More-2-Eat; Implementation of INPAC
Conditions: Acute Care Medical
Sponsor: University of Waterloo

STUDY PROTOCOL
Open Access
More-2-Eat: evaluation protocol of a
multi-site implementation of the Integrated
Nutrition Pathway for Acute Care
Heather Keller1,2*
, Celia Laur2, Renata Valaitis2, Jack Bell3, Tara McNicholl2, Sumantra Ray4, Joseph Murphy5,
Stephanie Barnes6 for the More-2-Eat team
Abstract
Background: Nutrition care in hospitals is often haphazard, and malnourished patients are not always readily
identified and do not receive the care they require. The Integrated Nutrition Pathway for Acute Care (INPAC) is an
algorithm designed to improve the prevention, detection and treatment of malnutrition in medical and surgical
patients. More-2-Eat is an evaluation of the implementation of INPAC care activities (e.g. screening) in five
diverse medical units from different hospitals in Canada. The primary purpose is to understand how tailored
implementation affects INPAC uptake and factors that impact this implementation. The principal outcome is a
toolkit that can provide guidance to others.
Methods: This participatory action research uses a before-after time series design to address several research
questions focused on implementation and uptake of INPAC (e.g., Does the implementation of INPAC improve the
detection of malnutrition? Do nutrition care related knowledge, attitudes and practices scores of unit staff change
with the implementation of INPAC?). A six-month developmental phase where baseline data were collected is
followed by a twelve-month implementation phase and a three-month sustainability phase. Qualitative and
quantitative data are collected concurrently, and to address key research questions, these data are merged.
Quantitative data are collected on-site by trained local dietitians and include chart audits of nutrition care
practices and a more detailed assessment of recruited patients on quality of life, disability, frailty, food intake
and barriers to food intake. Thirty-day post discharge follow up for these patients occurs by researchers via a
telephone interview at three time points within baseline and implementation phases, to ascertain the same and
other outcomes (e.g. readmission to hospital). Qualitative data include focus groups and key informant interviews
completed by researchers, monthly teleconferences among the sites and site-completed forms that track
implementation activities. Resource utilization of dietitian time for various care activities (e.g. assessment) and
staff time to assist patients at mealtimes is also collected.
Discussion: More-2-Eat provides an example of how implementation can be tailored when a care algorithm is
embedded into routine practice. The project also highlights important learning points with respect to data
collection and techniques to support implementation.
Trial registration: Retrospectively registered ClinTrials.gov Identifier: NCT02800304 June 7, 2016.
Keywords: Malnutrition, Hospitals, Nutrition assessment, Health plan implementation
* Correspondence: hkeller@uwaterloo.ca
1Schlegel-University of Waterloo Research Institute for Aging, University of
Waterloo, 250 Laurelwood Drive, Waterloo, ON N2J 0E2, Canada
2Faculty of Applied Health Sciences, University of Waterloo, 200 University
Ave, Waterloo, ON N2L 3G1, Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Keller et al. BMC Nutrition  (2017) 3:13 
DOI 10.1186/s40795-017-0127-5

Background
Internationally collated evidence demonstrates that up
to half of patients admitted to hospital suffer from or are
at risk of malnutrition (under-nutrition) [1–5]. Three-
quarters of these malnourished patients are not being
detected and thus are nutritionally undertreated [6]. This
issue is especially of concern for medical patients who
are more likely to be malnourished than surgical patients
[3, 6] and for those over the age of 65 who are more
likely to be malnourished than younger patient popu-
lations (46% vs. 35% for < 65 years; [7]). Poor food in-
take is also common and results from multiple factors
including poor food quality, food/eating preferences,
feeling unwell and other disease side effects, as well
as barriers to food intake, such as not being able to
access the tray or requiring eating assistance [8, 9].
Both poor hospital food intake and malnutrition lead
to negative health outcomes including a longer length
of stay, readmission, and comorbidities and mortality
[3, 7, 10–14].
Despite the considerable evidence describing malnutri-
tion and poor food intake in hospitalized patients, these
issues continue to be undetected and undertreated due
to a lack of recognition, prioritization and integration of
key care activities (e.g. screening) within the interdiscip-
linary team [15, 16]. Identifying notable gaps in the care
system will drive the identification of potential solutions
to improve these outcomes. For example, dietitian con-
sults are typically haphazard [6, 17] and standardized
nutrition screening programs could ensure that mal-
nourished patients are identified and treated. Patients
report many barriers to food intake [18] and effective
low-technology solutions could be a feasible way to ad-
dress these issues. Physician and nurse attitudes, know-
ledge and nutrition care activities demonstrate that
education and training are needed to promote and
sustain best practice [14, 19–27]. It is anticipated that
improving care processes in hospital would also prevent
iatrogenic malnutrition.
Best practice recommends engaging the team to be-
come ‘food aware’ and to treat nutrition as a central
therapy; malnutrition has serious consequences, and
for many patients food is the medicine they require
[14, 25, 28, 29]. Screening to detect malnutrition and
monitoring of food intake are important strategies to
ensure that patients receive the required nutrition
care [14, 23–26, 30, 31]. Focusing mealtimes on food
intake and ensuring that staff is available to assist with
mealtime activities are also important [28, 30, 32–36].
Continuing nutrition care for malnourished patients post
discharge has also been recommended [14, 27, 36]. In
response to these best practice recommendations and to
improve nutrition care practice, a treatment algorithm for
hospital use in medical and surgical patients was created.
The Integrated Nutrition Pathway for Acute Care
(INPAC) was designed to be a feasible, evidence and
consensus-based algorithm to improve nutrition care [37]
(Fig. 1). Key decision points promote quality nutrition care
for every patient, at the appropriate time, by the right
health provider. Care activities include: 1) screening at ad-
mission with the valid and reliable Canadian Nutrition
Screening Tool (CNST) [38]; 2) using subjective global as-
sessment (SGA) to definitively diagnose malnutrition after
screening and assist with triaging patients for individual-
ized assessment and care [39, 40]; 3) monitoring of food
intake for all patients, with frequency depending on nutri-
tional status; 4) implementation of preventative practices
to support food intake and address common mealtime
barriers; and 6) inclusion of nutrition concerns and hos-
pital treatment on discharge communications to support
patient transitions to community care. Tools to assess
food intake and identify mealtime barriers, and a ques-
tionnaire to identify the knowledge, attitudes and practices
(KAP) of hospital staff have also been developed [41–43].
Now that these knowledge products are available, a know-
ledge translation program that provides the necessary
educational, training and supporting materials, as well as
strategies to implement the INPAC is needed.
Other research has attempted to improve nutrition
care in hospitals, yet this research to date is scant. Prior
implementation research in this area of care has been
limited to key segments of a pathway (i.e., screening
only) [44, 45] or a specific patient population [46]. How
implementation occurs for a comprehensive pathway
such as the INPAC is not known, nor is it known what
resources are needed for such implementation. Gaps also
exist regarding patient reported outcomes and how the
unit context and climate potentially influences imple-
mentation. This knowledge is needed before dissemin-
ation of any innovation to improve nutrition care in
hospital, including the INPAC is undertaken [47–50].
An observational study that monitors how sites imple-
ment INPAC, the educational techniques and strategies
that are most successful, resource utilization and im-
pacts on staff roles and patient reported outcomes would
provide a substantial contribution to this field where
implementation research is just beginning. Further un-
derstanding and documenting, in sequence, the key steps
that are required for implementation and sustainability
of this complex intervention will be of benefit to the im-
plementation science community as a whole.
This manuscript describes the protocol for the More-
2-Eat study (M2E). This study has the overarching aim
of optimizing nutrition care in hospitals and thus per-
formance of the healthcare system, ensuring that malnu-
trition and poor food intake are prevented, detected and
treated. An allied but separate component that will not
be described in this protocol is an embedded feasibility
Keller et al. BMC Nutrition  (2017) 3:13 
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randomized control trial, focused on high protein
supplementation in frail elderly patients during and
post hospitalization. M2E is a participatory action re-
search study [51] with the primary objective of evalu-
ation [52] of the implementation of INPAC in five
diverse Canadian hospitals. The principal outcome of
this work will be the development of a toolkit that
provides strategies, tips, resources and tools for others
to use when implementing INPAC. Healthcare is
considered a complex adaptive system and thus par-
ticipatory action research is appropriate for evaluating
an implementation program that relies on change
within this system [51, 53–55]. Process and outcome
evaluation will also address the following research
questions:
1. Does the implementation of the INPAC increase the
detection and subsequent treatment of malnutrition
in hospital patients? What strategies are
implemented to prevent iatrogenic malnutrition?
2. Does the implementation of the INPAC improve
patient reported outcomes (e.g., food intake and
reduce mealtime barriers to intake)?
3. Does the implementation of the INPAC improve
knowledge, attitudes and perceived practices of
hospital staff?
4. How does the implementation of the INPAC vary
with context of hospital/unit environments?
5. What are the barriers and facilitators to successful
implementation and what are the necessary
ingredients for sustainability?
6. What is the resource utilization (e.g. time of staff)
for the implementation of the INPAC?
Methods
M2E is a participatory action research study [51] with a
before-after time series design. The primary aim is to
conduct an evaluation of the implementation of INPAC
in five sites. Multi-methods are used to address the vari-
ous research questions and a mixed methods approach
Fig. 1 The Integrated Nutrition Pathway for Acute Care [37]
Keller et al. BMC Nutrition  (2017) 3:13 
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with a triangulation design using the convergent model
[56] is used to explicitly merge qualitative and quantita-
tive data that will describe how implementation varies
by context of hospital site.
Overview of the More-2-Eat project
Selecting the Sites: Five diverse hospitals were carefully
selected through a request for proposals process (Royal
Alexandra Hospital; Niagara Health, Greater Niagara
General Site; The Ottawa Hospital; Concordia Hospital,
and Pasqua Hospital Regina Qu’Appelle Health Region).
A single medical unit within each chosen hospital is the
site for all data collection for M2E. Sites were chosen to
be diverse geographically, as well as varied in the type of
medical patient (e.g. stroke, geriatric, general medicine)
and current status with respect to nutrition risk screen-
ing (i.e. 3 of 5 sites were doing some level of screening
on patients with varied processes). At the time of re-
cruitment, no sites were using SGA to diagnose and
triage patients. This diversity was required to understand
the reality of implementing INPAC activities where
processes and resources are different [51, 57]. Sites
demonstrated commitment from the organization and
core members of the unit team (e.g. director of care, lead
nurse, physician, clinical nutrition manager, chief execu-
tive office of the hospital) as part of the site proposal
process [48, 50, 58–61]. Three of the five sites had par-
ticipated in the Nutrition Care in Canadian Hospitals
(NCCH) study, which was a prevalence investigation fo-
cused on describing the issues of malnutrition, outcomes
and care practices in hospitals [3, 7, 17]. This initial
NCCH study led to a program of research, which resulted
in the development of INPAC and now, M2E. Mapping of
this program of research onto the Knowledge-to-Action
Framework [62] is provided in Fig. 2. An interdisciplinary
and intersectoral national and international team of
experts, researchers, medical professional educators,
stakeholders and knowledge users was assembled to
inform M2E. Key decision makers and change agents
(e.g. Canadian Malnutrition Task Force, Dietitians of
Canada) are part of this group.
Resources and Tools for Integrating INPAC: The five
selected hospital sites were provided with funds to sup-
port M2E data collection and implementation activities.
Fig. 2 The development of the More-2-Eat project within the Knowledge-to-Action process theory. Reprinted from [62] with permission from
Dove Medical Press Ltd
Keller et al. BMC Nutrition  (2017) 3:13 
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The goal was to integrate and embed the care activities
of INPAC (described above) into the routine of the unit.
The ingredients for implementation were not dictated by
the research team, but strategies evolved and included
tailoring of materials developed centrally (e.g. educa-
tional slide decks), as well as invention of new know-
ledge translation products and activities [e.g. creation of
communication tools at the bedside to promote consid-
eration of patient needs for eating, such as reminders to
check for eyeglasses, dentures etc.]. Resources, tools,
strategies and behaviour change techniques are captured
in the data collection, as this divergence in implementa-
tion strategies is important for broader implementation
of INPAC [48, 49, 58, 60]. Sites are led by a research
champion (typically a clinical nutrition manager) and
one or two research associates (RAs) (clinical dietitians
and one nurse) who are seconded from their clinical role
for implementation and data collection activities. All
sites have developed a site implementation team (SIT)
(including key management, clinical and departmental
leads, unit staff representatives) that supports, and in
some cases, leads the direction of the project and provides
administrative navigation [48, 50, 58–60, 63]. A research/
facilitation team lead by the Principal Investigator (PI),
supports champions, RAs and the SIT through monthly
coaching/mentoring teleconferences, summarization of
local data for feedback, and guidance with change efforts.
This team consists of graduate students, post-graduate
trainees and a clinical expert, as well as the PI. The RAs
attended face-to-face training at the beginning of the
project to ensure consistency in all study procedures and
measures.
Phases of the More-2-Eat project
There are three distinct phases of M2E (see Fig. 3).
Developmental Phase (April-Dec 2015): This phase fo-
cused on finalizing data collection measures; assembling
and developing materials to support behaviour change in
the units; obtaining ethics board clearance (University of
Waterloo ORE#20590 and all hospital sites); signing
contracts for transfer of funds to the sites; face-to-face
training of RAs for data collection; face-to-face training
of site dietitians to conduct SGA; and collecting baseline
data (described below). The research/facilitation team
guided site champions and RAs extensively throughout
this phase for all site-focused activities, conducted train-
ing, and developed communication avenues for the sites
(e.g. Google group, monthly teleconferences, project
webinars for SITs). Champions, RAs, and in some sites,
SIT members reviewed and provided input into all data
collection instruments to ensure that forms were clear
and questions were relevant and written clearly to pro-
mote consistency across sites for data collection. An
M2E manual provided detail on data collection proce-
dures and key implementation activities. The manual
was reviewed several times iteratively by champions and
RAs with continual updating and refining through this
phase. Further training on implementation was provided
at the end of this phase with a face-to-face meeting of
champions, RAs and project team members. Theoretical
frameworks for behaviour change and implementation
techniques (e.g. Plan-Do-Study-Act (PDSA) cycles; [64])
were the focus of this training. Engagement of unit staff
and management to support sustainability [50, 58, 59, 65]
started during this phase and continues throughout the
project.
Implementation Phase (Jan-Dec 2016): This phase is
focused on testing and evaluating the tailored implemen-
tation of INPAC in individual sites. Care activities of
INPAC are defined (e.g. screening and referral for at risk
patients) and sites are flexible in their approach to
implement these components as research indicates
that such tailoring is necessary for uptake and sus-
tainability [47, 49, 58, 66]. Best practices with respect
Fig. 3 An overview of the data collected during the Developmental, Implementation and Sustainability phases of the More-2-Eat project
Keller et al. BMC Nutrition  (2017) 3:13 
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to implementation and evaluation are used [51, 58, 59].
Specifically, sites were provided with their baseline data so
that buy-in and strategies for making change could be
planned by each SIT. This team, led by champions, meets
biweekly to monthly to progress the implementation of
INPAC and report key activities to the research/facilitation
team. These meetings are roughly structured on the
Model for Improvement questions (What are we trying to
achieve? How will we know a change is an improvement?
What changes can be made that will result in an improve-
ment?) [64]. Sites identify areas for improvement based on
their current practice, creating their own action plan using
small tests with PDSA cycles to achieve the care activities
of INPAC. Prior work has demonstrated the relevance of
this approach to changing nutrition care practices in
hospitals [44–49, 53].
Monthly coaching/mentoring teleconferences occur
with all sites conducted by the research/facilitation team.
Data on progress towards implementation of INPAC is
collected each month and provided back to champions
for sharing with their implementation teams, administra-
tors and site staff. Sites also share resources and tools
that have been developed locally (e.g. posters, forms)
and these are assembled as potential examples of the
Implementation Toolkit.
Sustainability Phase (Jan- June 2017): This phase is fo-
cused on continued implementation of INPAC activities
to determine how they endure over time in the five sites.
It is limited to three months due to the end-date of
funding received for M2E. Data collection will occur
during this time frame. The virtual INPAC Implementa-
tion Toolkit will also be developed in this phase.
Consultation with stakeholders will occur to consider
how to spread INPAC care activities within and beyond
sites. Future funding to disseminate and support imple-
mentation of INPAC and to re-evaluate sustainability of
INPAC activities at M2E sites will be sought.
Theoretical foundation and frameworks used to guide
M2E
The M2E project is guided by several theories and
frameworks. The Knowledge-to-Action Process (KTA)
theory [66] is being used to understand and explain how
M2E fits within the broader program of research [62].
Specifically, that this work was initiated with a preva-
lence study defining the problem [3, 6, 7], which resulted
in the development of a knowledge translation product
(i.e. INPAC) to overcome the problem [37]. M2E is es-
sentially the action process of the KTA theory and spe-
cifically includes the following steps: adapting knowledge
to the local context; assessing barriers to knowledge use;
selecting, tailoring and implementing interventions; moni-
toring knowledge use; evaluating outcomes; and sustaining
knowledge use. New knowledge creation, synthesis and
tailoring will result with the development of the INPAC
Implementation Toolkit.
The Quality Implementation Framework [58] also sup-
ports this project as it summarizes the critical steps for
successful implementation. The steps within this frame-
work, relevant to M2E, include the initial consideration
of the host setting including the specific context, the
structure for implementation, the considerations for on-
going structure once implementation has started, and
finding ways to improve future application [58].
The COM-B (‘capability’, ‘opportunity’, ‘motivation’ and
‘behaviour’) theory is being used as the basis for behav-
iour change of staff towards the INPAC care activities
[67]. COM-B explains what needs to be influenced to
implement the various INPAC care activities, and specif-
ically the inter-relationship between how capability,
opportunity, and motivation can change behaviour. For
example, staff can be motivated by comparing their prac-
tice for screening to other sites; setting goals and track-
ing progress through audit and feedback continue to
motivate staff as they routinize screening for all admitted
patients. Staff need to understand how to perform the
screening and referral process, which ensures they have
the capability to undertake this care activity. Various
education forms are typically used (e.g. in-services, re-
minders). Opportunity speaks to finding those points in
the system for change that could dramatically enhance
uptake of the new behaviour. In the example of screen-
ing, embedding the nutrition screening questions into an
electronic medical record as a required field would en-
sure that screening occurs for all patients.
The Theoretical Domains Framework explains how the-
ory (e.g. COM-B), evidence (e.g. baseline data in M2E)
and practical issues need to be considered when changing
behaviour [68]. This framework maps 14 domains or
determinants of behaviour change (e.g. knowledge, skills,
environmental context, beliefs about capability and conse-
quences etc.). Data collection at baseline included facilita-
tors and barriers to making change and these could
conceivably be mapped onto the theoretical domains
framework and used to develop a determinant interven-
tion theory for INPAC. The Behaviour Change Tech-
niques taxonomy was used to identify and streamline a
variety of techniques that can be linked to these influences
to change behaviour [69]. The Behaviour Change Wheel
(BCW), a tool consistent with COM-B, lists interventions
and techniques that can be used to make change at vari-
ous levels of influence (e.g. incentivisation for staff; policy
for an institution; regulation for system level change)
[67]. Training M2E champions and RAs on the ele-
ments of these frameworks and theories helped them
to realize that education was not sufficient to make
change. The BCW has also helped the investigators to
consider how to influence the system with respect to
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integrating INPAC into care activities in all hospitals
in Canada.
Normalization Process theory [70] is primarily being
used by the researchers to frame the implementation
process, results and findings as well as increasing likeli-
hood of sustainable change. This theory will be helpful
in mapping contextual differences between the sites that
will be used to explain variation in uptake as we con-
tinue the evaluation. It will also be used to define the
key elements of the INPAC Implementation Toolkit,
which in essence will be an innovation. Mentoring and
coaching on implementation with sites is based on the
principles of the Model for Improvement [64, 71], which
has been shown to be effective for making health care
change [44, 47, 59]. This model offers a practical process
for SITs to institute and test a change process using
PDSA cycles.
Data collection
Data collection in the developmental phase
Goals for data collection in this phase were to begin to
understand: the context of the site (including staff KAP);
the site’s perceived facilitators and barriers to making
nutrition care improvements; prevalence of current nu-
trition care practices; and prevalence of key patient re-
ported outcomes. Multimethods were used to collect
these baseline data concurrently [54]. Table 1 provides
an overview of data collection measures for M2E.
Context Assessment: It is important to assess context to
understand how multi-level factors influence uptake of an
innovation [51, 58, 59, 72]. Context was assessed with
several measures/activities. A site survey completed by
champions and key site implementation team members
provided information on the site, staffing and food produc-
tion and delivery systems, including staff roles and resource
costs (e.g. cost of oral nutritional supplements, salaries). As
required, they consulted with various departments and
management within their site to complete this survey.
Knowledge-Attitudes-Practices (KAP) Survey: To further
understand context, a KAP survey was completed by 30
staff from each study unit (n = 150). RAs recruited staff
members
with
direct
patient
care
responsibility
to
complete this on-line survey; recruitment occurred via
email. Announcements at unit huddles and posting vari-
ous notices and memos were also used to recruit partici-
pants. Unit staff were provided with the information letter
about the study and this survey. The KAP survey was cre-
ated for M2E and focused on nutrition care practices con-
sistent with INPAC. The survey was developed and tested
for reliability in a separate site not included in M2E [43].
The questions are focused on staff knowledge on the
prevalence and causes of hospital malnutrition, barriers to
food intake, as well as attitudes on the importance of
nutrition to recovery and their current practices in nu-
trition care. Completion of the on-line survey indicated
their informed consent. Participants provided an email
address for administration of the follow-up survey to be
conducted at the end of the implementation phase, ap-
proximately one year later.
Focus Groups and Key Informant Interviews: Site RAs
recruited and scheduled key individuals within their
hospital for participation in qualitative interviews. Key
informants were department heads, members of the SIT
and staff members in key positions (e.g. dietitian, diet
technician, nurses, food service workers). It was left to
the discretion of the site champion to identify these in-
fluential site informants for a one-on-one interview.
Two or three focus groups (n = 11) were held at each
site over the lunch hour on two consecutive days; lunch
was provided. All staff on the unit that day were wel-
come to participate. The key informants and focus group
participants reviewed an information letter and provided
written consent before the discussion began. These
qualitative data will be used to understand the setting
and context, including suggestions for making improve-
ments in nutrition care within the unit [55, 65].
Table 1 Overview of data collection methods and their corresponding research question and phase of the study
Data collection form/method
Research question
Developmental phase
Implementation phase
Sustainability phase
Type of data
INPAC Audit
1 and 4
√
√
√
Quantitative
Detailed Patient Data
2
√
√
Quantitative
30-Day Follow-up
2
√
√
Quantitative
Focus Groups/ Interviews
4 and 5
√
√
Qualitative
Staff KAP questionnaire
3
√
√
Quantitative
RD/staff workload
6
√
√
Quantitative
Activity Time Test
6
√
Quantitative
DICE Scores
4
√
√
√
Quantitative
Scorecards
4 and 5
√
Qualitative
Monthly telephone calls
4 and 5
√
Qualitative
Site Survey
6
√
√
Quantitative
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Both focus groups and interviews were conducted by
one researcher to promote consistency. A semi-structured
interview guide that had been vetted by researchers, site
champions, and RAs was used and tailored to each site
based on the current nutrition care practices undertaken.
The Active Interview method [73] was used to build rap-
port and tailor interviews to informants. The researcher
visited the site for approximately two days to collect all
interview and focus group data as well as to conduct a site
visit to further understand the hospital and unit climate
for implementation.
A total of 40 key informant interviews were conducted
and 11 focus groups with various staff members (n = 89;
range of participants per site: 12–21; range of partici-
pants per focus group: 4–14). All interviews and focus
groups were audio recorded. Interview data were profes-
sionally transcribed and checked by the interviewer.
Focus group audio-recordings were not transcribed but
extensive notes were taken from audio recordings by the
researcher. Audio recordings were reviewed upon com-
pletion of each day of data collection in the site, with
memos written to support development of the under-
standing of the setting and to identify further lines of
inquiry with subsequent interviews [74, 75]. A key com-
ponent of this qualitative data collection was to deter-
mine barriers and facilitators to change processes and
specifically INPAC activities. These data are necessary to
identify areas for improvements as well as priming the
sites for this change [49, 53, 58, 76]. Collection of this
information is a key step in the KTA process.
Audits of Nutrition Care Activities for Patients: The
proportion of patients receiving INPAC nutrition care
activities (e.g. % screened, assessed, receiving advanced
care) is a primary outcome. This information was col-
lected through unidentified patient (e.g. their unit bed
number was only used) chart review over four consecu-
tive weeks during baseline data collection. The day of
the week on which chart review occurred was consistent.
All patients on the unit that day had their medical chart
reviewed to determine: if and when they had been
screened; if SGA was completed; when and if they were
assessed by a dietitian if applicable; what nutrition diag-
noses were made; if and what barriers to food intake
were assessed; if and when food intake or body weight
monitoring occurred and what forms of nutrition treat-
ment occurred. Gender and age were also noted as well
as admission date to the unit. A total of 700 patients
were included in the audits for the five sites during base-
line. Informed consent was not required for this audit,
however some hospitals ethics boards required notices
for patients and families to view on the unit to inform
them
that
an
anonymous
chart
review
was
being
completed for this research project. INPAC audits were
collected with a paper form and were transferred into
M2E project RedCAP™on-line forms for secure data
capture and access by researchers.
Patient Reported Outcomes & Detailed Patient Data
Collection: To assess patient reported outcomes, re-
source utilization and to track frailty and disability, 40
patients were recruited over a four-week period during
baseline from each study unit (total n = 200). This
sample size was chosen primarily for feasibility reasons,
considering the workload of the RAs with implementa-
tion and data collection. Patients were eligible for this
detailed assessment if: they were likely to be hospitalized
for a minimum of three days; admitted from the com-
munity and expected to return to the community; able
to speak and read English, or at the bilingual site,
French; consumed an oral diet (could have enteral or
parenteral supplementation); did not have delirium or
dementia, as assessed at admission by nursing (as some
assessments require cognitive capacity); and provided
written consent to data collection procedures including
a telephone follow up post discharge with research staff
from the University of Waterloo. Staff from the circle of
care identified eligible patients who were interested in
hearing about the study and the RA completed informed
consent and measurements. Demographics, admission
diagnosis and length of stay were recorded. The patient
was screened with the CNST [38]. SGA was completed
if they were at risk, and the clinical dietitian providing
care to the unit was notified of the status of the patient.
If nutrition treatments were in place, these were re-
corded. The SGA is used to diagnose malnutrition and
includes information on dietary intake, weight, symp-
toms, functional capacity and metabolic requirements,
as well as a physical exam for fat, muscle and edema.
Patients were then classified as either well nourished
(A), mildly/moderately or suspected of being malnour-
ished (B), or severely malnourished (C) [39]. Patients
reported their perceptions of food intake (more than
enough, enough, not enough) and their current nutri-
tional health (excellent, very good, good, fair, poor).
Frailty was assessed with the 5-m walk [77] and hand
grip strength [78]. Three trials were completed if pos-
sible. Non-ambulatory patients or those who could not
transfer safely did not complete the 5-m walk and
reasons for non-completion were noted. The walk was
performed in an unobstructed, well-lit, predetermined
area of the hospital, where patients were asked to walk
at a comfortable pace between a previously determined
0- and 5-m marker on the floor [77]. Once the re-
searcher said ‘go’, the timer was started with the first
footfall over the 0-m line, and the timer was stopped with
the first footfall over the 5-m line [77]. Hand grip strength
was assessed in the dominant arm using the Southampton
Protocol and a Jamar hydraulic hand dynamometer [78].
The RA demonstrated how to conduct the measure and
Keller et al. BMC Nutrition  (2017) 3:13 
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the patient was seated preferably in a chair, but otherwise
in bed. If the dominant arm had an IV, the non-dominant
arm was used. If the patient was unable to complete either
frailty measure, reasons for non-completion were noted.
The average of the three attempts at each of these mea-
sures was determined for analyses.
Disability was assessed with the 7-item Nagi scale where
patients reported their perceived difficulty in completing
activities (e.g. pushing or pulling a large object like a living
room chair, picking up small objects with fingers) [79].
Quality of life was assessed with the SF-12 [80]. Both of
these measures were completed by interview with the site
RA. Nutritional status, frailty and quality of life measures
were used to characterize participants.
Two patient-reported outcomes are anticipated to
change with INPAC implementation, food intake and
barriers experienced at mealtimes. Patients self-reported
the proportion of overall intake of food on the tray and
intake of each provided beverage (0, 25, 50, 75, 100%)
for a single meal, as well as their appetite, reasons for a
lower than usual appetite and any challenges they expe-
rienced at the meal with the My Meal Intake Tool (M-
MIT) [42]. Where necessary, the RA completed this
measure based on interview with the patient. A separate
meal was used to assess a list of 18 barriers to food
intake as well as to obtain the perception of patients
with respect to the importance they and staff placed
on nutrition for their recovery using the Mealtime
Audit Tool (MAT) [41]. This tool was completed by
interview with the RA.
The final form of assessment for these detailed patient
data collections was focused on determining resources
utilized at mealtimes to support the patient to eat. Staff/
volunteers or family at all meals on a single day were
asked to check off care activities they provided for these
patients (e.g. opening tray, providing eating assistance).
It is anticipated that after INPAC implementation, more
help will be provided to patients who need it. All de-
tailed patient data collection was transferred from paper
forms to RedCAP™for transmission to researchers.
Patients who received the detailed assessment and
provided follow up call information received a telephone
call from the research/facilitation staff at the University
of Waterloo, approximately 30 days after patients were
discharged.
Patients
provided
consent
to
have
re-
searchers contact them or a proxy for follow up and
their phone numbers were provided to the research staff.
Up to five telephone attempts were made to reach the
patient before trying the proxy (if provided) for an add-
itional three times. Quality of life (SF-12), disability
(Nagi scale), self-reported weight change, use of food/
meal services or help, food related activities of daily liv-
ing, frequency of eating alone, perceptions of nutritional
health, food intake and appetite were reported. Patients
also self-reported being prescribed a special diet and re-
ceiving recommendations for community services and if
they followed these recommendations, use of oral nutri-
tional supplements, as well as visiting health profes-
sionals for care, including a dietitian. If the patient had
visited the emergency room or was admitted to hospital
this was also recorded. Proxies reported on the death or
readmission of the patient if they could not be located. If
the patient was unreachable and the proxie’s knowledge
of the patient’s health status was adequate, the proxy
completed the survey on behalf of the patient. Of the
n = 200 detailed patient data collection participants,
93% (n = 185) of patients provided follow up informa-
tion. Of those patients that provided contact informa-
tion, 59% (n = 109) completed the 30-day follow-up
during baseline data collection.
Other Data: In addition to the patient level data of the
INPAC audits and detailed patient assessments to collect
process and outcome data, further data were collected at
the site level. This additional data was collected over a
4-week period, and included tracking of dietitian time
on the unit for nutrition care activities such as time for
assessment, monitoring and treating patients. As the
patients included in the detailed assessments were not
necessarily representative of all patients on the unit,
average length of stay in the year prior to the develop-
mental phase will be collected. To estimate resource cost
for mealtime activities described above in the detailed
patient assessment, time required and staff roles at each
hospital need to be matched to these activities. At each
site an average time to complete these activities was de-
termined from monitoring up to 10 episodes of an activ-
ity (e.g. time it takes to assist a patient to consume all
food on their tray) and noting the staff members who
routinely completed these tasks. This data collection was
performed on any patient and staff member on the unit
who required these care activities. The activity, time to
complete, and the staff (e.g. registered nurse, personal
support worker) that completed the task were noted. As
no personal information was recorded for these time-
testing patients or staff, informed consent was not re-
quired. This time assessment was completed by the RAs
and data on time required for each activity was submit-
ted to the researchers on an Excel spreadsheet.
Data collection in the implementation and sustainability
phases
M2E is currently in the implementation phase. Patient
level data include the same measures as those collected
during the developmental phase. The only addition to
this data collection is the inclusion of a second hand
grip strength for the detailed patient assessments if the
patient is discharged more than 48 h after the initial
strength measurement. This second measure is included
Keller et al. BMC Nutrition  (2017) 3:13 
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in the protocol to see any potential change in this meas-
ure as a result of nutrition care practices for the patient.
During the implementation phase, INPAC audits are
completed twice per month, mostly on the same day of
the week as with the baseline collection. A target of 20
patients per month for detailed assessments (e.g. SGA,
SF-12, frailty, resource use at meals) was set. Dietitians,
and in some sites diet technicians, monitor how they
used their time in patient care activities one week per
month. Monthly INPAC audits and detailed patient as-
sessment reports summarizing these data are provided
back to the sites to aid in the planning of their imple-
mentation of INPAC and to demonstrate the integration
into practice. An amalgamated monthly INPAC report
summarizes all five sites and is used to compare and
contrast progression. The amalgamated report is also
provided to assist in goal setting for each site. This type
of continuous feedback is an important technique for
behaviour change management and implementation
[44, 51, 58, 65, 81, 82]. Thirty-day follow-up of patients
occurs between the fourth and sixth months of imple-
mentation with the goal of attaining 40 patients per site
who agreed to this telephone follow up questionnaire
completed by the researchers. This is repeated again
between months 10 and 12 of implementation for a
goal of n = 400 during the implementation phase.
Qualitative and quantitative data is also being collected
on the implementation process. Sites document on an
INPAC Scorecard, various activities undertaken to im-
plement INPAC. This includes meetings between the
champion, RAs, SIT and other stakeholders in the site.
The content for the recording of the meeting objectives
and activities is structured under the Model for Im-
provement (What are we trying to change? How will we
know a change is an improvement? What changes can
be made that will result in an improvement?) [64].
People attending, dates, and expected date of achieving
discussed goals are also tracked. The INPAC Scorecard
also includes a table for noting any education or training
activities with staff (date, number attending, primary
audience, topic, and if evaluation was conducted). Any
self-reflection on learnings from the implementation
process (barriers, facilitators, recommendations for other
sites) and educational activities are also recorded. Fi-
nally, any meetings with decision makers or any other
activities that could be considered part of implementa-
tion are recorded.
Scorecards are reviewed by the research/facilitation
team and used as the basis for monthly teleconferences
with all sites. These teleconferences are audio-recorded
and used as a mechanism for sharing learnings and suc-
cessful strategies, to attain advice on challenges experi-
enced and to receive co-mentoring and facilitation
from the researchers and other champions and RAs
[51, 58, 59]. Each month the discussion is led by the PI
and each site provides a brief update on key activities.
The group then discusses a key area of INPAC they are
currently implementing (e.g. screening, SGA, Standard
Care, discharge planning etc.). Administrative points on
data collection are also discussed to promote data qual-
ity and consistency. Minutes of the meeting are circu-
lated to the sites within one week of the meeting.
The DICE® Score [83], from business change manage-
ment, provides a subjective numerical rating that can be
used to predict potential success with implementation of
a change activity within each site. Four members of the
research/facilitation team meet face-to-face on a quar-
terly basis to review the progress made by the sites for
implementation and to share their DICE® Scores. Each
team member develops their numerical scores based on
the DICE® structure (Duration, Integrity, Commitment
and Effort) [83] independently, based on their diverse
perspectives from interacting with the sites; descriptors
and activities specific to the project were used to sup-
port ratings. Perspectives vary as each member of this
team have slightly different interactions with champions,
RAs and SITs (e.g. CL and BD participate in site visits
and on-site training of SGA, RV manages all data and
enquiries; HK manages the team overall and provides in-
dividual coaching to sites via phone and email). A mid-
implementation site visit was conducted by some of
these researchers/facilitators and memos on the observa-
tions and informal discussions were completed and
discussed with the entire research/facilitation team.
DICE® scores were completed before and after these
mid-implementation site visits. After team discussion,
the individual DICE® scores are averaged across the four
researchers/facilitators. The DICE® calculator indicates if
scores are in the Win, Worry, or Woe Zones with re-
spect to potential success of implementing and sustain-
ing the INPAC care activities [83].
Key informant interviews will be conducted with the
champion, RAs, members of the SIT and any other influ-
ential stakeholders in each site in the 11th month of the
implementation phase. These interviews will be focused
on stakeholder perceptions of what was necessary for
successful implementation as well as how to sustain the
gains in INPAC care activities. Focus groups will be con-
ducted with unit staff, and will be held over a lunch time
with food and beverages offered. These shorter discus-
sions will be focused on what were the biggest perceived
changes, benefits to staff and patients during INPAC im-
plementation and ideas on how they can be sustained.
As with baseline, these site participants will complete
written informed consent prior to the discussion and site
champions and RAs will facilitate the scheduling. The
staff KAP survey will be completed by the same 30 staff
per unit recruited at baseline. To facilitate timely
Keller et al. BMC Nutrition  (2017) 3:13 
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completion, the on-line survey site will be opened in the
10th month of implementation. The research team will
invite staff members who participated at baseline by
email to complete the survey. If the staff member no
longer works on the unit or does not respond, further
staff will be recruited by site RAs to meet the quota of
30 per site to allow for group level analysis. A few add-
itional questions asking the staff member to rate the
changes observed and their benefits have been included
with the original questions used at baseline. These ques-
tions will be reviewed by the investigatory team and site
teams to ensure that wording is clear.
Results from the implementation phase on success with
integrating INPAC activities into practice, as well as the
staff KAP survey results and preliminary results from the
focus group and key informant interviews, will be reviewed
at a stakeholder meeting held at the end of the implemen-
tation phase.
The
purpose of
this
final face-to-face
stakeholder meeting, which will include investigators, col-
laborators, champions and RAs, will be to celebrate success
and consider how INPAC can be spread within the test
sites and disseminated further. The INPAC Implementation
Toolkit will be a key discussion point. This will be virtual
toolkit located on a collaborator’s website (Canadian Mal-
nutrition Task Force, www.nutritioncareincanada.ca).
INPAC audits (eight over three months) will be com-
pleted during the Sustainability Phase with the primary
purpose of determining if INPAC care activities that have
been implemented are retained during this three-month
period. The average length of stay for patients on the unit
during the implementation year will be calculated for
comparison to the year prior to implementation.
Statistical analyses
This is an extensive data collection with quantitative,
qualitative and mixed methods analyses planned. The
following discussion is focused solely on the research
questions, however it is anticipated that a variety of sec-
ondary data analyses will also be completed. The statis-
tical packages RStudio (version 3.2.4), SPSS Version 23,
and Excel will be used for all analyses. Qualitative data
will be categorized and displayed with both Excel and
NVivo 11. The principal objective is the development of
a knowledge product, the INPAC Implementation Tool-
kit that provides a guide for others wishing to imple-
ment INPAC activities in their site. It is anticipated that
such a tool will promote knowledge translation to reach
the overall aim of this work. An outline of the toolkit
content has been circulated among co-investigators,
collaborators, RAs and champions to identify what are
essential concepts and aspects for inclusion (e.g. how to
stimulate change, use of behaviour change techniques to
make change, example knowledge translation tools such
as patient or staff posters etc.). It is anticipated that this
group of stakeholders and others will provide input at
various points over the next year to finalize the toolkit,
which will be virtual. It is also anticipated that a descrip-
tive manuscript on the toolkit will be submitted to an
open access journal.
Research Question 1: Site level analyses will be com-
pleted by graphical presentation of INPAC activities (e.g.
screening) from the 36 audits collected over baseline,
implementation and sustainability phases. Where pos-
sible multi-level mixed effects linear regression models
will be explored to determine changes over time within
the site clusters. Descriptive analyses and graphical
presentation will also be completed to report the triaging
process (e.g. % at risk who received SGA and proportion
of malnourished via SGA who received an assessment)
and what advanced and standard nutrition care activities
are commonly used within the sites to prevent and treat
malnutrition. These latter analyses may be completed
within site only.
Research Question 2: Patient reported outcomes of
food intake (M-MIT) and barriers to food intake (MAT)
will be averaged per site, per month and these medians
will be graphically presented by month, by site. Where
possible
multi-level
mixed
effects
linear
regression
models will be explored to determine changes over time
within the site clusters. Site differences will be explored
and interpreted using knowledge of the various INPAC
activities implemented at each site.
Research Question 3: Staff KAP are collected at base-
line and at the end of the implementation phase. The
same staff at each hospital is anticipated to complete
these surveys. Where this occurs, paired t-tests (or
Wilcoxon matched pairs signed ranks test) will be used
to determine differences in total knowledge/attitude and
practice scores as well as mean differences in individual
items. It is anticipated that there will be some loss of
participants from baseline and new staff will be recruited
to make up the quota for the site. Unmatched analysis
will be used in this case (e.g. t-test, Mann Whitney U).
The second administration also includes some questions
focused on sustainability. These and the demographics
of participants will
be descriptively
presented
(e.g.
proportion, median).
Research Question 4: Both qualitative and quantitative
data will be used in a triangulation design using a
convergent model [53] to address the question of how
INPAC implementation varied with the context of hos-
pital/unit environment. It is anticipated that the monthly
descriptive run charts currently used to provide feedback
to sites that display implementation of INPAC activities
over time will be used to highlight the quantitative
differences among sites in implementation success for
key aspects of INPAC. Qualitative data from monthly
teleconferences, scorecards, memos from site visits,
Keller et al. BMC Nutrition  (2017) 3:13 
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focus group/key informant interviews and DICE® scores
will be used to interpret quantitative differences.
Monthly telephone call recordings are reviewed after
the call by one or more researchers with memos and de-
scriptive notation of key activities recorded. Scorecards
and monthly telephone calls are descriptively analyzed
and key content is displayed as matrices [75]. Matrices
are organized by site, across INPAC activity (e.g. screen-
ing) and data are deductively coded by using the COM-
B model to categorize strategies and behaviour change
techniques used by sites to implement each INPAC
activity (e.g. techniques to implement volunteer train-
ing that are focused on building capability). Content
analysis [75] will be used to summarize these data to
identify the most common techniques used for vari-
ous INPAC activities.
The average DICE® score across the research team per
quarter will be a key component to address this question.
This subjective rating will be analyzed quantitatively by
determining the median across time points for a site, as
well as the difference between baseline and final DICE®
scores. Sites in the Woe zone for DICE® are anticipated to
have slower implementation of INPAC activities and po-
tentially poorer sustainability. Focus group and interview
data (coding and analysis described below) will inform
common contextual challenges (e.g. retraining for new
staff, keeping the unit engaged with the change process).
It is anticipated that meta-matrices will be completed to
summarize these data and aid in interpretation and com-
parison of sites [75]. Run chart examples of quantitative
data, case scenarios, themes and quotes will be used to
display and merge these qualitative and quantitative data.
Member checking with site champions, RAs and SITs on
this analysis will occur [54].
Research Question 5: A thematic qualitative analysis
[74, 75] will be used with the focus group and key in-
formant interview data collected at baseline and the end
of the implementation phase. Analysis has begun for the
baseline data. All data were professionally transcribed
and checked by the interviewer (CL). NVivo 11 was used
to inductively code and structure the data by one re-
searcher (CL), although support for developing the cod-
ing structure based on the data was provided by a
second researcher (RV). Only the interview data was
fully coded as this method was found to provide the
richest data, with focus group data used to complement
and reinforce emerging themes. Focus group data re-
cordings were reviewed several times by a single re-
searcher (CL) and memos written to capture this data.
These memos and the coded transcripts are being ana-
lyzed thematically [74, 75]. A single researcher who con-
ducted the interviewers, completed all line by line and
higher order inductive coding (CL). This initial coding
and tentative theme ideas were reviewed and discussed
with a second researcher (RV). Themes took form as
memos describing the theme, and identifying themes
with data (e.g. quotes); matrices of themes, subthemes
and quotes were used to display this analysis. These
summary documents were reviewed by two researchers
(HK and RV) to help refine and condense. A thematic
diagram has been developed based on this group ana-
lysis. To confirm, refine and extend these developing
themes, three researchers (HK, RV, JB) other than the
lead for this analysis (CL), reviewed original uncoded
transcripts (n = 15 across all sites from 40 interviews)
and reviewed the thematic structure developed by CL. It
is anticipated that a similar process will be used for the
second set of focus group and key informant interview
data to analyze and develop themes focused on sustain-
ability and learnings from implementation. It is antici-
pated that member checking of the thematic structure
with site champions, RAs and SIT will occur [54].
Research Question #6: Site champions provided key
resource information (e.g. number of dietitians in hos-
pital and serving the study unit, salary level) on the site
survey. RAs also completed a meal activity time test on
5–10 episodes of each mealtime activity (e.g. how long it
takes to assist a patient with eating; how long does it
take to set up a tray) to determine average time and thus
potential resource cost for providing these standard care
activities described in INPAC. Additionally, dietitians
noted their time in various patient related activities be-
fore and during implementation (e.g. number and time
taken to screen, complete SGA, complete a full assess-
ment, arrange advanced care strategies such as medica-
tion pass of oral nutritional supplement). These data will
be used to describe the resources required to implement
the care activities in INPAC. Average time spent in
INPAC activities during developmental and implementa-
tion phases, per site will be calculated and compared.
Costs attributed to dietitian and other staff time for
mealtime activities will be averaged across the sites,
using their own data on staff and other resource costs.
With the SF-12 data there is the potential to also
conduct further analyses on how quality of life rated by
participants is associated with resource utilization.
Discussion
M2E is a robust and comprehensive qualitative and
quantitative data collection that will provide unique in-
sights into implementation processes and approaches
that can achieve improved nutrition care practices in
acute care hospitals. Using theory and frameworks to
guide data collection and implementation are a strength
of this study, as is the multi-site participatory action ap-
proach. INPAC implementation requires coordination
and involvement of a variety of staff and departments to
effect change in care processes throughout the hospital
Keller et al. BMC Nutrition  (2017) 3:13 
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stay. Data collection procedures, merging of qualitative
and quantitative data in analysis to address research
questions and understand implementation will be useful
to other implementation scientists. Learnings from the
developmental and implementation phases can guide
further complex intervention research.
Abbreviations
BCW: Behaviour Change Wheel; INPAC: Integrated Nutrition Pathway for
Acute Care; KAP: Knowledge, attitude and practices; M2E: More-2-Eat project;
MAT: Mealtime audit tool; M-MIT: My Meal Intake Tool; PDSA: Plan-Do-Study-
Act cycles; PI: Principle investigator; RAs: Research associates; SGA: Subjective
global assessment; SIT: Site implementation teams
Acknowledgements
The M2E implementation study team includes the following co-investigators
(C. Basualdo- Hammond, P. Bernier, L. Curtis, D. Duerksen, P. Douglas, , L.
Gramlich, M. Laporte), collaborators (L. Dietrich, J. Dubin, K. Jeejeebhoy, A.
Maybee, M. Mourtzakis, S. Robbins, R. Sawatzky, H. Truber), champions (M.
Atkins, D. Butterworth, S. Obiorah, R. Nasser, M. Stickles-White, M. Tom) and
research associates: (M. Booth, S A. Digweed, Doering, S. Cowan, C. Marcell, L.
Vescio). Canadian Malnutrition Task Force has provided in-kind project
management through the Director Bridget Davidson who is also part of the
research/facilitation team. NNEdPro has specifically supported key aspects of
implementation toolkit development and will provide dissemination across its
network. Dietitians of Canada, Canadian Nutrition Society and the Canadian
Society of Nutrition Management also support dissemination of this work.
Funding
Canadian Frailty Network SIG2014-08.
Availability of data and materials
Not applicable.
Authors’ contributions
HK is the primary investigator and lead of this project. CL, RV, and TM are
university researchers involved in data collection. CL was instrumental in review
of data collection materials during development and conducted focus groups
and key informant interviews. RV manages all quantitative data, while TM
analyzes monthly teleconference data. SR had an advisory role particularly in
the educational components of the study as well as functioning as a doctoral
advisor to CL’s work on and around this study. JB provided expertise on change
management. SB and JM are site research associates collecting data and
implementing INPAC. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
No personal data is noted herein.
Ethics approval and consent to participate
University of Waterloo (ORE #20590) and site ethics boards: Niagara Health Ethics
Board, Ottawa Health Science Network Research Ethics Board, Health Research
Ethics Board of the University of Alberta, Regina Qu’Appelle Health Region
Research Ethics Board, University of Manitoba Health Research Ethics Boards and
Concordia Hospital Research Ethics Committee, approved and provided
clearance for this research study. Data collection directly from patients or staff
required informed written consent which was attained prior to data collection.
Author details
1Schlegel-University of Waterloo Research Institute for Aging, University of
Waterloo, 250 Laurelwood Drive, Waterloo, ON N2J 0E2, Canada. 2Faculty of
Applied Health Sciences, University of Waterloo, 200 University Ave,
Waterloo, ON N2L 3G1, Canada. 3School of Human Movement and Nutrition
Sciences, The University of Queensland & The Prince Charles Hospital, Rode
Road, Chermside, QLD 4032, Australia. 4NNEdPro Global Centre for Nutrition
and Health (Affiliated with: Cambridge University Health Partners, Wolfson
College Cambridge and the British Dietetic Association), St John’s Innovation
Centre, Cowley Road, Cambridge CB4 0WS, UK. 5The Ottawa Hospital |
L’Hôpital d’Ottawa, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada. 6Concordia
Hospital, 1095 Concordia Ave, Winnipeg, MB R2K 3S8, Canada.
Received: 3 December 2016 Accepted: 7 January 2017
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