, parent focus groups (n = 6; 48 participants), and experts (n = 13) (phase A). A draft questionnaire was refined with key intercept interviews of 107 parents/caregivers (phase B). Test–retest reliability (phase C), based on intra-class correlations (ICC), Kappa (κ) statistics, and Wilcoxon tests was assessed with 133 parents/caregivers. Criterion validity (phase D) was assessed using Receiver Operating Characteristic (ROC) curves by comparing scores on the Toddler NutriSTEP to a comprehensive nutritional assessment of 200 toddlers with a registered dietitian (RD). The Toddler NutriSTEP was reliable between 2 administrations (ICC = 0.951, F = 20.53, p < 0.001); most questions had moderate (κ ≥ 0.6) or excellent (κ ≥ 0.8) agreement. Scores on the RD nutrition risk rating and the Toddler NutriSTEP were correlated (r = 0.67, p < 0.000). The area under the ROC curve for moderate and high RD risk ratings were 84.6% and 82.7%, respectively. Cut-points of ≥21 (sensitivity 86%; specificity 61%) (moderate risk) and ≥26 (sensitivity 95%; specificity 63%) (high risk) were determined. The Toddler NutriSTEP questionnaire is both reliable and valid for screening for nutritional risk in toddlers.

To examine if zinc food fortification makes a significant contribution to dietary zinc intake and to describe zinc-fortified food usage, amongst Canadian preschoolers.Cross-sectional data were used from the NutriSTEP validation project for which preschoolers (3-5 years) from across Ontario were recruited using convenience sampling. Three-day food records were used to estimate mean daily zinc intake and children were stratified by age group for analysis. Comparisons were then made to the Dietary Reference Intakes, whilst accounting for zinc from zinc-fortified foods and supplements and also whilst excluding zinc from zinc-fortified foods, to determine the prevalence of inadequate (Estimated Average Requirement (EAR)) and excessive (Tolerable Upper Intake Level (TUL)) zinc intakes. The contributions (%) made to total zinc intake by zinc-fortified foods, unfortified foods and zinc-containing supplements were determined as were contributions made to zinc intake by zinc-fortified foods, categorized by fortified-food type.Fewer than a third (30%, n = 76) of participants ate zinc-fortified foods and only 3% (n = 7) used a zinc-containing supplement. Including the contribution from zinc-fortified foods, 25% (n = 32) of 3-year-olds (n = 128) had mean zinc intake (range 7.0-7.6 mg/day) marginally above the TUL (7 mg/day). Zinc-fortified foods contributed only 2.3 +/- 5.8% (mean% +/- SD) to total zinc intake. The mean intake of the 25% of 3-year-olds above the TUL is attributed to their higher mean energy and protein intakes (p0.001) as compared to 3-year-olds not consuming zinc at levels above the TUL. Even excluding zinc-fortified foods, the prevalence of inadequate zinc intakes (EAR) (n = 254) was zero. Fortified breakfast cereals contributed most (77 +/- 41%) (mean% +/- SD) to zinc intake derived from zinc-fortified foods.Overall, zinc-fortified foods and supplements contributed minimally to the total dietary zinc intake amongst these preschoolers. These children did not have inadequate intakes of zinc and intakes in excess of the TUL were only evident in the youngest age group. Food fortification and parental choice to use a multivitamin-mineral supplement did not appear to play a role in either preventing inadequate or causing excessive zinc intake.

Purpose: Parents’ health literacy skills include food and nutrition knowledge, as well as the ability to read, comprehend, and use information related to their children’s health. The evaluation of a nutrition education booklet within the NutriSTEP™ ( Nutri tion S creening T ool for E very P reschooler) Project was conducted. Parents’ nutrition education needs and their sources of nutrition information were also assessed. Methods: Eight dietitians from four provinces conducted in-person interviews with a sample of 322 parents. Parents were asked their perception of the booklet and reported learning. Dietitians’ written feedback on the booklet and their recorded comments and nutrition advice to parents were gathered. Results: Collated feedback led to significant revisions to the booklet. Parents reported increased knowledge from the booklet; 38% wanted more information on nutrition, while 25% wanted to know more about preschoolers and physical activity. The top three sources of nutrition advice for this parent sample were physicians, dietitians, and public health units. Conclusions: Written materials must be evaluated with the target audience to improve readability and comprehension. Further nutrition education efforts should be targeted through parents’ main sources of nutrition information. Further research is needed on nutrition education intervention effectiveness to promote positive health outcomes.