A Web-Based Health Application to Translate Nutrition Therapy for Cardiovascular Risk Reduction in Primary Care (PortfolioDiet.app): Quality Improvement and Usability Testing Study

Abstract

Background: The Portfolio Diet, or Dietary Portfolio, is a therapeutic dietary pattern that combines cholesterol-lowering foods to manage dyslipidemia for the prevention of cardiovascular disease. To translate the Portfolio Diet for primary care, we developed the PortfolioDiet.app as a patient and physician educational and engagement tool for PCs and smartphones. The PortfolioDiet.app is currently being used as an add-on therapy to the standard of care (usual care) for the prevention of cardiovascular disease in primary care. To enhance the adoption of this tool, it is important to ensure that the PortfolioDiet.app meets the needs of its target end users.

Objective: The main objective of this project is to undertake user testing to inform modifications to the PortfolioDiet.app as part of ongoing engagement in quality improvement (QI).

Methods: We undertook a 2-phase QI project from February 2021 to September 2021. We recruited users by convenience sampling. Users included patients, family physicians, and dietitians, as well as nutrition and medical students. For both phases, users were asked to use the PortfolioDiet.app daily for 7 days. In phase 1, a mixed-form questionnaire was administered to evaluate the users' perceived acceptability, knowledge acquisition, and engagement with the PortfolioDiet.app. The questionnaire collected both quantitative and qualitative data, including 2 open-ended questions. The responses were used to inform modifications to the PortfolioDiet.app. In phase 2, the System Usability Scale was used to assess the usability of the updated PortfolioDiet.app, with a score higher than 70 being considered acceptable.

Results: A total of 30 and 19 users were recruited for phase 1 and phase 2, respectively. In phase 1, the PortfolioDiet.app increased users' perceived knowledge of the Portfolio Diet and influenced their perceived food choices. Limitations identified by users included challenges navigating to resources and profile settings, limited information on plant sterols, inaccuracies in points, timed-logout frustration, request for step-by-step pop-up windows, and request for a mobile app version; when looking at positive feedback, the recipe section was the most commonly praised feature. Between the project phases, 6 modifications were made to the PortfolioDiet.app to incorporate and address user feedback. At phase 2, the average System Usability Scale score was 85.39 (SD 11.47), with 100 being the best possible.

Conclusions: By undertaking user testing of the PortfolioDiet.app, its limitations and strengths were able to be identified, informing modifications to the application, which resulted in a clinical tool that better meets users' needs. The PortfolioDiet.app educates users on the Portfolio Diet and is considered acceptable by users. Although further refinements to the PortfolioDiet.app will continue to be made before its evaluation in a clinical trial, the result of this QI project is an improved clinical tool.

Keywords: dietary application; dietary portfolio; eHealth; mobile phone; nutrition therapy; portfolio diet; quality improvement; usability testing.

Conflict of interest statement

Conflicts of Interest: MEK has received funding from a Toronto 3D Knowledge Synthesis and Clinical Trials foundation PhD scholarship award and is a part-time employee at Inquis Clinical Research, a contract research organization. LC was a Mitacs Elevate postdoctoral fellow jointly funded by the government of Canada and Canadian Sugar Institute (from February 2019 to August 2021). AJG has received consulting fees from SoLo GI Nutrition and an honorarium from the Soy Nutrition Institute. PJ serves as an unpaid member of the steering group of trials funded by Appili Therapeutics (Control COVID-19 trial: ClinicalTrials.gov NCT04448119), Abbott Vascular (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL] trial: ClinicalTrials.gov NCT01205776; comparing XIENCE stent in participants with unprotected left main coronary artery disease with coronary artery bypass graft surgery; no active involvement for >3 years, no coauthored publication, but still listed as an original member of the statistical executive committee), and Terumo (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Standard DAPT [dual antiplatelet therapy] Regimen [MASTER DAPT] trial: ClinicalTrials.gov NCT03023020; comparing abbreviated DAPT with prolonged DAPT in patients with a drug-eluting stent; ongoing active involvement as a member of the steering group). MEF has received research support from Amgen; Astra Zeneca; Novartis; and Novo Nordisk. CWCK has received grants or research support from the Advanced Foods and Materials Network, Agriculture and Agri-Food Canada, Almond Board of California, American Pistachio Growers, Barilla, Calorie Control Council, Canadian Institutes of Health Research, Canola Council of Canada, International Nut and Dried Fruit Council, International Tree Nut Council Nutrition Research & Education Foundation, Loblaw Companies Ltd, Pulse Canada, Saskatchewan Pulse Growers Association, and Unilever. He has received in-kind research support from the Almond Board of California, American Peanut Council, Barilla, California Walnut Commission, Kellogg Canada, Loblaw Companies Ltd, Quaker (PepsiCo), Primo, Unico, Unilever, and WhiteWave Foods; has received travel support or honoraria from the American Peanut Council, American Pistachio Growers, Barilla, California Walnut Commission, Canola Council of Canada, General Mills, International Nut and Dried Fruit Council, International Pasta Organization, Loblaw Companies Ltd, Nutrition Foundation of Italy, Oldways Preservation Trust, Paramount Farms, Peanut Institute, Pulse Canada, Sabra Dipping, Saskatchewan Pulse Growers Association, Sun-Maid, Tate & Lyle, Unilever, and WhiteWave Foods. He has served on the scientific advisory board for the International Tree Nut Council, International Pasta Organization, Lantmannen, McCormick Science Institute, Oldways Preservation Trust, Paramount Farms, and Pulse Canada. He is a member of the International Carbohydrate Quality Consortium, executive board member of the diabetes and nutrition study group of the European Association for the Study of Diabetes; is on the clinical practice guidelines expert committee for nutrition therapy of the European Association for the Study of Diabetes; and is a director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. DJAJ has received research grants from the Saskatchewan and Alberta Pulse Growers Associations; the Agricultural Bioproducts Innovation Program through the Pulse Research Network; Advanced Foods and Materials Network; Loblaw Companies Ltd; Unilever Canada and Netherlands; Barilla; Almond Board of California; Agriculture and Agri-Food Canada; Pulse Canada; Kellogg Canada; Quaker Oats Canada; Procter & Gamble Technical Centre Ltd; Bayer Consumer Care, Springfield, New Jersey; Quaker (PepsiCo); International Nut and Dried Fruit Council; Soy Foods Association of North America; the Coca-Cola Company (investigator-initiated, unrestricted grant); Solae; Haine Celestial; the Sanitarium Company; Orafti; International Tree Nut Council Nutrition Research & Education Foundation; Peanut Institute; Soy Nutrition Institute; Canola and Flax Councils of Canada; Calorie Control Council; Canadian Institutes of Health Research; Canada Foundation for Innovation; and the Ontario Research Fund. He has received in-kind supplies for trials as research support from the Almond Board of California, Walnut Council of California, Peanut Institute, Barilla, Unilever, Unico, Primo, Loblaw Companies Ltd, Quaker (PepsiCo), Pristine Gourmet, Bunge Limited, Kellogg Canada, and WhiteWave Foods. He has been on the speakers’ panel, served on the scientific advisory board, and received travel support and honoraria from Nutritional Fundamentals for Health–Nutramedica; Saint Barnabas Medical Center; the University of Chicago; 2020 China Glycemic Index International Conference; Atlantic Pain Conference; Academy of Life Long Learning; Almond Board of California; Canadian Agriculture Policy Institute; Loblaw Companies Ltd; Griffin Hospital (for the development of the NuVal scoring system); the Coca-Cola Company; Epicure; Danone; Diet Quality Photo Navigation; Better Therapeutics (formerly known as FareWell); Verywell; True Health Initiative; Heali AI Corp; Institute of Food Technologists; Soy Nutrition Institute; Herbalife Nutrition Institute; the Saskatchewan and Alberta Pulse Growers Associations; Sanitarium Company; Orafti; International Tree Nut Council Nutrition Research & Education Foundation; Peanut Institute; Herbalife International; Pacific Health Laboratories; Barilla; Metagenics; Bayer Consumer Care; Unilever Canada and Netherlands; Solae; Kellogg; Quaker Oats; Procter & Gamble; Abbott Laboratories; Dean Foods; California Strawberry Commission; Haine Celestial; PepsiCo; Alpro Foundation; Pioneer Hi-Bred International; DuPont Nutrition and Health; Spherix Consulting; WhiteWave Foods; Advanced Foods and Materials Network; Canola and Flax Councils of Canada; Agriculture and Agri-Food Canada; Canadian Agri-Food Policy Institute; Pulse Canada; Soy Foods Association of North America; Nutrition Foundation of Italy; Nutra-Source Diagnostics; the McDougall Program; Toronto Knowledge Translation Group (St Michael’s Hospital); Canadian College of Naturopathic Medicine; the Hospital for Sick Children; Canadian Nutrition Society; American Society for Nutrition; Arizona State University; Paolo Sorbini Foundation; and Institute of Nutrition, Metabolism and Diabetes. He received an honorarium from the US Department of Agriculture to present the 2013 WO Atwater Memorial Lecture. He received the 2013 Award for Excellence in Research from the International Nut and Dried Fruit Council. He received funding and travel support from the Canadian Society of Endocrinology and Metabolism to produce mini-cases for the Canadian Diabetes Association. He is a member of the International Carbohydrate Quality Consortium. His wife, Alexandra L Jenkins, is a director and partner of Inquis Clinical Research for the food industry; his two daughters, Wendy Jenkins and Amy Jenkins, have published a book for vegetarians that promotes the use of the foods described here, The Portfolio Diet for Cardiovascular Risk Reduction (Academic Press [Elsevier] 2020, ISBN: 978-0-12-810510-8); and his sister, Caroline Brydson, received funding through a grant from the St Michael’s Hospital Foundation to develop a cookbook for one of his studies. He is also a vegan. JLS has received research support from the Canadian Foundation for Innovation; Ontario Research Fund; Province of Ontario Ministry of Research, Innovation and Science; Canadian Institutes of Health Research; Diabetes Canada; PSI Foundation; Banting & Best Diabetes Centre; American Society for Nutrition; International Nut and Dried Fruit Council Foundation; National Dried Fruit Trade Association; National Honey Board (the US Department of Agriculture honey Checkoff program); International Life Sciences Institute; Pulse Canada; Quaker Oats Center of Excellence; United Soybean Board (the US Department of Agriculture soy Checkoff program); the Tate & Lyle Nutritional Research Fund at the University of Toronto; the Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers Association); and the Nutrition Trialists Fund at the University of Toronto (a fund established by an inaugural donation from the Calorie Control Council). He has received in-kind food donations to support a randomized controlled trial from the Almond Board of California, California Walnut Commission, Peanut Institute, Barilla, Upfield, Unilever, Unico, Primo, Loblaw Companies Ltd, Quaker, Kellogg Canada, WhiteWave Foods (Danone), and Nutrartis. He has received travel support, speaker fees, and honoraria from Diabetes Canada, Dairy Farmers of Canada, FoodMinds LLC, International Sweeteners Association, Nestlé, Pulse Canada, Canadian Society for Endocrinology and Metabolism, GI Foundation, Abbott, General Mills, Biofortis, the American Society for Nutrition, Northern Ontario School of Medicine, International Tree Nut Council Nutrition Research & Education Foundation, European Food Safety Authority, Comité Européen des Fabricants de Sucre, Nutrition Communications, International Food Information Council, Calorie Control Council, and Physicians Committee for Responsible Medicine. He has, or has had, ad hoc consulting arrangements with Perkins Coie LLP, Tate & Lyle, Wirtschaftliche Vereinigung Zucker eV, Danone, and Inquis Clinical Research. He is a member of the European Fruit Juice Association Scientific Expert Panel and a former member of the Soy Nutrition Institute scientific advisory committee. He is on the clinical practice guidelines expert committees of Diabetes Canada, European Association for the Study of Diabetes, and Canadian Cardiovascular Society, as well as Obesity Canada and the Canadian Association of Bariatric Physicians and Surgeons. He serves, or has served, as an unpaid scientific advisor for the food, nutrition, and safety program and the technical committee on carbohydrates of International Life Sciences Institute North America. He is a member of the International Carbohydrate Quality Consortium, executive board member of the diabetes and nutrition study group of the European Association for the Study of Diabetes, and director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. His wife is an employee of AB InBev.

Authors GH, CMC, SMG, RGJ, VSM, WW, AL, CH, JR, KS, DS, ESC, JAU, GLB, LAL have no conflicts of interest to disclose.

©Meaghan E Kavanagh, Laura Chiavaroli, Andrea J Glenn, Genevieve Heijmans, Shannan M Grant, Chi-Ming Chow, Robert G Josse, Vasanti S Malik, William Watson, Aisha Lofters, Candice Holmes, Julia Rackal, Kristie Srichaikul, Diana Sherifali, Erna Snelgrove-Clarke, Jacob A Udell, Peter Juni, Gillian L Booth, Michael E Farkouh, Lawrence A Leiter, Cyril WC Kendall, David JA Jenkins, John L Sievenpiper. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 21.04.2022.

Figures

Figure 1

Project overview. SUS: System Usability Scale.