Telehealth in Dietetic Practice: Current Use and Considerations

for Future Applications

Justine Zozula and Perry Smizer

12.3.18
Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

Introduction

It is universally known that technology has been rapidly advancing and that

technology use is widespread since the inception of the digital revolution. Reports

compiled by the United States Census Bureau show that as of 2016 roughly 90% of

households in the United States have a computer at home(1). Technology is already a

part of our day to day lives and redefined the way our healthcare system operates. This

implementation suggests that the use of technology, specifically telehealth, should be

expanded upon further in our healthcare system. According to the World Health

Organization, Telemedicine is defined as “ the delivery of healthcare services, where

distance is a critical factor”(2). telehealth falls under the umbrella term of e-health and

uses technology to communicate and relay information related to diagnosis, treatment,

evaluation, research and prevention of specific disease. Not only could expanding

telehealth improve the reach of healthcare, but if utilized within regular practice, there is

the potential to decrease the ever rising healthcare costs.

Previous studies have shown that using telehealth has provided access to

patients that would not have access to a primary care provider (3),and have also shown

willingness to try telehealth as supplementation to or in replace of their routine

in-person visit (4). In a study surveying user satisfaction of telehealth visits, patients

who had previously used telehealth indicated that the tele-visit had been as beneficial

as an in person visit (4). One study related to patient satisfaction conducted by Levine

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

et.al resulted in 85% of patients stating that they felt confident in their doctor’s use of

telemedical devices, 78% of patients responded that they would use telehealth visits

again to see their doctor, 68% of patients answered that the telehealth visit had saved

them money and time on travel and 70% of the patients would recommend telehealth to

people they know(4).

Providers have also shown interest in trying telehealth and using new technology

(5). There are, however, potential barriers to this new technology. One barrier to

telehealth is that some patients do not have a mobile device to use to contact clinicians.

Other barriers include the potential of providing too much information to patients,

concerns regarding liability, initial expenses regarding compliant devices, as well as

issues that may arise in relation to ethical or moral code with the need of keeping

private information confidential and secure(5,30).

While there is a plethora of information regarding telehealth and telehealth in

general, little is known on how telehealth can be fully utilized within the dietetic field.

Some studies related to weight loss and telehealth show promising results, and while

there is very limited research on how telehealth can be implemented for nutrition

counseling or assessment, there is no information on what the current opinions are of

Registered Dietitians and the implementation of telehealth in their field. Due to these

large gaps, the purpose of our study is to determine how telehealth is currently being

used in the dietetic field, what the benefits and barriers of telehealth are and the

perceptions of current Registered Dietitians regarding future uses.

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

Methods

The search for our topics of interest was completed using the Academic Search

Complete, Medline and PubMed databases. Our initial search included the terms

telemedicine or telehealth or telecare AND nutrition counseling AND children. This first

search yielded 1613 results, which was quickly narrowed down to 173 results after

limiting the search more. The limitations incorporated were: peer reviewed, subject

terms, academic journal source and finally, of the english language. The 173 articles

were narrowed down to 13 applicable studies based on title and utilization of telehealth,

finally abstracts were read. Articles were excluded from our results if they did not

mention nutrition or nutrition counseling, was not a study with measurable outcomes,

was a review article, did not directly influence the target population and were nursing

home bound if of elderly age.

From that initial search, additional searches were completed using key terms

and phrases such as: telemonitoring, telepractice, telenutrition, Registered Dietitians

and telemedicine, nutrition and telemedicine, nutrition counseling and video

consultation. Over 2,000 results came from this search. A secondary search pertaining

to clinician perspectives regarding telehealth was conducted simultaneously. Key terms

and phrases for our secondary search included: Registered Dietitian’s perspectives and

telemedicine health, clinician attitudes and telemedicine or telehealth, opinions and

telemedicine. This search produced over 500 results. For all queries, the search was

limited to full text, peer reviewed articles that were primary sources from 2008-2018 and

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

when possible, the reference lists of articles reviewed were manually reviewed for

potential additional articles.

Articles were included in our preliminary collection if they were conducted after

2008, mentioned telehealth or an affiliated term and was related to nutrition, specifically

nutrition assessment or consultation. From there we broadened our inclusion criteria to

include telehealth and other clinical practice in order to determine other current use.

Finally, we included clinician perspective. The title and abstract of each article, after

cursory exclusion, were then read and reviewed to determine if the study should be

included in this review. As mentioned above, the reference lists of the articles, which

were deemed appropriate for this review, were also analyzed. This lead to three articles

that were outside our search range to be included due to content applicability ( 8, 15,

16).

In the end, 25 original research studies were compiled and analyzed. Out of

these 25, ten were cohort studies, eight were randomized control studies,three were

quantitative research studies that incorporated surveys and two were qualitative

research studies, one that utilized focus groups and the other an interview process.

Finally there was one systematic review and one clinical trial incorporated into our

research.

Results

Current uses in Nutrition

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

Out of the twenty-five articles included, eleven pertained to current telemedical

uses in nutrition. Seven in relation to weight loss and four in relation to other nutritional

usage. The remaining fourteen articles were split between other clinical uses of

telemedicine, nine studies total, and finally five pertained to clinician’s perspective.

Telemedicine and Weight loss:

Of the eleven studies, seven reviewed the use of telemedicine in weight loss.

Four studies were randomized control trials (6, 8,9,11), one was a non randomized

control trial (12) and the final two studies were classified as cohort studies (7,10). These

studies varied from children and adolescents (6,7,10), adults (8,9,12) elderly

participants(11) and were from multiple locations including the United States, Germany,

Columbia and Australia. The studies utilized either a video-conferencing component, or

a mobile cell-phone element.

Five of the studies yielded statistically significant results at the end of their

studies in relation to their outcome (7-10,11) while two determined there was no

significant difference in their findings (6,12).

Of the randomized control trials, three found statistically significant differences in

weight reduction measurements, such as weight loss, decrease in waist circumference

and decrease in BMI, when comparing the telemedical intervention group to the control

groups (8,9,11). Patridge S. et al utilized a mobile health component to improve eating

behaviors of young adults by incorporating text messaging. The intervention group

received five calls with a dietitian for coaching, two months of weekly text messaging

that targeting specific interventions per week, weekly emails and access to the

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

program’s app and website. In comparison, the control group received a two page

handout with dietary guideline information, an introduction call and four text messages

over three months. At the end of this study, the telemedicine intervention group

weighed 2.3kg less than the controls after 9 months when compared (95% CI -3.3, -1.3,

p<0.01). Alencar et.al employed weekly video-conferencing sessions with a dietitian for

twelve weeks in conjunction with monthly video-conferencing sessions with a physician

for the intervention group. In comparison, a control group received no telemedical

supplementation, aside from the initial video conference examination with the study’s

physician as well as calorie and activity recommendations from the dietitian. This

resulted in significant differences in percent of body weight lost ( 7.2 +/- 4.4% vs 1.5%

+/-4.1%), body fat percentage ( -9.0+/- 8.3% vs 1.3+/-7.7%) and amount of steps taken

per day ( 30,163.8 +/- 30,117.6 vs -5972 +/- 22,286) when compared to the control

group. Finally, Izquierdo et al conducted monthly telemedical video consultations with

dietitians and diabetic nurses for 2 years as part of the IDEATel (Informatics and

Diabetes Education and Telemedicine) project, which resulted in the women involved in

the telemedical intervention group decreasing their waist circumferences by 1.2 cm over

two years (Adjusted baseline: 111.56 +/-1.16 cm, Adjusted two year: 109.69+/-1.20cm),

while their counterparts in the control group increasing their waist circumferences by

roughly 1 cm ( Adjusted baseline: 110.76+/-1.17cm, Adjusted two year: 111.28

+/-1.20cm) . On the other hand, the final randomized control trial, conducted by Davis

et.al, concluded that there was no discernable difference between the telemedicine

intervention group which incorporated weekly family based telemedicine interventions

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

for 12 weeks when compared to the control group who had weekly physician visits for

12 weeks. The lack of significant differences between the two groups was then

interpreted as telemedicine counseling being just as effective in weight loss intervention

as in person physician interventions. The non-randomized control trial produced by

Kuzmar et al. also yielded non statistically significant differences in weight reduction

assessment when comparing their telemedical intervention group, which entailed virtual

weekly monitoring as well as emails and online messaging, to the traditional in person

counseling control group. However, the authors did note that less participants dropped

out of the telemedicine group (9%) compared to the traditional group (13%) and more

participants failed to lose weight or measurements in the traditional group (35%)

compared to the telemedicine group (21%).The studies definition of failure was

specified as not losing any total weight, or if there was no decrease in BMI, Waist

circumference, hip circumference, or waist to hip ratio.

The last two studies included in this grouping were cohort studies (7,10). Schiel

et al. incorporated telemedicine to assess physical activity and eating habits in

overweight and obese children by way of mobile phone sensors which yielded high

usability and comfortability with the technology provided to them as well as significant

weight loss. Subjects had an average loss of 7.1+/- 3.0kg which resulted in a statistically

significant BMI reduction (p<.01) in participants. Nourse et.al, also integrated

telemedicine with diet and exercise interventions by way of multiple video-conference

sessions with a personal trainer and a weekly video-conference session with a dietitian

for obese adolescents. Intervention outcomes for this particular study had been looking

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

for weight loss reduction in order to improve cardiovascular function and a positive

difference was noted between baseline levels and post intervention levels in total

cholesterol (159+/-27 vs 147 +/-23 mg/dL, p<.004), LDL (91 +/- 20 vs 81+/-.08 mg/dL,

p<.004), and Waist to Hip Ratios (0.87 +/-0.08 vs 0.84+/- 0.08, p<.03) when compared

using paired t test.

Most of the studies had relatively large sample sizes of 50 plus participants

(6,7,9,11,12), however, two studies (8,10) had less than 50 participants as part of the

sample. Alencar et. al only had 25 obese men and women participate in their study

while Nourse et. al only had 20 adolescents participate. In addition to sample size, other

limitations of note included homogeneous patient demographics (6), limited or no

patient demographics (7,8) volunteers which may have skewed participation willingness

(10) or create an unbalance between interventions (12) and finally, large loss to follow

up (11).

Uses of Telehealth in Nutrition Unrelated to Weight Loss:

While nutrition related interventions featuring telehealth mainly focuses on weight

loss, there were four articles located that show that other uses of telehealth in the

dietetic field have been attempted. Three of the four articles are cohort studies (13-15),

while the final study is a randomized control trial (16). These studies vary in topic,

however, they have a nutrition component that was deemed important to this review.

Two of the cohort studies incorporated video conferencing with a dietitian as the

intervention (13,15), while the final cohort study used an internet based e-health

program (14). Johnson et.al looked into patient opinions and satisfaction regarding

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

telemedicine and nutrition counseling. A total of 135 patients were included in the study,

98% of the patients had beneficial experiences with their telemedicine visit, with 79% of

patients keeping their televisit, which consisted of a video-conference session.

Kariyawasam also utilized video-conferencing, however, this study assessed the

effectiveness of telemedicine for dietary counseling with patients who had been

diagnosed with hyperphosphatemia. This particular study assessed patients diagnosed

with Established Renal Failure who subsequently experienced hyperphosphatemia due

to hemodialysis. Patients received nutrition counseling which resulted in a decrease in

phosphate levels from the time of the referral (2.46 +/- .47 mmols/l) to 6 months after

their telemedicine intervention (1.96 +/- .16 mmols/l; p value < .02). In contrast,

Moessner et al, attempted to utilize an e-health program to determine if it could assist in

providing professional care in the prevention and early intervention of eating disorders.

With the help of this telemedicine program, 9.5% of the participants received treatment

after participating in the program for three months with 24.4% stating they sought

treatment due to use of the program.

The final study included in this grouping was a randomized control trial (16)

which looked into how to utilize telehealth for diabetes education purposes. A total of 56

diabetic adults were randomly assigned to either the telehealth intervention group where

they had a video-consultation with a dietitian regarding diabetes education and glycemic

control or to an in-person consultation receiving the same education. This study utilized

a questionnaire to gauge psychosocial function in relation to diabetes, which indicated

participants had statistically significantly improved compared to their baseline testing

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

immediately after education training, which persisted at the 3 months follow up in both

groups (2x3 ANOVA testing;p<.005). In addition to psychosocial function, glycemic

control also improved, when analyzed by the 2x3 ANOVA, in both groups after

education (p<.001) . One thing to note is that patient satisfaction was very high in the

telemedical group with 84% of patients responding they would use telehealth again if

available.

For this grouping of studies, sample size again was a limitation. Two of the

studies had less that 50 participants in their sample (13,15), while two had more than 50

participants (14,16). Two of the studies experienced technical difficulties with

telemedical visits (13,15), while one study had a very short study period (14). The

randomized control trial (16) had several limitations including the lack of a true control

group who received no treatment, as well as baseline demographic differences between

the intervention and control groups.

Novel Uses of Telemedicine for Monitoring and Patient Education in Various

Diseases or Conditions:

There are many uses of telemedicine in other medical fields. Nine articles look at

how telemedicine has been used in other clinical fields. Five of the studies were cohort

studies (18, 19, 21, 22, 23), two of the studies were randomized control trials (17, 24),

one study was a clinical trial (25) and another was a systematic review (20). Eight of the

articles found that telemedicine improved the outcome or provided care that was similar

to clinical service (17-23, 25). The one article that had no improvement in the target

outcome looked at CVD reduction through telephone based intervention delivered by a

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

clinical pharmacist specialist (CPS). The study was a randomized control trial and the

results of this study found no reduction in CVD risk score as compared to the control

group (24). There was a second randomized control trial, out of these 9 articles, that

assessed the ​efficacy of self-monitoring blood pressure for titration of antihypertensive

medication. This study found that telemonitoring and self monitoring were effective in

lowering systolic blood pressure, as compared to clinic monitoring, after 12 months. The

telemonitoring group had a mean systolic blood pressure that was significantly lower

than usual care after 6 months (17).

Two of the nine studies looked at how telemedicine is used in machine based

learning (19,23). The first study assessed a machine based learning software

development kit (SDK) for four different arcs of motion for shoulder movement. The

results found that there was a 5 degree difference between the SDK and the goniometer

(19). The second study assessed whether machine based learning techniques used

with telemonitoring datasets would help to predict hospital admissions for COPD, as

well as help to determine when to start corticosteroids. The second aim of this study

was to assess if adding weather data also increased predictions. The results of the

study found that there were significant improvements in predictions of hospital

admissions for COPD, however, there was no significant improvement in predictions for

the addition of weather data (23).

Two studies measured efficacy as the outcome (18, 20). The first study was an

Occupation-Based Coaching intervention for families with children who have Autism

Spectrum Disorder. The result of this study found that telehealth was effective at

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

delivering the intervention to parents and increased their efficacy. It was increased child

participation (18). The second study was a systematic review that looked at

telemedicine for caregivers of cancer patients.The review found that there was

statistical significance of the caregivers efficacy as measured by their emotions and

ability to help patients manage their symptoms (20).

Another study looked at the effectiveness of video telehealth and telephone

appointments for patients with diabetes mellitus (DM), hypertension (HTN) or

hyperlipidemia (HLD). The results found that this method was effective in medication

management conducted by clinical pharmacy specialists. When analyzed by a paired ​t

test, the DM group had reduction in HbA1C that was 2.42% (p<0.0001). The HTN group

had decrease in blood pressure of 11.00 mm Hg (p<0.001). And the HLD group had 77

patients taking a statin dose that was the goal outcome at discharge. A limitation of this

study is the chosen sample population. This study was conducted using a very specific

population group and therefore may impact generalizability (21).

Another study assessed in-person versus telehealth for discrete trial training

therapists. This was a cohort study that only included 7 participants. The results showed

that the target skills were similar between the in-person training as compared to the

telehealth training. The Multiple Stimulus without Replacement (MSWO) Preference

Assessment had a higher number of training trials for in-person. In-person training had

more prompts (M=7.3) than the telehealth training (M= 4.75). A limitation to this study is

the very small sample size (22).

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

Another cohort study assessed an aspect of telemonitoring that is still new and

has limited data. This study looked at the adherence of patients with chronic conditions

to measure scheduled vital signs at home using telemonitoring. The results showed that

there was 64.1% adherence for all measurements. The measurements included

noninvasive blood pressure, pulse oximetry, spirometry, electrocardiogram (ECG),

blood glucose level, body temperature, and body weight. Adherence was determined by

assessing the number of scheduled events and the number of actual measurements

that were performed. This was used to calculate the adherence ratio. Adherence was

significantly higher in those that were monitored in a hospital setting as compared to

those that were monitored in a community setting (P=0.02), when analyzed by a

2-sample ​t​ test . The measurements that had a higher adherence in a hospital setting

were spirometry, body weight, and body temperature (25).

Clinician Perspective Regarding Telemedicine Use:

The final component to our review included obtaining the opinions and attitudes

of clinicians surrounding the use of telemedicine within every day practice. Five articles

were obtained that directly measured clinician opinion and attitude with current of future

use of telemedicine. Three of the studies included were quantitative studies which

incorporated a web based survey (26, 29,30), while two where qualitative research

studies, one with interviews (27) while the other held focus groups (28).

Grassl et. al, utilized a web-based survey that assessed the perception of health

care professionals in obstetrics and telemedicine. The survey was completed by 244

health care professionals. Among the health professionals, 72.9% were not very

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

convinced to use telemedicine in obstetrics, however 72% of physicians were hopeful

of using apps as a way to monitor pregnancy. The other 36.1% of non-physicians were

not optimistic about using an app to monitor pregnancy. The overall findings showed

that non-physicians were not in favor of using telemedicine. One factor of note is that

the obstetricians that had work experience of 10 years or more were not convinced of

the potential use of telemedicine (26). ​ ​Goodwin et al, also incorporated a web based

survey assessing how video-consultation impacted medical officer’s attitude, knowledge

and practice changes in remote areas of Australia. The participants filled out a survey

after every televisit with a patient which resulted in 350 surveys completed. Of all the

medical officers surveyed, 86% stated that the telehealth consultation had changed the

care management they gave to the patient, 93% said they would use telemedicine again

and 100% would recommend using telehealth to colleagues. Although many positive

responses were seen, 57% of participants stated they experienced technical difficulties

and 71% of respondents indicated they still faced logistical difficulties, which was

defined by the article as no show patients. The final study incorporating a web based

survey was completed by Levy et al, who looked into the perceptions of Child and

Adolescent Mental Health Service staff members in Northern Scotland. A majority of the

respondents (69%) had prior experience using telemedicine for various reasons

including administrative related work (76%), clinical usage (62%), educational purposes

(55%) and a few had previously used telemedicine for therapy visits (24%). Most

participants believed that telemedicine could improve access (83%), that it could reduce

travel time and cost of patients, parents and caregivers (98%) or that it would decrease

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

the amount of time missed from school or work (61%). In contrast, a few respondents

worried that incorporating telemedicine into daily practice may cause extra work stress

and burden upon staff or that technical difficulties would be a big issue.

Two other studies incorporated into this section were qualitative research studies

that utilized either a focus group or interview component of key informants. Kolltveit

et.al, assessed the perception of health care professionals who used telemedicine with

patients who have diabetic foot ulcers. This study used focus groups to collect data. The

results of this study showed a general positive perception of telemedicine as a way to

provide care to people with diabetic foot ulcers. There were three ways that the health

care professionals saw telemedicine benefit their practice. These included increased

knowledge of wound assessment and skills, improved documentation quality, and

communication among specialists and primary health care (28).

Comparatively, Whelan et. al, interviewed key decision makers including Nutrition

and Dietetic department heads and senior dietitians, regarding awareness of a

particular telephonic program as well as perception and sustainability. Unfortunately,

most were not aware of the program offered, however, were able to still give opinions

regarding telemedical use. Many were in favor of telemedicine in everyday practice due

to improved flexibility for patients as well as predicted the use of telemedicine would

increase interest and therefore have good outcomes. In contrast, the participants

indicated that they would prefer an initial consultation in order to have face to face

contact due to the telephonic nature of the program.

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

It is interesting to note that none of these articles related to clinician perspective

were completed in the United States, but mainly came from Scotland (30), Australia

(27,29), Germany (26) and Norway (28).

Discussion

Unfortunately many of the studies included had very big variations between

them which included difference in length of treatments, mode of delivery system with

different ways utilized, as well as different types of study design. Due to these

inconsistencies regarding study design and outcomes, this should be taken into

consideration when assessing these results.

Despite this, it is clear from this literature review that there are many uses for

telemedicine and many modes incorporating telemedicine into the healthcare industry.

Multiple studies noted no difference between the telemedicine group and the in person

typical care (24), which could potentially be interpreted that telemedical care is just as

effective for an outcome, whether that be education, weight loss, or dietetic counseling

(6,12,26) as in person typical treatment. There was also some evidence that

telemedicine ended up being beneficial for a specific outcome, which could be

interpreted that telemedicine allowed for more flexibility for the patient to be able to see

a clinician, less travel time expended, comfortability of seeing a clinician in a more

comfortable setting (7-11,15).

Clinician perceptions were mainly positive with current usage of telemedicine

technology as well acknowledgement of the benefits surrounding future use in respect

to patient care, flexibility for both patient and provider, accessibility to specialists, and

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

kept appointments (26,27, 28,29, 30), however there continue to be concerns related to

technical difficulties and work burden (27,29,30).

Despite current routine usage of telemedicine in other clinical practices,

telemedicine in nutrition is mainly utilized for weight loss programs, and there was no

information regarding Registered Dietitian’s perceptions on current or future use. Due to

the lack of this information and the relatively small studies outside of weight loss

programs, studies analyzing perception of RDs related to telemedicine and its potential

other uses, as well as studies that incorporate nutrition assessment or counseling are

necessary in order to determine feasibility of this rapidly advancing and expanding

health care tool.

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Telemedicine in Dietetic Practice: Current Use and Considerations for Future Applications

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