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Review

Content, Quality and Accuracy of Online Nutrition Resources for the Prevention and Treatment of Dementia: A Review of Online Content

by
Justine Lee
†,
Julie Nguyen
† and
Fiona O’Leary
*
Discipline of Nutrition and Dietetics, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health and the Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006, Australia
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this study.
Dietetics 2022, 1(3), 148-163; https://doi.org/10.3390/dietetics1030015
Submission received: 29 May 2022 / Revised: 4 July 2022 / Accepted: 13 July 2022 / Published: 3 October 2022
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Abstract

:
(1) Background: The internet is a popular information source; however, research evaluating online nutrition-related dementia information is limited. This review characterised content, quality, and accuracy of online dementia-specific nutrition resources for dementia prevention and treatment. (2) Methods: JBI methodology for scoping reviews guided the study. Searches used Google search engine with terms related to dementia and nutrition. Webpages from government, organisational and commercial sources were included; blogs, social media and media sources were excluded. DISCERN tool evaluated content quality; accuracy was assessed against ESPEN and WHO guidelines. Differences in mean DISCERN scores were calculated using ANOVA. (3) Results: 105 webpages from eight countries were included. Webpages were mainly from organisational sources (n = 65) and covered nutrition-related prevention (n = 52) including diet–disease relationships (n = 81). Fewer webpages provided information on dementia related eating issues. The total mean DISCERN score (SD) was 50 ± 8, indicating overall good quality. All government webpages provided accurate information. Commercial webpages had some inaccuracy (ESPEN: 3% mixed, 3% inaccurate; WHO: 3% mixed, 3% inaccurate). (4) Conclusions: Information was of reasonable quality and mostly accurate. Further information on dementia-related eating issues is needed. Future research could address readability, understandability and actionability and examine other sources, such as social media, blogs or forums.

1. Introduction

The increasing prevalence of dementia is a health concern worldwide. According to the World Health Organisation (WHO), in 2015, there were almost 48 million people living with dementia around the world and an estimated 9.9 million people newly diagnosed each year [1]. Dementia is a broad term used to group a range of symptoms involving progressive cognitive decline and changes in behaviour that affect the individual’s ability to perform everyday tasks [2]. As there is currently no known cure for dementia, the prevention of its onset and delay of its progression in at-risk individuals remains the focus in clinical practice and the public health domain [3].
Nutrition is a key area for both dementia prevention as well as the management of nutritional issues arising from dementia. Evidence shows that there are potential benefits of a nutritious diet as a preventative approach to dementia providing hope in reducing the risk and progression of dementia [4,5,6]. Throughout the progression of the disease, nutritional issues, notably weight loss and malnutrition, are frequently observed [7]. A study conducted by Kai et al. reported that almost 50% of elderly patients with mild Alzheimer’s disease (AD) had some form of eating disturbance such as appetite change, and over 80% of elderly patients with AD had difficulty eating and swallowing [8]. This is an area of concern as there is an association between the decline in nutritional status and rapid decline in cognition [9,10], increased institutionalisation [11] and mortality [12]. The critical role of diet and nutrition in dementia exemplifies the importance of providing accurate nutritional information and resources to people with dementia and their families and carers.
Despite the growing number of information sources, people with dementia and their carers continue to feel inadequately informed [13,14], with a need for further information on topics such as treatment options [15], disease progression and advice on characteristic behaviours [15,16]. A recent study [14] revealed that the common sources of information reported by people with dementia and their carers included the internet, health and social care professionals, charitable organisations, printed information sheets and friends/family. The internet was the most popular choice due to the ease of access to large quantities of information; however, its use was also linked to the feeling of being overwhelmed.
The internet is a space for the dissemination of a vast array of medical and health knowledge from government, private and non-profit sectors, as well as content sharing between users of the internet [17]. Online information is constantly changing as content is updated, added, and removed. Existing studies show that the quality of health information varied across medical domains and websites, and the quality of dementia-specific health information also varied [18,19,20]. Studies predominantly evaluated a small sample of websites from Western countries such as Canada [20], the United States (US) and the United Kingdom (UK) [19] and may not reflect the current and rapidly changing nature of online content and the scientific evidence base. It appears that there has been less emphasis on the importance of nutrition in dementia and its impact on health outcomes, with another study reporting online articles that did emphasise nutrition as a method of prevention were found to be of lower quality [21]. Although new evidence and guidelines on nutrition in the prevention and treatment of dementia have emerged in recent years [3,22], the evaluation of how this information is disseminated online and its quality have yet to be explored.
To address the lack of research, the aim of this study was to characterise the content, evaluate the quality and assess the accuracy of nutrition information found on the internet for the prevention and treatment of dementia.

2. Materials and Methods

2.1. Study Design

This review of information resources available online via the internet was guided by the Joanna Briggs Institute (JBI) methodology [23] for a traditional scoping review. An iterative process was used to develop inclusion criteria and search strategy and to extract and analyse data from relevant online nutrition resources for the prevention and treatment of dementia. The data collection and assessment processes were performed independently by two researchers.

2.2. Data Collection

Online resources were identified as webpage links that resulted from search terms entered into the search bar of Google search engine. Google was chosen to best capture the online content available, as it is the most popular search engine worldwide, with more than 90% of online searches taking place through Google [24]. The search was conducted on September 8 to 24, 2021 using Google Chrome, Version 93.0.4577.82 (x86_64) in incognito mode to ensure search history, cache and cookies did not affect the search results.
Two rounds of searches were performed: the first by specific search terms, and then by country. Using Google search operators, the first round of searches were performed using terms related to brain health and dementia and were combined with terms related to nutrition [25], producing 52 search terms (Supplementary Table S1). A second search was conducted to capture websites from different countries. The top 10 English-speaking countries where the search term ‘dementia’ had the highest interest based on the proportion of all queries in the region [26] over the past 12 months were identified using Google Trends on 30 August 2021 (Supplementary Table S2). The country names were then combined with previous search terms to generate an additional 520 search terms.
An audit tool was developed on Microsoft Excel (Version 16.53) to record search and assessment results from relevant webpages. The tool was piloted, and adjustments were made accordingly. Ten webpages (9.5% of total webpages) were randomly selected, and outcome measures assessed to determine interrater reliability. Interclass correlation coefficients (ICC) calculated for each outcome measure exceeded 0.9, which indicated excellent interrater reliability [27].

2.3. Inclusion and Exclusion Criteria

The first 10 webpage links that appeared in the search for each search term were considered in order to capture the most viewed pages, as data suggests users seldom review search results beyond the first page [28]. This did not include links labelled “Ad”. Considered webpages were included if they were (i) available in English, (ii) written sources of information (including infographics), (iii) more than half of content was nutrition-related information for the prevention and/or treatment of dementia, determined by visually gauging number of lines with relevant content and (iv) webpages were provided by government, organisation, or commercial websites. The webpages were categorised into government, organisation or commercial webpage type according to the definitions used in Storr et al. [29].
Webpages from commercial sources were further restricted to only include webpages from online health information providers or medical institutions or clinics, as these websites are reported to be the most popular sources of consumer health information on the internet [30]. Search results were excluded if they were classified as media/news networks, social media, discussion board/forums or blogs, or scientific articles/academic journals. Additional exclusion criteria included duplicated webpages, payment/subscription content, audio/video content, presentation slides or broken links with an error message.
Additional inclusion criteria were added for the second search to include only government and peak body webpages, as these are considered to be critical information sources, and overall quality was generally perceived to be ‘good’ on E-government websites [31]. The second search excluded all commercial and organisation webpages that were not produced by dementia/Alzheimer peak bodies. Peak bodies were defined as not-for-profit, non-government organisations representing their sector, by offering integrative functions such as sector capacity building, conducting research, disseminating information and providing policy development advice to their sector, government, decision makers and the community [32,33].

2.4. Outcome Measures

2.4.1. Characterisation of Web Page Content

Webpage context was determined based on whether information addressed the prevention or treatment of dementia or both. A list of topics related to nutrition and the prevention and/or treatment of dementia was established based on common nutrition concerns identified in previous literature (i.e., weight loss, forgetting or refusing to eat, appetite change, dysphagia, and changes in eating behaviour) [34]. Additional topics were inductively identified from webpage content based on emerging topics from webpage content. Webpage content was coded against these key topics and three (specific dietary patterns, dietary supplements, and oral nutrition supplements) were further explored by noting specific recommendations provided by webpages.

2.4.2. Quality of Web Page Content

The DISCERN instrument is a standardised rating system that uses a Likert scale (1 = no; 2–4 = partially meets criterion; 5 = yes) to rate the quality of written consumer health information on treatment choices by assessing the reliability of the evidence sources and specific details of treatment information. DISCERN was chosen as it is a validated and reliable tool [35] and has been used in similar studies exploring the quality of online health information for consumers [20,35,36,37,38,39]. For this study, ‘treatment’ was any nutrition-related intervention suggested by the resource for the treatment or prevention of dementia. Questions 9 and 11, referring to the description of how treatments work and risk of treatments, were excluded, as they were less applicable to nutrition-related interventions and treatments [37]. Webpages were graded against 14 questions in the modified DISCERN tool, to determine total score for quality (14–25 = very poor, 26–35 = poor, 36–45 = fair, 46–55 = good, ≥56 = excellent) [38]. Statistical analysis of DISCERN results were performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics 27). The normality of data was established using the Shapiro–Wilk statistic. Descriptive statistics were used to summarise the scores (including mean and SD), and one-way analysis of variance (ANOVA) tests with Bonferroni correction were performed to compare mean scores between website types, webpage context and countries. Due to the small sample size, the single score from Luxembourg was grouped with scores from Ireland to perform the post hoc country analysis.

2.4.3. Accuracy of Nutrition-Related Web Page Content

Webpage content was compared against 16 European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on nutrition in dementia [22] and eight nutrition-related WHO guidelines on the risk reduction of cognitive decline and dementia [3]. These guidelines were chosen as they provided strong evidence-based recommendations. Webpage content was coded based on the extent to which the advice was accurate, mixed or inaccurate according to the guidelines. Content that was not included or not applicable was also noted. The applicability of guidelines to webpage content was determined by the context of the webpage (Supplementary Table S3).

3. Results

A total of 5270 webpages were obtained from both searches, 105 of which met the study inclusion criteria for assessment. Webpages included were predominately from organisation sources (n = 65), with the largest proportion from peak body organisations (n = 34). Webpages providing information on nutrition-related prevention of dementia (n = 52) were most common in the search. Overall, the search yielded webpages from eight countries, with approximately half originating from the US (n = 53), followed by UK (n = 26) and Australia (n = 10) (Table 1). Sixty-eight webpages provided the date produced/updated, which ranged from 2009 to 2021. The majority (n = 44) of webpages with dates, had been produced/updated in the past three years, since 2019.

3.1. Webpage Topics

Frequently discussed topics in prevention and/or treatment were diet–disease relationships (n = 81), general healthy eating (n = 70) and specific dietary patterns (n = 53) (Table 2). The Mediterranean diet (n = 31) was most examined in the context of dementia prevention and promoting general health and wellbeing, followed by the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet (n = 23) and the Dietary Approaches to Stop Hypertension (DASH) diet (n = 11). Nutrition-specific strategies were often discussed in the context of treatment. Strategies for reduced intake/appetite (n = 35) and eating/swallowing difficulties (n = 34) were most explored, conversely a smaller number of webpages addressed strategies for malnutrition/weight loss (n = 18).

3.2. Quality of Webpage Content

There was no significant difference found between mean DISCERN scores for different types of websites. For webpage contexts, DISCERN scores were higher in webpages with information on treatment or both treatment and prevention compared to prevention alone. Analysis showed scores varied between countries, but significance was lost after adjustment for multiple analyses (Table 1). The total mean score ± SD for all countries was 50 ± 8, which indicates overall good content quality. Webpages from Ireland (n = 2) had the highest mean score of 65, indicating excellent content quality, and the lowest score was 43, indicating fair content quality from Singapore (n = 2) webpages (Table 1). A portable document format (PDF) link from Alzheimer’s Disease International received a full score of 70, and the lowest score of 31 was obtained from a webpage by Alzheimer’s Research UK, suggesting poor quality. Low scores were mainly obtained in Section 1, assessing the resource reliability, as the webpage lacked clear aims and did not disclose information sources used.

3.3. Accuracy of Nutrition-Related Webpage Content

3.3.1. Webpage Information Accuracy by Guideline

The most discussed ESPEN guideline category was “strategies to support oral nutrition support”, with an average of 27 webpages including guidelines within this category, and the least common category included was “artificial nutrition and hydration” (Table 3). ESPEN guideline 7 was most frequently included. Of the 43 webpages where guideline 7 was applicable, 39 included the guideline, all of which provided accurate information. Conversely, guidelines 16, 18 and 19, under “artificial nutrition and hydration” were not covered in any webpages. The “Oral supplementation–nutrient supplementation” category had the highest number of applicable guidelines, though results showed a mixture of accuracies. For instance, guideline 10a included 22 webpages with accurate information (79%), three webpages with mixed accuracy (11%) and three webpages with inaccurate information (11%).
In the WHO guidelines, the most discussed guideline category was “nutrition intervention” (Table 4). In this category, guideline 1b was most included; however, results showed that while 67 webpages (96%) were accurate, three webpages (4%) had mixed accuracy. Guideline 1c had a mixture of accuracies, where 25 webpages (78%) had accurate information, 4 webpages (13%) mixed accuracy and 3 webpages (9%) inaccurate information. The least commonly discussed categories were “management of diabetes mellitus” (n = 8) and “management of dyslipidaemia” (n = 8).

3.3.2. Webpage Information Accuracy by Website Type

On average, organisational webpages addressed more guidelines (ESPEN 31%; WHO 41%) than government (ESPEN 24%; WHO 27%) and commercial (ESPEN 23%; WHO 29%) webpages. All government webpages (n = 13) provided accurate information in line with ESPEN and WHO guidelines, whereas commercial webpages provided a mixture of accurate information (ESPEN: 17% accurate, 3% mixed accuracy, 3% inaccurate; WHO: 23% accurate, 3% mixed accuracy, 3% inaccurate) (Figure 1).

3.3.3. Webpage Information Accuracy by Website Country of Origin

Webpages assessed from seven of eight countries discussed ESPEN guidelines, while all eight countries addressed WHO guidelines (Figure 2). On average, webpages from Ireland discussed majority of applicable ESPEN guidelines (45%), while New Zealand webpages discussed an average of 53% of applicable WHO guidelines. Australian websites addressed an average of 10% of applicable ESPEN guidelines with mixed accuracy, which was the highest among the countries; however, there was no inaccurate information presented. Websites that originated from the US had the highest inaccuracy count, with 2% of ESPEN and WHO guidelines discussed inaccurately and 2% of ESPEN and WHO guidelines with mixed accuracy (Figure 2).

4. Discussion

This is the first study to review and assess the quality and accuracy of nutrition information provided by webpages on the prevention and treatment of dementia. The quality of webpage content was good overall. Assessment against the ESPEN and WHO guidelines suggested that overall accuracy was reasonable. The results also identified nutrition topics that were less well addressed, and those areas with mixed accuracy and inaccurate advice such as dietary supplementation and oral nutrition supplementation.
Diet–disease relationships and general healthy eating advice were the most discussed topics overall. The most popular diet recommended was the Mediterranean diet. This was consistent with findings by Robillard et al. [21], who reported the Mediterranean diet to be one of the most frequently discussed complementary and alternative interventions available online for dementia prevention. In this study, the MIND diet was the second most represented diet and was predominately found in organisational and commercial webpages. Early studies on the diet have been associated with slower cognitive decline and decreased risk of AD [39,40]. However, this diet is still relatively new, developed in 2015 [39]. The emerging research on the MIND diet has yet to be embodied in information online, with a majority of webpages recommending general healthy eating or the more popular Mediterranean diet. This may be related to the current WHO guidelines, published in 2017, which, at that time, did not specify the MIND diet for the prevention of dementia and cognitive decline, instead recommending a “Mediterranean-like diet” [3]. A small number of webpages included sample meal plans and/or recipes or related to their recommended dietary pattern, specifically for the MIND diet and general healthy eating. Some of these webpages included disclaimers to refer to a health professional for additional information and tailored advice; however, the majority were lacking strategies to help personalise meal plans and recipes to meet individual nutrition needs. Effective dietary advice and resources provided should be tailored to meet individual needs and consider multiple factors [41]. It is evident that although the internet provides access to an abundance of nutrition information, it is limited to providing generalised information.
There was no significant variation found in overall webpage quality, contradicting the findings of previous studies which used different measures to evaluate quality of general dementia information on websites [19,20,21]. Websites from government and non-profit organisational sources are generally recognised as providers of high quality, unbiased and reliable nutrition and health information [42], aimed at educating the public without the motive for commercial gain [29]. However, the results from this study found no significant difference between website types, with all groups rated within the ‘good’ content quality range. Similar results between website types were found in a review by Gkouskou et al. (2011) [43] and Hirasawa et al. (2013) [42] on the quality of nutritional information on the internet in health and disease. This differs from other studies, which reported that better quality advice was provided by government-based websites [44].
The most accurate source of information was provided in government webpages, which was consistent in other studies on health information [44]. This finding supports consumer perceptions previously reported in a systematic review of information quality of E-government websites, which found that consumers considered accuracy the most significant indicator of quality in 56% of reviewed studies [31]. Scullard et al. [45] also advises that healthcare professionals should be recommending government webpages when searching for health information online. However, it is important to note that among the reviewed government webpages, most provided general statements about topics and rarely went into detail, which could have inflated the accuracy score. This study found that organisation websites provided information with mixed accuracies. Organisation webpages collected were predominately from peak organisations such as Alzheimer’s Association, Alzheimer’s Society UK and Dementia Australia. The prominence of information from these peak body organisations supports the general recommendation for consumers to seek information and advice from these “reliable” sources [46]. Therefore, the mixed accuracy of information in this group raises concern, given that previous studies have reported that consumers most commonly access government and charity websites for information on dementia, as they are generally perceived as known and trusted sites [14].
Topics on specific nutrient supplementation and oral nutrition supplement use had mixed or inaccurate information. Both ESPEN and WHO guidelines do not recommend nutrient supplementation for the prevention of dementia or correction of cognitive decline unless there is a specific nutrient deficiency [3,22]. These recommendations exist as there is a lack of high quality or conclusive evidence to support the efficacy of dietary supplements and their use in dementia prevention or treatment [22]. Information on nutrient supplements claiming dementia-related benefits such as improved functioning and delayed progression, treatment and prevention of AD are available online, but such information is infrequently referenced in peer reviewed scientific studies [47]. However, research has shown nutrient supplement use to be common, especially among older adults [44]. Clinically, this may be an important point to note, as dietary supplement use in older adults is reported to remain high [48], and people with dementia or their family or carers may seek alternative treatments, dietary supplements and therapies [44]. Dementia can also impact an individual’s nutritional status due to challenges such as eating disturbances (i.e., appetite change) and eating and swallowing difficulties [8]. A systematic review on the effects of oral nutrition supplements in persons with dementia found that compliance to oral nutrition supplements increased intake of energy and protein, improving nutritional status [49], yet the topic of oral nutrition supplements was only covered in 11% of webpages. Thus, providing evidence-based information and guidance on oral nutrition supplement use to those who are experiencing eating difficulties is needed.
Webpages from the US accounted for the highest percentage of inaccurate information. Similar results were found by Storr et al. [29] on the accuracy of pregnancy-related nutrition webpages where the highest percentage of inaccurate information was found among American webpages. This is a concern, as consumers may be prone to retrieving information from more prevalent US websites associated with greater inaccuracies. Webpages from remaining countries did not convey any mixed accuracy or inaccurate information; however, all had sample sizes of less than 10. This indicates that results may not be representative of the overall quality or accuracy of the resources from these countries. Nonetheless, it is likely a reflection of the availability of nutrition information for dementia available in these countries. The presence and accuracy of information may also be related to the country’s public health priorities and policy in response to the increasing disease burden. To varying extents, all countries that produced results have outlined and initiated national plans for dementia. For instance, the significant presence of resources may reflect national responses of the US [50], UK [51] and Australia [52], which more comprehensively address implementation and integration throughout their plans [53]. On the other hand, countries that had no included search results, such as the Philippines [54], Ghana and South Africa [55], appear to have little public health emphasis and a lack of national plan or action on the issue.
Dementia risk reduction is a prioritised action area highlighted in the WHO global action plan for dementia [1] and is also emphasised as a common key objective in national plans, notably from the US [50], Australia [52] and Canada [56]. The results collected a higher proportion of webpages about dementia prevention, which supports alignment with the widespread recognition and effort to address this action area. The WHO action plan [1], WHO guidelines [3] and the 2020 report of the Lancet Commission on dementia prevention, intervention and care [57] highlights the link between increased risk and progression of dementia with risk factors including harmful alcohol consumption, mid-life hypertension, dyslipidaemia and commonly associated non-communicable diseases, including diabetes mellitus and obesity. Despite this, the results found that only a small number of webpages that addressed dementia prevention included information on the management and interventions for these risk factors, with the topics of diabetes mellitus and dyslipidaemia being least included. Furthermore, a significant difference in content quality was identified, with dementia prevention found to be of lower quality compared to webpages discussing treatment or both. This aligns with findings from a study on the quality of online health-related search results, which found that preventative health information tended to be of lower quality compared to information on treatments of injuries and illnesses [58]. Topics on alcohol intake and strategies for managing overeating or weight gain were not included in a large portion of webpages. Interestingly, less than half of applicable webpages did not include the reducing or ceasing of harmful drinking, which parallels findings by Ostry et al. (2007) [59], who reported that about 15% of ‘congruent advice’ was provided on alcohol on popular Canadian health websites. These insights demonstrate a gap in the information available online and trend of lower information quality in the critical area of dementia prevention. This, in turn, reflects the shortfall in raising awareness and educating the public to address this WHO action area and increasing rate of dementia prevalence worldwide.

4.1. Study Limitations

There are several limitations of this study. Due to the dynamic and ever-changing nature of internet content, the small sample size of this review only provides a ‘snapshot’ of online information available from one search engine, from a specific time period and from one location (Sydney, Australia). Moreover, the study excluded several other information sources that are commonly used by consumers for health information, including most commercial sources [60] and all social media [14], blogs, discussion boards and video/audio sources [15]. Furthermore, it was necessary to use subjective judgement during the assessment of webpage information and use of the DISCERN tool, which provides opportunity for observer bias. This was addressed through the piloting of the assessment tool, discussion between researchers to establish consensus and calculation of ICC. The search did not exclude any specific countries. The study methodology assumed ESPEN and WHO guidelines applied internationally and assessed resources from all countries accordingly. Many countries also had their own iteration of national general healthy eating recommendations, and some had additional practice guidelines for clinicians and dementia, for example, the National Institute for Health and Care Excellence (NICE) guideline 97 [61] used in the UK. Moreover, despite WHO releasing a Global Action Plan on Public Health Response to Dementia in 2017 with a target of 146 countries to adopt the plan by 2025, low- to middle-income countries such as Ghana are still in the developmental stages of their plans [62,63].

4.2. Study Implications and Future Directions

This was the first study to evaluate online dementia-specific nutrition information. Insights highlight the overall need to improve online nutrition resources for dementia prevention and treatment. It may also provide clinicians with an understanding and awareness on nutrition areas with limited resources and sources of higher quality and accurate information for their patients. From a public health perspective, findings could also be used to inform government or organisational policy and initiatives to improve the quality and prioritise the dissemination of accurate resources for public awareness and education. While the quality and accuracy of consumer health information are important, the readability, understandability and actionability [64] of online health advice should also be evaluated as an indicator of appropriateness of health literacy level related to the consumer’s ability to comprehend and apply the knowledge [65]. There remain opportunities for future studies to evaluate other online information sources excluded from this study such as social media, blogs and forums. As the internet contains vast collections of health information that is constantly evolving, there is an opportunity to produce consistent and updated research on emerging content available for people with dementia and their family and carers.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/dietetics1030015/s1, Table S1: Search term combinations used in first-round searches; Table S2: Top 10 English-speaking countries where the search term ‘dementia’ has the highest interest over the past 12 months from Google Trends; Table S3: Webpage contexts and applicability of ESPEN and WHO guidelines for assessment of content accuracy.

Author Contributions

Conceptualisation, F.O., J.L. and J.N.; methodology, J.L., J.N. and F.O.; validation, J.L., J.N. and F.O.; formal analysis, J.L., J.N. and F.O.; investigation, J.L., J.N. and F.O.; data curation, J.L., J.N. and F.O.; writing—original draft preparation, J.L. and J.N.; writing—review and editing, J.L., J.N. and F.O.; supervision, F.O. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Accuracy of information (%) in accordance with the European Society for Clinical Nutrition and Metabolism (ESPEN) and World Health Organisation (WHO) guidelines, by website type. Abbreviations: ESPEN, European Society for Clinical Nutrition and Metabolism; WHO, World Health Organisation. a Applicable guidelines determined by where guideline was potentially applicable as determined by context of webpage provided (prevention, treatment, or both). b Government webpage defined as “funded and run by local, state or federal government of a country” [29]. c Organisation webpage defined as “created by an organisation that is not for profit” [29]. d Commercial webpage defined as “created by a private company with the intention to make profit” [29]. e n refers to the number of webpages assessed according to the ESPEN and WHO guidelines.
Figure 1. Accuracy of information (%) in accordance with the European Society for Clinical Nutrition and Metabolism (ESPEN) and World Health Organisation (WHO) guidelines, by website type. Abbreviations: ESPEN, European Society for Clinical Nutrition and Metabolism; WHO, World Health Organisation. a Applicable guidelines determined by where guideline was potentially applicable as determined by context of webpage provided (prevention, treatment, or both). b Government webpage defined as “funded and run by local, state or federal government of a country” [29]. c Organisation webpage defined as “created by an organisation that is not for profit” [29]. d Commercial webpage defined as “created by a private company with the intention to make profit” [29]. e n refers to the number of webpages assessed according to the ESPEN and WHO guidelines.
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Figure 2. Accuracy of information in webpages (%) in accordance with the European Society for Clinical Nutrition and Metabolism (ESPEN) and World Health Organisation (WHO) guidelines, by country of website. Abbreviations: ESPEN, European Society for Clinical Nutrition and Metabolism; WHO, World Health Organisation. a Applicable guidelines determined by where guideline was potentially applicable as determined by context of webpage provided (prevention, treatment, or both). b n refers to the number of webpages assessed according to the ESPEN and WHO guidelines.
Figure 2. Accuracy of information in webpages (%) in accordance with the European Society for Clinical Nutrition and Metabolism (ESPEN) and World Health Organisation (WHO) guidelines, by country of website. Abbreviations: ESPEN, European Society for Clinical Nutrition and Metabolism; WHO, World Health Organisation. a Applicable guidelines determined by where guideline was potentially applicable as determined by context of webpage provided (prevention, treatment, or both). b n refers to the number of webpages assessed according to the ESPEN and WHO guidelines.
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Table
Table 1. Webpage characteristics and webpage DISCERN scores (N = 105).
Table 1. Webpage characteristics and webpage DISCERN scores (N = 105).
Webpage CharacteristicsWebpage DISCERN Score a
Characteristic Web Pages,
n (%)		Mean bSD
Website typeGovernment c13 (12.4)52.26.8
Organisation d65 (61.9)50.07.9
Commercial e27 (25.7)50.37.5
Webpage contextPrevention52 (49.5)47.57.2
Treatment 42 (40.0)53.16.7
Both 11 (10.5)53.58.4
Website country of originAustralia10 (9.5)53.97.3
Canada7 (6.7)48.67.7
Luxembourg 1 (1.0)53.0-
Ireland2 (1.9)65.05.7
New Zealand4 (3.8)48.55.4
Singapore2 (1.9)42.57.8
United Kingdom26 (24.8)51.57.4
United States53 (50.5)49.27.4
Abbreviations: SD, Standard deviation. a DISCERN tool scored out of 70 to assess webpage content quality. A higher score indicates higher content quality. b One-way ANOVA. Website type and website country of origin; p for trend 0.66, and 0.05, respectively. Non-significant on Bonferroni analysis. Webpage context ANOVA p < 0.001; Bonferroni analysis showed treatment, or both had higher scores than prevention (p = 0.001, p = 0.04, respectively). c Government webpage defined as “funded and run by local, state or federal government of a country” [29] d Organisation webpage defined as “created by an organisation that is not for profit” [29]. e Commercial webpage defined as “created by a private company with the intention to make profit” [29].
Table
Table 2. Nutrition-related topics of webpages exploring the prevention and/or treatment of dementia (N = 105).
Table 2. Nutrition-related topics of webpages exploring the prevention and/or treatment of dementia (N = 105).
Nutrition Related TopicsWebpages, n (%) a
General informationBackground information
  • Description of condition
11 (10.5)
  • Considers other health/medical conditions
45 (42.9)
  • Common changes to expect
40 (38.1)
  • Research in nutrition and dementia
67 (63.8)
Help and support
  • Additional help/support
59 (56.2)
  • Carer-specific information
39 (37.1)
Prevention and/or treatment informationDiet
  • Diet-disease relationship
81 (77.1)
  • Specific dietary patterns
53 (50.5)
  • Sample meal plan/recipes
8 (7.6)
  • General healthy eating
70 (66.7)
  • Dietary supplements
37 (35.2)
  • Oral nutrition supplements
12 (11.4)
  • Hydration
28 (26.7)
  • Alcohol
30 (28.6)
Nutrition-specific strategies
  • Malnutrition and/or weight loss
18 (17.1)
  • Eating/swallowing difficulties
34 (32.4)
  • Food supply
18 (17.1)
  • Reduced intake/appetite
35 (33.3)
  • Weight gain, overeating or insatiable appetite
9 (8.6)
a N = 105 webpages assessed, with varying number of nutrition-related topics discussed on each webpage.
Table
Table 3. Webpages n (%) and accuracy of included information related to the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on nutrition in dementia.
Table 3. Webpages n (%) and accuracy of included information related to the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on nutrition in dementia.
Category ESPEN Guideline aTotal Applicable b, n (%)Total
Included c,
n (%)		Accurate d, n (%)Mixed Accuracy d, n (%)Inaccurate d, n (%)Not
Included e, n (%)
Screening and assessment1. Malnutrition screening37 (35.2)5 (13.5)5 (100.0)0 (0.0)0 (0.0)32 (30.5)
2. Monitoring and documentation of body weight 37 (35.2)8 (21.6)8 (100.0)0 (0.0)0 (0.0)29 (27.6)
Strategies to support oral nutrition3. Mealtime environmental factors 42 (40.0)30 (71.4)30 (100.0)0 (0.0)0 (0.0)12 (11.4)
4. Nutrition for individual needs and preferences42 (40.0)36 (85.7)36 (100.0)0 (0.0)0 (0.0)6 (5.7)
5. Adequate food intake and support42 (40.0)37 (88.1)37 (100.0)0 (0.0)0 (0.0)5 (4.8)
6. Appetite stimulants41 (39.0)3 (7.3)1 (33.3)1 (33.3)1 (33.3)38 (36.2)
7. Educating caregivers43 (41.0)39 (90.7)39 (100.0)0 (0.0)0 (0.0)4 (3.8)
8. Causes of malnutrition44 (41.0)32 (74.4)32 (100.0)0 (0.0)0 (0.0)11 (10.5)
9. Dietary restrictions44 (41.9)15 (34.1)14 (93.3)1 (6.7)0 (0.0)29 (17.6)
Oral supplementation -nutrient supplementation 10a. Omega-3-fatty acid 34 (32.4)28 (82.4)22 (78.6)3 (10.7)3 (10.7)6 (5.7)
10b. Vitamin B1 97 (92.4)19 (19.6)17 (89.5)1 (5.3)1 (5.3)78 (74.3)
10c. Vitamin B6, vitamin B12 and/or folic acid 97 (93.3)24 (24.7)19 (79.2)3 (12.5)2 (8.3)73 (69.5)
10d. Vitamin E 98 (93.3)26 (26.5)20 (76.9)4 (15.4)2 (7.7)72 (68.6)
10e. Selenium 97 (92.4)15 (15.5)13 (86.7)1 (6.7)1 (6.7)82 (78.1)
10f. Copper 97 (92.4)15 (15.5)14 (93.3)0 (0)1 (6.7)82 (78.1)
10g. Vitamin D 96 (91.4)22 (22.9)17 (77.3)2 (9.1)3 (13.6)74 (70.5)
Oral supplementation -oral nutritional supplements11. ONS to improve nutritional status 58 (55.2)9 (15.5)9 (100.0)0 (0.0)0 (0.0)49 (46.7)
12. ONS to correct/prevent further cognitive impairment86 (81.9)2 (2.3)2 (100.0)0 (0.0)0 (0.0)84 (80.0)
13. Special medical foods 86 (81.9)2 (2.3)1 (50.0)0 (0.0)0 (0.0)84 (80.0)
14. Other nutritional products95 (90.5)12 (12.6)7 (58.3)3 (25.0)2 (16.7)83 (79.0)
Artificial nutrition and hydration 15. Patient prognosis and preferences 7 (6.7)6 (85.7)6 (100.0)0 (0.0)0 (0.0)1 (1)
16. Tube feeding for mild/moderate dementia6 (5.7)0 (0.0)0 (0.0)0 (0.0)0 (0.0)6 (5.7)
17. Tube feeding in severe dementia7 (6.7)6 (85.7)4 (66.7)2 (33.3)0 (0.0)1 (1)
18. Parenteral nutrition 7 (6.7)0 (0.0)0 (0.0)0 (0.0)0 (0.0)7 (6.7)
19. Parenteral fluids7 (6.7)0 (0.0)0 (0.0)0 (0.0)0 (0.0)7 (6.7)
20. Artificial nutrition in terminal phase7 (6.7)2 (28.6)1 (50.0)1 (50.0)0 (0.0)5 (4.8)
Abbreviations: ESPEN, European Society for Clinical Nutrition and Metabolism; ONS, Oral nutrition supplements. a Refers to ESPEN guidelines on nutrition in dementia [22]. b Total number of webpages where guideline was potentially applicable as determined by context of webpage provided (prevention, treatment, or both); c Sum of accurate, mixed accuracy, and inaccurate webpages; d Total number of guidelines included varied with webpage content; e Total number of webpages where guideline was potentially relevant but not reported in the webpage.
Table
Table 4. Webpages n (%) and accuracy of included information related to the World Health Organisation (WHO) guidelines for risk reduction of cognitive decline and dementia.
Table 4. Webpages n (%) and accuracy of included information related to the World Health Organisation (WHO) guidelines for risk reduction of cognitive decline and dementia.
Category WHO Guideline aTotal Applicable b, n (%)Total
Included c,
n (%)		Accurate d, n (%)Mixed
Accuracy d,
n (%)		Inaccurate d, n (%)Not
Included e, n (%)
Nutrition intervention 1a. Mediterranean-like diet 94 (89.5)51 (54.3)48 (94.1)3 (5.9)0 (0.0)43 (41.0)
1b. Healthy and balanced diet 95(90.5)70 (73.7)67 (95.7)3 (4.3)0 (0.0)25 (23.8)
1c. Vitamins B and E, PUFA and multi-complex supplementation91 (86.7)32 (35.2)25 (78.1)4 (12.5)3 (9.4)59 (56.2)
Interventions for alcohol use disorder2. Reduce/cease harmful drinking63 (60.0)21 (33.3)21 (100.0)0 (0.0)0 (0.0)42 (40)
Weight management3. Interventions for mid-life overweight and/or obesity62 (59.0)9 (14.5)9 (100.0)0 (0.0)0 (0.0)53 (50.5)
Management of hypertension 4. Management of hypertension62 (59.0)15 (24.2)15 (100.0)0 (0.0)0 (0.0)47 (44.8)
Management of diabetes mellitus 5. Management of diabetes 62 (59.0)8 (12.9)8 (100.0)0 (0.0)0 (0.0)54 (51.4)
Management of dyslipidaemia6. Management of dyslipidaemia 62 (59.0)8 (12.9)8 (100.0)0 (0.0)0 (0.0)54 (51.4)
Abbreviations: WHO, World Health Organisation; PUFA, Polyunsaturated fatty acids. a Refers to nutrition-relevant guidelines in the WHO guidelines for risk reduction of cognitive decline and dementia [3]. b Total number of webpages where guideline was potentially applicable as determined by context of webpage provided (prevention, treatment, or both); c Sum of accurate, mixed accuracy, and inaccurate webpages; d Total number of guidelines included varied with webpage content; e Total number of webpages where guideline was potentially relevant but not reported in the webpage.
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Lee, J.; Nguyen, J.; O’Leary, F. Content, Quality and Accuracy of Online Nutrition Resources for the Prevention and Treatment of Dementia: A Review of Online Content. Dietetics 2022, 1, 148-163. https://doi.org/10.3390/dietetics1030015

AMA Style

Lee J, Nguyen J, O’Leary F. Content, Quality and Accuracy of Online Nutrition Resources for the Prevention and Treatment of Dementia: A Review of Online Content. Dietetics. 2022; 1(3):148-163. https://doi.org/10.3390/dietetics1030015

Chicago/Turabian Style

Lee, Justine, Julie Nguyen, and Fiona O’Leary. 2022. "Content, Quality and Accuracy of Online Nutrition Resources for the Prevention and Treatment of Dementia: A Review of Online Content" Dietetics 1, no. 3: 148-163. https://doi.org/10.3390/dietetics1030015

APA Style

Lee, J., Nguyen, J., & O’Leary, F. (2022). Content, Quality and Accuracy of Online Nutrition Resources for the Prevention and Treatment of Dementia: A Review of Online Content. Dietetics, 1(3), 148-163. https://doi.org/10.3390/dietetics1030015

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