Digitally Supported Dietary Protein Counseling Changes Dietary Protein Intake, Sources, and Distribution in Community-Dwelling Older Adults

Digitally supported dietary counselling may be helpful in increasing the protein intake in combined exercise and nutritional interventions in community-dwelling older adults. To study the effect of this approach, 212 older adults (72.2 ± 6.3 years) were randomised in three groups: control, exercise, or exercise plus dietary counselling. The dietary counselling during the 6-month intervention was a blended approach of face-to-face contacts and videoconferencing, and it was discontinued for a 6-month follow-up. Dietary protein intake, sources, product groups, resulting amino acid intake, and intake per eating occasion were assessed by a 3-day dietary record. The dietary counselling group was able to increase the protein intake by 32% at 6 months, and the intake remained 16% increased at 12 months. Protein intake mainly consisted of animal protein sources: dairy products, followed by fish and meat. This resulted in significantly more intake of essential amino acids, including leucine. The protein intake was distributed evenly over the day, resulting in more meals that reached the protein and leucine targets. Digitally supported dietary counselling was effective in increasing protein intake both per meal and per day in a lifestyle intervention in community-dwelling older adults. This was predominantly achieved by consuming more animal protein sources, particularly dairy products, and especially during breakfast and lunch.


Dietary counselling, design, materials and BCTs
The dietary protein counselling intervention is developed with a similar approach as the blended home-based exercise program [17]. The process of the development of the design, feasibility phase until this Evaluation study is described following the Medical Research Council (MRC) framework for complex interventions. The combination of scientific literature, as well as practice-based evidence was encountered. Within behavioral nutrition and exercise interventions that target of lifestyle changes, the combination of group contacts with individual contacts is seen more often as successful [44,45]. The opportunity arises to incorporate several group-related BCTs and individual-related BCTs into the intervention components and materials.

3) Blended counselling
Our blended counselling can be introduced as the combination of face-to-face contacts and tele-health contacts (primarily videoconferencing with an application, as mentioned as digitally supported). Digitally supported dietary counselling has benefits of remote guidance including non-verbal communication, reduced travel time and costs. In current dietetics practice face-to-face contacts are most often used, which is beneficial for the clients' trust and to exchange documents. Especially in the population of older adults, the face-to-face contacts are common practice.

Identifications of the requirements for the dietician coach
Coaching tools 1) Feedback and monitoring 2) Interprofessional communication 3) Reporting > A shared coaching manual was developed and a coach CMS website. The coaching manual included information on the Coaching schedule (See Additional Document S1), theoretical framework, goals per visit, and other features to be able to carry out the intervention. We were aiming to improve knowledge, competence and skills, in order to increase the level of expertise of the (student) coaching professional. Topics as e-coaching, motivational interviewing and interprofessional collaboration were included. The coach CMS website was designed for interprofessional communication and reporting purposes.

Dietary counselling materials and BCTs
Additional to the scientific evidence, the requirements and functional components were collected by use of expert interviews. The following intervention materials were developed or encountered.

Functional component of the Dietary protein counselling intervention BCTs
Videoconferencing app (Skype) behavioral rehearsal, graded tasks, verbal persuasion about capability. Classroom lecture at baseline assessment; elaboration session information about health consequences, framing/reframing, behavioral practice/rehearsal (workbook/reading food labels), guided practice (direct experience/tasting), goal setting (1.2-1.5 g/kg/day), social comparison. Information magazine with emphasis on protein rehearsal of information (knowledge/competence), behavioral rehearsal. Two-week workbook; including recipes, protein product group list self-monitoring of behavior & goals, habit formation, behavior rehearsal, action planning. Group session after two weeks guided practice (videoconferencing/increase e-health literacy), feedback on behavior (coach/workbook), goal setting, graded tasks, problem solving, planning coping responses, social support (practical/emotional), social reward, verbal persuasion about capability. Monthly group visit e.g. action planning, problem solving, planning coping responses, social support.
Individual video-conferencing and counselling social support, social incentive/reward, action planning, feedback on behavior, goal evaluation, prompts/cues, problem solving (motivational interviewing).

Feasibility and Piloting
A pilot was performed with the dietary counselling intervention and materials with three existing exercise groups of community-dwelling older adults. These were selected from another region in the Netherlands, as the target population of the RCT was the Amsterdam metropolitan region. > After the pilots the information brochure and coaching manual was further developed and improved.

Evaluation
> RCT: Assessing effectiveness. The results of this dietary protein counselling intervention is furthermore published in this article.

Randomized: Clusters (n = 45) Older adults (n = 245)
Older adults Excluded (n = 12): Not meeting inclusion criteria (n = 12) Allocated to HBex; clusters (n=15), median 4, IQR= 3-5 Older adults (n=73) Received allocated intervention (n=65) clusters (n=15)  0.015 * P values for the comparison among the groups from baseline to 6 months and 12 months were calculated with the use of mixed-model analysis of repeated measures. Fixed factors include time and group*time interaction. Random intercepts include cluster and subject. Unless otherwise noted, no covariates added. a Covariates Sex and Age were added. b Model without cluster. CON, Control group (n=84); HBex, Homebased exercise training group (n=63); HBex-Pro, Home-based exercise training with dietary protein counselling group (n=65). # HBex-Pro is the reference group. † Difference in mean scores HBex-Pro vs HBex. ‡ Difference in mean scores HBex-Pro vs CON.