Dylan Steen, MD talks about several SuperWIN results that caught him happily by surprise and suggest plenty of room for follow-up research.
Dylan Steen, MD, coauthor of the SuperWIN (Supermarket and Web-Based Intervention Targeting Nutrition) study spoke recently with Patient Care® about some of the research team's findings that surprised him.
The novel study that looked at the effect on shopper’s dietary choices of in-store nutrition counseling and education found that the intervention improved dietary quality and that the impact was augmented by further training on how to use digital shopping tools.
Among the outcomes that surprised and excited Steen were the finding that dietary choices improved even in the control group which experienced only a minimal intervention; that participant visit adherence was as high as 100% all the way through and dropped only minimally after pandemic precautions were instituted; and that adding instruction in online grocery shopping for a cohort naïve to the process also had a statistically significant positive impact on nutrition choice.
Here he explains in more detail why some of the results widened his eyes and how he translates them into future research.
Dylan L Steen, MD, MS is associate professor, director of clinical trials and population heatlth research at the University of Cincinnati Heart, Lung & Vascular Institute, University of Cincinnati College of Medicine.
The following transcript has been lightly edited for clarity and style.
Patient Care Online. Did any of the findings from SuperWIN surprise you? Or did you have a sense that things would go in the significant direction?
Dylan Steen, MD. The answer is yes. And I will say part of the reason for the surprise is that we just don't know much about this area. So we just don't have another study like this, that would let us say, “Hey, well, we know that that study showed x, so based on that we're going to expect to see this.” That's not the case.
So for us, I think the increase [in overall DASH score] in the control arm was really interesting. And I think what's interesting about that is we did the medical nutrition therapy visit, but we did it in the retail clinic in the store and the Kroger dietitian did the counseling visit. And the reason I mentioned that is, why do I keep mentioning it was a Kroger dietitian? So think about yourself, let's say you want to eat less meat products, okay, many people are going more vegetarian or vegan and so forth. You may have had bad experiences trying some of these plant-based substitutes—many of us do. But what's amazing is when you have a retail-based dietitian, they know the brands. So there might be 35 options for a particular food, but they know the 1 out of 35 that customers actually say taste good. It doesn't taste gray and slimy. That it is spiced right. And, and that's incredibly important, because you're trying to get to people who have been eating certain things for decades. Or maybe their family has said “No, no, no, stop buying that—you may want to eat it, we refuse to eat it.” But if someone can say, “Okay, I'm going to pick something that's better for you.” And, this is the 1 out of the 35 options that they [the retail-based dietitian] know people say also tastes good, then you're more likely to keep buying. That's the magic, I think.
When I watch traditional dietary counseling systems, it’s people who work outside of these [retail] companies and oftentimes they don't know the products. So how do you make these sophisticated recommendations that really land? That’s critically important. People have so many different tastes and cooking styles, cultural backgrounds, wants and needs for the rest of their diet, that unless you really know the product very, very well, I don't think you can make those kinds of sophisticated recommendations.
We also gave the dietitians figures and tables of each participant’s own dietary intake for the counseling visit, so that they can look at them together, and really get to the meat of the visit, understand what needs to be worked on what was going right, what was going wrong, etc. We could do that in regular practice today.
I don't have to tell this audience of primary care providers about how often their patients stop following a diet or stop showing up at the dietitian or stop going to Weight Watchers. It is very difficult for people to maintain a diet—it’s one of the most difficult things in medicine, honestly, one of our biggest challenges. What we saw here was before the pandemic we actually had about 99% visit adherence—for the 6 educational visits where people came in over 3 months, people showed up; they showed up every single time. And even at 3 months out, at their last visit, there was 100% visit attendance. That is remarkable. This is a free-living community cohort and what it tells me is 1) participants don't do that if it's not convenient and accessible. They don’t do it if they're having an unpleasant experience, or they feel like they're not getting any value. That tells me something because that [visit adherence] is better than anything I've seen published to date. What's also remarkable about it, too, is if somebody says, “Hey, let’s have an even more intense version of SuperWIN. Instead of having them come back for 6 months, let’s do 12,” I think we can say okay, give it a shot, because if 3 months out and 6 visits in 100% of people are still attending, that tells you you can add. Adding probably always improves the dietary outcomes, the blood pressure outcomes and so forth. The problem with past interventions has been that people start to drop off. Anytime you add more and more visits, you get less and less attendance. So you compromise, you have this balance, right? You make it too intense, no one shows up. It's too short, it doesn't really work. But that's remarkable.
Now COVID, the pandemic hit us like everyone else. So when the US declared a national emergency on March 13 2020, we realized that applied to supermarkets. And so we literally had to stop all in-person visits. And we weren't prepared yet for how to resume them in a safe way. Remember, this is when we didn't know anything about COVID. And there were no vaccines, nothing to help. So at that stage, we had just randomized 20 people into it. So we actually had to withdraw those folks for their own safety. What would be the point of keeping them in a study because we wouldn't be able to give them any education, and then we'd just be exposing them potentially to danger. So the study leadership, myself, Dr. Couch and others, withdrew them. We did look at the data on folks once we restarted during the COVID pandemic with all these different safety precautions. And what was interesting is visit participation went down to probably about 80%, as opposed to the original 100%. And this is understandable; 80% is actually pretty good. And as somebody who took the phone calls from many of these participants, they had the same struggles that we had—they lost their jobs, their jobs switched, their kids were home from school, they couldn't get out, they had elderly parents they were caring for who they didn't want to potentially expose, and some people who simply refused to go into the store, because so many other customers are there. There's always that risk of exposure. So I think 80% is still good. I think it’s quite amazing that even in the COVID era, in the height of the pandemic, we were still getting that kind of visit attendance.
And then the final thing I'll say is that this was a late adopter population. The fact that the online enhancements worked, and were statistically significant, there was enough significant DASH increase from them, I think, is very interesting. Now I'm an early adopter of online shopping. So it is very unlikely I will eat a salad or a piece of fruit if I don't online shop—because of the convenience. But if I do, then I eat a pretty good diet. These were folks who elected not to do that [before participating in the study]. But by introducing it carefully, teaching them how to do it, made sure they had a great experience, they did benefit from it [online shopping]. So I think that's really interesting. With early adopters, like myself, you might expect to see even much bigger differences from online shopping. They might be huge. The problem is you can't do a randomized trial on these folks. Because you wouldn't be able to randomize me to not be able to online shop. What's interesting is this is one of the last times we can probably do this experiment on what the benefits are of online shopping. It’s becoming so prevalent that it's very hard to randomize people to no online shopping versus no experience in online shopping. It’s the perfect time to do this. And as you know, online shopping is exploding globally. So the incredibly important question: Does it work? Does it improve dietary intake?